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Sleeping Well As We Age
Insomnia is Not a Normal Part of Aging

Insomnia is a common complaint among older adults. Many assume that getting older means no longer sleeping well. However, illness, inactivity, poor sleep habits, and the inappropriate use of alcohol, caffeine and tobacco—rather than age—are the major causes of sleep problems in late life. Fortunately, proper medical care and changes in sleep habits can often bring about a good night’s sleep, without the need for sleeping pills.

A lack of exercise, an unstructured daily schedule, and fewer responsibilities leave older persons at increased risk for insomnia. Added to these risk factors are illnesses such as heart and lung diseases, depression and dementia, and chronic pain, which are common among older adults. In addition, sleep disorders including insomnia and restless legs syndrome can occur for no apparent reason. Fortunately, safe and effective treatments are now available.

Why and How We Sleep and Dream
To understand the current treatments available for sleep disorders, it is helpful to know why and how we sleep. Sleep is important for maintaining and restoring health, both of the body and brain. Sleep and dreaming are necessary for learning and memory, and to regulate blood pressure, blood sugar, and immune function.

The cycle of sleep and awakening is controlled by a small biological clock located at the base of the brain. The clock can be adjusted by exposure to daylight and the pattern of daily activity. The clock is set by nature to promote some sleepiness for a few hours early in the afternoon and more strongly from midnight to 7 a.m. The clock’s sleep promotion is counterbalanced by a wakefulness drive, which is strongest between 7 a.m. and 11 a.m.

The sleep phase of the sleep/wake cycle is divided into:

• dreaming or rapid eye movement sleep,
• shallow or light sleep, and
• deep or restorative sleep.

The stages of sleep mature from infancy into adulthood with progressively less time spent in deep sleep and dreaming and more time in shallow sleep. In addition, as we get older more adults tend to be “morning larks” (early-to-bed, early-to-rise) rather than “night owls” (going to bed late and getting up late). This tendency varies from person to person. Most age-related sleep changes occur in the early and mid years of life, changing little in old age. In fact, fifty percent or more of older adults have no sleep complaints.

One measure of sleep quality is sleep efficiency, which is the amount of time asleep compared to the amount of time spent in bed. Sleep efficiency is the only measure of sleep quality that changes significantly for those age 60 and older, and declines gradually at a rate of about 3 percent per decade. Overall, the sleep quality of healthy older adults remains relatively constant unless there is an illness.

Insomnia and Other Sleep Disorders in Late Life
Excessive daytime drowsiness affects less than two percent of older persons but as many as one third complain of problems getting to sleep and staying asleep. Insomnia is more common among:

• women,
• those who are widowed, separated or divorced, and
• those with financial difficulties.

Insomnia tends to come and go but when persistent, may signal the beginning or recurrence of depression.

Nearly 40 percent of sleeping pills are prescribed to older adults, although they make up less than 20 percent of the population. This is despite the risks of impaired memory, concentration, accidents, and dependency associated with some sleeping pills. Diagnosing sleep problems in an older person can be challenging because of the interplay of age, social factors, physical and mental illness, and medications.

What are the Causes and Effects of Insomnia?
Sleep problems can be the cause, effect, or complication of illnesses, mental disorders, and accidents. Just like temperature, pulse, and respiration, sleep should be considered a vital sign of health. The quality of one’s cycle of sleep and wakefulness can be a sign of health or illness.

Primary insomnia is sleeplessness that cannot be blamed on mental disorders, physical illness, medications or simple problems with scheduling. Excessive daytime drowsiness (called primary hypersomnia) is associated with nighttime periodic leg movements, restless legs syndrome, sleep apnea (pauses in breathing during sleep), and snoring. Periodic leg movement disorder and restless legs syndrome are also associated with complaints of insomnia and non-restorative sleep. In either case, to qualify as a sleep disorder, symptoms must interfere with social or intellectual function and occur three nights per week for a month.

Obsessive worry about sleep and the use of alcohol or sedatives may be both a cause and effect of insomnia. An occasional sleep problem can become persistent by self-defeating solutions such as spending too much time in bed, abandoning a regular schedule of sleep and waking, or using alcohol as a sleep aid.

