Insomnia & Sleep Disturbances In The Elderly

By Geriatric Physician, Dr. V. S. Natarajan

Sleep disturbances are one of the major health complaints of older adults.  The most frequent sleep complains in older adults is sleep maintenance insomnia, which is characterized by early morning awakening and frequent awakenings at night.

Approximately 50% of the population of age 65 or above have problems with sleep.

Sleep disorders and night wandering are often distressful to the elderly and their caregivers.  Sleep problems can also have serious medical consequences. In a large study of elderly residents of an urban community, insomnia was a strong predictor of mortality and morbidity.

Not recognizing and appropriately treating sleep disorders in later life may result in deterioration in the quality of life.  Therefore, improved knowledge about sleep and treatment strategies for sleep disorders in the older population are of significant clinical and social value.

The most prominent findings in sleep architecture in old age are:

  • A decrease in sleep efficiency
  • Increase in night awakenings
  • Decrease in the deepest stage of sleep
  • Early morning awakening

The ability to sleep during the night decreases with age, not feeling the need for sleep, because  daytime sleepiness increases.  Although the normal sleep architecture changes with age, with less time spent in the deeper levels of sleep, sleep disturbances in older population are often multifactorial.

Causes For Sleep Disturbance:

  • Primary insomnia – cause is not known
  • Psychologic stressors – eg. Bereavement, post-traumatic stress, forced retirement, social isolation.
  • Medical problems eg. Heart failure, asthma, arthritis, recent fractures, peptic ulcer, hiatus hernia, kidney failure, thyroid disease, Parkinson’s disease.
  • Psychiatric disorders – eg. Depression, dementia, anxiety
  • Medications – eg anti-psychotics, caffeine, diuretics, sedative-hypnotics.
  • Additionally sleep loss may exacerbate medical and psychiatric illnesses.

Clinical Evaluation:

A brief sleep history should be an integral part of general medical history and examination.  Some examples of questions that need to be asked when obtaining sleep history are provided below.

Questions  in a Sleep History :

  • Do you have difficulties falling asleep or staying asleep?
  • Do you feel that you are excessively sleepy during the day?
  • How many hours do you sleep per night?
  • How long does it take you to fall asleep after deciding to go o sleep?
  • How many times do you wake up during a typical night?
  • Do you snore loudly or stop breathing at night?
  • Do you have crawling or aching feeling in your legs when trying to fall asleep or at rest?
  • Do you walk, yell out or act your dreams during sleep?
  • Do you feel refreshed after a night of sleep?
  • Do you kick or twist your arm or leg during sleep?

Obviously, some of this information may be obtained from the bed-partner or care giver.

Treatment:

Drug therapy alone is not appropriate for the treatment of insomnia.  If drug therapy is used, it must be combined with educational and behavioural interventions. One of the most important educational approaches for insomnia includes modifying habits that are known to affect sleep.

Tips for sleep hygiene:

Regular sleep schedule: Patients should go to bed at the same time each night and more importantly get up at the same time each morning, even on week ends.

Bedtime routine: A regular pattern of activities brushing teeth, washing the face, setting the alarm clock can set the mood for sleep.  This routine is performed every night, at home or away.

Sleep conducive environment: The bedroom is dark and quiet and not too warm or too cold.

Avoidance of substances that interfere with sleep: Food and beverages that contain caffeine (eg, coffee, tea, drinks, chocolate) or alcohol, smoking, appetite suppressants and diuretics should be avoided, especially near bedtime.

Use of pillows: Pillows between the knees or under the waist can make problems lying supine with a large pillow under the knees may be helpful.

Regular exercise:  Exercise has shown to improve sleep in old people.  Whereas increased physical activity may improve sleep, inactivity can have a negative effect on sleep.  Exercise can help patients fall asleep naturally.  However, an exercise in the late evening can stimulate the cardiovascular and nervous systems and keep patients awake.

Relaxation: Stress and worry are major impediments to sleep. Patients who are no sleepy at bedtime can relax by reading or taking a warm bath.  Patients can aim to leave problems at the bedroom door.

Sleep restriction therapy involves limiting the time spent in bed and excluding daytime happening.  Other behavioural techniques include progressive muscle relaxation; medication or hypnosis and bio feedback.

Drug Therapies

Drug treatment with sedative-hypnotics, provides only symptomatic relief.  Continued use of hypnotics on a daily basis should be avoided, because they can be addictive, usually loose their effects (requiring escalation of disease and may produce rebound insomnia when withdrawn. Memory deficits, loss of balance, daytime drowsiness and falls may be more frequent in patients with disturbed sleep who are taking hypnotic medication.

Alcohol used at bedtime initially causes drowsiness, but it disrupts sleep later in the night and should be avoided in persons who have difficulty with night sleep.

A combination of sleep hygiene, behavioural treatment and drug therapy is recommended for the treatment of insomnia.

Sleep disorders are common among older people and have a significant impact on the quality of life.  Treatment of sleep disorders requires significant efforts in patient education, behavioural modification and often, medical management.  Drug therapy does not provide a long term solution to a sleep disorder.

Excerpts from the journal.- Link Age -by Senior Citizens Bureau 

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