14.
The Treatment of Sleep Disorders
of Older People

Among their findings, the panel concluded that although sleep patterns change during the aging process most older people with sleep disturbances suffer from any of a variety of medical and psychosocial disorders. The panel recommended that the diagnostic evaluation of sleep disorders begin with a careful clinical evaluation performed by an informed primary care physician. When necessary, referrals should be made to individuals or centers with specialized skills and tools for therapy. The panel recognized two types of disorders for which treatment may be beneficial: obstructive sleep apnea and insomnia. The mainstay for treatment for sleep apnea is the use of nasal continuous positive airway pressure. A thorough medical evaluation is essential prior to initiating treatment for insomnia, as its causes may be of psychiatric, pharmacological, or medical origin. The panel recommended that hypnotic medications not be the mainstay of treatment for insomnia as they may have habit forming potential if overused.

Introduction What Are the Changes in Sleep and Wakefulness as Functions of Aging and of Diseases of Older People? What Are the Diagnostic Criteria That Establish Clinical Abnormalities? Which Are Clinically and Epidemiologically Important? What Are the Indications for a Diagnostic Evaluation? What Sequence of Assessment Methods Should Be Used To Determine if the Diagnostic Criteria Are Met? What Are the Indications for the Treatment of Sleep Disorders? Indications for Treatment of Obstructive Sleep Apnea Indications for Treatment of Insomnia Complaints What Are the Common Medical Practices and Lay Treatment Practices and Their Health Implications? Insomnia Hypersomnia What Should the Medical Profession and General Public Know About Good Sleep Hygiene and Treatment of Sleep Disorders, and What Should Be Done To Increase awareness? What Are the Directions for Future Research? Conclusions and Recommendations Consensus Development Panel Speakers

 Introduction

The increase in the number of people over 65 and the rise in the proportion of older people represent a marked change in the demographic patterns in this country that will have profound social, economic, medical, and personal consequences. Individuals over 65 constituted 4 percent of the American population in 1900 and nearly 10 percent in 1972. By the year 2000, it is estimated that they will comprise over 13 percent of the population and by 2050 will represent more than 21 percent of Americans.

A large proportion of older people are at risk for disturbances of sleep that may be caused by many factors such as retirement and changes in social patterns, death of spouse and close friends, increased use of medications, concurrent diseases and changes in circadian rhythms. While changes in sleep patterns have been viewed as part of the normal aging process, new information indicates that many of these disturbances may be related to pathological processes that are associated with aging.

Although the exact numbers are not yet known, it has been estimated that disturbances of sleep afflict more than half of the people 65 and older who live at home and about two-thirds of those who live in long-term care facilities. Problems in sleep and daytime wakefulness disrupt not only the lives of older persons but also those of their families and caregivers. People over 65 years of age now constitute almost 13 percent of the American population but consume over 30 percent of all dispensed prescription drugs, as well as an unknown percentage of over-the-counter medicines. A large proportion of these drugs are sedatives and hypnotic agents, the safety and efficacy of which have not been established for older people. Nor has it been established to what extent drugs contribute to or alleviate problems of sleep. It is necessary to understand the causes of these disorders and to develop better treatment strategies, including non-pharmacological methods.

In addition to affecting the quality of life, troubled sleep has been implicated with excess mortality. Controversy also exists concerning the causes, diagnosis, assessment, and specific treatments of sleep disorders in older people.

In an effort to assess the current state of knowledge and determine what changes in sleep are clinically important, how sleep disorders are best diagnosed and treated, and how the public can establish good sleep practices, the following key questions are explored here:

 

	What are the changes in sleep and wakefulness as functions of aging and of diseases of older people? What are the diagnostic criteria that establish clinical abnormalities? Which are clinically and epidemiologically important?
	What are the indications for a diagnostic evaluation? What sequence of assessment methods should be used to determine if the diagnostic criteria are met?
	What are the indications for the treatment of sleep disorders?
	What are the common medical practices and lay treatment practices and their health implications?
	What should the medical profession and general public know about good sleep hygiene and treatment of sleep disorders, and what should be done to increase awareness?
	What are the directions for future research?

