The Mystery Of Insomnia In The Elderly

There are many reasons why someone over 60 might not want to sleep. It could be that they are unmotivated to go to bed, even though they know they should be getting rest. This could be due to a desire for more me-time, especially if someone feels overscheduled at work or at home. Alternatively, it could be that they are unable to sleep due to insomnia, poor sleep hygiene, or a misalignment with their circadian rhythm.

Other reasons for not wanting to sleep include underlying health issues, side effects of medication, or anxiety about sleep itself. As people age, they are more likely to develop health problems that can cause sleep disturbances, such as heart and lung conditions, gastroesophageal reflux disease, painful conditions like osteoarthritis, and neurodegenerative disorders.

Additionally, older adults tend to get sleepy earlier in the evening and sleep less deeply than when they were younger. They may also be unaware that it's normal for their sleep patterns to shift with age, causing them to feel sleepy earlier and wake up earlier.

Addressing the root cause of sleepless nights is essential, and if the issue persists, it is important to consult a healthcare professional for guidance.

Circadian rhythm misalignment

Circadian misalignment is a term that describes a variety of circumstances, such as inappropriately timed sleep and wake, misalignment of sleep/wake with feeding rhythms, or misaligned central and peripheral rhythms. Circadian misalignment can occur when the individual’s sleep-wake cycle is inappropriately timed relative to the biological night, when eating is misaligned with other biological rhythms, or when there is misalignment between the central (SCN) and peripheral rhythms. The suprachiasmatic nucleus (SCN) or "master clock", located in the brain, controls melatonin production, which helps regulate sleep.

Circadian misalignment has been linked to a variety of health issues, including metabolic disorders, psychiatric disorders, and an increased risk of physical diseases such as cardiovascular disease, diabetes, obesity, and cancer. For example, studies have shown that individuals with circadian misalignment tend to have higher levels of ghrelin, an appetite-stimulating hormone, and lower levels of leptin, a satiety hormone, which can lead to increased hunger and energy intake. Circadian misalignment can also reduce 24-hour energy expenditure and alter the levels of appetite hormones, further promoting weight gain and obesity.

Additionally, circadian misalignment can disrupt feeding behaviours and appetite-regulating hormones, leading to changes in glucose metabolism and mood. This misalignment can also increase the risk of mood disorders such as depression, bipolar disorder, and schizophrenia.

To address circadian misalignment, it is important to establish healthy sleep habits and routines, such as maintaining a regular sleep and wake schedule, avoiding long or late naps, reducing exposure to blue light from electronic devices before bed, and engaging in physical activity.

Sleep disorders

Other common sleep disorders among seniors include:

• Circadian Rhythm Sleep Disorders: Older people are at higher risk due to the deterioration of internal mechanisms regulating circadian rhythm. Advanced sleep-wake phase disorder, where individuals feel sleepy in the early evening and wake up between 3-5 am, is particularly common.
• Sleep-Related Breathing Disorders: These include obstructive sleep apnea and central sleep apnea, which are prevalent in older populations, especially those with dementia. Obesity, alcohol consumption, and smoking are contributing factors.
• Periodic Limb Movements and Restless Legs Syndrome: These conditions cause involuntary leg movements during sleep and an overwhelming urge to move the legs while resting, leading to nighttime arousals and tiredness the next day.
• REM Sleep Behaviour Disorder: People with this disorder physically act out their dreams, often involving violent movements that can be dangerous to themselves and their bed partner. This disorder is more common in elderly men and is linked to degenerative neurological conditions.

Causes of Sleep Disorders in Older Adults

There are several factors that can contribute to sleep disorders in older adults:

• Circadian Rhythm Changes: The endogenous circadian clock can be disrupted by changes in the body's natural internal clock, leading to altered sleep patterns.
• Medical Illness: Conditions such as hyperthyroidism, arthritis, heart failure, and chronic obstructive pulmonary disease can impact sleep.
• Psychiatric Illness: Depression and anxiety disorders are commonly associated with sleep disturbances.
• Medications: Polypharmacy, or the use of multiple medications, is a concern in older adults. Many drugs used to treat geriatric medical problems can disrupt sleep.
• Poor Sleep Hygiene: Habits such as daytime napping, excessive caffeine consumption, and irregular sleep schedules can contribute to sleep disorders.

