Dec. 7, 1999 -- For many older folks, a good night's sleep is but a dream. They have trouble falling asleep and awaken after only a few hours. Their daytime fatigue may be so overwhelming that they can't drive or participate in other normal activities.
About half of those who complain to their doctors about poor sleep end up with a prescription drug. Not only are these unnecessary but they also are habit-forming and can cause side effects, according to sleep researcher Michael Vitiello, PhD, a professor of psychiatry and behavioral sciences at the University of Washington in Seattle.
It is far better for people to consider what simple changes could be made to improve their sleep -- and to understand how sleep patterns change with age, Vitiello writes in the November/December 1999 issue of the journal Gerontology.
Common -- and normal -- sleep problems, which plague up to 40% of the elderly, include light sleep, frequent waking, and daytime fatigue. Among older people, there is also a decrease in the deep-sleep stage and an increase in periods of wakefulness during the night. "Compared with younger adults, even carefully screened noncomplaining older adults exhibit the sleep pattern changes described," writes Vitiello.
While many seniors complain of poor sleep, relatively few have true sleep disorders and even smaller numbers need commonly prescribed sleep medications. Sleep disorders in the elderly include apnea (a temporary cessation of breathing which can also affect younger people) and periodic limb movement, which can take the form of periodic leg movements during sleep (PLMS) or restless leg syndrome. In this syndrome, the person is gripped by strong urges to move his or her legs repeatedly before sleep, which prevent him or her from falling asleep.
Before a physician can diagnose a sleep disorder, he or she should perform a thorough medical examination, review medications the person is taking, and speak to the person's spouse or bed partner about their sleeping habits.
Sometimes medication is prescribed, but "although these drugs may be useful in the management of [short-term] insomnia, they fail to provide long-term relief from chronic sleep disturbances. Hypnotics [medications] can worsen existing sleep disturbances by inducing drug-dependency insomnia and, when the drug is discontinued after intermediate to long-term use, rebound insomnia and nightmares," Vitiello says.
Apnea can be treated by behavior modifications to lessen sleeping on the back, oral appliances that enhance the airway, weight loss, and elimination of medications that depress breathing. Sometimes respiratory stimulants, such as Diamox (acetazolamide); continuous positive airway pressure, which is administered through a mask the person wears at night; and surgery are also effective. Treatments for periodic limb movement disorders are less than ideal, according to the report. Although medications called benzodiazepines, including Klonopin (clonazepam) and Restoril (temazepam), can be used, they also cause daytime sedation and have little effect on the leg movements themselves, Vitiello writes.
Often the most effective approach to improving slumber is to ensure proper sleep "hygiene," which refers to "all the daily practices or routines that can either promote or impede nighttime rest." Some activities that help induce sleep are sticking to a regular bedtime, establishing pre-sleep rituals such as bathing, a light snack, or reading, exercising regularly but not within four hours of bedtime, refraining from caffeine within six hours of bedtime, avoiding smoking close to bedtime, taking a midafternoon nap, and avoiding alcohol and sleeping pills.
In reviewing this report for WebMD, Alon Avidan, MD, a neurologist at the University of Michigan Sleep Disorders Center in Ann Arbor, had high praise for Vitiello's suggestions to improve sleep hygiene. "The guidelines for good sleep hygiene should really be emphasized because this is exactly what we tell people who come to the sleep clinic," Avidan says. "If patients would follow some of these guidelines we could eliminate half of the visits to the clinic. Some of them have very bad sleep habits."
He also supported Vitiello's position that medications are overused. "The vast majority of people I see are on some sort of [benzo]diazepine and that is not a good thing. I try not to use Klonopin or narcotics because they generally disturb the sleep [patterns] and can exacerbate the apnea." However, he disagreed with Vitiello's medication suggestions for restless leg syndrome. "I have had good results with pramipexole, a dopamine 3 agonist," a medication that also sells as Mirapax.
In describing his approach to sleep problems, Avidan says, "We tell patients that [sleep changes] are physiological and that there are certain guidelines that they can follow that will help them. We help with relaxation techniques. ... What we are doing is treating the underlying medical problem causing the insomnia, reducing the drugs that they don't need to take, having them reduce alcohol to no more than half a glass."
- As people age, their sleep patterns naturally change, which can lead to complaints of light sleep, frequent awakenings, and daytime fatigue.
- These changes are considered normal, and in most cases medications are inappropriate because they are habit-forming and can have serious side effects.
- To alleviate sleep problems, people can make behavior modifications including having a regular bedtime, establishing pre-sleep rituals, exercising regularly, and avoiding caffeine, smoking, and alcohol before bedtime.
Updated April 2002 and reviewed by Michael W. Smith, MD, April 2002