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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:
- 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
- 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
- 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
- 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
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,
- caffeine, and
Use your bed and bedtime for sleep or intimacy only. Do not use
your bed for:
- 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
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
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).
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.
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
- 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
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
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
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
|Your brain and body are doing nothing while you sleep.
||Both the structure and function of the brain and body undergo
active repair during sleep.
|Everyone needs 8 hours of sleep a night.
||Although the average is 8 hours some people need 7, some need
|Older people do not need as much sleep as young adults.
||Older people do not sleep as deeply as younger persons but
the need for sleep does not decline with age.
|You can make up for a bad night’s sleep by napping during
||A brief nap can help temporarily but persistent sleepiness
during the day may mean you need to see your doctor.
|If you do not feel refreshed in the morning, spend more time
||Spending extra time in bed will interfere with the quality
of your sleep.
|Everyone snores and there are no health consequences.
||Snoring is not normal and can be a sign that your airway is
obstructed, preventing adequate oxygen to your heart and brain.
|Once you start taking sleeping pills you can never stop.
||Sleeping pills are safe and effective for short-term use.
Cognitive behavioral therapy can successfully help you reduce
or eliminate reliance on sleeping pills.
|It is your age not your illnesses that determine how well
||Sleep inevitably changes with age but most loss of sleep quality
in late life is due to illness or bad habits.
|Most insomnia is caused by worry.
Anxiety and depression do cause insomnia but so do arthritis,
heart disease, and dementia, each of which is treatable.
|A glass of sherry or some other kind of “night cap”
at bedtime will help you sleep.
||Alcohol is initially sedative but has a stimulant effect later
in the night. It also interferes with deep sleep and dreaming.
|Medications are the best way to counter a sleep problem.
||Change in sleep-related habits and attitudes are at least
as effective as medications.
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
- On weekends what is your earliest, latest, and usual Good Night
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
- On weekends what is your earliest, latest, and usual Good Morning
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:
||Time Up and Out of Bed
||Time of First Personal Contact
||Start daily activities (e.g. work, care giving,
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
- 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
- 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
- Avoid exercising within 4 hours of bedtime.
- Avoid caffeine and/or cigarettes for at least 4 hours before
- 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
- 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
Adapted from How to Sleep Well. Available at www.stanford.edu/~dement/howto.html.
Accessed April 25, 2007.
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:
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.
American Academy of Sleep Medicine (AASM)
One Westbrook Corporate Center, Suite 920
Westchester, IL 60154
Telephone: (708) 492-0930
Fax: (708) 492-0943
American Insomnia Association
One Westbrook Corporate Center, Suite 920
Westchester, IL 60154
Telephone: (708) 492-0930
Fax: (708) 492-0943
American Sleep Apnea Association
1424 K Street, NW, Suite 302
Washington, DC 20005
Telephone: (202) 293-3650
Fax: (202) 293-3656
Narcolepsy Network, Inc.
P.O. Box 294
Pleasantville, NY 10570
Telephone: (401) 667-2523
Fax: (401) 633-6567
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
National Heart, Lung, and Blood Institute (NHLBI) Health
P.O. Box 30105
Bethesda, MD 20824-0105
Telephone: (301) 592-8573
TTY: (240) 629-3255
Fax: (301) 592-8563
National Sleep Foundation
1522 K Street, NW, Suite 500
Washington, DC 20005
Telephone: (202) 347-3471
Fax: (202) 347-3472
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
If your doctor thinks you need to see a sleep specialist or visit
sleep center, find information online at:
SleepCenters.org by the American Academy of Sleep Medicine
Locate a sleep center
American Board of Sleep Medicine
Verify the credentials of a sleep specialist
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
The Foundation’s vision for America’s aging population
- 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;
- Promotion of healthy aging strategies for all older adults,
family caregivers, and others devoted to the overall health of
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
- 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
The Geriatric Mental Health Foundation can provide the names of
geriatric psychiatrists. Visit www.GMHFonline.org or call (301)
The production of this brochure was made possible in part by an
unrestricted educational grant from Takeda Pharmaceuticals North
Geriatric Mental Health Foundation
7910 Woodmont Avenue
Bethesda, MD 20814
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