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Older adults often have problems sleeping, including difficulty falling asleep, waking up during the night, and waking up very early in the morning. Daytime sleepiness is also common, with 20% of Americans living in the community reporting that they are “usually sleepy in the daytime.” At least half of older adults living in the community use either over-the-counter or prescription medications to help them sleep, but this is a very risky practice. Sleep problems decrease quality of life and can lead to injury or other health conditions. Sleep deprivation in tired individuals can cause mental difficulty, irritability, and poor judgment, and can lead to accidents. Poor sleepers take more medications, visit their healthcare providers more often, and rate their health as poorer than that of other people. Night time agitation in patients with dementia is a risk factor for placement in a nursing home. Up to 70% of caregivers report that nighttime difficulties and sleep disruption played a significant role in their decision to place an older adult in a nursing home or other institution.
The quality of sleep and sleeping patterns change with age, which reflects both the normal aging process and any physical or psychiatric conditions. Older adults also have more sleep troubles with jet lag and shift work. Several important changes related to age, both directly and indirectly, include the following:
Research suggests that many sleep problems in older adults are caused by underlying medical, psychological, or environmental conditions, rather than by the aging process itself. However, some primary sleep disorders, such as sleep apnea and periodic limb movements during sleep, become more common with age. In general, sleep problems are classified as either insomnia or excessive daytime sleepiness. Insomnia is difficulty falling asleep or staying asleep. It is usually caused by psychological, medical, or neurologic illness. Excessive daytime sleepiness is usually caused by a primary sleep disorder, such as sleep apnea. However, these symptoms can overlap quite a bit. Psychological or social problems Depression, anxiety, and dementia are the cause of sleep problems in many older adults. Depression is a particularly common cause. In fact, sleep disturbance in older adults who are not currently depressed may be a signal of future depression. Bereavement is also a common cause of sleep disorders, primarily because bereavement results in depression. Depressed people commonly wake up early in the morning, take longer to get to sleep, and wake up often during the night. Usually, treating the depression also improves the sleep problems. (See also Depression.) Anxiety and stress can also cause sleeping difficulty. In this case, the problem is usually trouble falling asleep or waking up early. Trouble falling asleep is often because of worrying at bedtime (see also Anxiety Disorders). Worry and stress can also affect the sleep of caregivers (see also Community-Based Care and Psychological and Social Issues). Dementia and delirium can disturb the sleep-wake cycle, with waking up often during the night, wandering in the night, becoming agitated, and sleeping less deeply (see also Dementia and Delirium). Dementia commonly causes disturbances in the sleep-wake cycle, resulting in sleeping in the daytime and being awake during the night. Lifestyle changes also contribute to sleep problems. For example, older adults may spend more time in bed because of less social and physical activity and a feeling that there is no reason to get up. Older adults in hospitals or nursing homes may have trouble sleeping because of conditions in the environment, such as temperature, noise, and bright lighting. Drug and alcohol use account for perhaps 10%–15% of cases of insomnia (see also Substance Abuse). Sleeping pills and other drugs with a sedative effect are often a concern. Chronic use of sedatives may result in only light, short periods of sleep. It may also lead to tolerance, or “getting used to” a drug, so that higher and higher doses are needed. If the sedatives are then suddenly stopped, insomnia may “rebound,” and the person may start taking sedatives again in a vicious cycle. Alcohol abuse is often associated with shorter periods of lighter sleep. In addition, some people think that using alcohol will help sleeping difficulties, but it actually makes the problem worse. Although alcohol may cause drowsiness initially, it interrupts sleep later in the night. Many cases of insomnia are due to underlying medical problems, including the following:
Sleep can also be affected by medications (eg, diuretics [“water pills”], bronchodilators) and by drinking caffeine or smoking close to bedtime. Some drugs for depression, Parkinson’s disease, or high blood pressure can bring on nightmares, resulting in sleep problems. Medications that are being taken for other conditions that have sedative effects (eg, some antidepressants) should be taken at bedtime if possible. Your healthcare provider or pharmacist can provide advice on when to take or avoid medications. Disturbances in the sleep-wake cycle Our bodies follow a natural rhythm of sleeping and awakening. This rhythm can be interrupted temporarily (eg, by jet lag), but in some people, this disrupted sleep becomes a regular pattern. In some cases, the cycle can become very irregular or out of “synch” (eg, in dementia). However, the most common problem in older adults is falling asleep early and waking up early. Falling asleep late and waking up late is also very common in older adults. In sleep apnea, breathing slows down or stops briefly every so often throughout the night during sleep. People with sleep apnea often wake up many times during the night because of blocked breathing, so they suffer from excessive daytime sleepiness. They may also have morning headaches, changes in personality, poor memory, confusion, and irritability. These people are typically unaware that they are waking up often during the night. A bed partner may report loud snoring or choking sounds during sleep. Sleep apnea is relatively common among older adults, more so in men than in women. It also becomes more common as we get older. Most people referred to sleep centers for evaluation of daytime sleepiness (70%) have sleep apnea. In some, people, sleep apnea is severe and needs treatment. The most important risk factor for sleep apnea is obesity and having a thick neck. Alcoholism is also an important risk factor. There also may be a link between sleep apnea and dementia (eg, Alzheimer’s disease), but this is currently being researched. Sleep apnea can be diagnosed for certain only in a sleep laboratory, where breathing and other bodily functions are monitored while a person is sleeping. Treatments for sleep apnea include the following:
Periodic limb movements during sleep Some people have problems with periodic uncontrolled spasms in their legs during the night. The legs move every 20–40 seconds, which can last a few hours or much of the night. This problem increases with age, so it is more common among older adults. Some people who suffer from periodic limb movements may be unaware of it. “Restless legs syndrome” is a similar disorder that produces uncontrollable urges to move the legs at night. These symptoms occur while the person is awake and can also involve the arms. Usually, people have leg discomfort at night or have trouble falling asleep. There may be a family history of this condition and, in some cases, an underlying medical disorder (eg, anemia, kidney disease, or a nervous system disorder). Like periodic limb movements, restless legs syndrome becomes more common with age. Many people with restless legs also have periodic limb movements. These two related problems can be debilitating because of having trouble falling asleep and waking up several times during the night. Sufferers are usually sleepy during the day and may be confused and irritable because of lack of sleep. During rapid eye-movement (REM) sleep, the brain is very active and people have vivid dreams. Some people also have muscular activity during this time that can result in sleep behaviors such as trying to respond to or act out a vivid dream. These behaviors may cause injury to the dreamer or to their bed partner. REM sleep behavior disorder may appear suddenly or become a chronic problem. It is more common in older men, and it may tend to run in families. Temporary REM sleep behavior disorder can be caused by drug or alcohol intoxication or withdrawal. Chronic REM sleep behavior disorder usually has no known cause, although sometimes it is associated with conditions that result in a neurologic problem (eg, drug intoxication, tumor, blood vessel problem, infection, degenerative disorder, or trauma). The sleeping environment must be made safe. The following measures are helpful:
Sleep Disturbances in the Hospital or Nursing Home Insomnia is common while in the hospital. Sleep-related breathing disorders (eg, sleep apnea) may be particularly common in adults hospitalized for heart disease or stroke. People in nursing homes also frequently have sleep problems, including having their sleep interrupted and waking up often during the night. Usually, several factors are involved, including illness, medications, change from usual nighttime routines at home, inactivity, and a too brightly lit or noisy environment. Not being exposed to bright light during the day may also be a factor. Sleeping pills or other sedatives are often used for sleep problems in hospitals or nursing homes, but can create other problems themselves. In some studies, non-drug treatments improved sleep in institutional settings, and they may reduce the chances of becoming delirious in the hospital. Evaluation and Assessment for Sleep Disorders You should discuss sleep problems with your healthcare provider. Many people assume that sleep problems are an unavoidable part of aging and don’t mention them to their healthcare provider. Many healthcare providers frequently screen for unreported sleep problems by asking the following types of questions:
Let your healthcare provider know how long sleep problems have been present and whether you’ve been under additional stress, have leg twitching, etc. Temporary disturbances lasting 2–3 weeks are usually caused by a specific situation (eg, shift work, worry about finances, etc). Problems that last longer than a month indicate a more serious, underlying medical or psychiatric condition, and a more detailed evaluation is needed. When you have an office evaluation for persistent sleep problems, your sleep partner should come with you to also provide information because you may not be aware of certain symptoms. Keeping a “sleep log” can be helpful. Sleep logs should include information on the quality of your sleep for a 2-week period. The log can be kept by you, your bed partner, or a caregiver. Every morning, the following information about the last 24 hours should be entered in your sleep log:
Your healthcare provider will perform a physical examination, focusing on information you provided about your sleep history. For example, painful joints suggest evaluation for arthritis, while bed wetting would be followed by evaluating for diabetes or for heart, kidney, or prostate problems. Your healthcare provider will also likely check your mental functions. Laboratory testing may be needed, depending on the results of the history and physical examination. In some cases, your healthcare provider will refer you to a sleep laboratory for specialized testing. One particularly useful test called polysomnography can identify specific sleep disorders, such as sleep apnea, periodic limb movement disorder, or other unusual behaviors during sleep. Various portable devices are being developed for measuring nighttime activity or breathing difficulties at home. Although occasional sleeping difficulties may be an unavoidable consequence of getting older, there are ways to improve overall sleep quality. For example, sticking to a regular sleep-wake schedule and limiting time in bed to no more than 7 or 8 hours a night can help counteract both the tendency to nap during the day and a more broken up sleep-wake pattern. Daytime naps because of boredom or medications often can be corrected by increasing physical activity or changing medication(s). Ways to Improve Sleep Quality
