©2002
The changes that aging brings tend to come upon us unnoticed at first...like the passing of the seasons. Slowly, over time, we become aware that our eyesight is less keen or our hearing less acute. In the same way, our experience of sleep is altered. It's not that our sleep needs decline with age. In fact, research demonstrates: Our sleep needs remain constant throughout adulthood. Most of us still require the same seven to nine hours of sleep a night that we did when we were younger, even in our golden years. However, a good night's rest may prove more elusive as we grow older. Lifestyle changes and behavioral practices may play their part. Daytime naps may make us less tired at bedtime. Poor sleep habits may have become entrenched; we may associate our beds with television or reading, not sleeping. Stress and bereavement may lead to early awakenings or interrupted sleep. And in the silence of our bedrooms, the bark of a neighbor's dog or a passing siren may trouble us more than when we were younger. Medical conditions and the physical changes associated with aging may play their own roles. Nighttime aches and pains may lengthen the time it takes to fall asleep...and interrupt sleep thereafter. A number of medical and psychiatric conditions may affect sleep adversely. And there are many medical disorders more common among older people. For example, middle-aged and elderly people suffer from at least four sleep disorders in numbers far greater than younger people: sleep apnea, restless legs syndrome, periodic limb movements disorder, and advanced sleep phase syndrome. (The good news is that these are all treatable conditions.) Medical problems that include arthritis, heartburn, osteoporosis, and heart and lung disease may also interrupt, delay or abbreviate sleep, as may some of the drugs used to treat these conditions. The need to use the bathroom more frequently may make nighttime risings common. Psychiatric conditions including depression and anxiety may lead to sleep difficulties as well. SLEEP CHANGES AS WE GROW OLDER
Before examining how sleep changes with age, it's necessary to understand the
basic sleep stages. Normal sleep consists of two major states: REM (Rapid Eye
Movement) sleep and NREM (nonREM) sleep. NREM sleep is divided further into four
sleep stages, numbered stage 1, 2, 3 and 4. Sleep typically begins with stage 1
before progressing into the later stages. Sleep deepens with each stage achieved;
stages 3 and 4 (also called delta sleep) provide our bodies' deepest sleep. Our
fifth stage is REM sleep, where dreaming occurs.
WHAT DO SLEEP STAGES HAVE TO DO WITH SLEEPING WELL? In general, changes in one's sleep architecture or stages affect how deep sleep is. Middle-aged and elderly people tend to spend less time in deeper sleep than younger people. By age 60 or 70, many adults experience a decrease in the proportion of time spent in delta sleep. This is particularly true for elderly men. However, the percentage of REM sleep remains relatively stable. In late adulthood, the first REM sleep periods come faster than in earlier years. Are the kinds of dreams experienced different? Some research suggests that older men tend to have more passive, inner-directed dreams, while older women tend to dream more active, outgoing dreams. ARE YOU SLEEPING MORE, BUT ENJOYING IT LESS? Interestingly, the average total sleep time increases slightly after age 65. But so do reports of difficulty falling asleep. One study found that after 65, 13 percent of men and 36 percent of women reported taking more than 30 minutes to fall asleep. What causes this difficulty? Research suggests that physiological and lifestyle changes are at fault. The elderly generally secrete lesser amounts of certain chemicals that regulate the sleep/wake cycle. Both melatonin (a substance produced by the pineal gland that promotes sleep) and growth hormone production decrease with age. There are also changes in the body temperature cycle which occur with age. These factors may cause, or be a consequence of, sleep problems. In addition, a decrease in exposure to natural light and a change in diet may exacerbate sleep difficulties. Some researchers theorize that daytime inactivity (lack of exercise) and decreased mental stimulation may also lead to the "aging" of sleep. Falling asleep isn't the only difficulty older people may face at night. Sleep also becomes more shallow, fragmented and variable in duration with age. The elderly wake more frequently than younger adults. Recent research suggests that the aging bladder can contribute to a substantial degree of sleep disturbance in the elderly. A tendency to feel sleepier during the day than when younger results from these increased nocturnal awakenings. It's important to remember that many healthy elderly individuals have no or few sleep problems. PERSISTENT TROUBLE FALLING ASLEEP AT NIGHT OR FREQUENT DROWSING BY DAY IS NOT NORMAL OR INEVITABLE WITH AGE. Sometimes, age-related changes mask underlying sleep disorders. For example, sleep apnea, a breathing disorder, is more common in the middle and elder years. The repeated awakenings caused by a literal lack of breath lead to daytime sleepiness. How to tell whether daytime drowsiness is a result of a sleep disorder, sleep deficit or depression? By consulting a sleep specialist, who is skilled in diagnosing the problem and treating both symptom and cause. Many older people consider poor sleep not worth complaining about and as inevitable and constant as death and taxes. ACTUALLY, THERE ARE MANY THINGS YOU CAN DO ABOUT POOR SLEEP, AND THERE ARE MANY REASONS TO DO SOMETHING ABOUT SLEEP.
