Insomnia and Aging

Insomnia is defined as habitual sleepiness, or the inability to experience restorative sleep on a nightly basis. Insomnia is an issue for nearly half of all adults in the U.S. over the age of 60. The most common symptoms associated with insomnia in older people include the following:

• Taking at least 30 to 45 minutes to fall asleep
• Waking up in the middle of the night on multiple occasions
• Waking up at a relatively early hour and being unable to fall back asleep
• Feeling exhausted and unproductive the following day

The term ‘short-term insomnia‘ describes initial insomnia symptoms. Doctors will usually diagnose patients with ‘chronic insomnia‘ if their symptoms persist for more than one month; in many cases, secondary insomnia will continue even after the original root cause has been treated. Although the symptoms of insomnia will vary between people, two general types have been identified. Sleep onset insomnia indicates the individual has trouble falling asleep, while sleep maintenance insomnia occurs when someone is unable to remain asleep for normal durations and routinely wakes up in the middle of the night.

Insomnia may be diagnosed as a primary or secondary disorder. Primary insomnia is considered a standalone condition that arises independently, while secondary insomnia is brought on by different physiological factors. The consensus among today’s physicians is that most elderly insomniacs experience secondary insomnia, brought on in most cases by medical conditions and/or side effects of prescription medication.

Insomnia has been linked to changes in sleep architecture. Sleep architecture is defined as the ‘progression of sleep across the night’, and consists of three distinct segments:

• The first segment consists of two stages of light sleep.
• The second segment consists of two stages of deep sleep, also known as slow-wave sleep.
• The first and second segments are collectively referred to as nonrapid eye movement (non-REM) sleep.
• The third segment consists of rapid eye movement (REM) sleep.
• Most adults will cycle through the non-REM and REM sleep phases every 90 to 120 minutes. This process is known as the circadian rhythm.

The amplitude of circadian rhythm in most adults will decrease with age, and this can cause gradual changes to sleep architecture. On a nightly basis, elderly adults tend to experience lower amounts of slow-wave sleep and higher levels of shallow sleep. The amount of REM sleep will also decline by roughly 10 minutes per night for every decade of life.

One common problem among seniors is difficulty with thermoregulation, or the body’s ability to control and maintain a healthy core temperature. Thermoregulation can affect sleep architecture, since body temperature plays a key role in our sleep patterns: a person tends to wake up in the morning when his/her temperature rises, and will usually begin feeling tired around bedtime as his/her temperature declines. Loss of thermoregulation can cause body temperature to fall out of step with the circadian rhythm. This process, known as circadian desynchronization, can put people at risk for insomnia and other sleep-onset issues, as well as hypothermia and hyperthermia during certain times of the year.

Additionally, a wide range of chronic illnesses and conditions associated with old age can lead to secondary insomnia. These include:

• Parkinson’s disease, dementia and other neurological disorders
• Prostate enlargement, bladder failure and other issues that cause incontinence
• Cancer
• Heart failure
• Gastrointestinal conditions
• Respiratory problems

Depression, anxiety and other psychiatric disorders have been linked to insomnia, as well. However, it is currently unclear whether these disorders directly cause insomnia, or vice versa.

Bad sleeping habits can also exacerbate the effects of insomnia. Elderly adults ? especially those who are retired ? are more likely to take daytime naps. Older individuals also spend more time in bed compared to younger people, and tend to rise at early or irregular times. All of these habits can significantly alter one’s sleep architecture.

Insomnia can lead to serious consequences. Adults with this condition routinely experience daytime drowsiness and the inability to properly concentrate. Together, these two factors put insomniacs at greater risk for falls, automobile accidents and other potentially hazardous situations. Other side effects of long-term insomnia include increased irritability and chronic headaches.

Other Sleep Problems and Aging

In addition to insomnia, older people are considered more susceptible to other dyssomnia and parasomnia sleep disorders.

One of the most common dyssomnia disorders in older adults is sleep apnea. This condition is characterized by temporary loss of breath for up to 60 seconds during sleep; due to its disruptive nature, apnea can greatly affect circadian rhythm. There are two classifications for the disorder: obstructive sleep apnea (OSA), which affects breathing by obstructing the airway; and central sleep apnea (CSA), which is triggered by improper communication between the brain and breathing muscles. OSA is the more common of the two; roughly 24% of older women and 9% of older men have been diagnosed with obstructive sleep apnea.

