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Sleep in the Elderly: Problems and Solutions

Changing Sleep Patterns

Sleep changes as we age – as any one over the age of 50 knows. Not only do changes in sleep patterns occur, but there is also an increased incidence of many sleep disorders. Frequent awakenings
One of the most common changes in the elderly is the occurrence of frequent awakenings during the night. While these awakenings are sometimes caused by physical conditions (pain, the need to urinate) it has been shown that the aging process itself causes sleep to become more fragmented.

Changes in the biological clock
Another change that can occur with aging is a shifting of the biological clock. Many elderly people are surprised that they fall asleep earlier in the evening and may awaken before sunrise. The biological clock – the part of the brain that regulates sleep, temperature, and certain hormones – shifts sleep and wake times, so that it becomes more difficult to stay awake in the evening and easier to wake up early in the morning.

The solution is to figure out how much sleep time you need, which might be different from how much sleep you want. You can do this by keeping track of the total number of hours spent sleeping in a 24 hour period (remember to include any daytime naps) for two weeks and then calculate the average sleep you get in 24 hours. You should stay in bed only for the time you need to sleep plus 30 minutes (to allow for some time to fall asleep) each night. For example, if you need 6 hours of sleep, spend only 6.5 hours in bed. The corollary is to avoid naps (if you like to nap, just decrease your time in bed at night) since napping will take away from the time you will sleep at night.

Use the bed only for sleeping: It sounds silly but our bodies pick up on a lot of subconscious clues. If you have trouble falling asleep, try avoiding non-sleep-related activities in bed. Therefore, do not pay bills, watch television or read in bed. Use the bed only for sleeping and sex.

Avoid alcohol, tobacco, and coffee in the evening: Alcohol relaxes you and can help you fall asleep. However, when the alcohol wears off it has the opposite effect, causing awakening and fragmented sleep during the remainder of the night. Therefore, avoid the "nightcap" and do not drink alcohol within six hours of bedtime.

Caffeine, as we all know, helps us wake up, so you should avoid it after 3:00 p.m.

Exercise: Exercise is great at any age and when you exercise in the late afternoon, it increases the amount of deep sleep that you will experience. However, exercise in the evening can get your adrenaline pumping and keep you awake.

Wind down: Don't expect yourself to fall asleep immediately. Wind down in the evenings. Develop a relaxing routine such as reading (in a chair) before getting into bed.

If maintaining healthy sleep hygiene doesn't help, it is possible that you might have a more serious problem.

Common Sleep Disorders

Three sleep disorders become more prevalent in the elderly: sleep apnea, restless legs syndrome (and periodic limb movements of sleep) and REM behavior disorder.

Sleep Apnea is diagnosed by an overnight study of sleep and breathing patterns called a polysomnogram. While there are many treatments for sleep apnea, the most common utilizes a nasal CPAP – a machine that blows pressurized air in through the nose, helping people with this condition get adequate airflow to the lungs, allowing them to sleep well and feel refreshed.

Important signs and symptoms of sleep apnea to watch for are:

• Snoring
• Pauses in breathing while asleep
• The need to urinate many times at night (without having a large prostate)
• Being overweight
• Non-refreshing sleep

Restless Legs Syndrome
Restless legs syndrome (RLS) is not often discussed, but is actually fairly common, occurring in 10-15% of the population. People with RLS complain of a discomfort in the legs (rarely the arms or chest) that is relieved only by walking. The feeling is often described as ants crawling on the skin.

This uncomfortable sensation only occurs when a person is not moving (either sitting still or lying down) and is always worse at night. Generally, people afflicted with RLS also notice that they unconsciously move their legs as well. Sometimes they describe their legs as jumping on their own, or they notice that while sitting, they are constantly jiggling them. Since RLS occurs mostly at night while the body is at rest and is relieved by movement, falling asleep and staying asleep can become very difficult.

Even when RLS sufferers manage to fall asleep, they have frequent jerking of the limbs called periodic limb movements of sleep (PLMS). Many elderly people develop PLMS – 34% of those over age 60 – even people who do not suffer from RLS and who have no other sleep complaints. The number of people who have the symptoms of RLS increases with age, and some people who had mild symptoms when they were younger may find that the symptoms get much worse as they age.

There are many different medications available to treat both RLS and PLMS. These include medications that are usually used for Parkinson's disease, pain control and seizure disorders. It is important never to treat yourself for this condition, but instead to see a doctor with special knowledge about the diagnosis and treatment of RLS.

REM Behavior Disorder
REM behavior disorder (RBD) occurs when someone acts out a dream in his or her sleep. Usually when you dream, your muscle tone is decreased – you are, in fact, partially paralyzed. In rare instances, some people do not have a decrease in their muscle tone and begin to act out their dreams. In addition, the dreams frequently become more violent than normal, and are often described as nightmares. The classic situation is one in which someone wakes up punching a pillow and remembers dreaming he was in a fight.

RBD is very rare, occurring most frequently in older men. Common causes of RBD include the use of certain medications (especially anti-depressants such as Prozac and Paxil) and withdrawal from certain sedatives (such as alcohol). RBD can also be associated with Parkinson's Disease, narcolepsy, and certain other neurologic diseases (e.g. rare brain degeneration disorders, strokes in certain areas of the brain). Usually, however, the cause is a mystery. Fortunately, there is effective medication for this problem. If you would like more information, check with a sleep specialist in your area, or call the American Academy of Sleep Medicine, at (507) 287-6006.

Conclusion

There are many changes in sleep that occur with aging and a few disorders that become more common as we age. It is therefore very important to remember to maintain healthy sleep hygiene as you age. If you think you may have a serious sleep disorder, you should discuss your concern with your internist or primary care physician to see if you need referral to a sleep specialist for further testing and treatment. Sweet dreams!