The Mystery Of Elderly Insomnia: Why Can't They Sleep?

Sleep is an essential part of our lives, and as we age, our sleep patterns and needs can change. Older adults often experience disruptions in their sleep, and understanding the reasons behind this can help improve sleep quality. One common reason is the change in the body's internal clock, which can cause older people to feel sleepy earlier in the evening and wake up earlier in the morning. Medical conditions, such as heart disease, diabetes, and arthritis, can also impact sleep. Additionally, medications, lifestyle choices, and mental health conditions can play a role in sleep disturbances. It is important to maintain good sleep hygiene, such as having a consistent sleep schedule and avoiding substances that interfere with sleep. While older adults may need the same amount of sleep as younger adults, the quality of their sleep may differ, with older people experiencing more fragmented and lighter sleep.

Circadian rhythm changes

As people age, the function of the SCN deteriorates, disrupting circadian rhythms and directly influencing when people feel tired and alert. This is known as a phase advance, causing older adults to feel tired earlier in the afternoon and wake up earlier in the morning. Research has also shown that older adults spend more time in the earlier, lighter stages of sleep and less time in the later, deeper stages, leading to more fragmented and less restful sleep.

The production of hormones such as melatonin and cortisol may also play a role in sleep disturbances in older adults. Melatonin is a sleep hormone that is normally produced in response to darkness, helping to promote sleep by coordinating circadian rhythms. As people age, the body tends to secrete less melatonin, which may contribute to sleep difficulties.

Additionally, older adults often have insufficient exposure to daylight, which is one of the most powerful cues for maintaining circadian rhythms. This insufficient exposure to daylight can further disrupt their sleep patterns.

Lifestyle factors

Exercise

Regular exercise can significantly improve sleep patterns in older adults. It is recommended to exercise daily, but not within three hours of bedtime, as it may interfere with falling asleep. Getting enough sunlight, especially in the late afternoon, can also be beneficial.

Substance Consumption

Substances like caffeine, alcohol, and tobacco can negatively impact sleep. Caffeine, commonly found in coffee, tea, soda, and chocolate, can delay the body's circadian rhythm and keep individuals awake. Alcohol may induce sleep initially but disrupts sleep quality by making it challenging to stay asleep. Smoking, specifically nicotine, disrupts the circadian rhythm, leading to increased daytime sleepiness and reduced sleep duration.

Napping

While napping was once believed to be detrimental to sleep, current research suggests that short daytime naps can be beneficial. Limiting naps to no more than 30 minutes and avoiding late afternoon or evening naps can help improve nighttime sleep.

Sleep Schedule and Routine

Maintaining a consistent sleep schedule is crucial for older adults. This includes going to bed and waking up at the same time each day, even on weekends or while travelling. Additionally, developing a relaxing bedtime routine can aid in falling asleep. Some activities to consider include reading, listening to soothing music, or taking a warm bath.

Bedroom Environment

Creating a comfortable and distraction-free bedroom environment is essential. Keeping the room at a pleasant temperature, not too hot or cold, and ensuring it is quiet and dark can promote better sleep. It is advisable to avoid watching television or using electronic devices like computers, cell phones, or tablets in the bedroom, as the light from these devices may disrupt sleep.

Meals and Snacks

Consuming large meals close to bedtime can interfere with sleep. It is recommended to eat dinner at least four hours before bedtime. However, a light bedtime snack may be beneficial, with warm milk being a popular choice due to its natural sedative-like properties.

Medical conditions

Sleep problems are common in older adults, with many experiencing less sleep than they need. This can be caused by a variety of medical conditions, including:

Cardiovascular Disease

A study showed that 39% of people with cardiovascular disease regularly slept fewer than 6.5 hours, resulting in an increased risk of death.

Chronic Pain

Pain and sleeplessness can create a vicious cycle, with less sleep leading to more pain. Conditions such as arthritis can cause pain that disrupts sleep.

Alzheimer's Disease

Alzheimer's disease often changes a person's sleeping habits. Some people with Alzheimer's sleep too much, while others don't sleep enough. Some wake up many times during the night, while others wander or yell at night.

Mental Health Conditions

Depression and anxiety are common causes of sleep problems in older adults. These conditions can make it difficult for individuals to fall asleep or stay asleep throughout the night.

Parkinson's Disease

Up to 40% of people with Parkinson's disease have obstructive sleep apnea, according to the Parkinson's Foundation.