A few days of insomnia or restless sleep can be the result of a simple illness like the common cold or a change in routine, like staying in a hotel. However, insomnia lasting four weeks or longer likely has a more complex cause. Older adults with insomnia that lasts four weeks or longer should consult a physician.

Questions You and Your Doctor Should Consider
If you are concerned about the quality of your sleep, talk to your
doctor:

• If you have difficulty falling asleep and staying asleep
• If you do not feel rested upon awakening
• If you feel sleepy or fatigued during the day

Be sure to tell your doctor how long you have had problems sleeping. The length of the symptoms is important both for diagnosis and treatment.

Also, tell your doctor about your sleep habits and any medications, illnesses or recent events that may contribute to your sleep difficulties. In particular you may wish to discuss:

• How many times you awaken at night and how long it takes you to return to sleep
• How often you visit the bathroom during the night
• If pain or difficulty breathing interferes with sleep
• If you snore, choke or gasp while asleep
• If you are so sleepy during the day that you are at risk for nodding off or falling asleep while driving
• If you have an urge to move your legs or have uncomfortable sensations in your legs during rest or at night
• If you feel muscular tension or anxiety when trying to fall asleep
• Whether or not you have a routine such as reading or a warm bath that helps you relax before bedtime
• If you worry that you will not get enough sleep
• If you nap, how frequently and for how long
• If exercise and exposure to outdoor light is part of your daily routine
• How much caffeine, alcohol, or tobacco products you consume during the day or night
• If you use over-the-counter (non-prescription) medications or anything else as a sleep aid
• If worrisome thoughts intrude to prevent falling asleep or returning to sleep if you wake in the middle of the night
• If you feel sad, depressed or anxious
• Whether or not a recent life change event may have changed your pattern of sleep
• If you are a caregiver for someone with dementia or another disabling illness

Questions for Your Bed Partner
If you share a bed with another person, it can be helpful to have that person speak with your physician about your sleep habits. A sleep partner may be able to comment on your breathing during the night, and whether or not you snore, gasp, make choking sounds, and if so, how often and for how long. A sleep partner can also tell your physician if there has been a change in your mood or emotions, or if you have increased your use of alcohol, caffeine, nicotine, other drugs, or medications.

Two abbreviated forms used to provide physicians information on sleep timing and the regularity of daily social rhythms are included below. Once you have recorded your routine for one week, your physician can use the record to develop an individual treatment plan.

What to Expect from Treatment
The treatment of a sleep disorder can help improve quality of life, including physical and mental health. Learning about good sleep habits and suggestions for changes can be very effective. Those with chronic insomnia can expect their sleep to improve with treatment. However, modest improvements are more likely than a complete cure, particularly for older persons accustomed to sleeping pills (sedative/hypnotics). With proper treatment, many older adults can reduce the dose or frequency of sleeping pills.

Changes in Sleep Habits
A doctor providing help for a sleep disorder may discuss your individual sleep habits (often called “sleep hygiene”) and needs, and suggest changes in your habits and in your environment. You can try a number of changes that may promote better sleep by reducing those things that make you too alert.

First, know what to avoid. The following can disrupt sleep:

• exercise in the evening,
• a late meal,
• too many beverages in the evening,
• nicotine,
• caffeine, and
• alcohol.

Use your bed and bedtime for sleep or intimacy only. Do not use your bed for:

• snacking,
• reading, or
• watching TV.

If you are not sleepy, do not go to bed. If you are not asleep within 15 minutes, try leaving the bedroom and reading in dim light. Avoid watching TV or using a bright light, which can make you too alert. Return to your bed only when sleepy.

Napping. Often, napping can be disruptive to a good night’s sleep. If you must nap, take one short nap of about an hour in the early afternoon before 3 p.m. If you can eliminate naps altogether, you may sleep better at night.

Amount of Sleep. At night, limit your time in bed to 7-8 hours to ensure that sleep is continuous rather than broken up over a longer period of time. A person who tries to make up for poor sleep with extra time in bed will instead experience more awakenings and disruptions in the natural sleep pattern. By limiting your time in bed to 7-8 hours nightly, you may increase the quality of your sleep and improve your daytime well-being and alertness.

