Evie Summers
Sleep is a complex process that changes as we age. Older people tend to experience less time in the slow-wave NREM stage, making it easier for them to wake up throughout the night and feel tired in the morning. This shift in sleep patterns can be attributed to various factors, including increased prevalence of sleep disorders such as insomnia, sleep-disordered breathing, and restless leg syndrome. Additionally, older adults are more likely to take medications and experience medical conditions that affect their sleep quality. While insomnia is a common sleep disorder among the elderly, it is important to note that sleep problems in older adults are not always indicative of a sleep disorder and can be a natural progression of aging. However, if sleep issues persist and negatively impact daily life, seeking medical advice is recommended.
| Characteristics | Values |
|---|---|
| Prevalence of sleep disorders | High |
| Insomnia | Most common sleep disorder |
| Sleep disordered breathing | Most common in individuals with vascular dementia |
| Alzheimer's dementia | Presents with insomnia and excessive daytime napping |
| Restless leg syndrome | Prevalence of 10-35% among those over 65 |
| REM sleep behaviour disorder | More common in men over 50 |
| Circadian rhythm disorders | More common with age |
| Sleep duration | Older people need less sleep |
| Sleep quality | Older people experience less slow-wave NREM sleep |
| Sleep patterns | Older people go to bed and wake up earlier |
| Sleep medication | Should be used with caution due to risk of dependence and withdrawal |
| Non-pharmacological interventions | Underused by healthcare practitioners |
| Melatonin | May be effective in older adults |
| Other herbal medications | Valerian, chamomile, hops, kava-kava, passionflower |
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What You'll Learn
Insomnia and other sleep disorders
As people age, their sleep patterns change. Older adults tend to go to bed and wake up earlier, and the amount of time spent in each type of sleep decreases. Sleep tends to be shorter and lighter, and they may wake up more often during the night. Many older adults don't sleep well, and insomnia is the most common sleep disorder among the elderly. It is characterised by trouble falling or staying asleep, or waking up too early, resulting in a lack of quality sleep.
There are many causes of insomnia in older adults, and it is often related to other factors such as illness, medications, mental health, pain, or emotional stress. Older people are also more likely to take medications and have medical conditions that can affect their sleep. For example, people with Alzheimer's dementia commonly experience insomnia and excessive daytime napping, while sleep disordered breathing is the most common sleep disorder in individuals with vascular dementia. Additionally, older adults are more susceptible to the effects of caffeine and are more easily impacted by emotional stress and physical changes.
Excessive daytime napping can lead to a reversal of the sleep-wake cycle, causing further disturbances in sleep patterns. Older adults may also experience an increase in the frequency of daytime naps, which can impact their ability to fall asleep at night. It is important to note that while sleep patterns do change with age, persistent sleep difficulties could indicate an underlying sleep disorder.
Treatment options for insomnia in older adults include non-pharmacological interventions, such as maintaining a consistent sleep schedule, exercising, avoiding caffeine and tobacco, and limiting activities in bed. If these measures are ineffective, doctors may consider prescribing sleep medications, although this requires careful consideration due to the risk of dependence and withdrawal. Melatonin receptor agonists, such as ramelteon, have shown efficacy in older adults for sleep initiation insomnia. Antidepressants and anti-histamines have also been used to treat insomnia, but they may increase the risk of falls and cause orthostatic hypotension, especially in the elderly.
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Medication and treatment options
Older adults tend to experience less time in the "slow-wave" NREM stage, making it easier for them to wake up throughout the night. This can lead to a feeling of tiredness in the morning and a constant feeling of never getting enough rest. While these changes are normal and do not indicate a sleep problem, older adults are more prone to insomnia and other sleep disorders.
Before starting treatment for insomnia, it is important to rule out other conditions that may contribute to it, such as sleep apnea, untreated psychiatric illness, endocrine disorders, neurologic disorders, chronic obstructive pulmonary disease, asthma, heart failure, and gastroesophageal reflux disease. A medication review is also crucial, as many antidepressants, antihypertensives, sedatives, antihistamines, and steroids can interfere with sleep.