Neurological Conditions

Neurological conditions such as multiple sclerosis and traumatic brain injuries can also disrupt sleep.

Gastrointestinal Conditions

Gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS) are examples of gastrointestinal conditions that can impact sleep.

Lung or Respiratory Conditions

Chronic obstructive pulmonary disease (COPD) and asthma are conditions that may increase the risk for obstructive sleep apnea.

Poor Bladder Control

Nocturia, or nighttime urination, increases with age and can contribute to sleep disruptions.

Medication Side Effects

Many older adults take medications that can disrupt sleep, including diuretics, antihypertensive drugs, oral corticosteroids, antidepressants, and anti-anxiety medications.

Substance Use

Caffeine, alcohol, and smoking can also contribute to sleep problems in older adults. Caffeine and nicotine are stimulants that can delay sleep and cause disruptions throughout the night. Alcohol can increase the risk of sleep apnea and make it more difficult to stay asleep.

Medication

Benzodiazepines

Benzodiazepines are the most commonly prescribed drugs for insomnia, but they come with a host of side effects, especially for older adults. These include:

• Cognitive and psychomotor impairments
• Falls
• Fractures
• Motor vehicle accidents
• Increased risk of developing or exacerbating depression
• Tolerance and withdrawal symptoms
• Residual daytime sedation
• Motor incoordination
• Cognitive impairment
• Increased risk of falls

Nonbenzodiazepines

Nonbenzodiazepines, such as zolpidem, zaleplon, and eszopiclone, are often viewed as safer alternatives to benzodiazepines. However, they still carry risks of adverse effects, including:

• Delirium
• Falls
• Fractures
• Residual daytime sedation

Antidepressants

Antidepressants like trazodone and mirtazapine are sometimes prescribed for insomnia at low doses. However, they are not FDA-approved for this use and should be considered off-label. Trazodone, in particular, can prolong the QT interval and cause orthostatic hypotension.

Doxepin

Doxepin, a histamine antagonist, is the only antidepressant approved by the FDA for insomnia treatment. It is available in very low doses (1-6 mg) and has been shown to improve sleep parameters in older adults with a safety profile comparable to a placebo. Higher doses should be avoided due to high anticholinergic side effects.

Orexin Receptor Antagonists

Orexin receptor antagonists, such as suvorexant, block the binding of wake-promoting neuropeptides, thereby suppressing wake drive. Suvorexant has been found effective in improving sleep onset and maintenance in older adults with insomnia. However, it may cause residual daytime sedation.

Ramelteon

Ramelteon is a melatonin receptor agonist that promotes sleep by interacting with melatonin receptors. It is approved for prolonged use and is effective in improving sleep onset. It does not cause rebound insomnia or withdrawal symptoms upon discontinuation.

Melatonin

Melatonin is a dietary supplement that has been shown to slightly improve sleep onset and duration. However, its efficacy may vary due to inconsistent product quality.

Valerian

Valerian is a herbal supplement that is relatively safe but has equivocal benefits on sleep quality.

Trazodone

Trazodone, an antidepressant, is commonly used off-label for insomnia. While it can improve sleep quality and continuity, it carries significant risks, including orthostatic hypotension and QT interval prolongation.

Sleep disorders

In addition to insomnia, older adults may also experience sleep disorders such as sleep apnea, restless leg syndrome, and REM sleep behavior disorder. Sleep apnea is a condition where breathing briefly pauses during sleep, which can lead to high blood pressure, stroke, or memory loss if left untreated. Restless leg syndrome causes an urge to move the legs while resting or sleeping, and can be treated with medication, warm baths, exercise, and relaxation techniques. REM sleep behavior disorder causes people to physically act out their dreams, disrupting their sleep.

Circadian rhythm sleep disorders are also common in older adults, as their internal clocks become less efficient with age, resulting in earlier bedtimes and wake-up times. This can be further exacerbated by a lack of exposure to daylight, which is an important cue for maintaining circadian rhythms.

To improve sleep quality and duration, older adults can make changes to their sleep habits and lifestyles. This includes establishing a regular sleep schedule, avoiding naps in the late afternoon or evening, developing a bedtime routine, reducing distractions and electronic usage in the bedroom, and maintaining a comfortable temperature and lighting in the sleeping environment. Exercise, avoiding large meals and caffeine close to bedtime, and limiting alcohol consumption can also promote better sleep.

Frequently asked questions