Sleep Problems in the Elderly

A primary sleep disorder means there is not another medical or psychiatric cause. Individuals of all ages can be affected by sleep disorders, including older adults.

Insomnia is one of the most common medical complaints, especially in older adults. It often coexists with medical, psychiatric, sleep, or neurological disorders.

Insomnia may also be associated with stress, medications, poor sleep habits, or changes in the sleep environment, according to research.

A study about sleep problems in older Singaporeans reported that those who had trouble sleeping were more likely to have existing conditions and be less physically active.

Health conditions that may cause sleep problems include:

• Parkinson’s disease. This is a neurodegenerative disorder where how often it occurs, or incidence, increases with age. Up to 40 percent of people with Parkinson’s disease have obstructive sleep apnea, according to the Parkinson’s Foundation.
• Alzheimer’s disease. Alzheimer’s may cause daytime drowsiness and difficulty staying asleep at night.
• Chronic pain like arthritis pain.
• Cardiovascular disease. A study showed that 39 percent of people with cardiovascular disease regularly slept fewer than 6.5 hours, resulting in an increased death risk.
• Neurological conditions. Examples include multiple sclerosis and traumatic brain injury.
• Gastrointestinal conditions. Gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS) are examples of gastrointestinal conditions.
• Lung or respiratory conditions. Examples of these conditions include chronic obstructive pulmonary disease (COPD) and asthma. These conditions may increase the risk for obstructive sleep apnea.
• Poor bladder control.

Medications

Many older adults are on medications that can disrupt sleep. These include:

• diuretics for high blood pressure or glaucoma
• inhaled anticholinergics for COPD
• antihypertensive drugs for high blood pressure
• oral corticosteroids (prednisone) for rheumatoid arthritis and lupus
• antidepressants and anti-anxiety medications (anxiolytics)
• antihistamines for allergies
• levodopa for Parkinson’s disease
• donepezil (Aricept) for Alzheimer’s disease

Caffeine, alcohol, and smoking may also contribute to sleep problems.

• The stimulant caffeine may reduce sleep time by causing a delay in the body’s circadian rhythm, according to research.
• Alcohol may increase the risk for sleep apnea by 25 percent.
• Research shows that nicotine disrupts the circadian rhythm, causing more daytime sleepiness and less sleep time, including less REM sleep.

The sleep problems older adults most commonly experience include:

• Obstructive sleep apnea, or brief interruptions in breathing during sleep that occur if the upper airway repeatedly becomes blocked. It affects an estimated 20 to 60 percent of people over 65 years old.
• Restless leg syndrome (RLS), or the overwhelming need to move your legs during sleep, may start at any age, but it more severely affects middle-aged and older adults who may experience it more frequently and for longer periods.
• REM behavior disorder (RBD), or the vivid acting out of dreams during sleep, may occur when the brain chemical that paralyzes your muscles during REM sleep does not function properly. A study found that up to 7.7 percent of 456 participants over 60 years old without Parkinson’s disease had probable RBD.
• Circadian rhythm sleep disorders disrupt the daily sleep-wake cycle of the body’s internal clock. As you age, your internal clocks become less efficient, resulting in falling asleep and waking up earlier.

Other sleep disorders that can affect anyone of any age include:

• Insomnia is difficulty falling asleep, staying asleep, or restless sleep. According to some studies, 50 to 70 percent of people over 65 years old have symptoms of insomnia.
• Periodic limb movement disorder, or involuntary movement of the limbs during sleep, does not have a known cause, but it may originate in the central nervous system.

To make a diagnosis, your doctor will ask about your symptoms and conduct a physical examination to look for any underlying conditions. They may also ask you to complete a sleep diary for 1 to 2 weeks to learn more about your sleep patterns.

The diagnosis of insomnia requires three main components:

• persistent sleep difficulty
• adequate sleep opportunity
• associated daytime dysfunction

If your doctor suspects a primary sleep disorder, particularly obstructive sleep apnea, they will recommend either an in-lab sleep study called a polysomnography (PSG) or an at-home sleep test (HST).

Sleep study

A polysomnogram sleep study is usually done at night in a sleep lab. You should be able to sleep as you normally would at home.

If your doctor orders an in-lab sleep study, a technician will place sensors on you to monitor your:

• body movement
• breathing
• snoring or other noises
• heart rate
• brain activity

You may also have a finger device to measure the oxygen in your blood.