 What Are the Changes in Sleep and Wakefulness as      Functions of Aging and of Diseases of Older People?       What Are the Diagnostic Criteria That Establish       Clinical Abnormalities? Which Are Clinically and       Epidemiologically Important?

Sleep is a distinctive and essential component of human behavior. Nearly a third of the life of a normal adult is spent sleeping. Sleep is divided into rapid eye movement (REM) and non-REM sleep. REM sleep is characterized by a low amplitude pattern in the EEG, an associated loss of muscle tone, and the presence of rapid eye movements. Non-REM sleep is characterized by sleep spindles and slow wave activity in the EEG. Sleep is differentially distributed into the dark portion of the daily cycle of light and dark. This regulation of sleep reflects basic brain mechanisms that provide the circadian organization of both behavioral and physiological processes.

During aging there are typical changes in the pattern of sleep. The amount of time spent in deeper levels of sleep diminishes. There is an associated increase in awakenings during sleep and in the total amount of time spent awake during the night. In part, these changes appear to represent a loss of effective circadian regulation of sleep.

In carefully screened, medically healthy, older subjects, there are relatively few individuals who have symptoms related to these changes in sleep and in the distribution of sleep and waking behaviors. Many older individuals, however, suffer from a variety of medical and psychosocial problems and these are very often associated with disturbances of sleep. These include psychiatric illnesses, particularly depression; Alzheimer's disease and other neurodegenerative diseases; cardiovascular disease; upper airway incompetence; pulmonary disease; arthritis; pain syndromes; prostatic disease; endocrinopathies; and other illnesses.

The diagnostic categories that establish clinical abnormalities of sleep arise from two sets of data. The first is derived from evaluation of the patient's history, which is classified into syndromes as have been described in the International Classification of Sleep Disorders. None of the disorders are specific for older people, but nearly all occur in this population. The second set comes from electrophysiological studies. Both provide valuable information, but each has its own limitations.

There is little agreement among workers in the field about what is clinically normal and what is clinically abnormal, except in extreme cases (for example, high values of indices of sleep disordered breathing). Also, measurements are not obtained in a standardized way. Much needs to be learned, and an important first step is to decide upon a standardized approach to data collection. The new classification scheme is an important first step in the standardization process.

In the assessment of the behavioral aspects of sleep, standardization is needed before epidemiological subpopulations can be defined and surveyed. The validity (including face validity) and reliability of standardized instruments and settings must be determined before sensitivity, specificity, and prevalence are assessed. Additional considerations are cost and ease of measurement. With standardized, agreed-upon instruments intra- and intersubject variability can be measured and linked with other clinical observations.

Standardized approaches to data collection for both the clinician and the researcher are particularly important in the measurement of variations over time. In many situations clinical action is based on an inference that the patient's condition has changed. If this judgment is guided by a psychometric instrument, then the reliability of the estimated change, in the presence of intrasubject variability, must be established.

The rapid and thorough evaluation of new and existing technology will aid in the development of standardized approaches to data collection. The evaluation begins with the specification of the clinical need. Comparisons with competing technology must be made as objectively as possible, and the ideal research design for accomplishing this is the randomized double-blind clinical trial.

It is difficult to answer questions about changes in sleep and wakefulness as functions of aging or of disease in older people because basic epidemiologic descriptive studies have not yet been carried out. Studies of the distribution of sleeping patterns and "disorders" need to be conducted in the "community" utilizing a representative sampling scheme so that the relationship of sleep patterns to possibly pertinent cultural, demographic, and other variables can be explored.

There is a need for epidemiological studies of sleep disorders: international and cross-cultural comparisons and case-control studies may confirm and generate etiological hypotheses. The natural history of certain sleep disorders is not well described: Do they spontaneously remit? What is the relationship to cardiovascular disease and life expectancy? Cohort studies may help advance our understanding of the natural history of these disorders.

