Sleep and Cognition: Implications among

the Elders

Thomas B. Virden III, Ph.D., ABPP

Arizona Neuropsychological Association

September 15, 2018

Objectives!

• Identify at least 3 aspects of cognition impacted by sleep patterns

• Identify sleep patterns most deleterious to cognitive functioning

• Identify sleep patterns most advantageous to cognitive

functioning

Bad Sleep is Bad

• Insomnia and sleep duration problems common in elders

• Poor sleep is reported in about 50% of individuals 65 and older

• Poor sleep in elders is often linked to:– Depression

– Suicide

– Cardiovascular disease

– General mortality

– Functional impairment

– Low quality of life

– Increased use of sleep aids

• Contributes to falls

Cognitive Decline

• Short night sleep and frequent daytime naps lead to decrements

in:

– Vigilance

– Recall

– Processing speed

– Executive functioning

– Attention

– Concentration

– Visual memory

Do you know how much (or little)

you sleep?• People often underestimate their sleep

• Reports of poor or little sleep, when recordings are quite normal

• 105 individuals 60 and over were give nap opportunities

– 40% did not perceive at least 2 naps

• That 40% were more likely to score 26 or less on the MMSE

• Nocturia in half adults 66 and older

– 21% in men and 27% in women over 20

– More nocturia means less sleep quality (Fung, et al. 2017)

Nguyen-Michel, et al. (2015)

Fung, et al. (2017).

In the Brain

• Slow wave sleep seems to benefit

– Prefrontal cortex

– Hippocampus

• Possibly impacting PFC and HPC dependent cognition

– Thus, poor sleep may be more likely to impact that area of cognitive functioning

– Working memory

– Inhibition

– Controlled processing speed

– Memory and recall

Memory Issues, Maybe Not an

Issue?• In home monitoring studies:

– 48-55 SWS decline relates to memory decline

– 55 and older get less SWS

• But does not correlate to memory decline

– Decoupling of memory with SWS in older adults

Scullin, M. K. (2013)

But the PFC…!

• Sleep continuity seems to be the culprit in those 55 and older

• With more continuity comes better

– Inhibitory control

– Memory recall

– Verbal fluency

Wilckens, et al., (2014)

Length Matters

• Short and long sleep duration is linked to:

– Increased mortality

– Stroke

– Diabetes

– Heart disease

– Depression

Chicken and Egg?

• 7 year longitudinal study of 3,820 individuals 60 and over.

• Higher mortality rate for those with a sleep duration of over 10

hours

• Controlling for

– General health

– Cognitive functioning

– Quality of Life

– Depression

Mesas, López-García, León-MuñozGuallar-Castillón, &

Rodríguez-Artalejo (2010).

Sleep Duration and Cognitive

Impairment• 695 men and women aged 40-65 in Germany

– If sleep remained stable, no problem

– If sleep increased 7h to 8.5 hours over a couple of years

• Decreased cognitive functioning.

• 500 men and women aged 60 and older in Turkey

– Less than 6 hours per night

– Daytime sleepiness lasting 1 hour or more

Loerbroks, Debling, Amelang, & Stürmer (2010).

Soykok, et al. (2017).

The Bronx Aging Study

• 375 men and women 75-85

• Controlled for

– hypnotic medications

– physical morbidity

– Education

• Those who reported longer sleep duration did worse on verbal

short term memory tests

Schmutte, et al. (2007)

Individual Deviations

• 50 African American individuals aged 50-80

• Self-report sleep duration and quality

• Tests of cogntitive functioning over 2-3 weeks:

– Stroop

– Clock drawing

– Rey AVLT

• The more someone deviated from the average sleep duration, the

more pronounced cognitive decline became.

Gamaldo, Allaire, & Whitfield (2010)

7 +/-2?

• 15,385 Nurses 70 years and older over a 6 year period

– 5 hours per day worse cognition than those sleeping 7 hours per day

– 9 hours per day worse cognition than those sleeping 7 hours per day

– A decrease in cognitive functioning was also noted if sleep deviated from

their average by 2 hours or more.

Devore, et al. (2014).

Is Napping a Problem?

• In the VA, 192 men aged 60 and over

– Sleep monitors and MMSE

– 6 month follow up

• If daytime napping decreased within that 6 month period,

cognition improved

– Daytime wakefulness did not seem to have an impact

Dzierzewski, et al. (2014).

Napping Healthily

• 2,974 Men and Women aged 63 and older in China

• Controlled for BMI, depression, nighttime sleep duration

• 4 Post lunch napping categories

– Non nappers

– Short nappers (less than 30 minutes)

– Moderate nappers (30-90 minutes)

• Average nap among all nappers was 63 minutes

– Extended nappers (90 minutes or more)

• Moderate nappers fared on cognition better than both extended and non nappers

• Short nappers fared better than non nappers

Li, et al. (2017)

A Nonpharmacological

Treatment?• Exercise and cognitive stimulation

• 126 subjects 65 and older with low levels of activity

– Less than 2 days per week

• Combinations of 4 treatments:

– Stretching

– Aerobics

• 60 min 3x week

– Sensorimotor games

• Tracking movement

• Matching tones Pa, et al.. (2014)

More Exercise and Cognition!

(With a bit of Light)

• Educational lectures

– Art, History, Science

– Multiple choice quizzes at the end

• Improvements in all groups according to the Sleep Disorders

Questionnaire

– Stretching + Education had the best effect

• Light therapy has also shown to be moderately effective in

improving sleep in cognitively impaired individuals

– No measures on cognitive improvement, howeverChiu, et al. (2017)

Pa, et al.. (2014)

In Sum: Aspects of Cognition

• Prefrontal and Hippocampal aspects of cognition appear most

impacted by sleep

– Working memory

– Inhibition

– Recall

– Processing speed

– Moreso in PFC in elders

Deleterious Sleep Patters

• Too little or too much!