The technician will watch you through a video camera in the room. You can talk with them if you need any help. During your sleep, the devices will continuously record your information on a graph. Your doctor will use this to diagnose if you have a sleep disorder.

For older adults, it’s recommended to first use nonpharmaceutical treatments like cognitive behavioral therapy (CBT) for sudden and chronic insomnia. This is because older adults may already be taking multiple medications.

Therapy

Cognitive behavioral therapy can happen over a 6-week period or longer and include:

• sleep education
• stimulus control
• time in bed restrictions

Studies show that CBT largely improved sleep quality for people with insomnia. The studies suggest that it is more effective because it helps target both the quality and quantity of sleep.

You can develop good sleeping habits by:

• going to bed and waking up at the same time each day
• using the bed only for sleep and sex, not other activities like work
• doing quiet activities, like reading, before bed
• avoiding bright lights before bed
• keeping a soothing and comfortable bedroom environment
• limiting liquid before bed
• eating 3 to 4 hours before bedtime
• exercising regularly but not right before bedtime
• taking a warm bath to relax
• avoiding naps

If you have trouble falling asleep within 20 minutes, you may want to try getting up and doing something before going back to bed. Forcing sleep may make falling asleep harder.

If these changes aren’t enough, your doctor may recommend medication. Read on to learn more about sleeping pills and other medical treatments.

Medications

If you have underlying issues that are interfering with your sleep, your doctor may prescribe medications. Medication shouldn’t replace good sleeping habits, but it may provide some relief in the short term.

Melatonin, a hormone produced by your brain in response to darkness, helps induce sleep faster and restores your sleep-wake cycle. Exposure to light at night can prevent the production of melatonin.

Synthetic melatonin supplements can be bought over the counter. People most commonly use melatonin for insomnia and improving sleep in certain conditions such as jet lag. However, there is limited scientific evidence to support the chronic use of melatonin in most cases.

Your doctor may be able to recommend which medications might work best for you and how long you should take them, depending on what’s causing your insomnia.

Some common types of sleeping medications include:

• Benzodiazepines such as temazepam (Restoril) and triazolam (Halcion) reduce anxiety and promote sleep by binding to gamma-aminobutyric acid (GABA) receptors in your brain. However, they are potentially addictive and not recommended for older people due to the possibility of cognitive impairment, falls, and fractures.
• Nonbenzodiazepines (Z-drugs), including zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta), slow your brain’s activity to help you sleep by specifically working on your brain’s GABA-A receptors. They may cause morning drowsiness if you’re taking long-acting medication. They are also potentially addictive and not recommended for older people.
• Certain antidepressants approved by the Food and Drug Administration (FDA), such as doxepin (Sinequan), may be prescribed in low dosages for chronic insomnia. They may help you stay asleep longer and reduce the number of times you awaken. These drugs mainly work by blocking histamine, which is an alerting neurotransmitter.

It’s recommended to only take sleeping pills on a short-term basis. However, insomnia treatment is individualized. Your healthcare professional will help create a specific treatment plan for you.

Long-term use of sleeping pills can cause complications, especially in older adults. Other common side effects of benzodiazepines and Z-drugs include:

• headaches
• dizziness
• nausea
• fatigue
• drowsiness

You should avoid drinking alcohol while taking sleeping pills.

Medical treatments

Some medical treatments that are sometimes recommended for older adults are:

• continuous positive airway pressure (CPAP) devices to treat obstructive sleep apnea
• specific antidepressants to treat insomnia
• dopamine agents for restless leg syndrome and periodic limb movement disorder
• iron replacement therapy for restless leg symptoms

Sleep remedies include over-the-counter (OTC) antihistamines, such as diphenhydramine (Benadryl), which induce drowsiness. However, the chronic use of antihistamines has been associated with dementia.

Talk with your doctor before taking any OTC medications. They may interact negatively with medications you’re already taking.

In older adults, ongoing sleep disorders can lead to bigger concerns like depression and the risk of falling.

If quality of sleep is the main issue, cognitive behavioral therapies may be more beneficial, especially for insomnia. This means developing good sleeping habits through sleep education, stimulus control, and time-in-bed restrictions. Changes can take up to 6 weeks or more.

If cognitive behavioral therapies don’t work for your insomnia, your doctor may prescribe medication or other treatments, but sleep medication is not a long-term solution. Managing your sleeping habits can be the most effective way to get quality sleep.