Similarly, it is difficult to determine which diagnostic criteria are important in establishing clinical abnormalities. The field of sleep disorder research has largely approached this problem by attempting to separate "normal" from "abnormal" or "diseased." However, population distributions of the phenomena employed as diagnostic criteria (e.g., periodic movements in sleep or apneic episodes) are not well described. Current threshold values are usually not validated; and test characteristics (sensitivity, specificity, predictive values) are largely unavailable. Furthermore, inter- and intraobserver variation in test interpretation has been rarely studied.

While the severe forms of clinical entities, such as sleep apnea, are generally accepted and criteria agreed upon, mild and moderate forms are not well distinguished. Study of the distribution of these phenomena in populations, linking them to clinical outcomes, is lacking. For example, persons with a mild degree of periodic movements in sleep or apnea may be asymptomatic and not suffer any appreciable morbidity. It will be difficult to establish diagnostic criteria if the frequency of these events is not linked to natural history studies and eventual health outcomes and functional impairment.

 What Are the Indications for a Diagnostic Evaluation?       What Sequence of Assessment Methods Should Be       Used To Determine if the Diagnostic Criteria Are Met?

Diagnostic evaluation begins with the recognition of a potential disorder by patient history or physician suspicion. Screening questions should include: 1) patient satisfaction with his or her sleep; 2) intrusion of sleep or fatigue into daily activities; and 3) complaint by bed partner or other observers of unusual behavior during sleep. A positive response to these questions should trigger a more detailed history of the onset, severity, duration, and pattern of the complaint, and lead to a differential diagnosis.

Three major types of sleep complaints are excessive sleepiness (hypersomnia), difficulty in initiating or maintaining sleep (insomnia), and strange or unusual behavior during sleep (parasomnias).

A careful medical history is needed to determine the presence and severity of concomitant disease. The history of snoring, breathing pauses, or periodic movements during sleep is sometimes better described by the bed partner or other observers. Prescribed medications, especially sedatives, alcohol use, and self medication can have a significant effect on sleep and may impair cardiopulmonary mechanisms during sleep. Psychiatric history and evaluation identify anxiety, depression, or major life events which are known to affect sleep habits or hygiene. In some cases the use of a patient sleep log to evaluate sleep/wakefulness patterns will serve to identify rhythmic or circadian disturbances or to document the magnitude of sleep intrusion into daily activities. Appropriate physical examination will depend upon the nature of the complaint and history elicited from the patient. For example, heavy snoring may necessitate a detailed examination of the nose and throat. Appropriate laboratory tests may be similarly indicated.

Given additional training and education, primary care physicians should be capable of initial assessment and management of the majority of sleep disorders presenting in the older population. When necessary, referrals should be made to individuals or a center with recognized skills in the indications for and application of more specialized tools, such as polysomnography or multiple sleep latency tests for diagnosis and recommendations for therapy.

Polysomnography is indicated when a sleep related breathing disorder is suspected and may be useful for certain behavior or movement disorders during sleep.

Polysomnography followed by a multiple sleep latency test is useful for establishing the diagnosis of narcolepsy and for quantitating daytime sleepiness. At present, there are insufficient data to assess the value of polysomnography in the routine evaluation of insomnia, depression, or dementia.

Limited monitoring on an ambulatory basis may be useful to assess efficacy of therapy for sleep apnea. Technologic advances, standardization of variables, and cost-effectiveness need to be addressed before incorporating ambulatory monitors into epidemiologic studies or the clinical practice of sleep disorders medicine.

  What Are the Indications for the Treatment of Sleep          Disorders?

The goals of therapy of sleep disorders can be classified as:

	Reducing morbidity;
	Reducing excess mortality; and
	Improving quality of life for patient and family.

