Sleep and Aging

Sleep and Aging Overview:

Several generalizations can be made regarding sleep and aging characteristics.

Compared with younger persons, elderly persons tend to achieve less total nighttime sleep.

However, it cannot be assumed that elderly persons require less sleep.

Sleep related complaints and use of sedative hypnotics are more common in the older population than in younger patients. As with most bodily functions, sleep deteriorates as we age.

Several primary sleep disorders are associated with aging. Primary sleep disorders may delay sleep onset, cause multiple arousals and awakenings, and promote excessive daytime sleepiness.

Wandering behavior and confusional arousals may occur, especially in patients with dementing disorders. In rare instances, behaviors emanating from sleep may result in serious injury to the patient or bed partner.

Although the elderly spend more time in bed, they have more awakenings, less slow-wave sleep, lower sleep efficiency, and are more easily aroused from sleep. Increased daytime sleepiness may be the effect of such a pattern.

REM Sleep

Overall, the sleep-wake cycle in the elderly may be fragmented, with interrupted nighttime sleep and daytime wakefulness interrupted by naps. The deepest stages of non-REM sleep are frequently reduced or nonexistent in elderly persons.

However, REM sleep tends to be preserved. Although a mild deterioration in sleep quality may be normal in the aging process, an elderly patient's complaint of significantly disrupted nighttime sleep or impaired daytime functioning because of excessive sleepiness must be evaluated.

Insomnia

Insomnia is a problem in all stages of life but is particularly common after age 65. A number of factors, including advanced age, psychosocial influences, medical illness, and the use of medications and alcohol may disturb sleep architecture. The two main causes given for insomnia were worries and physical discomfort.

Alterations in work status and finances after retirement may cause anxiety and depression with resultant insomnia. Other significant factors are the death of a partner or loved ones, hospitalization, a change in residence to a nursing home or child's home, or extended travel.

Circadian rhythm

Another common age associated sleep change relates to the circadian rhythm of the typical sleep period. Although exceptions exist, elderly persons tend to go to sleep earlier in the evening and to awaken earlier in the morning. Early morning awakening is a common complaint in the elderly.

Some people find it annoying to awaken spontaneously at 4:30 a.m. instead of at 6:30 a.m. In these persons, if the onset of evening sleeps is not correspondingly earlier, sleep deprivation and excessive daytime sleepiness may result.

Daytime napping may compound the problem by reducing the drive for sleep at the usual bedtime hour, resulting in delayed sleep onset and a further decrease in the duration of nighttime sleep.

Other Sleep disorders

Less common in elderly persons, but sometimes dramatic, is the development of a "night owl" pattern, with bedtime delayed until the early-morning hours.

This sleep-wake cycle may have been tolerated in the younger years during employment, when the cues of early-morning bright light were stronger and the regularity of sleep-wake hours was greater.

On retirement, however, these cues weaken, and the sleep-wake cycle may become delayed by several hours. These patients may complain of day-night reversal, where sleep does not begin until dawn and then continues until mid-afternoon.

Sleep and Aging – Treatment for disorders

Because many factors influence the sleep-wake cycle, treatment must be individualized according to the patient's specific symptoms and findings from the patient's evaluation. Several generalizations are possible.

Implementation of good sleep habits and daily physical activity should help create an environment conducive to restorative sleep. Even if poor sleep habits are not responsible for insomnia, elimination of such habits can minimize their perpetuating influence.

Daily exercise and exposure to daylight can help reinforce the circadian cycle. These measures have the greatest potential for improving the quality of sleep in elderly persons. Exposure to bright light for 30 to 60 minutes in the evening may benefit patients with early bedtimes who complain of early-morning awakening.

Patients may be advised to avoid going to bed until they feel as though they can easily fall asleep. An extended wakeful time in bed (e.g., more than 30 minutes) should be avoided to minimize further reinforcement of hyperarousal. In addition, patients should plan relaxing nighttime activities before bedtime.

Low dosages of sedating antidepressants are especially helpful in patients with depressive symptoms. While potentially valuable in offering relief of insomnia, hypnotic agents should not be regarded as the ultimate solution to a sleep problem.

They should be used under limited circumstances, following evaluation of the patient's symptoms and in the context of good sleep habits. Consultation with a sleep disorders specialist should be considered in patients with marked daytime sleepiness, because this symptom can be dangerous.

Guidance regarding the management of chronic insomnia and sleep-related behavioral problems also may be obtained from a sleep disorders specialist. Formal sleep studies are appropriate when a primary sleep disorder is suspected.