Sleep Disorders and Aging

Are you one of millions of seniors in the US who think life would be pretty good... if you could just get some sleep? Sleep disturbances are very common in older people. Changes in sleep patterns may be a normal part of aging, but many other factors common in older people contribute to sleep problems. These include physical illness or symptoms, medication side effects, changes in activity or social life, and death of a spouse or loved one. Sleep disorders decrease quality of life in older people by causing daytime sleepiness, tiredness, and lack of energy. Poor quality of sleep also can lead to confusion, difficulty concentrating, and poor performance on tasks. Sleep disorders also are linked with premature death. The biggest sleep problem in older people is a feeling of not getting enough sleep (insomnia) or not being rested.

• Many take longer to fall asleep than they did when younger.
• Elderly people actually get the same amount of sleep or only slightly less sleep than they got when younger, but they have to spend more time in bed to get that amount of sleep.
• The sensation of insomnia often is due to frequent nighttime awakening. For example, older people tend to be more easily wakened by noises than younger people.
• Daytime napping is another cause of nighttime wakefulness. Older people are more likely to be sleepy during the day than younger people, but too much sleepiness during the day is not part of normal aging.

Normal sleep has different stages that cycle throughout the night. Sleep specialists classify these as rapid eye movement (REM) sleep and non-REM sleep.

• REM sleep is the stage in which muscles relax most completely. Dreaming occurs during REM sleep.
• Non-REM sleep is subdivided into stages. Stages 1 and 2 constitute light sleep and stage 3 is called deep sleep. Deeper sleep generally is more refreshing.

Sleep changes with age. Older people are less efficient sleepers and have different patterns of sleep than younger people.

• The duration of REM sleep decreases somewhat with aging.
• The duration of stage 1 sleep increases, as does the number of shifts into stage 1 sleep. Stages 3 decreases markedly with age in most people, especially men. In people aged 90 years or more, stage 3 may disappear completely.

Among older people, women are more likely to have insomnia than men. More than half of people older than 64 years have a sleep disorder. The rate is higher among long-term care facility residents.

The sleep disorders that increase with age are sleep apnea and periodic limb movements of sleep (PLMS). Periodic limb movement disorder is also called nocturnal myoclonus. The prevalence of PLMS increases with age and may be found in a third or more of patients over 60.

Sleep apnea is the interruption of breathing during sleep. It is commonly caused by obstruction (blockage) of the airway. Rarely sleep apnea is caused by a problem in the nervous system, which controls breathing. Sleep apnea is very common among older overweight people.

• People with sleep apnea often wake up gasping in the night. They may thrash around in bed or get up and wander around in a confused state.
• Sleep apnea can result in daytime sleepiness, high blood pressure, heart rhythm problems, increased risk for heart disease and stroke, an increased risk for motor vehicle accidents.
• Sleeping medications can worsen sleep apnea by relaxing throat muscles too much.

Periodic limb movements in sleep refer to repetitive leg jerks during sleep. These jerks may awaken the person from sleep and usually disturb the bed partner. Many describe the movements as kicking movements. The movements may occur in only one leg or both legs.

Medical disorders may also disrupt sleep.

• Pain is one of the most common reasons for poor sleep in older people.
• Heart failure often causes breathing problems that can disturb sleep.
• Rapid heartbeat and palpitations can interrupt sleep.
• Other breathing problems that can disturb sleep include heart disease, certain neurological problems, and emphysema.
• A frequent need to urinate and other urinary problems may cause frequent awakenings.
• Persons with Parkinson's disease may experience frequent urination, difficulty turning in bed, and difficulty getting out of bed. These problems may impair sleep.
• Gastroesophageal reflux disease (GERD) causes discomfort that can interfere with sleep.
• Constipation can cause discomfort that can disturb sleep.
• Allergies, sinus problems, nasal congestion, and similar problems can disrupt sleep.

Mental disorders are another common reason for sleep problems in older people.

• Depression disrupts sleep in all ages, and this condition is especially common in older people. Many people with depression have trouble falling asleep at night or wake in the night and are unable to go back to sleep.
• Dementia, especially Alzheimer's disease, increases the length of stage 1 sleep and decreases stage 3 and REM sleep. Dementia is linked to more episodes of sleep disruption and awakening, nocturnal wandering, and daytime napping.
• Bipolar disorders, psychosis, and anxiety can result in difficulty falling asleep and/or staying asleep.