Sleep disorders have been classified extensively. The major focus of this conference could, however, be summarized as dealing with two primary types of complaints or disorders, for which there is evidence to suggest that treatment is beneficial. These consist of:

	The hypersomnias, primarily represented by obstructive sleep apnea; and
	The insomnia complaints, which can be due to a variety of psychiatric and medical disorders.

Indications for Treatment of Obstructive Sleep Apnea

Obstructive sleep apnea is a potentially reversible cause of daytime hypersomnia, which may be associated with comorbid conditions and even excess mortality. Effective treatment is available for many patients. Development of better and more effective treatment strategies should, however, be encouraged. Treatment is recommended for more severe degrees of this disorder. Objective indices of severity elicited by polysomnography should include a high index of respiratory disturbances per hour, repetitive episodes of hypoxemia, and an abnormally shortened sleep latency. Strict guidelines for therapy have not been adequately validated to dictate thresholds for distinguishing less severely affected patients. At the present time, considerable reliance is made on clinical judgment to initiate a therapeutic trial or regimen.

Indications for Treatment of Insomnia Complaints

Complaints of insomnia are very common in the older patient. Insomnia is a symptomatic expression of a constellation of medical conditions that are not entirely related one to another. Insomnia may be of psychiatric (e.g., depression, anxiety), physiological (e.g., central apnea, limb movement), pharmacological (e.g., prescribed or unprescribed drugs or alcohol), or of medical origin. It may coexist with other sleep disorders (such as apnea), but this may be merely coincidental.

Since insomnia has many causes, the indications for treatment are dependent on the etiology. A thorough medical evaluation is essential prior to initiating treatment. Indications for therapy will be driven by the underlying cause and severity of symptoms.

Attention was given to periodic movements in sleep which appear to be very common in the older patient. Certain pharmacological treatments appear to be effective in patients who find this condition distressing. There is, however, insufficient evidence at this time to indicate whether or not the disease state or its treatment affect morbidity in the older patient. Moreover, the long-term benefits and risks of treatment of periodic movements in sleep are unknown, and, therefore, further investigations are recommended.

Insomnia may also be related to circadian rhythm disorders. Amplitude and phase relationships are often altered in the older person. These changes may produce a variety of somatic complaints and sleep disturbances. Such alterations occur during shift work, transmeridian travel, or changes in daily routine or sleep patterns (earlier arousal and earlier bedtime tendency), or they may occur spontaneously.

Therapy should be directed toward appropriate control of the environment and adequate counseling of the patient and the employer. It may include appropriately timed bright light exposure.

Insomnia resulting from medical or psychiatric causes should be managed primarily by appropriate treatment of the underlying condition.

 What Are the Common Medical Practices and Lay        Treatment Practices and Their Health Implications?

Insomnia

Although hypnotic medication is frequently prescribed by physicians for insomnia and secured either across the counter or "extralegally," hypnotic medication should not be the mainstay of management for most of the causes of disturbed sleep.

Since a large proportion of individuals with chronic insomnia have psychiatric complaints, particularly depression, but also anxiety, panic states, alcoholism, and others, treatment should be directed toward the underlying disorder. In the case of depression the tricyclic antidepressants are frequently useful in the absence of contraindications. One can take advantage of the sedative effect of some of these agents in addition to their more specific effect on the depression. Some agents may actually cause sleeplessness and should be used in the morning.

Other diseases and conditions which cause or contribute to insomnia, such as congestive heart failure, hyperthyroidism, pulmonary disease, esophageal reflux, and arthritis, should be treated specifically with the reminder that medications such as steroids and theophylline may cause sleep disturbance, as can the timing of administration of diuretics.

Pharmacologic therapy may be helpful if it is determined that periodic movements in sleep are contributing to insomnia and require treatment. The long-term benefits of treatment have yet to be determined.