Cardiovascular disease is a serious concern for people with sleep apnea. These two conditions are often co-morbid, or simultaneously present in the same patient, and older people with one are more likely to also acquire the other. Obstructive sleep apnea is considered a predictor for coronary artery disease, and has also been associated with conditions like hypertension, heart failure, stroke and cardiac arrhythmia. Central sleep apnea has been widely reported in patients with congestive heart failure, as well.

A recent study by the American Heart Association argued that individuals who deal with chronic sleep fragmentation are at higher risk for arteriosclerosis, or hardening of the arteries. The study also drew a link between long-term sleep fragmentation and high levels of infarction, or tissue death caused by oxygen depletion. Both arteriosclerosis and infarction are considered predictors for stroke and cognitive impairment.

Narcolepsy is a dyssomnia disorder characterized by daytime fatigue and somnolence, or the strong desire to sleep. This can cause episodes known as ‘sleep attacks’, during which the individual will spontaneously fall asleep regardless of their present location or time of day. Other narcolepsy symptoms include routine hypnagogic hallucinations, which usually occur when someone is falling asleep or waking up; cataplexy, which refers to a spontaneous loss of muscular control; and sleep paralysis, or the inability to physically move upon waking. A diagnosis of Narcolepsy Type 1 or 2 is rare/uncommon at any age, and for most afflicted individuals begins to manifest in the mid-late teen years, with sleepiness and associated symptoms often worsening with age. A secondary peak of diagnosis occurs at ages 45-60.

Restless legs syndrome is another dyssomnia reported by elderly sleepers. Those who experience this condition often report an itching sensation beneath the skin, sometimes accompanied by tingling, cramping or physical pain. These symptoms typically set in around bedtime, and can lead to sleep-onset insomnia. The condition known as periodic limb movement disorder shares the same symptoms as restless leg syndrome, but there is one distinct difference: periodic leg movements only affect people during sleep, which can lead to sleep fragmentation and/or circadian disruption.

Snoring is one of the most commonly diagnosed parasomnia disorders among adults of all ages. Seniors are particularly prone to snoring, due to weakened airway muscles that help regulate proper breathing during sleep. While snoring does not normally carry any life- or health-threatening concerns, the condition is seen as a predictor for more serious problems like stroke or heart disease.

Additionally, the condition known as REM sleep behavior disorder is most often diagnosed in people over the age of 60; the disorder is associated with some age-related neurological conditions, such as Alzheimer’s and Parkinson’s disease. People with the disorder are unable to fully operate their muscles during REM sleep, when most dreaming occurs. This temporary paralysis can cause them to thrash or flail their limbs, stand up or walk around; some patients have reported more abnormal routines, such as eating or bathing while still asleep.

Now that we have discussed dyssomnias, parasomnias and other sleep-related conditions that often affect older people, let’s look at some popular sleep aids and other treatment methods.

Sleep Aids for Seniors

An estimated 20% of seniors take some form of sleep aid for long-term insomnia and other chronic sleep-related disorders. A wide range of medication classifications and types are available in the United States, and each category carries a unique set of effects, characteristics and user warnings. You should always consult your physician before taking any type of sleep aid for the first time.

First let’s tackle the basic sleep aid classifications. Side effects, dependency risks and other information about specific medications can be found in the tables below.

Benzodiazepine Hypnotics: Benzodiazepine receptor agonists (known as BzRAs, or ‘benzos’, for short) are a group of prescription drugs that slow down the body’s central nervous system (CNS) through interaction with gamma-aminobutyric acid (GABA) neurotransmitters. Benzodiazepines are considered minor tranquilizers that can be used to neutralize anxiety and induce sleep. However, due to the strength of these drugs, most older patients begin their regimen at half the recommended dose as younger patients. Benzos also exhibit dangerous interactions with alcohol, so patients should never mix the two. Commonly prescribed types of benzodiazepine include the following:

• temazepam: Sold under the brand Restoril®, temazepam reduces anxiety and triggers muscle relaxation. It is commonly prescribed for sleep maintenance insomnia, but considered less effective at aiding sleep-onset insomnia.