Non-Pharmacological Treatments
Cognitive behavioural therapy for insomnia (CBT-I) is the gold standard for treating insomnia in all populations, including older adults. While it is time-intensive and does not offer immediate results, it is a recommended first-line treatment option compared to hypnotic medications in older adults.
Other non-pharmacological treatments include:
- Maintaining a sleep diary
- Getting exercise and eating nutritious meals
- Avoiding tobacco and caffeine
- Going to bed only when tired
- Waking up at the same time each morning and avoiding naps during the day
Pharmacological Treatments
If non-pharmacological treatments are not effective, your doctor may consider prescribing sleep medications. Choosing appropriate insomnia medication for older adults requires careful consideration, as some medications can lead to dependence and withdrawal risks.
Pharmacologic options for older adults include:
- Low-dose doxepin: A tricyclic antidepressant that has shown modest advantages over a placebo for sleep maintenance and duration but not for sleep initiation. Headaches and somnolence are common side effects, and higher doses should be avoided due to potential cognitive difficulties.
- Melatonin: Melatonin at a dose of 2 mg has been approved in Europe for the short-term treatment of insomnia in patients aged 55 and older. It is also available as a receptor agonist, such as ramelteon, which has shown efficacy in older adults for sleep initiation insomnia.
- Sedating antidepressants: Trazodone and mirtazapine are often prescribed at bedtime for insomnia, especially when used in conjunction with depression. However, little scientific evidence supports their efficacy in treating insomnia without associated depression, and they can increase the risk of falls and cause orthostatic hypotension.
- Non-benzodiazepines: Shorter-acting non-benzodiazepines like zolpidem, eszopiclone, and zaleplon carry a lower risk of side effects. However, they should be avoided in older adults with dementia and cognitive impairment.
- Orexin receptor antagonists: These target wakefulness-promoting neuropeptides that regulate the sleep-wake cycle and have been studied in older adults with no significant efficacy or safety differences compared to younger adults.
It is important to note that barbiturates, chloral hydrate, and longer-acting benzodiazepines should be avoided in older adults due to the high risk of overdose, dependence, and adverse effects like daytime sedation, falls, and confusion.
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Lifestyle factors and sleep habits
As people age, their sleep patterns change. Older adults tend to go to bed and wake up earlier than younger adults, and the amount of time spent in each type of sleep decreases. Sleep tends to be shorter and lighter, and older adults may wake up more frequently during the night. Many older adults experience insomnia, which is the most common sleep disorder among the elderly. It is characterised by difficulty falling or staying asleep, or waking up too early, resulting in a lack of refreshing sleep. Other sleep disorders prevalent in older adults include sleep apnea, restless leg syndrome, REM sleep behaviour disorder, and circadian rhythm disorders.
- Exercise and nutrition: Regular exercise can help regulate sleep for individuals aged 50 to 78. It is also important to maintain a healthy diet, as eating too much or too close to bedtime can disrupt sleep.
- Substance use: Avoid tobacco and caffeine, as these substances can negatively impact sleep. Alcohol consumption should also be moderated, as it can disrupt sleep patterns.
- Sleep environment: Reserve your bed exclusively for sleeping. Avoid activities such as watching TV, working, or playing video games in bed. Ensure your bedroom is comfortable, dark, and quiet to promote better sleep.
- Sleep schedule: Establish a consistent sleep schedule by going to bed and waking up at the same time each day. Avoid taking naps during the day, as it can disrupt your nighttime sleep.
- Managing stress: Ageing can make individuals more susceptible to emotional stress, which can impact sleep. Find healthy ways to manage stress, such as meditation or relaxation techniques.
- Limit screen time: Avoid looking at electronic devices like cell phones or tablets before bed. The blue light emitted by these devices can interfere with your sleep hormones.
- Seek professional help: If you continue to experience sleep difficulties, consult a doctor or a sleep specialist. They can provide guidance, recommend sleep aids, or prescribe appropriate sleep medications if necessary.
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Sleep duration and quality
Older people tend to experience less time in the "slow-wave" NREM stage of sleep, which can cause them to wake up more frequently throughout the night, resulting in feelings of tiredness in the morning. This aligns with the observation that older adults tend to become "light sleepers" and prefer going to bed earlier while also waking up earlier. It is common for older individuals to feel the need for longer sleep durations or daytime napping. While such sleep changes are typically normal, they may, in some cases, indicate an underlying sleep disorder.