Sleep Schedule. As you introduce new sleep habits, follow them every day of the week. An important element in getting good sleep is sticking to a schedule. So even if you have not had a restful sleep, get out of bed at the same time every morning. This helps the “sleep clock” at the base of your brain function better.

Relaxation. By trying different relaxation techniques, you may be able to fall asleep more easily. Through relaxation training, you learn to recognize and reduce muscle tension. By practicing relaxation techniques daily, you can improve your natural relaxation response. In one method, the individual is instructed to progressively tense then relax muscle groups in a step-by-step manner and reflect on the feeling as tension is released. Other relaxation techniques to combat insomnia include guided imagery (for example, imagining you are on a slow train gently rocking back and forth), breathing with your abdomen rather than your shoulders (as in yoga), and meditation (for example, mentally repeating the word “one”).

Snoring and Sleep Apnea. To combat snoring and sleep apnea (prolonged pauses in breathing), sleep on your side and if excess weight contributes to the problem, try to slim down. Avoid alcohol and sedatives, which can make the problem dangerously worse. Sleep apnea can be diagnosed in a sleep center or at home with a polysomnogram (a study to measure an individual’s sleep cycles). Diagnosing the problem is important because sleep apnea is a curable cause of heart disease, dementia, and depression.

Education about sleep and changes in sleep habits are helpful for most persons with sleep problems. However, other treatments may be needed for those who cannot maintain good sleep habits or who rely on sleeping pills (sedative/hypnotics).

Therapy
Cognitive behavioral therapy combines elements of positive sleep habit changes (as described above) in a structured format and offers long-term benefits. During four to six sessions of cognitive therapy, the mental health care provider and the patient talk to identify misconceptions such as “everybody needs 8 hours of sleep,” “you can make up for a bad night’s sleep by spending more time in bed” or “I’m too old to exercise.”

Also, the patient can learn how to reduce the use of sleeping pills. Cognitive behavioral therapy and changes in sleep habits can lead to a gradual reduction in the use of sleeping pills. This approach is typically more successful than simply trying to cut down on pills without professional help.

With therapy, the patient and provider work on identifying and managing situations and habits that disrupt sleep in order to establish a better, more regular sleep/wake cycle. By establishing daily routines, the quality of sleep can improve for many older persons.

For a list of patient-based behaviors to improve sleep (Consumer Checklist for Healthy Sleep), see page below.

Medications
Medication may be necessary for patients whose insomnia is not helped through changes in sleep habits and therapy and for those with periodic limb movements or restless legs syndrome. As a first step, the patient should withdraw from stimulant beverages (like coffee and tea) and over-the-counter medications that interfere with either the quality of sleep or the performance of routine activities during the day, such as driving. Always check with your doctor first before stopping any prescribed medication.

Over-the-counter medications that impair sleep include:

• pain relievers (analgesics) with caffeine,
• some cough and cold medicines, and
• decongestants with phenylpropanolamine or pseudoephedrine.

Prescription medications that may cause insomnia include:

• atenolol (for high blood pressure, chest pain, and heart attacks),
• thyroid preparations,
• cortisone (a steroid hormone often used to treat inflammation),
• theophylline (for wheezing, shortness of breath, and difficulty breathing)
• levodopa (for Parkinson’s disease, shingles, and restless legs syndrome), and
• quinidine (for abnormal heart rhythms).

Persons with sleep disorders should not use over-the-counter medications that are marketed as sleep aides or “PM” pain relievers (analgesics) that contain the antihistamines diphenhydramine or doxylamine. In older people, these may cause side effects, such as mental confusion or bladder or bowel disturbances.

Melatonin is used as a “natural” sedative but is not regulated by the Food and Drug Administration (FDA). Melatonin varies considerably in content from one brand to the next, and there is little research to support its use. For persons wishing to use an herbal product, teas made from German chamomile (Matricaria recutita) or passion flower (Passiflora incarnata) or capsules of valerian (Valeriana officinalis) are popular. However herbal remedies are not regulated by the FDA and they may vary considerably in content from one brand to the next.