• Deviations from your own average duration

• Excessive napping

Advantageous Sleep Patterns

• ‘Healthy’ seems individualistic, but there appears to be a range

– More than 5, less than 9

• Continuity!

• While napping a great deal may be problematic, keeping it within

a 30-90 minute range may be better than not napping at all

Any Questions Keeping You

Awake Tonight?

References

Carlson, B. W., Neelon, V. J., Carlson, J. R., Hartman, M., & Bliwise, D. L. (2011). Cerebral Oxygenation in Wake and During Sleep and Its Relationship to

Cognitive Function in Community-Dwelling Older Adults Without Sleep Disordered Breathing. Journals Of Gerontology: Series A: Biological Sciences

And Medical Sciences, 66A(1), 150-156.

Chiu, H. L., Chan, P. T., Chu, H., Hsiao, S. S., Liu, D., Lin, C. H., & Chou, K. R. (2017). Effectiveness of Light Therapy in Cognitively Impaired Persons: A

Metaanalysis of Randomized Controlled Trials. Journal Of The American Geriatrics Society, 65(10), 2227-2234.

Devore, E. E., Grodstein, F., Duffy, J. F., Stampfer, M. J., Czeisler, C. A., & Schernhammer, E. S. (2014). Sleep Duration in Midlife and Later Life in

Relation to Cognition. Journal Of The American Geriatrics Society, 62(6), 1073-1081.

Dzierzewski, J. M., Fung, C. H., Jouldjian, S., Alessi, C. A., Irwin, M. R., & Martin, J. L. (2014). Decrease in Daytime Sleeping Is Associated with

Improvement in Cognition After Hospital Discharge in Older Adults. Journal Of The American Geriatrics Society, 62(1), 47-53

Fung, C. H., Vaughan, C. P., Markland, A. D., Huang, A. J., Mitchell, M. N., Bliwise, D. L., Ancoli-Israel, S., Redline, S., Alessi, C. A., & Stone, K. (2017).

Nocturia is Associated with Poor Sleep Quality Among Older Women in the Study of Osteoporotic Fractures. Journal Of The American Geriatrics Society, 65(11), 2502-2509. doi:10.1111/jgs.15027

Gamaldo, A. A., Allaire, J. C., & Whitfield, K. E. (2010). Exploring the Within-Person Coupling of Sleep and Cognition in Older African Americans.

Psychology And Aging, 25(4), 851-857.

More References

Li, J., Cacchione, P. Z., Hodgson, N., Riegel, B., Keenan, B. T., Scharf, M. T., Richards, K., & Gooneratne, N. S. (2017). Afternoon Napping and

Cognition in Chinese Older Adults: Findings from the China Health and Retirement Longitudinal Study Baseline Assessment. Journal Of The American

Geriatrics Society, 65(2), 373-380.

Loerbroks, A., Debling, D., Amelang, M., & Stürmer, T. (2010). Nocturnal sleep duration and cognitive impairment in a population-based study of older

adults. International Journal Of Geriatric Psychiatry, 25(1), 100-109.

Mesas, A. E., López-García, E., León-Muñoz, L. M., Guallar-Castillón, P., & Rodríguez-Artalejo, F. (2010). Sleep duration and mortality according to health

status in older adults. Journal Of The American Geriatrics Society, 58(10), 1870-1877. doi:10.1111/j.1532-5415.2010.03071.x

Nguyen-Michel, V., Lévy, P., Pallanca, O., Kinugawa, K., Banica-Wolters, R., Sebban, C., Mariani, J, Fournier, E. & Arnulf, I. (2015). Underperception of

Naps in Older Adults Referred for a Sleep Assessment: An Insomnia Trait and a Cognitive Problem?. Journal Of The American Geriatrics Society, 63(10),

2001-2007.

Pa, J., Goodson, W., Bloch, A., King, A. C., Yaffe, K., & Barnes, D. E. (2014). Effect of Exercise and Cognitive Activity on Self-Reported Sleep Quality in

Community-Dwelling Older Adults with Cognitive Complaints: A Randomized Controlled Trial. Journal Of The American Geriatrics Society, 62(12), 2319-

2326.

Does this guy sleep?

Schmutte, T., Harris, S., Levin, R., Zweig, R., Katz, M., & Lipton, R. (2007). The Relation Between Cognitive Functioning and Self-Reported Sleep

Complaints in Nondemented Older Adults: Results From the Bronx Aging Study. Behavioral Sleep Medicine, 5(1), 39-56.

doi:10.1207/s15402010bsm0501_3

Scullin, M. K. (2013). Sleep, Memory, and Aging: The Link Between Slow-Wave Sleep and Episodic Memory Changes From Younger to Older Adults.

Psychology and Aging, 28(1), 105-114.

Soykok, G., Yilmaz, R., Senturk, A. I., Cevic, S., Figul Gocke, S., Kayim Yildiz, O., & Toaktas, S. (2015). Association of sleep quality and daytime

sleepiness with cognition in the elderly. Turkish Journal Of Geriatrics / Türk Geriatri Dergisi, 18(2), 123-129.

Wilckens, K. A., Woo, S. G., Kirk, A. R., Erickson, K. I., & Wheeler, M. E. (2014). Role of Sleep Continuity and Total Sleep Time in Executive Function

Across the Adult Lifespan. Psychology And Aging, 29(3), 658-665.