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As we age, most of us will experience bodily changes that affect how we sleep. These changes often become more pronounced later in life, and the effects may be influenced by chronic illness or the side effects of prescription medication. As a result, sleep problems and disorders are relatively common among seniors.
Epidemiological self-report studies suggest that many older adults sleep seven hours or less, which might be health-compromising to some degree. A survey of adults over the age of 65 by the National Institutes of Health also found that 13% of men and 28% of women require more than 30 minutes to fall asleep.
All sleep disorders fall under one of two general categories. Dyssomnias refer to any condition that either causes severe drowsiness or affects one’s ability to fall or stay asleep; examples of dyssomnia include insomnia and sleep apnea. Parasomnias, on the other hand, are disorders characterized by inappropriate or irregular behaviors that occur during sleep, such as sleepwalking and night terrors.
This article will discuss some of the most common dyssomnia and parasomnia disorders among elderly people, as well as other health-related factors that may impact their quality of sleep and some of the most common treatment methods.
First, let’s discuss the most common dyssomnia disorder among older men and women: insomnia.
Insomnia is defined as habitual sleepiness, or the inability to experience restorative sleep on a nightly basis. Insomnia is an issue for nearly half of all adults in the U.S. over the age of 60. The most common symptoms associated with insomnia in older people include the following:
The term ‘short-term insomnia‘ describes initial insomnia symptoms. Doctors will usually diagnose patients with ‘chronic insomnia‘ if their symptoms persist for more than one month; in many cases, secondary insomnia will continue even after the original root cause has been treated. Although the symptoms of insomnia will vary between people, two general types have been identified. Sleep onset insomnia indicates the individual has trouble falling asleep, while sleep maintenance insomnia occurs when someone is unable to remain asleep for normal durations and routinely wakes up in the middle of the night.
Insomnia may be diagnosed as a primary or secondary disorder. Primary insomnia is considered a standalone condition that arises independently, while secondary insomnia is brought on by different physiological factors. The consensus among today’s physicians is that most elderly insomniacs experience secondary insomnia, brought on in most cases by medical conditions and/or side effects of prescription medication.
Insomnia has been linked to changes in sleep architecture. Sleep architecture is defined as the ‘progression of sleep across the night’, and consists of three distinct segments:
The amplitude of circadian rhythm in most adults will decrease with age, and this can cause gradual changes to sleep architecture. On a nightly basis, elderly adults tend to experience lower amounts of slow-wave sleep and higher levels of shallow sleep. The amount of REM sleep will also decline by roughly 10 minutes per night for every decade of life.
One common problem among seniors is difficulty with thermoregulation, or the body’s ability to control and maintain a healthy core temperature. Thermoregulation can affect sleep architecture, since body temperature plays a key role in our sleep patterns: a person tends to wake up in the morning when his/her temperature rises, and will usually begin feeling tired around bedtime as his/her temperature declines. Loss of thermoregulation can cause body temperature to fall out of step with the circadian rhythm. This process, known as circadian desynchronization, can put people at risk for insomnia and other sleep-onset issues, as well as hypothermia and hyperthermia during certain times of the year.
Additionally, a wide range of chronic illnesses and conditions associated with old age can lead to secondary insomnia. These include:
Depression, anxiety and other psychiatric disorders have been linked to insomnia, as well. However, it is currently unclear whether these disorders directly cause insomnia, or vice versa.
Bad sleeping habits can also exacerbate the effects of insomnia. Elderly adults, especially those who are retired, are more likely to take daytime naps. Older individuals also spend more time in bed compared to younger people, and tend to rise at early or irregular times. All of these habits can significantly alter one’s sleep architecture.
Insomnia can lead to serious consequences. Adults with this condition routinely experience daytime drowsiness and the inability to properly concentrate. Together, these two factors put insomniacs at greater risk for falls, automobile accidents and other potentially hazardous situations. Other side effects of long-term insomnia include increased irritability and chronic headaches.
In addition to insomnia, older people are considered more susceptible to other dyssomnia and parasomnia sleep disorders.
One of the most common dyssomnia disorders in older adults is sleep apnea. This condition is characterized by temporary loss of breath for up to 60 seconds during sleep; due to its disruptive nature, apnea can greatly affect circadian rhythm. There are two classifications for the disorder: obstructive sleep apnea (OSA), which affects breathing by obstructing the airway; and central sleep apnea (CSA), which is triggered by improper communication between the brain and breathing muscles. OSA is the more common of the two; roughly 24% of older women and 9% of older men have been diagnosed with obstructive sleep apnea.