Sleep deprivation has measurable negative effects on performance and physical and
mental health. If you haven't had a good night's sleep, you're likely to pay for
it. The price may be high: Reduced energy, greater difficulty concentrating,
diminished mood, and greater risk for accidents, including fall-asleep crashes.
Work performance and relationships can suffer too. And pain may be intensified by
the physical and mental consequences of lack of sleep.
First, the bad news: Older people are likely to suffer both medical disorders
that may disrupt sleep and specific sleep disorders. The medical disorders
include:
All these medical problems can interrupt, delay and/or shorten sleep. For example, arthritis patients may have difficulty falling asleep because of painful joints. Or they may be awakened by pain. A 1996 National Sleep Foundation (NSF) Gallup Poll found that 30 percent of all nighttime pain sufferers experience arthritis pain at night. The number rises to 60 percent for those over age 50. Nighttime pain sufferers in this age group who experience difficulty sleeping lost an average of 2.2 hours of sleep, 10.7 nights a month. If you suffer from arthritis, ask your doctor about treatment. Other types of chronic or occasional pain can be sleep-stealers too. In the 1996 NSF Gallup Poll, back pain was cited by 64 percent of those who had nighttime pain in the past year. Headaches, muscular aches and pains, leg cramps and sinus pain were cited by 44 percent to 56 percent. Behavioral and pharmacological approaches may help. Heart patients often suffer sleep difficulties as well. Most stable congestive heart failure patients suffer sleep-disordered breathing. Almost half in a recent study had apneic (loss of breath) attacks. (More on apnea later.) Apnea requires treatment as well. When GER whose chief symptoms are heartburn and regurgitation occurs during sleep, nocturnal awakenings may follow. About five percent of Americans suffer from heartburn nearly every day. Daytime GER is normal after eating. Nighttime GER can be problematical and marked by wheezing and chronic cough. Repeated awakenings and daytime sleepiness may ensue. Raising the head of the bed may alleviate symptoms. Or drug treatment may be indicated. Other medical conditions affect sleep too: asthma, chronic interstitial lung disease, neuromuscular disease, etc. Individuals with asthma may experience frequent awakenings due to bronchospasm. One study found such awakenings weekly in 74 percent of asthmatic patients.
Menopause is another source of potential sleep problems...for women. The hot
flashes and associated breathing changes that most women experience during this
time appear to disturb sleep and may lead to daytime fatigue.
Seventy-five percent of menopausal women suffer from hot flashes, on average for five years. While the total sleep time for women suffering hot flashes did not differ from women who didn't experience them in one study, hot flashes were associated with more frequent arousals: once every eight minutes on average. Next-day fatigue and lethargy seem to be more likely consequences than excessive daytime sleepiness. Apnea rises in women starting at age 50. Women who experience apneas and hot flashes appear likely to experience the latter before the former. This respiratory connection was explored in research using "paced respiration," or scheduled breathing at the beginning of the hot flash. This approach significantly reduced the frequency of hot flashes. Another approach involves hormonal treatment with progesterone and estrogen. (Hot flashes are associated with reduced estrogen production.) Naps may help alleviate fatigue too. However, if insomnia is a problem, naps should be avoided. They can contribute to nighttime sleep difficulty.