• loprazolam: This drug is normally prescribed for extreme insomnia, and should not be used to address minor sleep issues. Due to loprazolam’s long half-life, users may feel excessive drowsiness and lack of focus the day after taking it. Brands include Dormonoct® and Havlane®.

• flurazepam: Like loprazolam, flurazepam has a long half-life and is discouraged as a sleep aid except in cases of severe insomnia. It is sold under the brand name Dolmane®.

• clonazepam: clonazepam is considered a highly potent benzodiazepine with lesser sedative effects. It is often used to treat sleep conditions like restless leg syndrome and chronic fatigue syndrome. Clonazepam is sold as Klonopin® in the U.S.

• diazepam: Sold in the U.S. as Valium®, diazepam is used to treat a wide range of conditions, including short-term insomnia.

• lorazepam: Like diazepam, lorazepam (sold as Ativan®) can be used as a sleep aid for people with short-term insomnia. Due to its highly addictive nature, most physicians will not prescribe the drug for long-term or chronic sleep issues.

• nitrazepam: This drug is usually prescribed for people with short-term insomnia, but can also be used to manage epilepsy. Nitrazepam is sold under the brand name Mogadon®.

• estazolam: Due to its intermediate half-life, estazolam (sold as ProSom®) is still widely prescribed as an insomnia treatment.

Other benzodiazepine drugs that can be used as sleep aids include Alprazolam (Xanax®) andFlunitrazepam (Rohypnol®). However, these drugs are rarely prescribed for insomnia due to their highly addictive nature.

Benzodiazepines

DRUG NAME	BRANDS	SIDE EFFECTS	DEPENDENCY RISKS
temazepam	Restoril®	Dizziness, daytime drowsiness, muscle weakness, headaches, blurred vision	High
loprazolam	Dormonoct®, Havlane®	Dizziness, daytime drowsiness, nausea, headaches, blurred vision	Very High
flurazepam	Dalmane®	Dizziness, daytime drowsiness, inability to stand or walk, memory loss	Very High
clonazepam	Klonopin®	Dizziness, daytime drowsiness, loss of appetite, slurred speech, headache	High
diazepam	Valium®	Dizziness, daytime drowsiness, constipation, memory loss, muscle weakness, nausea, double vision, rash, irritability	Very High
lorazepam	Ativan®	Dizziness, daytime drowsiness, constipation, memory loss, muscle weakness, nausea, double vision, rash, irritability	Very High
nitrazepam	Mogadon®	Dizziness, daytime drowsiness, headache, muscle weakness	High
estazolam	ProSom®	Dizziness, daytime drowsiness, headache, muscle weakness, irritability	High

Non-benzodiazepine Hypnotics: Commonly referred to as Z-Drugs, these medications (like the previous category) are classified as benzodiazepine receptor agonists. The key difference between the two groups is selectivity: benzos act on a wide range of receptors to trigger different effects, while Z-drugs focus exclusively on inducing sleepiness. Additionally, Z-drugs carry lower dependency risks and less pronounced side effects when compared to benzos. For these reasons, physicians generally prefer Z-drugs over benzos when prescribing a sleep aid. The four most common Z-Drugs prescribed today are:

• zolpidem: This drug is manufactured under several trade names, including Ambien®. Zolpidem can be used to treat short-term insomnia and restless leg syndrome.

• zaleplon: Sold under the name Sonata®, zaleplon is primarily used to treat insomnia. This drug carries similar side effects to some benzos, including anterograde amnesia, drowsiness and agitation.

• zopiclone and eszopiclone: These short-acting Z-drugs are less effective at treating insomnia, but also carry a lower risk of dependency. The most common brand is the eszopiclone label Lunesta®.

• ramelteon: Although it is technically not a Z-drug, ramelteon (sold as Rozerem®) behaves in a similar way: rather than targeting GABA receptors, the drug acts on melatonin receptors. Ramelteon is not habit-forming at all, and made history as the first prescription sleep aid to not be classified as a controlled substance. Ramelteon has proven especially effective at treating insomnia and other sleep disorders in older people.

