Challenges of treating seniors with sleep problems

A graying population makes the issue of insomnia in the elderly an important topic for physicians, nurses, and assisted living facility staff.  It is not clear whether declining sleep quality is a normal consequence of aging or is a result of other illnesses and medications seniors often take.  Either way, older people are more prone to sleep maintenance insomnia and have significantly less deep sleep than young adults.  They are more likely to have restless legs syndrome and apnea.

A Gallup Poll found that 25 percent of seniors think they have a sleep problem. Most people told the pollsters they were concerned about sleep medication because of the risk of developing dependency. They also understood that sleep is important for both health and subjective quality of life.

The most common sleep problem for older people is sleep maintenance insomnia. This is a complicated issue, and it's often overly simplistic to assume that insomnia has just a psychiatric or medical or psychological cause. The large majority of people experience changes in sleep architecture and circadian rhythms as they age. Older people also frequently have other medical problems that affect sleep and require medication that may affect sleep. People experience both physiological and psychological changes as they age.  The fragmented patterns experienced by elderly individuals can be due to the degeneration or dysfunction of the circadian processes.  These include subtle changes in the brain.

Many older people live in institutions. While this style of living may affect sleep quality for both good and ill; it provides a chance for researchers to get good data about sleep patterns. It turns out that two out of three nursing home residents have at least one sleep disorder. Among those living in assisted living the prevalence is slightly lower, but still over 50%.

Apnea is loosely correlated with age, and sleep apnea can affect short-term memory. Sometimes the cognitive decline experienced by older people is traceable to apnea.

Neuroscientists have recently found that the decline in slow-wave deep sleep in older people is a proximate cause of declining memory in seniors. Older adults have both less slow-wave sleep and less activity in the prefrontal cortex, as determined by functional MRI studies. Fewer memories are formed. Scientists have artificially provided electrical stimulation to the prefrontal cortex and induced both more deep sleep and better memory retention.

Light therapy and behavior therapies are important in multimodal treatment of insomnia, and sleep hygiene includes both regular physical and social activities to preserve entrainment of circadian rhythms affecting sleep.

Restless legs syndrome incidence rises with age.  The only good drugs for RLS are dopamine agonists, and they are known to have low tolerance among the elderly. People sometimes just have to live with untreated RLS.

Studies have suggested that sleep apnea and nocturnal myoclonus are especially prevalent among the elderly. People who have sleep apnea and/or nocturnal myoclonus typically have significantly less REM sleep, significantly more stage 1 sleep, and significantly more awakenings than normal sleepers.

Older Women

More women have insomnia several times a week than men. Senior women are more likely to report sleep problems than senior men.  This is exacerbated by social expectations and family roles.  They are more likely to be the primary caregiver than men and more likely to shoulder a larger share of the housework.

Sleepiness leads to weight gain by discouraging physical activity. Depressed REM sleep leads to overeating.  Both men and women gain weight with advancing age, but the link with poor sleep seems more pronounced in women.

Postmenopausal women (but not premenopausal women) with sleep apnea have been found to have changes in heart EKG patterns. The changes may indicate a higher chance of heart problems.

Sleep Disorders in Patients With Dementia

Neurodegenerative diseases often damage areas of the brain that produce neurotransmitters and hence affect sleep patterns.  Unusual sleep behavior may exacerbate or result from the neurodegenerative disease.

Sleep disruption related to dementia is of particular interest to doctors involved with patients in long-term care facilities and to family members of the patient. Sleep disorders are common in patients with dementia, due to neurodegenerative processes in areas in the brain that regulate sleep-wake patterns and circadian rhythm mechanisms.   This is one reason living with a person with dementia can be difficult.  Treatment of dementia may help, but only to a limited extent.

Cognitive Behavioral Therapy

CBT is recognized as an effective method of addressing insomnia, although its use is limited because of concerns about cost, time, and skepticism about its efficacy among some. CBT regiments differ from practitioner to practitioner, but they usually involve interactive education and follow-up in sleep restriction, stimulus control, sleep hygiene, and relaxation training. Often those with a history of sleep problems have formed incorrect or negative thoughts and ideas about getting to sleep and the sleep process, and therapy can help them change their minds. Old people sometimes 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 8 hours in bed every night, even when they are not sleeping, and that is also not true.

CBT works for elderly people. This has been demonstrated many times. It doesn't work for everyone or every time, but it is a good option that helps people without the use of drugs. Given that elderly people tend to take many prescription drugs, methods to avoid adding even more drugs are often particularly welcome.

How do you get CBT for sleep problems? Ask a nurse or doctor wherever you get your main medical care. They wiil probably not be able to provide this service directly, but they may know about CBT practitioners in your area and covered under your insurance.

Related: Sleep Aids for Seniors


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