INSOMNIA IS A SYMPTOM, NOT A DISORDER IN ITSELF.
If you experience difficulty falling asleep, staying asleep, or enjoying a restful night's slumber, you're suffering from insomnia. It's a common symptom in the U.S., reported by nearly half of Americans surveyed in a 1995 National Sleep Foundation (Sleep in America) Gallup Poll. Insomnia may last for days (transient), weeks (short-term) or months (chronic). Some think that the longer insomnia lasts, the harder it becomes to treat. If you suffer from insomnia that lasts for more than a few days, you should consult your physician. The underlying cause should be identified, if possible, then treated. Unfortunately, this is not always possible. Chronic insomnia will probably require longer term treatment than other types. Sleep medication is generally considered a short-term solution. INSOMNIA MAY BE CAUSED BY MANY FACTORS:
Insomnia may be secondary to other disorders as well, such as restless legs syndrome or advanced sleep phase disorder. These sleep disorders are more common in the elderly too. Moreover, they increase in frequency as we enter middle age. Other sleep disorders more common in the elderly are characterized by noise and movement.
Out of the mouth of babes snores are rarely heard. Snoring increases with age.
It's caused by the partial obstruction of the airway during sleep. About 40
percent of the adult population snores. Snoring is more common among those who
are middle-aged or older and overweight.
THE SLEEP APNEA CYCLEDuring the night...
Next day... SNORING MAY BE ASSOCIATED WITH DAYTIME SLEEPINESS. Loud snoring punctuated by multiple, nightly brief episodes of breathing cessation suggest the presence of sleep apnea. Sleep apnea, like snoring, is more common among the obese. However, in elderly people, the obesity-sleep apnea connection is far less pronounced. Sleep apnea occurs in four percent of middle-aged men and two percent of middle-aged women. In males over 65, the figure rises to 28 percent; for women, the number climbs to 24 percent. Sleep apnea is treatable. Unfortunately, the vast majority of sufferers don't know they have the disorder. It is often a bed partner's concern that triggers diagnosis and treatment. Sadly, sleep apnea is linked to a three to seven time increase in risk for falling asleep at the wheel. Diagnosis and treatment are important. What does diagnosis entail? For an objective evaluation, individuals should seek referral to a sleep disorders clinic. In an overnight sleep study at a sleep disorders clinic, individuals are monitored by noninvasive polysomnographic equipment that measures respiration (breathing) and arousal through EEG (brain wave) readings. If the disorder is mild, a sleep specialist may recommend weight loss, use of pillows and/or change in sleep position (avoiding lying on one's back), and abstinence regarding alcohol and sedatives which worsen apnea. However, if the disordered breathing is moderate to severe, a device known as a CPAP (continuous positive airway pressure) is in order. This device gently propels air into the airway, keeping it open. Treatment with dental devices and surgery are other alternatives to be considered.
A discussion of movement disorders affecting sleep brings us to PLMD (note the L)
and RLS. The L stands for legs, the limbs most affected in these disorders. In
PLMD (periodic limb movements disorder), periodic leg movements disrupt the
sufferer's night: Legs jerk repeatedly, kicking every 20 to 40 seconds through
the night. Not surprisingly, these leg kicks trigger frequent arousals. The end
result? Daytime sleepiness and nighttime insomnia.