Medications are another cause of sleep disturbance. Older patients in the US consume an average of 5-9 daily medications, some of which can interfere with sleep and wakefulness.

• Sedative antidepressants and sedative antipsychotics can cause daytime drowsiness. Sleeping during the day interferes with nighttime sleep.
• Beta-blocker medications can cause difficulty falling asleep, an increased number of awakenings, and vivid dreams.
• Prolonged sleeping medication use may cause daytime drug withdrawal effects or daytime drowsiness.
• Theophylline and caffeine are stimulant drugs. These drugs increase wakefulness and decrease total sleep time. Caffeine's effect can last as long as 8-14 hours and maybe more pronounced in older patients. Over-the-counter pain relievers, cold or allergy remedies, appetite suppressants, and tonics may contain caffeine.
• The stimulant nicotine affects sleep like caffeine. Smokers have more sleep disturbances than nonsmokers. Smokers also have difficulty falling asleep and decreased sleep duration. Even a nicotine patch can disrupt sleep.

Lifestyle and social factors can contribute to sleep disorders.

• Many older people are less active, and their bodies are not as ready for sleep at the end of the day.
• Alcohol can disrupt sleep.
• Daytime sleeping or lying on the bed to read or watch television can interfere with nighttime sleep.
• Sadness and bereavement can interfere with sleep.
• Everyday stress can make sleep more difficult.

Often the bed partner is first to notice problems with a person's sleep. Symptoms of sleep disorders reflect the feeling of not getting enough sleep.

• Feeling tired (fatigue)
• Difficulty concentrating or paying attention
• Not feeling rested
• Unable to go to sleep
• Taking a long time to go to sleep at night
• Frequent awakening at night
• Unable to go back to sleep after awakening
• Daytime sleepiness
• Sleep apnea may cause symptoms in addition to those already named.
• Morning headaches
• Wake up confused
• Snoring
• Wake up gasping for breath

Occasional insomnia is normal. If you have insomnia on a regular basis, you should see your health care provider about it. Nightly insomnia lasting more than a few nights warrants a visit to your health care provider.

A complete medical interview and physical examination are important. Your health care provider will ask you questions about your symptoms, lifestyle, and habits. You may be asked about your current and past medical problems and medications. You will probably be asked to keep a sleep diary for several days or weeks. You will write down the times you wake up and go to sleep. Your bed partner may be asked about your actions during sleep. After the interview, your health care provider may know what causes your sleep problem. You may also be referred to a sleep specialist. An underlying medical or mental problem warrants referral to the appropriate specialist.

Sleep evaluation

You may be asked to stay overnight at the sleep disorders center's laboratory. A full-night polysomnogram records several different body functions while you sleep.

• Electroencephalography (EEG) - brain waves
• Electrooculography (EOG) - Eye movements
• Electromyography (EMG) - Chin muscle tension and leg movements
• Electrocardiography (ECG) - Heart rate and rhythm
• Pulse oximetry - Blood oxygen saturation level

You may be hooked up to a portable recorder rather than stay overnight at the center.

• The portable recorder is placed on your body in the afternoon, and you are then sent home to sleep in your own bed, or you may be instructed on how to place and activate it.
• These recorders are more convenient and often less expensive than a laboratory polysomnogram. They have been shown to be just as effective in many cases for diagnosing and initiating treatment for obstructive sleep apnea.
• Portable studies are not appropriate for the evaluation of sleep disorders other than obstructive sleep apnea.

Treatment for a sleep disorder depends on the underlying cause.

Sleep hygiene refers to sleep-improving lifestyles and habits. Changing your lifestyle and habits improves many sleep problems; therefore, sleep disorder treatment begins with improved sleep hygiene.

