Healthcare professionals who have worked with older adults have witnessed the consequences of sleep deprivation — from physicians finding senior patients asleep on exam tables to MRI techs awakening them in the machine and therapists ushering sleepy seniors up and down hospital halls.
All adults, regardless of age, need about eight hours of sleep a night. Lack of sleep can contribute to a number of problems, with particular implications for senior health. Sleep apnea, for example, occurs more often in those over age 60. It can rob organs of essential oxygen, cause fatigue, and increase the risk of high blood pressure. Sleep-deprived seniors may be confused, less alert, and more prone to fall asleep while driving or performing other important activities. Sleep deprivation also puts them at a greater risk for falling.
It’s important for healthcare professionals to help identify possible sleep problems and then refer their senior patients to the appropriate practitioners for further assessment.
Sleep in Older Adults
The image of a sleepy grandparent napping throughout the day may appear normal, but this is a misconception. According to the Geriatric Mental Health Foundation and a 2006 Sleep Medicine Clinics report, about 50 percent of seniors experience no problems with sleep.
According to the report, sleep efficiency — the amount of time spent in bed versus how much time is spent sleeping — among adults over 60 declines at rate of 3 percent per decade. Seniors tend to be lighter sleepers and are more likely than younger adults to experience sleep phase disorder, where they go to bed and awaken earlier.
The onset of sleep is governed by a neurological relationship between the brain stem — which primarily governs the awakening process — and the hypothalamus, where the onset of sleep is controlled by the suprachiasmatic nucleus (SCN). This biological clock, located where the optic nerves cross, comprises two tiny structures containing approximately 20,000 neurons. Depending on light signals from the optic nerve, the SCN instructs the pineal gland to increase or decrease production of the sleep-inducing hormone melatonin. This circadian rhythm is reinforced by any number of external cues — from frying bacon in the morning to reading a few pages from a book at night.
There are two main stages of sleep. The most active stage is rapid eye movement (REM) sleep. The eyes move as if watching scenery pass by in a car, and the muscles are rendered immobile. Non-rapid eye movement (NREM) is a series of four substages shifting from light to deep sleep. The brain cycles between NREM and REM sleep several times through the night. Seniors, however, often experience less of the deeper stages of sleep.
Problems with Sleep
Sleep-related problems are sometimes unavoidable. Social changes, from moving into a caregiver’s home to grieving over the loss of a loved one, can severely disrupt a senior’s biological clock. Many sleep issues in older adults result from some combination of lifestyle choices, primary sleep disorders, senior health problems, or the medications used to treat them.
Caffeine and nicotine, both stimulants, can hamper the ability to fall asleep. Alcohol, while it can induce drowsiness, affects the brain’s ability to regulate the deeper stages of sleep. Beyond substances, some seniors work against their body’s changing rhythm by trying to maintain the stay-up-late schedule of their youths, leading instead to sleep deprivation.
Difficulty falling or staying asleep is not an age-related problem. Insomnia can interfere with both length and quality of sleep for a number of reasons, from mental and physical health to medications. Women and those experiencing such severe stressors as loss of a spouse or financial problems are more at risk, though it can happen to anyone. A patient who experiences insomnia longer than four weeks should be assessed by a healthcare professional. Some of the more typical contributors to insomnia include:
- Lack of physical activity (or exercising shortly before bed)
- Health issues
- Mental health problems, especially depression
- Unstructured living
- Chronic pain
Excessive daytime drowsiness, called hypersomnia, is the telltale sign of sleep deprivation and could be indicative of underlying problems. A professional assessment of your patient’s sleep habits is the first step to addressing these problems. Relying on your patient’s history, important questions to ask include:
- How long have you been having difficulties sleeping?
- Do you feel rested when waking up?
- Do you get sleepy in the daytime, especially when sitting still?
- Do you wake up at night? How frequently, including trips to the bathroom?
- Does your sleep partner notice any breathing problems, such as gasping and loud snoring? Do you stop breathing entirely for more than a few seconds?
- Do you have discomfort or restlessness in your legs to the extent you cannot fall asleep or are frequently awakened?
- Do you feel depressed or anxious?
- Do you have racing thoughts or worries when trying to fall asleep?
- Do you take naps, and if so, how frequently and for how long?
- Do you eat or drink anything within two to four hours before bedtime, especially alcohol or caffeine?
- Do you smoke?
- What do you do to relax?
- How much physical activity do you engage in?