Once counterproductive medications have been eliminated, the physician should use the following principles to direct the drug therapy. First, the lowest effective dose of a drug with the shortest duration of action should be used intermittently throughout the week, not every night. Kidney and liver problems may prolong the action of even short-acting medications. Short-acting medications are less likely to impair daytime alertness and performance of routine activities.

The first goal of drug therapy for sleep problems is modest improvement in sleep rather than a total cure. Patients should understand that sleeping pills are a temporary solution and should be reduced and then stopped after two to three weeks under a doctor’s care. Changes in sleep habits offer the best chance of long-term improvements in sleep but require the most effort. “Rebound insomnia” is insomnia that returns after sleeping pills are abruptly stopped. Some persons need to gradually withdraw from sleeping pills to avoid rebound insomnia.

Your doctor should choose the most appropriate medication by considering the following. Sedative/hypnotics (sleeping pills) are dangerous for those with undiagnosed sleep apnea (prolonged pauses in breathing) and may not be the best treatment for restless legs syndrome. Most of the recent research into the treatment of insomnia comes from studies of benzodiazepines and benzodiazepine receptor agonists zolpidem, zaleplon, eszopiclone, and melatonin receptor agonist ramelteon. They are safe and effective for transient, situational sleep disturbances but are not better than cognitive behavioral intervention.

Yet because of the inconvenience of controlled substance prescriptions, and fears of dependency, impaired concentration, and accidents, some doctors prefer to prescribe a sedative antidepressant or the antihistamine diphenhydramine. There is little research to support the use of sedative antidepressants unless the sleep disturbance is the result of depression. And as mentioned above, dyphenhydramine is not recommended for older persons.

Zolpidem like eszopiclone is FDA-approved for chronic administration. The extended release formulation of zolpidem will help an individual fall asleep and stay asleep. Because of its rapid onset and brief duration of action zaleplon may be best for patients who fall asleep only to awaken well before “good morning” time. These drugs may be substituted for benzodiazepines or other “sleepers” upon which the patient has become dependent. But in rare instances they may cause other sleep disorders such as sleepwalking or sleep-eating. Ramelteon helps patients fall asleep by reducing the wakefulness drive but may be less helpful in getting patients back to sleep once awake. Unlike zolpidem, eszopiclone, zaleplon, and the benzodiazepines, ramelteon is not designated as a controlled substance and may offer less risk of daytime sedation.

You’re Never Too Old to Get a Good Night’s Sleep
Problems with getting a good night’s sleep are common among older adults. But sleep quality can be improved with simple steps. This involves learning about sleep, practicing good sleep habits, and stopping bad habits. Treatment for sleep disorders may also include reducing or stopping medications that interrupt sleep, treating disorders like depression that directly affect sleep, and, in some cases, properly using sleeping pills (sedative/hypnotics).

Myth and Reality About Age and Sleep

Abbreviated Self-Report Measures of Sleep Habits and Lifestyle Regularity Sleep Timing
If “Good Night Time” is the time when you finally go to bed to sleep, then…

• On weeknights what is your earliest, latest, and usual Good Night Time?
  • ___:___ ___:___ ___:___
• On weekends what is your earliest, latest, and usual Good Night Time?
  • ___:___ ___:___ ___:___

If “Good Morning Time” is the time when you get of bed to start your day then…

• On weeknights what is your earliest, latest, and usual Good Morning Time?
  • ___:___ ___:___ ___:___
• On weekends what is your earliest, latest, and usual Good Morning Time?
  • ___:___ ___:___ ___:___

On average, how long in minutes does it take you to fall asleep once you start trying? ______ Minutes
On average, how much sleep in minutes do you lose from waking up at night? ______ Minutes

Social Rhythms or Lifestyle Regularity
Please record the following:

Adapted from: Monk TH, et al. Measuring sleep habits without using a diary: The Sleep Timing Questionnaire. SLEEP. 2003;26:208-212. Monk TH, et al. A simple way to measure daily lifestyle regularity. J Sleep Res. 2002;11:183-190.