Cardiovascular disease is a serious concern for people with sleep apnea. These two conditions are often co-morbid, or simultaneously present in the same patient, and older people with one are more likely to also acquire the other. Obstructive sleep apnea is considered a predictor for coronary artery disease, and has also been associated with conditions like hypertension, heart failure, stroke and cardiac arrhythmia. Central sleep apnea has been widely reported in patients with congestive heart failure, as well.
A recent study by the American Heart Association argued that individuals who deal with chronic sleep fragmentation are at higher risk for arteriosclerosis, or hardening of the arteries. The study also drew a link between long-term sleep fragmentation and high levels of infarction, or tissue death caused by oxygen depletion. Both arteriosclerosis and infarction are considered predictors for stroke and cognitive impairment.
Narcolepsy is a dyssomnia disorder characterized by daytime fatigue and somnolence, or the strong desire to sleep. This can cause episodes known as ‘sleep attacks’, during which the individual will spontaneously fall asleep regardless of their present location or time of day. Other narcolepsy symptoms include routine hypnagogic hallucinations, which usually occur when someone is falling asleep or waking up; cataplexy, which refers to a spontaneous loss of muscular control; and sleep paralysis, or the inability to physically move upon waking. A diagnosis of Narcolepsy Type 1 or 2 is rare/uncommon at any age, and for most afflicted individuals begins to manifest in the mid-late teen years, with sleepiness and associated symptoms often worsening with age. A secondary peak of diagnosis occurs at ages 45-60.
Restless legs syndrome is another dyssomnia reported by elderly sleepers. Those who experience this condition often report an itching sensation beneath the skin, sometimes accompanied by tingling, cramping or physical pain. These symptoms typically set in around bedtime, and can lead to sleep-onset insomnia. The condition known as periodic limb movement disorder shares the same symptoms as restless leg syndrome, but there is one distinct difference: periodic leg movements only affect people during sleep, which can lead to sleep fragmentation and/or circadian disruption.
Snoring is one of the most commonly diagnosed parasomnia disorders among adults of all ages. Seniors are particularly prone to snoring, due to weakened airway muscles that help regulate proper breathing during sleep. While snoring does not normally carry any life- or health-threatening concerns, the condition is seen as a predictor for more serious problems like stroke or heart disease.
Additionally, the condition known as REM sleep behavior disorder is most often diagnosed in people over the age of 60; the disorder is associated with some age-related neurological conditions, such as Alzheimer’s and Parkinson’s disease. People with the disorder are unable to fully operate their muscles during REM sleep, when most dreaming occurs. This temporary paralysis can cause them to thrash or flail their limbs, stand up or walk around; some patients have reported more abnormal routines, such as eating or bathing while still asleep.
Now that we have discussed dyssomnias, parasomnias and other sleep-related conditions that often affect older people, let’s look at some popular sleep aids and other treatment methods.
An estimated 20% of seniors take some form of sleep aid for long-term insomnia and other chronic sleep-related disorders. A wide range of medication classifications and types are available in the United States, and each category carries a unique set of effects, characteristics and user warnings. You should always consult your physician before taking any type of sleep aid for the first time.
First let’s tackle the basic sleep aid classifications. Side effects, dependency risks and other information about specific medications can be found in the tables below.
Benzodiazepine Hypnotics: Benzodiazepine receptor agonists (known as BzRAs, or ‘benzos’, for short) are a group of prescription drugs that slow down the body’s central nervous system (CNS) through interaction with gamma-aminobutyric acid (GABA) neurotransmitters. Benzodiazepines are considered minor tranquilizers that can be used to neutralize anxiety and induce sleep. However, due to the strength of these drugs, most older patients begin their regimen at half the recommended dose as younger patients. Benzos also exhibit dangerous interactions with alcohol, so patients should never mix the two. Commonly prescribed types of benzodiazepine include the following:
Other benzodiazepine drugs that can be used as sleep aids include Alprazolam (Xanax®) and Flunitrazepam (Rohypnol®). However, these drugs are rarely prescribed for insomnia due to their highly addictive nature.