Z-Drugs

DRUG NAME	BRAND(S)	SIDE EFFECTS	DEPENDENCY RISKS
zolpidem	Ambien®	Dizziness, daytime drowsiness, stuffy nose, dry mouth, nausea, constipation, diarrhea, headache	High if taken for longer than two weeks
zaleplon	Sonata®	Dizziness, daytime drowsiness, numbness, tingling, nausea, vision problems, constipation, diarrhea, headache	Medium
zopiclone and eszopiclone	Lunesta®	Bitter metallic taste, daytime drowsiness, chest pain, cold symptoms, headache, lightheadedness	Medium
ramelteon	Rozerem®	Dizziness, daytime drowsiness	Low

Non-prescription Antihistamines: Histamines serve a number of useful purposes in the body, including regulation of your sleep-wake cycle. Antihistamines, as the name implies, are used to induce drowsiness in patients with insomnia and other conditions affecting their ability to become tired. Diphenhydramine is the most commonly prescribed over-the-counter antihistamine sleep aid; brands with diphenhydramine include Nytol, Sominex, Excedrin and Tylenol PM. Allergy relief brands like Benadryl also contain diphenhydramine, and may be prescribed as sleep aids. Doxylamine is another antihistamine that has proven to be an effective sleep aid; this is the active ingredient in Unisom sleep tablets. Other antihistamines usually prescribed for allergy relief may also be used as sleep aids, including chlorpheniramine and hydroxyzine.

Pain Relievers: These medications may be prescribed for sleep-related issues that stem from chronic pain. Unlike antihistamines, pain relievers normally do not cause daytime drowsiness. Acetaminophen, the active ingredient in Tylenol®, may be used to induce sleep. Doctors may also prescribe non-steroidal inflammatory drugs like ibuprofen, which is found in brands like Advil® and Motrin®.

Herbs and Supplements: As many as 1.5 million use alternative and natural sleep aids Many herbal and dietary supplements on the market can be used to treat insomnia and other sleep disorders. Melatoninis arguably the most commonly prescribed sleep aid supplement. The drug  is considered effective for most people with sleep-onset or sleep maintenance insomnia ? although results have been mixed for long-term insomniacs. Melatonin can also ease jet lag symptoms. Other supplemental options include Valerian root, a flowering plant with sedative properties; and 5-HTP, a supplement derived from tryptophan (the chemical in turkey meat that causes drowsiness).

Non-prescription Options

	BRANDS	SIDE EFFECTS	DEPENDENCY RISKS
Antihistamines
Diphenhydramine	Nytol®, Sominex®, Excedrin PM®, Anacin PM®, Tylenol PM®	Dizziness, daytime drowsiness, dry mouth, constipation, nausea, difficulty during urination	Low
Doxylamine	Unisom®	Dizziness, daytime drowsiness, blurred vision, dry mouth/nose/ throat, constipation	Low
Chlorpheniramine	Chlorphen®	Dizziness, daytime drowsiness, blurred vision, dry mouth/nose/ throat, constipation, irritability	Low
Hydroxyzine	Hydroxyzine (Generic)	Dizziness, daytime drowsiness, blurred vision, dry mouth, constipation, nausea, headache	Very Low
Pain Relievers
Acetaminophen	Tylenol®	Dizziness, sweating, nausea, loss of appetite, trouble during urination, light-headedness, unusual bruising or swelling, yellowing of the skin and eyes	Very Low
Ibuprofen	Advil®, Motrin®	Dizziness, sweating, nausea, constipation, gas, diarrhea, mild itch or rash, ringing in the ears	Very Low
Herbs & Supplements
Melatonin	Generic supplement	Dizziness, daytime drowsiness, stomach cramps, depression, irritability	Very Low
Valerian Root	Generic capsules and extracts	Dizziness, headaches, nausea, irritability, anxiety	Very Low
5-HTP	Generic supplement	Dizziness, daytime drowsiness, abdominal pain, headache, heartburn, constipation, gas, diarrhea, depression, anxiety	Low

Finally, a word about nursing homes and other long-term care facilities. Many staff members at these facilities rely on sleep aids to manage sleep issues with their clients. Sleep aid regimens also allow everyone living in the facility to adopt the same sleep schedule. However, the chronic use of the older sleeping pills in the elderly can produce undesirable side effects not normally reported in other patients. These effects may include impaired memory and alertness, incontinence and physical imbalance, as well as unwanted daytime drowsiness. For this reason, low-risk drugs with minimal side effects like Ramelteon and Melatonin are usually the preferred sleep aids for elderly patients.

