Sleep Disorders and the Elderly

Sleep has been shown to be a very important component of healthy ageing. Studies have shown that lack of sleep and even too much sleep can affect longevity.

Complaints of poor sleep or excessive daytime sleepiness are more common in older persons. The elderly endure significant changes to their established sleep/ wake patterns such as retirement, reductions in physical and social activity and in some cases institutionalization. Surveys have shown 26-45% of older people complain of insomnia.

Changes in sleep as a result of ageing

The most striking age related change in sleep physiology is a reduction in the amount and amplitude of delta sleep. Compared with younger persons, elderly persons spend more time in bed relative to the amount of time they are actually asleep.

sleep

Although the elderly do not require more time to fall asleep (sleep latency), they awaken more frequently during the night and stay awake longer. They may nap more during the day and are more sensitive to changes in time zones and other environmental cues. The diurnal pattern of the elderly tends to become polyphasic, like that of the infant.

Because sleep disturbances are often transient responses to situational stresses or new surroundings, only disturbances persisting more than one month are considered clinically significant.

Factors which disturb sleep patterns

  • Anxiety
  • Depression
  • Pain
  • Discomfort due to constipation
  • Urgency, frequency, nocturia
  • Restless legs
  • Cramps
  • Daytime napping
  • Nocturnal cough or breathlessness
  • Unrealistic expectations
Diagnosis

Diagnosis check

Diagnosis depends on sleep history, psychiatric history and medical history.

The sleep history includes:

  1. Specific times of going to bed and arising.
  2. Timing and frequency of the complaint.
  3. Length of time spent awake during the day.
  4. Use of alcohol, tobacco, caffeine- containing beverages and medications.
  5. Daytime drowsiness
  6. Snoring, gasping respirations during sleep.
  7. Precipitating factors such as pain, emotional distress, and use of drugs and alcohol.

Psychiatric history should look for any anxiety or depression.

Medical history should look for any cardiovascular, pulmonary, musculoskeletal and central nervous system disorder.

The history should be followed by a thorough physical examination of all the systems.

Treatment of insomnias
  1. Non-pharmacologic treatment

The most important principle in managing insomnia is to consider sleeping pills a last resort.

The aim of non pharmacologic measures is to strengthen the association of time spent in bed with sleeping and to weaken its association with activities incompatible with sleep (worrying, lying awake).

These goals can be met with careful attention to:

  • Sleep hygiene. The elderly person should be advised to adhere to a regular schedule of going to sleep and arising, even on weekends and holidays.
  • The sleeping area should be kept at a comfortable temperature and as noise free as possible.
  • It is important that the bed not be associated with the frustration of trying to get to sleep. This means not using the bed for nonsleep activities such as reading or watching television. The person should be advised that when they lie awake for more than 30 minutes, they should leave the bedroom, engage in some other activity until tired, and then return to bed. If the person tends to lie awake for long periods of time, they should adjust their schedule to go to bed later.
  • Fluids, drugs, exercise. Good sleep hygiene also includes avoiding nocturia by limiting the ingestion of fluids near bedtime. Caffeine containing beverages and tobacco have stimulating effects and can interfere with sleep when taken to late in the evening. Finally, regular exercise is extremely beneficial in promoting sleep, particularly when not engaged in too close to bedtime.
  1. Pharmacologic therapy. Despite these measures some persons will require therapy with a sedative drug. However due to the possible side- effects this drugs should only be given under medical supervision.
  2. Special mention must be made of the sleep hormone melatonin. Used widely in Europe for stimulating sleep, initial reports seem to indicate that it helps in promoting sleep in the older person. Not available in Malaysia yet hopefully in the future this will be a safer alternative for promoting sleep in the older person.
  3. Simple advice for poor sleepers:
  • Rise at a regular and early hour.
  • Maintain activity during the day.
  • Avoid coffee or tea during the evening
  • Do not go to bed hungry.
  • Warm milky drink in the evening.
  • Do not go to bed too early.