Older people often have problems related to sleep. They may have difficulty falling asleep, and are more likely to sleep less deeply and to awaken frequently at night. Mental and physical illnesses are often responsible for sleep problems among the elderly.
Older adults who experience reduced sleep quality are more likely to be irritable and to be affected by various conditions, including depression, attention and memory problems, daytime drowsiness and falls at night. Many common medical conditions including diabetes and cardiac disease are also associated with impaired sleep. In addition, older adults are more likely to use over-the-counter or prescription sleeping pills, which sometimes cause various health effects.
Some older adults have sleep problems that are significant enough to be diagnosed as sleep disorders. According to the U.S. National Institutes of Health (NIH), the most common sleep disorders include:
- Insomnia. Nearly half of all adults age 60 and older experience some form of insomnia.
- Sleep apnea and other breathing problems.
- Movement disorders. Older adults are more vulnerable to movement disorders such as restless leg syndrome (RLS) and periodic limb movement disorder (PLMD).
Several factors are believed to be responsible for the difficulties that older people often encounter when trying to sleep. These include physical changes, increased sensitivity to noise, emotional and physical illness, changes in sleep cycles or the use of certain medications.
Older people often attribute sleep difficulties to the aging process and may not realize that the symptoms are actually the result of an illness or condition, such as a sleep disorder. However, sleep disorders can also cause or exacerbate both physical and psychological disorders. Patients are encouraged to consult a physician if they notice a change in sleeping patterns or if they become tired during the day. Various tests are available to help diagnose the nature of sleep difficulties.
Maintaining optimal health is crucial to ensuring sleep quality among older people. Studies have found that older people in good health are more likely to report good sleeping habits than those with significant health issues. In addition, older people who maintain a positive attitude, exercise regularly, are actively engaged in the community and have a good support network are less likely to report sleep problems.
Several lifestyle changes can help older people to sleep better. In some cases, medications may be recommended to help improve sleep.
About sleep & aging
As people age, the quality of their sleep is often adversely affected. In many cases, this is due to insomnia that may cause people to feel tired during the day. In other cases, older people may be diagnosed with other sleep disorders.
Many older people sleep well. A recent survey by the National Sleep Foundation found that older people in good health, with a high quality of life, may actually sleep better than younger people. However, many other older people do not get quality sleep on a consistent basis. This is especially true of those who have various physical and mental health conditions.
Contrary to popular myth, older people do not require less sleep than younger people. Instead, all adults require between seven and nine hours of sleep each night. However, many older adults struggle to obtain adequate sleep. A survey of adults over the age of 65 found that 13 percent of men and 36 percent of women take more than a half-hour to fall asleep, according to the U.S. National Institutes of Health (NIH).
Once older people do fall asleep, their sleep often tends to be more shallow than that of younger people. Sleep consists of five stages. The first four stages are called non-rapid eye movement (REM) sleep. The fourth stage of non-REM sleep is called delta sleep, and is the deepest stage of sleep. It is also the stage in which growth hormone, which regulates cell division and protein synthesis necessary for growth, is produced. Older people tend to spend less time in this stage of sleep than younger people.
The fifth stage of sleep is called REM sleep. It is the stage in which dreaming occurs. Older people spend a similar amount of time in REM sleep as younger people, although they do tend to wake more often during the night than younger people.
Older adults who experience reduced sleep quality are more likely to be irritable and to be affected by various conditions, including depression, attention and memory problems, daytime drowsiness, and falling at night. In addition, people who have a poor sleep quality are more likely to use over-the-counter or prescription sleeping pills, which sometimes cause adverse health effects.
Some older adults have sleep problems that are significant enough to be diagnosed as sleep disorders. According to the NIH, the most common sleep disorders among older adults are:
- Insomnia. Nearly half of all adults age 60 and older experience some form of insomnia. There are many potential insomnia triggers, but the need to use the bathroom is the most common insomnia source among older adults. Increased prostate size typically causes older men to have to urinate more often, whereas incontinence often occurs in older women. When older adults wake frequently at night, they are also at increased risk of falling.
- Breathing problems. Many older people experience breathing problems during sleep that interfere with the ability to get proper rest. Snoring and sleep apnea (in which patients temporarily stop breathing during sleep) are examples of breathing problems that are more likely to occur in older people. Among people over age 65, 28 percent of males and 24 percent of females experience sleep apnea, according to the National Sleep Foundation. This condition has also been shown to increase the risk of falling asleep while driving by three to seven times.