Other general measures such as sleep hygiene can be used as adjuncts to treatment of the specific causes of insomnia and tried when the cause is not clear or is unspecified. Sleep hygiene measures include regularization of bedtime (generally later rather than earlier); the use of the bedroom primarily for sleeping and sexual activity; exercise; avoidance of alcohol and caffeine; reduced evening fluid intake; and in the case of esophageal reflux, elevation of the head of the bed.

Short-term intermittent use of hypnotics and sedative tricyclics may be useful for temporary problems such as bereavement, dislocation, and situational anxiety. There are no studies that demonstrate their long term effectiveness. Given the changes in drug metabolism associated with increasing age, all medication should be used with caution, especially those with long half-lives. Older people should avoid over-the-counter sleep medication due to their anticholinergic effects and questionable efficacy. L-Tryptophan (another commonly used over-the-counter sleep-inducing agent) has been associated with eosinophilic myalgia syndrome and has been withdrawn from the market.

The role of pharmacological, behavioral, and phototherapeutic management of disorders of circadian rhythm regulation is currently under investigation.

Hypersomnia

When treatment is indicated for hypersomnia due to obstructive sleep apnea, certain general measures, if successfully initiated, may suffice. These include weight loss; avoidance of alcohol, sedatives and hypnotics; the avoidance of the supine sleeping position; and management of nasal and asopharyngeal disease.

The mainstay of treatment is the use of nasal continuous positive airway pressure (CPAP), which is frequently successful. It and other devices (including tongue retaining and jaw advancing appliances and cervical collars) need further study.

Where other measures, including nasal CPAP, fail or are unacceptable, surgical procedures may become an appropriate alternative treatment. Uvulopalatopharyngoplasty has been reported to be successful. There is evidence that the procedure may have better success when tailored to a demonstrated site of obstruction. Tracheostomy may be required if other procedures are unacceptable or fail.

In all therapeutic interventions there should be long-term outcome assessment.

 What Should the Medical Profession and General          Public Know About Good Sleep Hygiene and           Treatment of Sleep Disorders, and What Should Be           Done To Increase Awareness?

The answer to this question involves defining the target audience, determining what information should be conveyed, and deciding how best to transmit the information.

Physicians and medical students, nurses, social workers and counselors, rehabilitation and respiratory therapists, discharge planners, and pharmacists and other allied health professionals are the groups to be approached first. We anticipate particular interest from providers of services to the older people including area agencies on aging, senior centers, and nursing homes.

Other special groups that are affected by sleep disorder issues include employers, pharmaceutical companies, members of the legal profession, and developers of technology. Funders of research, both public and private, must be involved in this developing field. Education also must be directed toward decision makers at local, state and national levels, including regulatory and legislative groups. There are also key decision makers in the private sector such as those in the insurance industry and health care systems.

Educational efforts must include the very groups we wish to help: the older persons, their families, and caregivers.

The information to be conveyed will differ in content, style, and depth depending on the audience--professionals, patients, and media. A particular educational emphasis is desirable for new physicians and researchers, even while it is recognized that there are many unanswered questions. Nevertheless there are general concepts that could be useful for all groups. The content should include concepts of sleep physiology and pathophysiology, and assessment and differential diagnosis.

Discussion of treatment approaches including technological devices, drugs, and lifestyle should address disadvantages as well as advantages. For audiences unfamiliar with the issue of sleep and the older person, the magnitude of the personal and societal toll in accidents, health, and unhappiness must be conveyed. Other key points include proper use of medications, preventive health measures, and good sleep hygiene practices. Individuals may satisfactorily cope with insomnia, and it may be transient. On the other hand, persistent insomnia may reflect major disease, and competent clinical consultation may be desirable.

Imagination and sustained effort are at the heart of the many educational efforts. For health professionals one goal is to include information on sleep in the curriculum of schools-not an easy task. More standard educational efforts include appropriate lay and professional publications, professional conferences, and continuing education. Lay or advocacy groups can contribute to the total educational effort, as well as benefit from it. Reaching the public can be facilitated by utilizing existing networks, for example, state and area agencies on aging, coordinated through the Administration on Aging. There are opportunities for communicating information in newsletters published by churches, hospitals, and senior centers. There is particular need to involve citizen groups who direct their efforts toward the older person. All media groups should be encouraged to discuss these issues.