The causes of sleep problems should be corrected whenever possible. Primary sleep disorders (eg, sleep apnea) or medical conditions that lead to sleep problems should be treated. Nighttime pain can be treated with appropriate pain relievers. Clinical depression can be treated with appropriate antidepressant drugs, counseling, or other therapies. If sleep problems are related to medications, changing the type of drug or the dosage can be helpful. However, you should never start or stop taking medications without first consulting your healthcare provider. There are drugs available for short-term use to help people fall asleep, but no drugs have been shown to improve performance or mental alertness the next day, so it is not clear that sedation from these drugs has the same restorative effects as natural sleep. Even when used for a short term, there is reason to be cautious: many of these drugs can leave you groggy the next day, and they have been shown to increase the chances of falling and breaking a hip. Short-acting medications are usually prescribed for people who have trouble falling asleep, while medications that last longer are usually prescribed for people who have trouble staying asleep. In addition to any drug treatment, techniques to improve sleep quality, such as limiting napping during the day and avoiding alcohol, are recommended. Sedatives are not generally used to treat chronic insomnia, because long-term use can lead to complications such as increased risk of confusion, falling, and fractures in older adults. Some drugs (eg, benzodiazepines) can lead to dependence or mental difficulties if taken for a long time. Research also suggests that long-term use of sleeping pills is associated with increased illness and early death. In fact, it has been suggested that the nightly use of prescription sleeping pills is a health hazard similar to smoking one to two packs of cigarettes per day. Certain drugs can be effective for specific sleep disorders. For example, clonazepam can be highly effective for treating REM sleep behavior disorder, with little evidence of complications with long-term treatment. Older adults with periodic limb movement disorder or restless leg syndrome may benefit from drugs called “dopamine agonists.” Over-the-counter (OTC) sleep aids Nearly half of older adults use OTC sleeping pills. The most commonly used products include antihistamines that cause sedation, acetaminophen preparations (with or without antihistamines), alcohol, and melatonin. Antihistamines such as diphenhydramine are common ingredients in both OTC sleeping pills and nighttime pain relievers intended to help someone sleep. Diphenhydramine is generally not recommended for older adults because it can have several side effects, including delirium, trouble urinating, and constipation. In addition, tolerance develops to its sedating effects after several weeks, which means that it becomes less effective at improving sleep. Alcohol is also not recommended as a sleep aid. Although it causes some initial drowsiness, it can interfere with sleep later in the night and may actually worsen sleeping difficulties. Some sleep aids contain natural products, such as melatonin or valerian (see also Complementary and Alternative Medicine). Research evidence is mixed regarding the effectiveness of these products, with some studies reporting benefits and other studies reporting none. Also, valerian contains several different chemicals, so there is the possibility of a number of side effects. Several behavioral treatments can effectively improve sleep quality without having to use drugs. Behavioral treatments can provide reliable and lasting benefits for people with insomnia. Correcting poor sleep habits by using the following measures seems to be especially helpful among older adults with insomnia:
Identifying and changing any inaccurate beliefs and attitudes about sleep can also be helpful. This includes learning the difference between changes in sleep that are normal with increased age and changes that may indicate a medical condition may be developing. Learning relaxation techniques to recognize and relieve tension and anxiety (eg, tensing and relaxing muscle groups, or biofeedback techniques) are more effective for younger people than for older adults. In some research studies, older adults with insomnia have benefited from exposure to bright light (either natural sunlight or an artificial light source). Light treatment was helpful using light of different intensities, for different lengths of time, and at different times during the day. Light exposure during the evening seems to be particularly useful in older adults who fall asleep early and wake up early. Difficulty staying asleep has been successfully treated by being exposed to bright light for 2 hours (similar to the amount of outdoor light at mid-day). Being exposed to bright light even for a short time in the morning has improved sleep in some healthy older adults. It is important to remember that light therapy should be administered only by trained professionals. You should never stare at the sun or other bright light, because this can cause vision problems. Taking a bath before going to bed can improve the quality of sleep in older adults, perhaps because bathing increases body temperature. A moderate amount of exercise also improves sleep in healthy, inactive people aged 50 and older. However, strenuous exercise should not be done immediately before bedtime. |
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Published: 6/28/2005