While PLMD may be diagnosed infrequently by primary care physicians, the disorder is all too common among the elderly. In one study, approximately 45 percent of the elderly had at least a mild form of PLMD. As with sleep apnea, evaluation at a sleep disorders center is the first step. Drug treatment can be very successful, with anti-Parkinsonian drugs (e.g., carbidopa-levodopa) controlling the majority of cases. Other medications include dopamine agonists and sedative-hypnotics (calming, sleep-inducing medications). Patients should be monitored closely during treatment for side effects or adverse reactions. Achieving the proper dose of the most effective medication may take time. ARE YOU A NIGHTWALKER? RLS, or restless legs syndrome, is less common than PLMD. The distinction between the two disorders is that in RLS, the leg movements occur continually when the body is at rest. The movements of PLMD occur in sleep. RLS symptoms include an uncomfortable sensation in the foot, calf or upper leg that feels like something is crawling or moving inside the limbs, or tickling or aching deep inside them. This sensation is yoked with a compulsion to move the legs. Movement resolves the symptoms, but the syndrome is unrelenting. Within seconds or minutes, the sensations return. If the legs are not moved, they frequently jump involuntarily. Since rest brings on symptoms, and walking offers relief, sufferers are often called nightwalkers. Symptoms are always worse at night and sometimes only present nocturnally. If individuals do manage to fall asleep, leg movements lead to frequent awakenings or near awakenings. Next-day fatigue is endemic. Although the precise cause of RLS remains a mystery, in some cases, RLS may be due to iron deficiency, dialysis, pregnancy or peripheral neuropathy. Iron deficiency is a common and eminently treatable cause. Pregnancy, of course, is time-limited. In some cases, polysomnographic evaluation may not be indicated. However, there are other cases, particularly if there is accompanying neurologic disease, or if the movements have an aggressive or generalized quality to them, that may require a polysomnographic evaluation. Treatment can begin immediately with the same range of medications as indicated for PLMD. DO YOU ACT OUT YOUR DREAMS? One sleep disorder combines dreams with movement: REM sleep behavior disorder. Most sleepers are virtually paralyzed during REM or dreaming sleep; people with REM sleep behavior disorder do not have this motor inhibition and literally act out their dreams. They may crash into furniture, break windows or fall down stairs, leading to self-injury or hurting others. Such sleep is hardly restful! Most sufferers are men over 50. Drug treatment with clonazepam can eliminate the dream disturbances and improve sleep for sufferers and those who live with them. IS YOUR TIME OF DAY THE NIGHT TIME?
Those suffering from advanced sleep phase syndrome (ASPS) and delayed sleep phase
syndrome (DSPS) sleep and wake at inconvenient times. Individuals with ASPS sleep
earlier than their desired clock time, while DSPS sufferers find sleep elusive
for hours after their desired clock time. Trying to sleep when their bodies are
alert, or rise when their bodies are sleepiest, can lead to insomnia or excessive
daytime sleepiness. Individuals may rely on sleeping pills or alcohol to
manipulate their sleep schedules.
DSPS patients may appear to be suffering from insomnia, especially if they insist on trying to sleep at a "normal" bedtime. One distinguishing characteristic is that in other types of insomnia, sleep problems include that of maintaining sleep throughout the night. DSPS sufferers have no problem sleeping...if they observe their own schedules. Another distinction is that most chronic insomniacs experience a variability in their nighttime experiences. This is not the case for DSPS patients. Treatment of DSPS requires "resetting" the biological clock by using bright light exposure, medication or chronotherapy. Chronotherapy involves delaying bedtime by three hours progressively each day until the desired bedtime is reached. Although difficult to accomplish, this approach can work if individuals can alter their schedules daily and protect their sleep from interruptions. Exposure to bright light early in the morning (six to nine a.m.) induces a phase advance, leading to an earlier sleep onset that evening. However, patients must avoid bright light exposure during the evening as this would tend to delay sleep onset. Medication is another option: Hypnotics and melatonin may help, but many questions remain about their duration of use and the long-term safety of melatonin. ASPS may be confused with depression. While ASPS appears to be a rare condition, it is more common in seniors. Complaints of difficulty staying awake in evening social situations are one marker of ASPS. Insomnia at the end of the sleep period is another. Treatment for ASPS includes bright light therapy and chronotherapy. The three-hour phase advancement of chronotherapy is implemented every other day. The bright light exposure is scheduled for late afternoon or evening.