Insomnia, the most common sleep disorder among older adults, is characterised by difficulty falling or staying asleep, resulting in non-refreshing sleep. It is prevalent in more than 50% of the elderly population and can be classified as transient, acute, or chronic. Acute insomnia is often related to identifiable causes, such as caffeine consumption, excessive dinner intake, recent surgery, or emotional stress. Older adults are also more susceptible to other sleep disorders like sleep apnea, restless legs syndrome, and REM sleep behaviour disorder.
The duration and quality of sleep in older adults can be influenced by various factors. Firstly, older individuals are more likely to take medications and experience medical conditions that affect their sleep. Illnesses, mental health issues, and pain can also contribute to disrupted sleep patterns. Additionally, ageing is associated with increased sensitivity to emotional stress and physical changes, which can further impact sleep quality.
To improve sleep duration and quality, older adults can implement several strategies. Maintaining a consistent sleep schedule, including both bedtime and wake-up time, is essential. While napping is generally beneficial, excessive daytime napping should be avoided to prevent sleep-wake cycle disruption. Regular exercise and nutritious meals can promote better sleep, while substances like tobacco and caffeine should be limited. It is also important to use the bed only for sleeping and avoid activities like watching TV or playing video games in bed.
In cases where sleep difficulties persist, seeking medical advice is recommended. Doctors may suggest sleep medications, but these require careful consideration due to potential side effects and risks of dependence. Non-pharmacological interventions, such as melatonin receptor agonists (e.g., ramelteon) and herbal remedies (e.g., valerian, chamomile), may also be explored.
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Age-related sleep changes
Additionally, older adults are more likely to take medications and have medical conditions that affect their sleep. Factors such as illness, medications, mental health, and pain can contribute to sleep difficulties. Sleep disorders, such as insomnia, sleep apnea, restless leg syndrome, and REM sleep behaviour disorder, become more prevalent with age. Insomnia, characterised by trouble falling or staying asleep, is the most common sleep disorder among the elderly.
It is important to distinguish between normal age-related sleep changes and potential sleep disorders. If you consistently experience difficulty falling asleep or feel tired during the day, it may be necessary to consult a doctor. They may recommend lifestyle changes, such as regular exercise, nutritious meals, avoiding caffeine and tobacco, and maintaining a consistent sleep schedule. In some cases, they may also prescribe sleep medications, although these should be approached with caution due to potential side effects and risks of dependence.
The use of sleeping pills should be carefully considered, as prolonged use may lead to psychological dependence rather than addressing the underlying sleep issue. Additionally, older adults should be cautious when using certain medications to treat sleep disorders. For example, longer-acting benzodiazepines should be avoided due to the risks of daytime sedation, falls, and confusion. Instead, non-benzodiazepines like zolpidem, eszopiclone, and zaleplon may carry a lower risk of side effects. Melatonin receptor agonists, such as ramelteon, have also shown efficacy in treating insomnia in older adults.
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Frequently asked questions
Older people tend to experience less time in the "slow-wave" NREM stage, which can cause them to wake up more frequently throughout the night. Other factors that can cause sleep troubles include illness, medications, mental health, and pain, as well as caffeine, exercise, and emotional stress.
Insomnia is the most common sleep disorder among older adults, affecting more than 50% of elderly people. Other common sleep disorders include sleep apnea, restless legs syndrome, REM sleep behaviour disorder, and circadian rhythm disorders.
A good night's sleep typically leaves you rested and energised in the morning. Signs that you may not be getting enough quality sleep include waking up tired, feeling easily annoyed, and having trouble falling or staying asleep.
Older adults need around seven to nine hours of sleep each night, which is similar to the amount needed by younger adults. However, older adults tend to go to bed earlier and wake up earlier, and they may also experience an increase in daytime napping.
There are several strategies that older adults can use to improve their sleep. These include maintaining a consistent sleep schedule, avoiding caffeine and tobacco, getting regular exercise, and establishing a relaxing bedtime routine. If sleep troubles persist, it is recommended to consult a doctor or sleep specialist.