Do I Have a Sleep Disorder?
The National Institutes of Health suggests the following steps to determine if you might have a sleep disorder. Talk to your doctor if any of the following is a concern.

• It takes you more than 30 minutes to fall asleep at night.
• You awaken frequently during the night and have trouble getting back to sleep.
• You awaken too early in the morning.
• You often do not feel well rested despite spending 7-8 hours or more asleep at night.
• You feel sleepy during the day and fall asleep within 5 minutes if you have the opportunity to nap or you fall asleep at inappropriate times during the day.
• Your bed partner claims you snore loudly, snort, gasp, or make choking sounds while asleep or your partner notices your breathing stops for short periods.
• You have creeping, tingling, or crawling feelings in your legs that are relieved by moving or massaging them, especially in the evening and when you try to fall asleep.
• You have vivid, dreamlike experiences while falling asleep or dozing.
• You have episodes of sudden muscle weakness when you are angry, fearful, or when you laugh.
• You feel as though you cannot move when you first wake up.
• Your bed partner notes that your legs or arms jerk often during sleep.
• You regularly need to use stimulants (such as coffee) to stay awake during the day.

Consumer Checklist for Healthy Sleep

• Make sure the bedroom is quiet, restful and comfortable.
• Use the bed only for sleep and intimacy, not for snacking, listening to radio, or watching television.
• Go to bed and wake up at the same time each day. This will set and rewind your biological sleep clock.
• If you cannot fall asleep in 20 minutes, get up and do something boring until you feel sleepy.
• Develop a get-to-sleep ritual that will let you relax before bedtime.
• Avoid exercising within 4 hours of bedtime.
• Avoid caffeine and/or cigarettes for at least 4 hours before bedtime.
• Avoid alcohol for at least 2 hours before bedtime, and do not use alcohol as a sleep aid.
• Try wearing socks to bed; this lowers your core temperature and promotes sleep.
• Avoid being too hungry or too full at bedtime.
• Avoid drinking large amounts of fluid after 6 p.m.
• If you must nap during the day, limit it to 30 minutes before 3:00 p.m.
• Get regular exercise and daily exposure to outdoor light.
• Take a hot bath 90 minutes before bedtime.
• If you find yourself watching the time through the night, place the clock face out of sight. Do not watch the clock.
• Ask your doctor if the way you take medications for your heart, blood pressure, breathing or pain can be improved.
• Persistent insomnia, snoring and excessive daytime sleepiness are not normal parts of aging. See your doctor or a sleep medicine specialist.

Adapted from How to Sleep Well. Available at www.stanford.edu/~dement/howto.html. Accessed April 25, 2007.

Resources
National Sleep Foundation. 2003 Sleep in America Poll. Online: www.sleepfoundation.org
Your Guide to Healthy Sleep. U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute. NIH Publication No. 06-5271. November 2005. Online: www.NHLBI.NIH.gov/health/public/sleep/healthy_sleep.pdf

Alzheimer Disease Behavioral Symptoms Protocols. International Longevity Center. For sleep disturbance in dementia see: http://iucar.iu.edu/research/behavioralprotocols.html. Accessed April 30, 2007.

Organizations
American Academy of Sleep Medicine (AASM)
One Westbrook Corporate Center, Suite 920
Westchester, IL 60154
Telephone: (708) 492-0930
Fax: (708) 492-0943
Website: www.aasmnet.org

American Insomnia Association
One Westbrook Corporate Center, Suite 920
Westchester, IL 60154
Telephone: (708) 492-0930
Fax: (708) 492-0943
E-mail: aiainfo@aasmnet.org
Website: www.americaninsomniaassociation.org

American Sleep Apnea Association
1424 K Street, NW, Suite 302
Washington, DC 20005
Telephone: (202) 293-3650
Fax: (202) 293-3656
Website: www.sleepapnea.org

Narcolepsy Network, Inc.
P.O. Box 294
Pleasantville, NY 10570
Telephone: (401) 667-2523
Fax: (401) 633-6567
E-mail: narnet@narcolepsynetwork.org
Website: www.narcolepsynetwork.org