Treatment of Sleep Disorders in Older Adults

The treatment of sleep disorders in older adults should address the underlying causes. Non-pharmacological interventions, such as cognitive behavioural therapy, stimulus control therapy, and sleep restriction therapy, are often effective. Pharmacological interventions may be considered if non-pharmacological approaches are ineffective, but they should be used with caution due to potential side effects and interactions with other medications.

Poor sleep hygiene

Inconsistent Sleep Schedules

Having an irregular sleep schedule can negatively impact your sleep quality. This includes going to bed and waking up at different times each day, as well as taking long or late naps during the day. A consistent sleep schedule is crucial for regulating your body's internal clock and promoting healthy sleep.

Substance Use

The use of stimulants, such as caffeine and nicotine, especially later in the day, can interfere with your sleep. Caffeine is a well-known stimulant that can keep you wired even when you want to rest. Similarly, while alcohol may make you feel sleepy initially, it can disrupt your sleep later in the night. Reducing or avoiding the consumption of these substances, especially close to bedtime, can improve your sleep hygiene.

Electronic Device Usage

The use of electronic devices, such as cell phones, tablets, and laptops, before bed can negatively impact your sleep. The blue light emitted by these devices suppresses melatonin production, a hormone that regulates sleep. Additionally, the mental stimulation from these devices can make it harder to fall asleep. It is recommended to unplug from electronics at least 30 minutes to an hour before bedtime to improve sleep hygiene.

Inadequate Bedroom Environment

Your bedroom environment plays a crucial role in sleep hygiene. Factors such as light, noise, temperature, and comfort can impact your sleep quality. Bright lights and noise can disturb your sleep, while an uncomfortable mattress, pillow, or temperature can make it difficult to fall and stay asleep. Optimizing your bedroom environment by using curtains, earplugs, adjusting the temperature, and ensuring comfortable bedding can improve sleep hygiene.

Lack of Relaxing Routines

Engaging in activities that promote relaxation before bed can improve sleep hygiene. This includes activities such as meditation, mindfulness, reading, journaling, or relaxation exercises. Instead of focusing on falling asleep, aiming for relaxation can make it easier to transition into sleep. Additionally, setting aside time during the day to address worries and anxieties can help calm your mind before bedtime.

Underlying health issues

There are many health issues that can cause sleep disturbances in older adults. These are some of the most common:

• Heart and lung conditions such as heart failure and chronic obstructive pulmonary disease (COPD). These conditions can affect breathing and make it difficult to sleep through the night.
• Gastroesophageal reflux disease (GERD), which can cause heartburn symptoms, especially after big meals late at night.
• Painful conditions, including osteoarthritis, which can make it difficult to get comfortable and sleep soundly.
• Urinary problems that cause frequent urination at night, such as an enlarged prostate or an overactive bladder.
• Mental health issues such as depression and anxiety can also disrupt sleep.
• Neurodegenerative disorders such as Alzheimer's and Parkinson's disease can affect sleep patterns and quality.
• Medication side effects. Many medications can interfere with sleep, and older adults taking multiple medications are at a higher risk of experiencing sleep disturbances.
• Restless leg syndrome (RLS), which causes unpleasant sensations in the legs when trying to fall asleep.
• Periodic limb movements during sleep (PLMS), which involves intermittent movements of the lower limbs that can disturb sleep.

Medication side effects

Diphenhydramine, a common ingredient in over-the-counter sleep aids and allergy treatments, is known to cause serious side effects in people aged 65 and older. These side effects include confusion, dizziness, urinary retention, and liver or kidney issues. The older the person, the greater the risk of adverse effects. Diphenhydramine can also cause decreased reaction times, leading to falls and accidents, especially at night. There is also evidence that its chronic use may be associated with the development of dementia.

Other medications that may cause or worsen sleep problems include opioid pain medications, which are associated with central sleep apnea, and benzodiazepines, which are habit-forming and negatively impact brain function.

Additionally, certain prescription sleep medications, such as eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien), are included on the American Geriatric Society's list of medications that adults aged 65 and older should avoid due to their potent effects and associated risks.

It is important to consult with a healthcare provider to review all medications and discuss alternative treatments for sleep disturbances, as medication side effects are a contributing factor to sleep issues in older adults.

Frequently asked questions