Alzheimer's disease and senile dementia are characterized by frequent sleep
disturbance, both for those so diagnosed and their caregivers. In fact, many
caregivers cite sleep disturbances, including night wandering and confusion, as
the reason for institutionalizing the elderly. Once institutionalized, these
elderly residents' sleep disturbances don't cease. Two-thirds of those in
long-term care facilities suffer from sleeping problems. While tranquilizing
drugs may be the drugs of choice at many institutions, these drugs can further
confusion and increase the risk of falls. Monoaminergic drug therapies, such as
modafinil, are under investigation and may improve behavior along with sleep
disturbances in these patients. Other categories of medication - including
neuroleptics, benzodiazepines, antidepressants, anticonvulsants, and beta
blockers - have shown positive effects in some cases.
Sleep problems should be evaluated in all patients. Depression may be mistaken for dementia, as may the effects of certain medications, malnutrition and alcohol abuse. Many elderly patients suffer from undiagnosed apnea, drug interactions and excessive drug use or dependence. In fact, the elderly use both prescription and over-the-counter medications far in excess of their proportion of the population. Alcohol interacts with many of these drugs. It also may exacerbate dementias not caused by alcohol abuse. Some experts advise elderly people to have no more than one alcoholic drink per day, even if they are taking no drugs and have no medical contraindications. That drink should not be taken before bedtime.
To make matters worse, older people are more likely to take a number of
medications that may adversely affect sleep. Common medications, such as
antidepressants (prescribed for depression) and antihypertensives (prescribed to
control high blood pressure), may have a negative impact on sleep.
Caffeine taken too late in the day (in coffee, tea, soda, chocolate) may lengthen sleep latency, the amount of time it takes one to fall asleep. Alcohol may speed sleep onset but leads to disrupted sleep later in the night. Nicotine, too, has been linked to sleep problems. In one study, smokers were much more likely than nonsmokers to report problems falling, and staying, asleep along with daytime sleepiness. Another study found that smokers are four times as likely as nonsmokers to suffer from sleep apnea. Nicotine withdrawal, too, can lead to short-term sleep problems - namely, increased awakenings Ñ along with a shorter period to fall asleep. Increased daytime sleepiness may follow. Use of a skin nicotine patch may also be associated with early morning awakenings and reduced total REM sleep, still another study suggests. Once the patch was removed, the length of time before REM sleep - and the percentage of REM sleep - were reduced.
If freedom to travel is one of the silver linings in the "cloud" of old age, jet
lag may well be akin to the rain that must fall. For jet lag is the price we pay
for crossing time zones. And with age, we appear to pay a heftier price. One
study found sleep disruption and daytime sleepiness to be longer lived in the
elderly than in younger subjects.
Jet lag resolves with time, but short-term use of sleep-promoting medications,
sleeping at local time and rising at local time, morning light when traveling
west, and avoiding morning light when traveling east, can help reset the
biological clock. Melatonin is also being studied in this context.
TIPS FOR SAFE DRIVING
It's important to remember that falling asleep at the wheel is a very real and
deadly consequence of driving when fatigued. If you're tired, don't drive.
The good news? Sleep knowledge is growing in leaps and bounds, and sleep research
is expanding. Research into the use of melatonin and growth hormone continue;
these approaches may prove promising for older adults with sleep problems. At
publication time, however, these hormones remain experimental and caution is in
order. However, new medications for many sleep disorders are under study, with
some nearing U.S. Food and Drug Administration (FDA) approval.
THE IMPORTANT THING TO REMEMBER IS THAT:Pursuit of a good night's sleep is a worthy goal...and within reach for many who once thought it impossible. return to National Sleep Foundation home page |