• Maintain a regular wake-up time.
• Maintain a regular time to go to sleep.
• Avoid or decrease daytime naps.
• Exercise daily but not immediately before bedtime.
• Use the bed only for sleeping or sex.
• Do not read or watch television in bed.
• Do not use bedtime as worry time.
• Avoid heavy meals at bedtime.
• Avoid or limit alcohol, caffeine, and nicotine before bedtime.
• Maintain a routine period of preparation for bed, (for example, washing up and brushing teeth).
• Control the nighttime environment with comfortable temperature, quietness, and darkness.
• Wear comfortable, loose-fitting clothes to bed.
• If unable to sleep within 30 minutes, get out of bed and perform a soothing activity, such as listening to soft music or reading, but avoid exposure to bright light during these times.
• Get adequate exposure to bright light during the day.

Overweight people who are habitual loud snorers may be helped by weight loss. If you snore loudly, abstain from alcohol or sedatives before going to bed. You also should avoid sleeping on your back. Avoid nonprescription, over-the-counter sleep aids. Examples are preparations that contain diphenhydramine (Benadryl), such as Tylenol PM. Their side effects can be very profound in older people.

You may wonder why your health care professional does not just prescribe a sleeping pill for you. The reason is that sleeping pills are linked with many side effects and complications, such as confusion, dizziness, balance problems, fall-related injuries, and daytime "hangover." Seniors should avoid taking these medications for long periods of time. These medications are considered to be only a short-term solution to a sleep problem.

If the sleep problem is caused by a medical or psychiatric problem, your health care provider may treat that condition, or refer you to a specialist. Your health care provider may discontinue or change a medication that impairs sleep.

The goal of drug therapy is to reduce insomnia without sacrificing daytime alertness. Other names for sleeping medications are hypnotics or sedatives. Usually, a sleeping medication is given only on a 2- to 4-week short-term basis. The underlying cause of the insomnia is treated during this period.

The most widely used sleep medications are benzodiazepines and benzodiazepine-like drugs. These medications are relatively safe because they are difficult to overdose. Tolerance develops quickly, and over time, a higher dose is required to get the same effect as the initial dose. The risk of becoming dependent on these medications is high. These medications may cause withdrawal symptoms. These are the reasons for using these sleep medications on a short-term basis. Examples are zolpidem (Ambien), lorazepam (Ativan), triazolam (Halcion), temazepam (Restoril), and zaleplon (Sonata). Recent changes in dosing for zolpidem were mandated by the Food and Drug Administration (FDA). Female patients should be started on a lower dose and the maximum dose would be 5mg because of differences in clearing the drug from their system.

Antidepressant drugs are sometimes used for people with chronic (long-term) insomnia. These drugs usually work even in people who have no depression. These drugs do not promote dependence. Examples are trazodone (Desyrel) and nefazodone (Serzone). Ramelteon (Rozerem) is a prescription drug that stimulates melatonin receptors. Melatonin is a hormone produced by the pineal gland (located in the brain) during the dark hours of the day-night cycle (circadian rhythm). Melatonin levels in the body are low during daylight hours. The pineal gland responds to darkness by increasing melatonin levels in the body. This process is thought to be integral to maintaining circadian rhythm. Ramelteon promotes the onset of sleep and helps normalize circadian rhythm disorders. Ramelteon is approved by the Food and Drug Administration (FDA) for insomnia characterized by difficulty falling asleep. Suvorexant (Belsomra), is a newer classification of medication for treating insomnia and acts by decreasing the activity in the wake system of our brain. For more information on insomnia medications, see Understanding Insomnia Medications.

Your health care provider probably will ask you to return for one or more follow-up visits.

Sleep disorders often can be at least partly prevented by developing healthy sleep habits.

See your health care provider regularly for proper care of any medical or mental problems.

Other things you can do to prevent or reduce sleeping disturbances:

• Take medications (prescription and nonprescription) only as directed.
• Get some exercise every day.
• Avoid eating a heavy meal close to bedtime.
• Avoid or limit alcohol, caffeine, and nicotine for several hours before bedtime.
• Maintain a regular sleep schedule.
• Avoid daytime naps.
• Use your bed only for sleeping or sex.
• Try not to use bedtime as worry time.

Sleep patterns change as we age. Persistent insomnia or daytime sleepiness is not a part of normal aging. Sleep disturbances are treatable or improve with treatment of the underlying condition.