- Movement disorders. Older adults are more likely to experience involuntary movement disorders, such as restless leg syndrome (RLS) and periodic limb movement disorder (PLMD). RLS causes feelings of discomfort in the legs that occur continuously when the body is at rest. It affects more than 20 percent of people age 80 and older, according to the NIH. PLMD causes patients to periodically and rapidly move their legs when the body is asleep. About 80 percent of people with RLS also have PLMD, according to the National Sleep Foundation. A condition that affects the muscles during REM sleep called rapid eye movement sleep behavior disorder typically affects men over the age of 50. This disorder causes patients to physically act out their dreams, and patients may cause self-injury or injury to others.
Potential causes of sleep problems
Several factors are believed to be responsible for the difficulties that older people encounter when trying to sleep. These include:
- Physical changes. Various aging-related changes in the body may contribute to sleep problems. For example, older people may produce and secrete lower amounts of melatonin, a hormone that is involved in regulating the sleeping and waking cycle. Lower production levels of growth hormone (which promotes deep sleep) and changes in body temperature cycle may also impact the sleep quality of an older person.
- Increased sensitivity to noise. As people age, they may become more sensitive to environmental noise that disrupts sleep.
- Emotional and physical illness or conditions. Patients with health problems tend to report poorer sleep than healthy individuals. In addition, people who experience physical pain frequently have difficulty falling asleep and have a poorer sleep quality. Sleep disorders can precipitate or exacerbate many medical conditions including diabetes and cardiac disease and mental disorders including depressive and anxiety disorders.
- Use of certain medicines. Older people are more likely than younger people to take medications regularly. Some of these medications are known to interfere with sleep, including asthma medications, blood pressure drugs, corticosteroids, cardiovascular drugs, decongestants and gastrointestinal drugs.
Alzheimer’s disease often affects the sleep patterns of older people with the illness. Some patients with Alzheimer’s may sleep excessively, whereas others do not sleep enough. Alzheimer’s patients often awaken frequently at night and may be found wandering around or yelling in the middle of the night.
Other conditions that may cause sleeping problems in older adults include:
- Sedentary lifestyle
- Chronic heartburn
- Emotional disorders (e.g., depression)
- Enlarged prostate
- Gastroesophageal reflux disease (GERD)
- Heart problems (e.g., heart failure)
- Lung disease (e.g., chronic obstructive pulmonary disease)
- Neurological disorders (e.g., Parkinson’s disease, dementia)
Signs and symptoms of sleep problems
The signs and symptoms of sleep problems vary according to which disorder is present. For example, people with insomnia have difficulty falling asleep or staying asleep. They often feel tired even after they have had a full night’s sleep.
Meanwhile, people with sleep apnea may experience breathing that stops during sleep. Loud snoring and choking or gasping associated with sleep may also occur. Patients with movement disorders, such as restless leg syndrome (RLS) and periodic limb movement disorder (PLMD), may experience discomfort in their legs or rapid jerking motions in their limbs during sleep. RLS and PLMD may cause excessive daytime fatigue and insomnia at night.
Diagnosis methods for sleep problems
Older people often attribute their sleep difficulties to the aging process and may not realize that their symptoms are actually the result of an illness or condition such as a sleep disorder. Patients are encouraged to consult a physician if they notice a change in their sleep patterns or if they find themselves frequently tired during the day.
In diagnosing sleep problems, a physical examination is performed to determine if there is a medical cause for the problem. During this examination, the physician will look for signs of conditions that may affect sleep, including heart disease, Parkinson’s disease, obesity and stroke. A medical history, which may include the patient’s current medications and a psychiatric history, will also be taken. Patients may be given a neurological (nervous system) examination if a neurological cause is suspected.
Patients may be asked questions regarding sleep patterns and symptoms experienced during waking hours. Family members or sleep partners may be asked to describe sleep patterns and behavior of patients. Patients will also likely be asked questions regarding lifestyle habits, such as smoking or the use of alcohol or caffeine. A sleep diarydetailing times and patterns of sleep may help discussions with a physician or sleep specialist.
Sleep disorders can sometimes be diagnosed by identifying medications that patients take. Because older patients are more likely to take medications than younger patients, it is important to inform the physician of all medications presently being used, including over-the-counter drugs and dietary supplements.