The Public Health Service must take a more active role in educating and disseminating information to the public. Without such effort, this consensus report may not receive the wide dissemination it deserves.

  What Are the Directions for Future Research?

The conference presentations emphasized the problem of sleep disorders in older age due to the demographic shift in the American population to an increasing proportion in the over-65 age group, and to the public awareness of the interest of the medical community in diagnosis and treatment of these disorders.

The study of sleep and sleep disorders has advanced rapidly in the past 30 years. This advance has been most prominent in studies of normal sleep throughout the life span. However, the classification, diagnostic criteria, understanding of the basic mechanisms, natural history, and the efficacy of treatment in sleep disorders are still in early stages so that further research in all these areas is necessary. This is particularly true for the older population in whom these conditions may be more frequent and disruptive.

It is always difficult to define classification and diagnostic criteria in a relatively new area where clinical descriptions and observations predominate and where the interpretation of objective measures, even with existing and new technology, is hampered. Certainly, large studies of control populations with proper sampling methods are necessary. This is particularly the situation in older populations where controls without confounding disease are more difficult to obtain.

It is often necessary in alleviating illness to press forward with clinical descriptions and treatment even without knowledge of the basic mechanisms. However, it is only with elucidation of these mechanisms that rational approaches to therapy can be effected. The study of these disorders in older patients, who often have other diseases, affords some unusual opportunities. For example, how does the dopamine depletion in Parkinson's disease patients affect sleep architecture and cardiopulmonary adaptation? Also, older patients may take one or more drugs for other conditions, and this may afford an opportunity for clinical observations.

There have been extensive studies of sleep mechanisms in experimental animals. Efforts should be made to identify appropriate animal models for sleep disorders. Now it is possible to study old animals, including primates, and these studies should provide insight into the basic mechanisms of sleep changes in aging. The new interest in disordered circadian rhythms as a clinical observation opens up new areas of research.

Modern research techniques used in selected human cases might help identify biological markers for some of these disorders. Opportunities for clinical and pathological correlation should be encouraged. The application or development of new research techniques should provide added understanding of the neurobiology of sleep and its disorders.

The natural history of many sleep disorders has not been well described. Longitudinal studies into older age would clarify the progress of these disorders and their effect on morbidity and mortality. This is also necessary if one is to judge the efficacy of various treatment modalities. Important questions that can only be answered by long-term studies are whether some of the variations noted in the older population are the result of aging or of concomitant disease; whether these variations need to be tested further; and whether these variations are responsible for other medical conditions. This latter point needs clarification because of the questions regarding sleep apnea with oxygen desaturation and various forms of dementia.

An important area of study is the disruption of normal circadian rhythms by transmeridian time shifts, dislocation such as moving to a nursing home, and shift work. These may result in sleep disturbances with attendant problems with family, driving, and recreation.

It is obvious from the data presented that extensive studies need to be done to settle the question of benefits of treatment in these disorders. Carefully controlled studies of well defined clinical groups will be necessary to establish the benefit of various therapies. It is equally important in clinical trials to look at the efficacy of different means of sleep hygiene practices, not only for therapy but for prevention.

Added knowledge about the effectiveness of treatment should spur studies of cost effectiveness of diagnostic methods and therapies.

In all the areas mentioned there are many opportunities for basic and clinical research. The enhanced interest in the older population should provide both challenges and opportunities for investigators.

  Conclusions and Recommendations

There is a need for epidemiologic investigations of sleep disorders: case control, cohort, and cross-cultural studies should be initiated. The information developed in these studies will aid in the understanding of the natural history, etiology, and prevention of sleep disorders.