Special Considerations for Treating the Elderly

Now that we’ve covered key information about sleep aids and other medications, let’s look at some of the unique considerations ? and most effective strategies ? for addressing sleep disorders in elderly people.

Weight gain is a major concern when treating insomnia in older patients. Poor sleep can lead to a lack of motivation and energy during the day, which in turn can discourage people from exercising or being physically active. Lack of sleep has also been proven to reduce levels of leptin, a ‘satiety hormone’ that is triggered after a meal; as a result, poor sleep can trigger overeating. Physicians treating older people with sleep disorders will often monitor weight gain, and may make dietary or exercise-related recommendations to help them keep their weight from reaching unhealthy levels.

Gender may also play a role in sleep disorder treatment. Senior women are more likely to report insomnia and other sleep problems than senior men, and the link between poor sleep and weight gain is more pronounced in women. A large number of postmenopausal women with sleep apnea have also reported changes in their EKG heart patterns; this is considered a predictor for heart failure and other cardiovascular conditions. In most cases, patients with serious heart-related issues will be unable to take benzodiazepines and other sleep aids with strong side effects.

Sleep disruption related to dementia is of particular interest to doctors who treat patients in nursing homes and long-term care facilities. Insomnia is fairly common among dementia patients, since neurodegenerative diseases like dementia can damage areas of the brain that regulate sleep-wake patterns and circadian cycles. Problem sleep can be also be an early indicator of dementia. A 2012 study found that older people who complained of daytime sleepiness, restless nights, and increased use of sleep aid medication were much more likely to get Alzheimer’s within two years; researchers noted that sleep problems were the single strongest early predictor of this form of dementia.

Other sleep disorders can be used to predict the onset of neurodegenerative disease in some patients, as well. REM sleep behavior disorder, for instance, is considered a predictor for the condition known as Lewy body dementia (LBD); LBD, like REM sleep behavior disorder, is characterized by daytime sleepiness and fatigue. REM sleep behavior disorder may also predict the onset of Parkinson’s disease. Similarly, obstructive sleep apnea (OSA) shares several causal factors with Alzheimer’s disease.

Cognitive behavioral therapy (CBT) has proven effective for many older people who are unable to take sleep aids and other medications. Many people with a history of sleep problems have formed incorrect or negative associations with falling and staying asleep, and therapy can help them adjust their mindsets. Some older patients 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 eight hours in bed every night, whether they are asleep or awake. Both of these ideas are misconceptions.

CBT regimens vary by practitioner. Sleep restriction, or helping clients adopt and maintain a more rigid sleep schedule, is a common component of CBT. Stimulus control is also key; this involves the gradual removal of bedroom activities that conflict with sleep, such as eating or watching television. CBT patients are usually encouraged to keep a sleep diary, which allows them to discuss nightly sleep patterns with their therapist at each session. Other popular methods include relaxation training and, in some cases, paradoxical intention; this procedure requires patients to stay awake for as long as possible. Treatment outcomes will depend on the patient, but most elderly individuals with sleep disorders receive between four and 12 CBT sessions. In the process, misconceptions and misinformation about sleep in general are eliminated, and better sleep hygiene habits are developed.

Apnea and other sleep-disordered breathing (SDB) conditions can be treated with continuous positive airway pressure (CPAP) machines. CPAP treatment may also decrease daytime sleepiness, and there are some indications that this method can inhibit cognitive impairment in demented patients. Institutional caregivers have self-reported that CPAP treatment decreased overall snoring and improved overall quality of life among patients.

Sleep Hygiene and Health for Seniors

Next, let’s explore some strategies that older people can adopt to improve their sleep hygiene and ensure a healthy circadian cycle each night. Leading experts offer the following tips for sleep-deprived seniors.

• Pick a sleep schedule and stick to it. Be sure to go to bed and get up at the same times every day, even on the weekends.

• Stay active during the day. Daytime napping can significantly affect your overall quality of sleep. Physical activity, on the other hand, will help you wind down at the end of the day and feel more tired when you retire for the night. Manage your day accordingly ? but try to avoid any strenuous exercise within three hours of bedtime.

