Sleep Well for Life

You wake up just as it is growing light outside, a half-hour ahead of your alarm clock. With a sigh, you close your eyes. If only you could go back to sleep. After a few minutes, you give up, tired, but not sleepy.  As you get out of bed, you wonder, “Why am I so tired all the time? I thought people needed less sleep as they got older.”

It isn’t true. Older adults need just as much sleep as younger ones, usually about eight hours a night. They just have more obstacles to getting the sleep they need.

Age-Related Changes in Sleep

About half of all older Americans suffer from insomnia, or lack of restful sleep. Among older adults, insomnia most commonly appears in the form of frequent awakenings throughout the night or early awakening in the morning. A number of physiological, age-related changes in sleep patterns are partly to blame. For example, older adults spend less time in the deepest stages of sleep, making it more likely that they will occasionally wake during the night. Older women, who are 50% more likely than men to experience sleep difficulties, often suffer from menopause-induced hot flashes that cause interruptions in sleep.  In addition, our biological clocks, or circadian rhythms, shift as we age, causing us to become tired earlier in the evening and wake up earlier in the morning.

Although scientists haven’t yet determined why sleep patterns change as we age, they are in hot pursuit of the answer. Dr. Phyllis Zee, Professor of Neurology and Neurobiology & Physiology at Northwestern University, as well as Director of the Sleep Disorders Center at Northwestern Memorial Hospital, has been studying families with familial Advanced Sleep Phase Syndrome, or ASPS.  This disorder causes people to have significantly advanced sleep cycles, often going to bed as early as 8:30 PM and rising by 5:00 AM. Although the inherited version of the disorder is rare, Dr. Zee hopes that studying it will help researchers identify the genes responsible for regulating circadian rhythms in humans. “If we can understand what may be going on in familial ASPS from a genetic and molecular standpoint,” she explains, “we may also be able to understand why aging causes older people to have a tendency to wake up early.”

Although these age-related changes in sleep patterns are real, they are usually minor. Dr. Saul Rothenberg, a psychologist at the Sleep Disorders Center of the North Shore Long Island Jewish Health System, points out that changed sleep patterns are not as important as total sleep time, which still needs to add up to the same amount required earlier in life.

Sleep and Disease

A much greater contributor to sleep problems than changes in sleep patterns are underlying age-related diseases. “The majority of sleep problems in older people are related to [other] medical conditions,” says Dr. Zee. “Several large epidemiological studies have shown that if you control for mental and physical disorders, the amount of sleep disturbance in the elderly goes down dramatically from 50 to about 10 percent.”

Among the common age-related illnesses and conditions that can disrupt sleep are arthritis pain, which can affect sleep onset or cause nocturnal awakenings; diabetes or bladder problems, causing frequent nighttime trips to the bathroom; and obesity and cardiovascular disease, which can make breathing more difficult. And ironically, sleep deprivation itself is a risk factor for many age-related diseases, particularly cardiovascular disease, diabetes, and obesity. This creates a vicious circle in which sleep disturbances and medical problems gradually undermine an older person’s health.

Hoping to break this cycle, Dr. Zee has begun testing whether interventions such as scheduled exercise or light exposure can improve sleep and thereby health in older persons. In a small study published in Sleep in 2000, Dr. Zee found that residents of an assisted living facility who attended regular morning and evening social and physical activity sessions showed an improvement in memory and in deep sleep. Further research has confirmed that exercise and light exposure, particularly in the evening, can help shift older persons’ sleep cycles.

Physical Sleep Disorders

Adding to the sleep difficulties older persons face, several physical sleep disorders become more prevalent in later life. One of the most common is sleep apnea, in which a sleeping person temporarily stops breathing for brief periods. This is due to a partial collapse of the upper airway. Very loud snoring and gasping for breath while sleeping are typical symptoms of sleep apnea. Older adults who suffer from obesity are at particular risk. Apnea, in turn, is a risk factor for a number of medical conditions, such as high blood pressure and heart disease. It can also contribute to daytime fatigue and disturb a spouse or bed partner’s sleep. The condition can be treated through the use of a nasal mask that keeps the airway open, or sometimes through surgery. Losing weight or sleeping on one’s side can also reduce the severity of apnea.

Another common sleep problem is periodic limb movement disorder. An estimated 40% of older persons have this disorder, which causes a person to suddenly move one or more limbs, usually the legs, at 5- to 90-second intervals during sleep. Although in most cases the disorder does not have a significant effect on sleep quality, when severe it can reduce deep sleep and lead to daytime fatigue. Like sleep apnea, the disorder can disrupt a bed partner’s sleep, and it often relies on a partner’s observations for diagnosis.

Restless legs syndrome is another disorder involving limb movement. However, this problem occurs primarily while the affected person is awake. He or she feels a “creepy-crawly,” uncomfortable sensation in one or both legs. The sensation is relieved only through moving the legs, usually by walking. This uncomfortable feeling often peaks in the evening and early night, leading to difficulty falling asleep. Discomfort can be reduced by applying hot or cold packs to the legs or massaging the legs and feet before sleeping. Both periodic limb movement and restless leg syndrome can also be treated with medication.

Treating Sleep Problems in Older Adults

Older adults suffering from insomnia have a variety of treatment options. Doctors can often provide sleep relief by treating underlying problems, whether they are age-related diseases or sleep disorders like apnea. Often, simple lifestyle changes can restore good sleep, such as eliminating caffeine or alcohol use, avoiding naps during the day, or reducing the dosage of certain prescription medications.

Even if insomnia persists despite such measures, older adults need not give up hope. Older adults with chronic insomnia can be treated just as younger people are: with drug therapy and cognitive-behavioral counseling. Of the two, cognitive-behavioral counseling is the preferred treatment. Although numerous sleep-inducing medications are available, they have side effects, can be habit-forming, and lose their effectiveness over time. And some research demonstrates that they are not as effective for long-term improvement as counseling.

A landmark study by C. M. Morin et al. in the March 17, 1999, issue of the Journal of the American Medical Association showed that among older adults, cognitive-behavioral therapy alone offered better long-term resolution of sleep problems than did medication alone or even combined medication and therapy. This surprising result, explains Dr. Rothenberg, “is most likely because those in combined therapy didn’t attribute their progress to themselves, but to the medication. It diminished their sense of self-efficacy.”

So what should an older person do if suffering from chronic insomnia? Dr. Rothenberg recommends that anyone having trouble sleeping see his or her primary care physician or contact a sleep center. “Don’t suffer with it, do something about it!” he urges. “Older people can resolve sleep problems just as well as younger people.”