A wide array of health issues can impact the quality of a senior’s sleep. Hormonal imbalances, pain and discomfort from arthritis, gastroesophageal reflux disease, or having to make frequent trips to the bathroom are among the most common. Seniors may be at an increased risk for falls at this time.
Some seniors live with a combination of problems that could hinder sleep. These senior health issues include:
- Alzheimer’s disease and other neurodegenerative diseases, which harm the circadian rhythm
- COPD, which inhibits breathing and proper oxygenation
- Major depression and other mental health issues that cause excessive sleep or severe sleep deprivation
- Alcoholism and substance abuse that disrupt the brain’s ability to regulate sleep cycles properly
- Bladder infections or prostate disease
Many prescription medications are capable of disturbing sleep. Over-the-counter medicines, supplements such as melatonin, and herbal remedies influence sleep as well. Healthcare professionals who prescribe, dispense, or administer medications need to fully understand the impact they can have on senior patients. Some of the more commonly prescribed medications for seniors that can adversely affect sleep include:
- Alpha and beta blockers for treating high blood pressure
- Theophylline, used to treat asthma
- Corticosteroids to treat inflammation and arthritis
- A host of antidepressants that include fluoxetine and other SSRIs
- Levodopa and other anti-Parkinsonian drugs
- Cholinesterase inhibitors, used to treat Alzheimer’s disease
Popular over-the-counter medications that may disrupt sleep include those that contain caffeine, decongestants with pseudoephedrine, and glucosamine and chondroitin.
Restless legs syndrome
When a person experiences periods of crawling, tingling sensations in the legs to the extent that sleep is impossible, they may have restless legs syndrome, also known as Willis-Ekbom Disease. Exercise, relaxation techniques, and soaking the legs in warm water may relieve symptoms. Medications for more severe cases include dopaminergic agents like Sinemet, benzodiazepines, and opiates.
If your senior patient has a history of snoring and repeatedly stops breathing for long periods — as long as 30 seconds or more — she should be assessed for sleep apnea at a sleep center. There are three types of sleep apnea: obstructive sleep apnea, caused by the soft palate blocking the airway, usually during the onset of deep sleep; central sleep apnea, resulting from a disorder of the nerves that control breathing; and complex sleep apnea, a combination of the obstructive and central types.
In addition to sleep deprivation, apnea is a causal agent of depression, hypothyroidism, dementia, and heart disease. Solutions to apnea range from something as simple as losing weight and avoiding sleeping on one’s back to a continuous positive airway pressure (CPAP) machine to help with proper breathing.
Achieving healthy and restful sleep for senior patients is a goal many healthcare practitioners share. We serve as a screen for identifying sleep problems and referring those patients to specialists. Bad sleeping habits, such as napping or trying to make up for lost sleep by staying in the bed longer, are correctable. So are many of the health and medication issues, and especially lifestyle choices. Here are a few tips to recommend to seniors who need to improve their sleep:
- Increase physical activity, as exercise is a powerful tool for inducing healthy sleep
- Try relaxation methods such as yoga, meditation, guided imagery, and proper breathing
- Bring order into your life — following a routine can greatly reduce stress
- Refrain from using the bed except for sleep and keep the bedroom clean and dark to make both more inviting
- Go to bed and wake up at the same time reinforce the circadian cycle
- Avoid nicotine, alcohol, food, and water a few hours before bedtime to reduce their effects on sleep
- Expose yourself to more light during the day in order to sleep better at night
- Talk with your healthcare provider before making any medication changes
- Keep pharmacological solutions as minimal and short-term as possible
Research in sleep medicine offers plenty of promise for improving senior health. For example, light therapy for Alzheimer’s patients has been shown to increase circadian rhythms during the day, lessening agitation and depression and improving sleep. Findings such as this could significantly improve the quality of life for seniors and those who care for them.
Efforts to reduce the risk of falling due to sleep-related problems and fall-detection technologies have also proven useful. Falls are a serious threat to senior health, responsible for millions of injuries each year. Information such as the Department of Health and Human Services’ “Your Guide to Healthy Sleep” is available to help people learn to live safely with sleep disorders. By looking out for any signs of sleep issues and knowing where to refer patients for assistance, healthcare professionals can help fight the sleep disruptions and disorders that affect senior health.
When you’re helping to advise seniors who face fall risk due to sleep-related problems, consider referring them for a medical alert device — they can increase a senior’s safety.