	Evaluation of sleep disorders begins with careful clinical evaluation performed by an informed primary care physician.
	Standardization of clinical measures and assessment of the specificity and sensitivity of diagnostic procedures is essential.
	Advanced skills and diagnostic tools are available and should be applied in appropriate patients.
	The objective of sleep disorder therapy is to reduce morbidity and mortality and improve the quality of life.
	Obstructive sleep apnea is a potentially severe and treatable cause of daytime hypersomnia.
	Restoration of airway competence is the objective in the treatment of severe sleep apnea.
	Insomnia is a complaint with multiple causes and requires different treatments.
	Hypnotic medications should not be the mainstay of treatment of insomnia, are overused and have habit forming potential.
	The value of good sleep hygiene should not be underestimated in the prevention and treatment of insomnia.
	Widespread knowledge about sleep and its disorders is lacking, and education at all levels is needed.
	The Public Health Service must take an active role in educating the public.
	Powerful new techniques, such as brain imaging, molecular biological tools, and neurochemical analyses, should be used in human studies and animal models to explore the basic mechanisms of sleep and sleep disorders.
	Sleep disorders in older people offer unique opportunities to study integrative neurologic, psychiatric, and cardiopulmonary functions.
	Current and new therapies and technologies must be evaluated by randomized controlled clinical trials.
	The Health Care Financing Administration should review current reimbursement policies, and continue to explore clinical data set requirements as these reimbursement policies for sleep disorders evolve.

Consensus Development Panel

Robert J. Joynt, M.D., Ph.D.
Panel and Conference Chairman
Vice President and Vice Provost of Health Affairs
University of Rochester
Rochester, New York

Morton C. Creditor, M.D.
Professor of Medicine and Director
Center on Aging
University of Kansas Medical Center
Kansas City, Kansas

Norman H. Edelman, M.D.
Professor of Medicine and Dean
University of Medicine and Dentistry of New Jersey
Robert Wood Johnson Medical School
Piscataway, New Jersey

David N.F. Fairbanks, M.D.
Clinical Professor of Otolaryngology--Head and Neck Surgery
George Washington University School of Medicine
Washington, D.C.

Israel Hanin, Ph.D.
Professor and Chairman
Department of Pharmacology and Experimental Therapeutics
Director
Neuroscience and Aging Institute
Loyola University Chicago Stritch School of Medicine
Maywood, Illinois

Linda Krogh Harootyan, B.A., M.S.W.
Director of Information
The Gerontological Society of America
Washington, D.C.

Robert Y. Moore, M.D., Ph.D.
Professor and Chairman
Department of Neurology
State University of New York at Stony Brook
Health Sciences Center
Stony Brook, New York

Woodrow Myers, M.D., M.B.A.
Commissioner of Health
City of New York
New York, New York

George W. Paulson, M.D.
Professor and Chairman
Department of Neurology
The Ohio State University
Columbus, Ohio

Martin Reite, M.D., Director
University Sleep Disorders Center
Professor
Department of Psychiatry
University of Colorado School of Medicine
Denver, Colorado

Paul D. Stolley, M.D., M.P.H.
Herbert C. Rorer Professor of Medical Sciences and Co-director
Clinical Epidemiology Unit
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Kingman P. Strohl, M.D., M.P.H. Chief
Pulmonology Division of Critical Care
Department of Medicine
University Hospitals of Cleveland
Cleveland, Ohio

Gerald van Belle, Ph.D. Professor
Department of Biostatistics
University of Washington
Seattle, Washington

Barbara F. Westmoreland, M.D.
Professor of Neurology
EEG Laboratory
Mayo Clinic
Rochester, Minnesota

Speakers

Sonia Ancoli-Israel, Ph.D., A.C.P.
"Critical Review of Epidemiological Studies on Sleep Apnea"
Associate Adjunct Professor
Department of Psychiatry
University of California at San Diego
La Jolla, California