|Drug Name||Brands||Side Effects||Dependency Risks|
|temazepam||Restoril®||Dizziness, daytime drowsiness, muscle weakness, headaches, blurred vision||High|
|loprazolam||Dormonoct®, Havlane®||Dizziness, daytime drowsiness, nausea, headaches, blurred vision||Very High|
|flurazepam||Dalmane®||Dizziness, daytime drowsiness, inability to stand or walk, memory loss||Very High|
|clonazepam||Klonopin®||Dizziness, daytime drowsiness, loss of appetite, slurred speech, headache||High|
|diazepam||Valium®||Dizziness, daytime drowsiness, constipation, memory loss, muscle weakness, nausea, double vision, rash, irritability||Very High|
|lorazepam||Ativan®||Dizziness, daytime drowsiness, constipation, memory loss, muscle weakness, nausea, double vision, rash, irritability||Very High|
|nitrazepam||Mogadon®||Dizziness, daytime drowsiness, headache, muscle weakness||High|
|estazolam||ProSom®||Dizziness, daytime drowsiness, headache, muscle weakness, irritability||High|
Non-benzodiazepine Hypnotics: Commonly referred to as Z-Drugs, these medications (like the previous category) are classified as benzodiazepine receptor agonists. The key difference between the two groups is selectivity: benzos act on a wide range of receptors to trigger different effects, while Z-drugs focus exclusively on inducing sleepiness. Additionally, Z-drugs carry lower dependency risks and less pronounced side effects when compared to benzos. For these reasons, physicians generally prefer Z-drugs over benzos when prescribing a sleep aid. The four most common Z-Drugs prescribed today are:
|Drug Name||Brand(s)||Side Effects||Dependency Risks|
|zolpidem||Ambien®||Dizziness, daytime drowsiness, stuffy nose, dry mouth, nausea, constipation, diarrhea, headache||High if taken for longer than two weeks|
|zaleplon||Sonata®||Dizziness, daytime drowsiness, numbness, tingling, nausea, vision problems, constipation, diarrhea, headache||Medium|
|zopiclone and eszopiclone||Lunesta®||Bitter metallic taste, daytime drowsiness, chest pain, cold symptoms, headache, lightheadedness||Medium|
|ramelteon||Rozerem®||Dizziness, daytime drowsiness||Low|
Non-prescription Antihistamines: Histamines serve a number of useful purposes in the body, including regulation of your sleep-wake cycle. Antihistamines, as the name implies, are used to induce drowsiness in patients with insomnia and other conditions affecting their ability to become tired. Diphenhydramine is the most commonly prescribed over-the-counter antihistamine sleep aid; brands with diphenhydramine include Nytol, Sominex, Excedrin and Tylenol PM. Allergy relief brands like Benadryl also contain diphenhydramine, and may be prescribed as sleep aids. Doxylamine is another antihistamine that has proven to be an effective sleep aid; this is the active ingredient in Unisom sleep tablets. Other antihistamines usually prescribed for allergy relief may also be used as sleep aids, including chlorpheniramine and hydroxyzine.
Pain Relievers: These medications may be prescribed for sleep-related issues that stem from chronic pain. Unlike antihistamines, pain relievers normally do not cause daytime drowsiness. Acetaminophen, the active ingredient in Tylenol®, may be used to induce sleep. Doctors may also prescribe non-steroidal inflammatory drugs like ibuprofen, which is found in brands like Advil® and Motrin®.
Herbs and Supplements: As many as 1.5 million use alternative and natural sleep aids Many herbal and dietary supplements on the market can be used to treat insomnia and other sleep disorders. Melatonin is arguably the most commonly prescribed sleep aid supplement. The drug is considered effective for most people with sleep-onset or sleep maintenance insomnia ? although results have been mixed for long-term insomniacs. Melatonin can also ease jet lag symptoms. Other supplemental options include Valerian root, a flowering plant with sedative properties; and 5-HTP, a supplement derived from tryptophan (the chemical in turkey meat that causes drowsiness).
|Brands||Side Effects||Dependency Risks|
|Diphenhydramine||Nytol®, Sominex®, Excedrin PM®, Anacin PM®, Tylenol PM®||Dizziness, daytime drowsiness, dry mouth, constipation, nausea, difficulty during urination||Low|
|Doxylamine||Unisom®||Dizziness, daytime drowsiness, blurred vision, dry mouth/nose/ throat, constipation||Low|
|Chlorpheniramine||Chlorphen®||Dizziness, daytime drowsiness, blurred vision, dry mouth/nose/ throat, constipation, irritability||Low|
|Hydroxyzine||Hydroxyzine (Generic)||Dizziness, daytime drowsiness, blurred vision, dry mouth, constipation, nausea, headache||Very Low|
|Acetaminophen||Tylenol®||Dizziness, sweating, nausea, loss of appetite, trouble during urination, light-headedness, unusual bruising or swelling, yellowing of the skin and eyes||Very Low|
|Ibuprofen||Advil®, Motrin®||Dizziness, sweating, nausea, constipation, gas, diarrhea, mild itch or rash, ringing in the ears||Very Low|
|Herbs & Supplements|
|Melatonin||Generic supplement||Dizziness, daytime drowsiness, stomach cramps, depression, irritability||Very Low|
|Valerian Root||Generic capsules and extracts||Dizziness, headaches, nausea, irritability, anxiety||Very Low|
|5-HTP||Generic supplement||Dizziness, daytime drowsiness, abdominal pain, headache, heartburn, constipation, gas, diarrhea, depression, anxiety||Low|
Finally, a word about nursing homes and other long-term care facilities. Many staff members at these facilities rely on sleep aids to manage sleep issues with their clients. Sleep aid regimens also allow everyone living in the facility to adopt the same sleep schedule. However, the chronic use of the older sleeping pills in the elderly can produce undesirable side effects not normally reported in other patients. These effects may include impaired memory and alertness, incontinence and physical imbalance, as well as unwanted daytime drowsiness. For this reason, low-risk drugs with minimal side effects like Ramelteon and Melatonin are usually the preferred sleep aids for elderly patients.