Patients are also urged to disclose information about any medical or neurological conditions, psychiatric disorders or other factors that may be causing sleep problems. In some cases, patients may be referred to a sleep center where sleep patterns are analyzed in depth by health professionals who specialize in sleep disorders. Some common tests that are performed to diagnose sleep disorders include:
- Sleep questionnaire. The Epworth Sleepiness Scale uses questions to measure the likelihood of dozing in certain circumstances, such as while sitting and reading.
- Polysomnogram (sleep study). Painless test conducted overnight while patients are sleeping. Electrodes placed on the body before sleep are used to monitor electrical activity of the brain (electroencephalogram), heart (electrocardiogram), movements of the muscles (electromyogram) and eye movements (electro-oculogram). These are measured as patients experience the different stages of sleep.
- Multiple sleep latency test (MSLT). Conducted in a similar method as a polysomnogram, but it is performed during daytime hours. It may be used to diagnose narcolepsy by determining how quickly a person falls asleep during regular waking hours.
- Repeated test of sustained wakefulness (RTSW). This test measures how long it takes for a patient to fall asleep by challenging the ability to stay awake. During the test, patients are placed in a quiet room with dim lighting and asked to remain awake. It is also used to diagnose narcolepsy.
However, most older patients do not require these specialized tests for their sleep problems to be diagnosed and treated.
Treatment and prevention for sleep problems
Maintaining optimal health is crucial to ensuring sleep quality among older people. Studies have found that older people in good health are more likely to report good sleeping habits than those with significant health issues. Not only does good health appear to be improve sleep, but impaired sleep also seems to be a cause of poor physical and mental health. In addition, older people who maintain a positive attitude, exercise regularly, are actively engaged in the community and have a good support network are less likely to report sleep problems.
Treatment of sleep disorders varies depending on the cause of the disorder. Underlying medical, neurological and psychiatric conditions may be treated if they are determined to be the cause of sleep disorders.
Some types of disorders can be treated (or prevented) by making lifestyle changes, such as:
- Avoid caffeine and alcohol. Foods and beverages that contain caffeine, such as chocolate, coffee and soft drinks, should be avoided during late afternoon or evening hours. Alcohol speeds the onset of sleep, but increases waking during the later half of the night.
- Avoid eating or drinking too close to bedtime. This can interrupt sleep. Also, avoid foods that may cause heartburn, such as tomato products and spicy foods. Lying down worsens heartburn and makes falling asleep more difficult.
- Avoid smoking. Cigarettes contain nicotine, which has been linked to difficulty falling asleep and problems waking. In addition, when smokers sleep they experience nicotine withdrawal, which may cause them to awaken.
- Maintain a healthy body weight. Many cases of sleep apnea (slowed or stopped breathing during sleep) occur among overweight or obese people. Weight loss can alleviate or eliminate the symptoms.
- Go to bed earlier. As people grow older, hormonal changes usually cause them to become sleepier earlier in the evening and to wake earlier in the morning. This is a natural occurrence. However, older people who continue to try to go to bed at the same time as they did when they were younger are more likely to have difficulty falling asleep and staying asleep.
- Exercise. Exercising 20 to 30 minutes a day often helps people sleep, although exercising too soon before bedtime can cause difficulties falling asleep.
- Find the right temperature for sleeping. Extreme temperatures can disrupt sleep.
- Get proper light exposure. Too little exposure to sunlight during the day can cause sleep problems at night. Bedrooms should be kept dark so light does not interfere with sleep.
- Control noise. Environmental noise can be minimized with ear plugs, rugs, heavy curtains or drapes or double-pane windows.
- Get a proper mattress. Mattress quality can impact sleep quality.
- Develop a routine to prepare for sleep. Performing the same relaxing tasks every night before bed, such as reading a book or taking a warm bath, can help prepare the body for sleep.
- Use the bed only for sleep and sex, and not for reading or television viewing.
- Only get into bed when tired.
- Maintain consistent sleep and wake times.
- Avoid or regulate nap times. Daytime naps may interfere with nighttime sleeping. Avoid naps or restrict nap times to a maximum of 20 or 30 minutes.
- Practice relaxation techniques before bedtime. These may include hot baths, relaxing music, progressive muscle relaxation, deep breathing techniques, meditation, guided imagery and self-hypnosis, and prayer.