• Get some vitamin D. Vitamin D has proven to improve sleep quality. You can boost your vitamin D intake by spending just 30 to 60 minutes in direct sunlight, and those who live in colder places can take vitamin D supplements.

• Don’t drink anything before bed. Alcoholic beverages can exacerbate the effects of insomnia and other sleep disorders. Other fluids before bedtime can cause problems for people with incontinence, as well. Keep fluid intake to a minimum for an hour or so before bedtime.

• Take a bath before bed. The warm water can aid thermoregulation, since your body temperature will drop after leaving the tub and you will feel more tired in the process.

• Convert your bedroom into a sleep sanctuary. Make sure your bedroom is reasonably dark and properly ventilated. Also avoid bedroom activities that hinder sleep, such as eating, watching television or using electronic devices. Be sure to get out of bed if you’re unable to fall asleep after 10-20 minutes, and only return to bed when you become tired. Basically make sure your mattress is just used for sleep. This will help train your body to fall asleep more quickly.

Additional Sleep Resources for Senior Citizens

We’ve combed the Web and compiled a wealth of reliable information on symptoms, treatments and other aspects of age-related sleep disorders. For more information on these topics, please visit the following online resources.

Forums

• +supportgroups: This website offers forum-style online support groups for a large number of medical and psychiatric conditions, including insomnia and other sleep disorders.

• Psych Forums: The ‘sleep’ section of this site features separate discussion threads for ‘insomnia’ and ‘primary sleep disorders’.

• PsychCentral: This forum thread explores trends and outcomes associated with CBT therapy for seniors with insomnia.

• Patient: This British forum site features 14 different sleep-related discussion threads, including sections on cognitive psychotherapy and sleep apnea.

• Insomnia Land: This popular blog features more than 600 postings on four different discussion threads dealing with insomnia.

Help and Support Groups

• American Sleep Association: The ASA features an extensive list of support groups for insomnia, restless leg syndrome, sleep apnea and other sleep disorders.

• Drugs.com: The insomnia support group found on this pharmacology-oriented site features more than 1,500 members, as well as more than 1,000 separate discussion threads.

• The Experience Project: Created to connect people living with the same physical and psychiatric conditions, this site offers dedicated discussion space for people with insomnia.

• American Sleep Apnea Association: The ASPA is home to the A.W.A.K.E. Network, a nationwide education and support group for people living with sleep apnea.

• Narcolepsy Network: This nationwide organization for people with narcolepsy offers 40 support groups in 25 U.S. states and the District of Columbia

Aging Sleep Studies and Findings

• Journal of Sleep Disorders: Treatment & Care: This academic, peer-reviewed quarterly covers a wide range of topics related to sleep disorders, including issues affecting senior citizens. The issue archive dates back to 2012.

• Journal of Sleep Disorders & Therapy: This open-access, peer-reviewed journal publishes research findings and academic articles related to insomnia, sleep apnea, restless syndrome and other sleep disorders that largely affect older people.

• American Family Physician: Dr. David N. Neubauer penned this comprehensive study of the effects, treatments and medications associated with age-related sleep disorders and conditions.

• The American Journal of Medicine: In this exhaustive journal article, doctors Nabel S. Kamel and Julie K. Gammack address the root causes and practical treatment methods of different aging sleep disorders.

• Sleep and Sleep Disorders in the Aging Adult: Published by University of California Television, this 58-minute video symposium features research findings presented by Dr. Jose Laredo of the UC San Diego Sleep Medicine Center.
• Benefits of Sleep.org

Senior Living Resource Guides

• NIH Senior Health: The National Institutes of Health features an entire section dedicated to insomnia, sleep apnea and other sleep disorders commonly reported in seniors.

• National Institute on Aging: Learn about the most common sleep disorders in seniors and their relationship with neurodegenerative diseases in the NIA’s ‘Get a Good Night’s Sleep’ guide.

• Healthy Sleep: This guide from Harvard University looks at contributing factors and effects of age-related sleep pattern changes.

• Alzheimer’s Association: Alz.org’s website features a page dedicated to sleep disorder treatments for people living with Alzheimer’s and other forms of dementia.

• UCLA Health: The ‘Sleep Older’ page published by UCLA Health features medical findings and physician recommendations for elderly people living with sleep disorders.