Now that we’ve covered key information about sleep aids and other medications, let’s look at some of the unique considerations ? and most effective strategies ? for addressing sleep disorders in elderly people.
Weight gain is a major concern when treating insomnia in older patients. Poor sleep can lead to a lack of motivation and energy during the day, which in turn can discourage people from exercising or being physically active. Lack of sleep has also been proven to reduce levels of leptin, a ‘satiety hormone’ that is triggered after a meal; as a result, poor sleep can trigger overeating. Physicians treating older people with sleep disorders will often monitor weight gain, and may make dietary or exercise-related recommendations to help them keep their weight from reaching unhealthy levels.
Gender may also play a role in sleep disorder treatment. Senior women are more likely to report insomnia and other sleep problems than senior men, and the link between poor sleep and weight gain is more pronounced in women. A large number of postmenopausal women with sleep apnea have also reported changes in their EKG heart patterns; this is considered a predictor for heart failure and other cardiovascular conditions. In most cases, patients with serious heart-related issues will be unable to take benzodiazepines and other sleep aids with strong side effects.
Sleep disruption related to dementia is of particular interest to doctors who treat patients in nursing homes and long-term care facilities. Insomnia is fairly common among dementia patients, since neurodegenerative diseases like dementia can damage areas of the brain that regulate sleep-wake patterns and circadian cycles. Problem sleep can be also be an early indicator of dementia. A 2012 study found that older people who complained of daytime sleepiness, restless nights, and increased use of sleep aid medication were much more likely to get Alzheimer’s within two years; researchers noted that sleep problems were the single strongest early predictor of this form of dementia.
Other sleep disorders can be used to predict the onset of neurodegenerative disease in some patients, as well. REM sleep behavior disorder, for instance, is considered a predictor for the condition known as Lewy body dementia (LBD); LBD, like REM sleep behavior disorder, is characterized by daytime sleepiness and fatigue. REM sleep behavior disorder may also predict the onset of Parkinson’s disease. Similarly, obstructive sleep apnea (OSA) shares several causal factors with Alzheimer’s disease.
Cognitive behavioral therapy (CBT) has proven effective for many older people who are unable to take sleep aids and other medications. Many people with a history of sleep problems have formed incorrect or negative associations with falling and staying asleep, and therapy can help them adjust their mindsets. Some older patients think their sleep cycle is permanently damaged and will never be better as a natural consequence of their age. and that is not true. Others believe they must spend eight hours in bed every night, whether they are asleep or awake. Both of these ideas are misconceptions.
CBT regimens vary by practitioner. Sleep restriction, or helping clients adopt and maintain a more rigid sleep schedule, is a common component of CBT. Stimulus control is also key; this involves the gradual removal of bedroom activities that conflict with sleep, such as eating or watching television. CBT patients are usually encouraged to keep a sleep diary, which allows them to discuss nightly sleep patterns with their therapist at each session. Other popular methods include relaxation training and, in some cases, paradoxical intention; this procedure requires patients to stay awake for as long as possible. Treatment outcomes will depend on the patient, but most elderly individuals with sleep disorders receive between four and 12 CBT sessions. In the process, misconceptions and misinformation about sleep in general are eliminated, and better sleep hygiene habits are developed.
Apnea and other sleep-disordered breathing (SDB) conditions can be treated with continuous positive airway pressure (CPAP) machines. CPAP treatment may also decrease daytime sleepiness, and there are some indications that this method can inhibit cognitive impairment in demented patients. Institutional caregivers have self-reported that CPAP treatment decreased overall snoring and improved overall quality of life among patients.
Next, let’s explore some strategies that older people can adopt to improve their sleep hygiene and ensure a healthy circadian cycle each night. Leading experts offer the following tips for sleep-deprived seniors.
We’ve combed the Web and compiled a wealth of reliable information on symptoms, treatments and other aspects of age-related sleep disorders. For more information on these topics, please visit the following online resources.
Help and Support Groups
Aging Sleep Studies and Findings
Senior Living Resource Guides