- Spend time outside. Increased exposure to natural sunlight helps the body’s circadian rhythm (the “internal clock”) to work properly. Two hours of bright-light exposure helps keep the sleep-wake cycle in tune.
Medications are sometimes prescribed to treat sleep disorders. They include:
- Benzodiazepines. Medications that help slow down the CNS. They help suppress rapid eye movement (REM) sleep and limit arousal. They may be prescribed to treat parasomnias (disorders that involve partial arousal or interference with sleep stage transition), teeth grinding (bruxism) or short-term (acute) insomnia. Because these medications can interfere with the normal sleep stages, can result in physical dependence and addiction, and appear to be associated with an increased risk of falls in older patients, the are not generally recommended for this population.
- Non-benzodiazepine sedative hypnotics. These drugs appear to work by binding to receptors in the brain that cause sedation.
- Stimulants. Medications that act on the CNS to produce excitation, alertness and wakefulness. They may be used to treat narcolepsy.
- Antidepressants. Medications primarily used to prevent or treat depression, anxiety and problems with obsession. They are not approved by the U.S. Food and Drug Administration (FDA) for the treatment of insomnia, but can be beneficial if the insomnia is associated with these mental disorders or certain chronic pain conditions.
Patients should be aware that a physician may need to adjust the dosage or change medications to achieve the best results with minimal side effects. In addition, the FDA has advised that antidepressants may increase the risk of suicidal thinking in some patients and all people being treated with them should be monitored closely for unusual changes in behavior.
- Hormone replacement therapy (HRT). Women who experience hot flashes during menopause may find that these episodes disrupt sleep. HRT medications sometimes are prescribed for these patients, although these medications may carry certain health risks.
- Dopamine agonists. Medications that mimic dopamine, a neurotransmitter (brain chemical) essential to thought, motivation, short-term memory and some emotions. Dopamine agonists may be used to treat restless legs syndrome (RLS, a sleep disorder characterized by unpleasant sensations in the legs).
In addition, there are many over-the-counter (OTC) sleeping pills, most of which contain an antihistamine, or herbal supplements (e.g., chamomile, valerian), that claim to promote sleep and are available at pharmacies and other stores. However, health experts generally recommend avoiding the use of OTC sleeping pills, especially for long periods of time, since they may have undesired side effects (e.g., dizziness, prolonged drowsiness), tend to lose effectiveness over time, and may interact with other medications currently being taken by the patient. The use of herbal supplements has yet to be fully evaluated for safety or effectiveness in the treatment of insomnia.
Other techniques that may be used to treat sleep disorders include:
- Cognitive behavioral therapy (CBT). This may help patients identify thoughts and behaviors that contribute to sleep problems, such as anxiety.
- Continuous positive airway pressure (CPAP). A device specifically used to treat sleep apnea. It involves wearing a mask over the nose that blows air into the throat at a pressure level appropriate for the patient. It keeps the throat open during sleep and prevents airway restriction.
In addition, patients with conditions such as narcolepsy may benefit from attending support groups.
Patients are urged to follow any physician recommendations regarding methods to improve their sleep. For example, patients diagnosed with heart failure are more likely to experience shortness of breath while lying down, which can disrupt sleep. Such patients are often urged to sleep with their head elevated to prevent or reduce such shortness of breath. Caretakers of patients with Alzheimer’s disease are urged to take special steps to protect the patient from potential injuries that can occur due to sleep problems related to the disease. Because these patients often wake frequently and may wander, caretakers are urged to put gates across stairs, keep floors clear of objects and lock away medications . Other safety tips include adding grab bars in the bathroom or placing a portable toilet in the bedroom.
Questions for your doctor on sleep and aging
Preparing questions in advance can help patients to have more meaningful discussions with healthcare professionals regarding their conditions. Patients may wish to ask their doctor the following questions related to sleep and aging:
- Are my sleep difficulties related to my age?
- Do I have a sleep disorder? If so, what type?
- What are some of the most common symptoms of sleep disorders?
- How will you determine whether I have sleep apnea?
- Should I consult a sleep center to determine the cause of my sleep disorder?
- What are my treatment options? What are the side effects of these treatments?
- How soon after beginning treatment will I see improvement in my symptoms?
- What steps can I take to improve the quality of my sleep?
- Will my sleep quality continue to deteriorate as I age?
- Given my age, are there any recommendations or restrictions on how much I should exercise?