National Center on Sleep Disorders Research National Heart, Lung, and Blood Institute National Institutes of Health
6701 Rockledge Drive
Bethesda, MD 20892
Telephone: (301) 435-0199
Fax: (301) 480-3451
E-mail: ncsdr@nih.gov
Website: www.nhlbi.nih.gov/sleep

National Heart, Lung, and Blood Institute (NHLBI) Health Information Center
P.O. Box 30105
Bethesda, MD 20824-0105
Telephone: (301) 592-8573
TTY: (240) 629-3255
Fax: (301) 592-8563
E-mail: NHLBIinfo@nhlbi.nih.gov
Website: www.nhlbi.nih.gov

National Sleep Foundation
1522 K Street, NW, Suite 500
Washington, DC 20005
Telephone: (202) 347-3471
Fax: (202) 347-3472
E-mail: nsf@sleepfoundation.org
Website: www.sleepfoundation.org

Restless Legs Syndrome Foundation
1610 14th Street, NW, Suite 300
Rochester, MN 55901
Telephone: (507) 287-6465
Info Line: (877) INFO RLS
Fax: (507) 287-6312
E-mail: rlsfoundation@rls.org
Website: www.rls.org

If your doctor thinks you need to see a sleep specialist or visit a
sleep center, find information online at:

SleepCenters.org by the American Academy of Sleep Medicine
Locate a sleep center
www.sleepcenters.org

American Board of Sleep Medicine
Verify the credentials of a sleep specialist
www.absm.org

Geriatric Mental Health Foundation
The Geriatric Mental Health Foundation was established by the American Association for Geriatric Psychiatry to raise awareness of psychiatric and mental health problems and issues affecting older adults, eliminate the stigma of mental illness and treatment, promote healthy aging strategies, and increase access to quality mental health care for older adults.

The Foundation’s vision for America’s aging population includes:

• Increased public awareness of the importance of mental health in the aging population;
• Removal of stigmas for those seeking mental health services;
• Increased access to quality mental health care for older adults; and
• Promotion of healthy aging strategies for all older adults, family caregivers, and others devoted to the overall health of our communities.

The Foundation focuses on public education targeted to the health care consumer and family caregiver about mental health promotion, and illness prevention, and treatment. The Foundation develops programs to enhance communication and foster broad collaboration between the aging and mental health research community, mental health care providers, and the general public.

Older Adults & Mental Health Brochure Series
This publication is part of a series of brochures published by the Geriatric Mental Health Foundation to provide information about the mental health of older adults. Other GMHF brochures include:

• Healthy Aging: Keeping Mentally Fit as You Age
• Substance Abuse and Misuse Among Older Adults
• A Guide to Mental Wellness in Older Age: Recognizing and Overcoming Depression (A Depression Recovery Toolkit)
• Depression in Late Life: Not a Natural Part of Aging
• Depression in Late Life (in Spanish) - Depresión Tardía: No Es Una Parte Natural Del Envejecimiento
• Coping with Depression and the Holidays
• Alzheimer’s Disease: Understanding the Most Common Dementing Disorder
• Alzheimer’s Disease (in Spanish) - Enfermedad de Alzheimer: Entendiendo Acerca de la Demencia Más Común
• Caring for the Alzheimer’s Disease Patient: How You Can Provide the Best Care and Maintain Your Own Well-Being To view brochures online, visit www.gmhf online.org/gmhf/consumer. Order from the website or call (301) 654-7850.

Find a Geriatric Psychiatrist
A geriatric psychiatrist is a medical doctor with special training in the diagnosis and treatment of mental illnesses that may occur in older adults. These include, but are not limited to, dementia, depression, anxiety, alcohol and substance abuse/misuse, and latelife schizophrenia.

The Geriatric Mental Health Foundation can provide the names of geriatric psychiatrists. Visit www.GMHFonline.org or call (301) 654-7850.

The production of this brochure was made possible in part by an unrestricted educational grant from Takeda Pharmaceuticals North America, Inc.

© 2008
Geriatric Mental Health Foundation

Geriatric Mental
Health Foundation
7910 Woodmont Avenue
Suite 1050
Bethesda, MD 20814
301-654-7850
www.GMHFonline.org
info@GMHFonline.org

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