Edward O. Bixler, Ph.D.
"Sleep Laboratory Studies of Insomnia: Specificity and Sensitivity"
Department of Psychiatry
Milton S. Hershey Medical Center
Pennsylvania State University
Hershey, Pennsylvania

Donald L. Bliwise, Ph.D.
"Clinical Consequences of Sleep Apnea for Cognitive Functions"
Senior Clinical Research Associate
Sleep Disorders Center
Stanford Medical School
Hoover Pavilion
Stanford, California

Mary A. Carskadon, Ph.D.
"Daytime Sleepiness: Clinical Consequences and Treatment"
Associate Professor of Psychiatry and Human Behavior
Brown University
Bradley Hospital
East Providence, Rhode Island

Charles A. Czeisler, M.D., Ph.D.
"Disorders of Circadian Function: Clinical Consequences and Treatment"
Director
Neuroendocrinology Laboratory
Brigham and Women's Hospital
Associate Professor of Medicine
Harvard Medical School
Boston, Massachusetts

William C. Dement, M.D., Ph.D., A.C.P.
"Disturbances of Sleep in the Older Person: Overview of Age-Related Changes in Sleep"
Lowell W. and Josephine Q. Berry Professor of
Psychiatry and Behavioral Sciences in the School of Medicine
Director
Sleep Disorders Clinic and Research Center
Stanford University
Palo Alto, California

Irwin Feinberg, M.D.
"Future Research Directions"
Professor of Psychiatry
Chief of Psychiatric Research
University of California at Davis
Medical Investigator
Veterans Administration Medical Center
Psychiatry Service
Martinez, California

Christian Guilleminault, M.D.
"When to Test? Indications for Evaluation"
Sleep Disorders Research Center
Stanford University
Palo Alto, California

Edward F. Haponik, M.D.
"Attitudes on Sleep Disturbances of Older Persons by Health Professionals"
Clinical Director
Pulmonary Medicine
Bowman-Gray School of Medicine
Winston-Salem, North Carolina

Anthony Kales, M.D.
"Clinical Diagnosis of Sleep Disorders"
Chairman and Professor of Psychiatry
Milton S. Hershey Medical Center
Pennsylvania State University
Hershey, Pennsylvania

Daniel F. Kripke, M.D.
"Periodic Movements in Sleep: Clinical Consequences and Treatment"
Professor of Psychiatry
Veterans Administration Medical Center
San Diego, California

Merrill M. Mitler, M.A., Ph.D.
"Insomnia in the Chronically Ill"
Director of Research
Division of Sleep Disorders
Scripps Clinic and Research Foundation
La Jolla, California

Timothy H. Monk, Ph.D.
"Shift Work and the Older Worker"
Associate Professor of Psychiatry
University of Pittsburgh School of Medicine
Western Psychiatric Institute and Clinic
Pittsburgh, Pennsylvania

Allan I. Pack, M.D., Ph.D.
"Where to Test? Ambulatory Monitoring or Sleep Laboratory: Cost Effectiveness and Test Validity"
Director
Penn Center for Sleep Disorders
University of Pennsylvania Medical Center
Philadelphia, Pennsylvania

Charles P. Pollak, M.D.
"Clinical and Social Consequences of Disordered Sleep"
Director
Institute of Chronobiology
Head
Sleep Wake Disorders Center
Associate Professor of Neurology in Neurology and Psychiatry
New York Hospital-Cornell Medical Center
White Plains, New York

Patricia N. Prinz, Ph.D.
"Sleep in Alzheimer's Dementia and in Healthy Not-Complaining Seniors"
Professor
Department of Psychiatry and Behavioral Sciences
Director
Sleep and Aging Research Program
University of Washington
Seattle, Washington

David M. Rapoport, M.D.
"Nonsurgical Treatment of Obstructive Sleep Apnea Syndrome"
Assistant Professor of Clinical Medicine
Department of Medicine
New York University Medical Center
New York, New York