As we age, sleep can become quite a challenge for some individuals. There are many factors that can contribute to this: normal bodily changes, chronic illness, side effects of medications, sleep apnea, depression, anxiety and grief to name a few. According to the National Sleep Foundation “older adults (65+) the sleep range is 7 to 8 hours.” Older adults generally do not sleep as deeply and wake up at intervals through the night. I like to equate the importance of sleep for us as human beings to the importance of gas to a car. Cars do not run well without gas, we do not run well without sleep.
As reported in the Tuck publication Sleep and Aging – Senior Sleep Guide 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 over the age of 60. Symptoms of insomnia include:
- Taking at least 30-40 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
Common chronic medical conditions associated with sleep disturbances are neurological conditions such as Parkinson’s disease, dementia, neuropathy and restless leg syndrome. Urinary issues are also a common culprit of interrupted sleep such as enlarged prostate or bladder dysfunction. Heart and lung disease as well as sleep apnea, depression and anxiety can also have a major impact on sleep.
Can Medications Help?
There are several classes of medications that can have a negative effect on sleep. Some prescription drugs include those that treat high blood pressure such as beta blockers, steroids such as prednisone, anti seizure medications, antidepressants and medications for attention deficit. Non prescription drugs can also contribute to sleep disturbance. Examples in this category would include Pseudoephrine, many cough and cold medicines, medications with caffeine such as over the counter migraine treatments.
Illegal drugs such as cocaine, amphetamines and methamphetamines as well as legal drugs such as alcohol and nicotine can also be contributing factors to poor quality sleep. Since marijuana is legal in Colorado, I felt it appropriate to mention this in the article. According to the National Institute of Health, “Preliminary research into cannabis and insomnia suggests that cannabidiol (CBD) may have therapeutic potential for the treatment of insomnia. Delta-9 thtrahydrocannabinol (THC) may decrease sleep latency (time to fall asleep) but could impair sleep quality in the long term.”
First Line of Defense
The first line of defense against sleep disturbance is identified as Sleep Hygiene. Some recommendations from University of Colorado Health related to sleep hygiene are:
- In the daytime, spend time outdoors or in natural light. Light helps the body produce melatonin which is a sleep promoting hormone. Participate in regular exercise but not before bedtime. Social activities, family and work can increase your activity level and prepare your body for a good night’s sleep
- Establish a pre-bed routine that involves engaging in relaxing activities. Sit quietly and breathe or listen to soft, calming music. A warm bath one hour before bedtime causes body temperature to rise, which can help you fall asleep. Avoid stimulating activities before bed such as watching a suspenseful movie or having an important conversation. Even the news can be stressful. Limit screen time – phone or computer one hour before bedtime.
- Take medications as prescribed in AM or PM. Some medications can make you alert or drowsy.
- Don’t go to bed too hungry or too full. A healthy bedtime snack may help you fall asleep. Alcohol can make it easier to fall asleep, but it can have a negative effect during the night: making you need to urinate more, causing you to have fragmented sleep or wake early.
- Do not drink caffeinated beverages in the evening such as coffee, tea or soda.
- Go to bed at the same time each night and get up the same time each morning. This helps to set your body’s natural clock.
- Make your bedroom as restful as possible. Keep temperature cool, minimal noise and light.
- Be comfortable and relaxed. Have comfortable pillows, mattress and pajamas.
- If you have trouble shutting your mind off, keep paper and pen next to your bed. If you think of things, write them down to deal with the next day.
- Use your bed only for sleep and sex. This helps make the brain connection between places (bedroom) and events (sleeping, sex). Avoid watching TV, reading, talking on the phone.
- Do not share your bed with pets. Pets can disrupt your sleep.
- If you do not fall asleep within 20 – 30 minutes, get up and do something boring (in another room). Try to keep lighting low so that you don’t stimulate yourself too much. When you are tired, go back to bed. Do this same routine if you wake up during the night and are having trouble going back to sleep.
There are many over the counter (OTC) sleep aids, many of which are not recommended in the older population. According to the Tuck article “an estimated 20% of seniors take some form of sleep aid for long-term insomnia.” You should always consult your primary care provider before taking any sleep aid for the first time.
The OTC night time sleep medicines such as Acetaminophen PM (Tylenol) or Ibuprofen PM (Advil/Motrin) contain Diphenhydramine which is an older, sedating antihistamine. Doxylamine is another antihistamine, this is found in Unisom or the store brand equivalent. The antihistamine class of drug can cause dizziness, daytime drowsiness, dry mouth, constipation, nausea, difficulty with urination. All of these side effects are not good for the older population.
What About Supplements or Natural Remedies?
There are a few herbs and supplements that can also be taken to improve sleep. Melatonin is a hormone that is normally in the body to regulate the sleep cycle. Sometimes, as we age, we do not produce as much melatonin and an OTC supplement might be helpful. It too does have potential side effects such as dizziness, daytime drowsiness, stomach cramps, depression and irritability.
Valerian root is an herbal supplement that may help reduce the amount of time it takes to fall asleep and/or help you sleep better. This plant based sleep aid does have reported side effects of dizziness, headache, nausea, irritability and anxiety.
5-HTP is an amino acid that is naturally produced in the body that works in the brain to increase production of serotonin. It can be produced commercially and taken as a supplement for sleep. The side effect profile includes dizziness, daytime drowsiness, abdominal pain, headache, heartburn, constipation, gas, diarrhea, depression and anxiety.
While these three options are more natural approaches to help with sleep, they are not without potential risk. Starting any of these supplements should begin with a discussion with your primary care provider.
If your sleep disturbance persists, your primary care provider may suggest a prescription hypnotic medication for you. Most of these medications are recommended for short term use. Benzodiazepines such as Ativan, Xanax, Restoril, Klonopin, Valium. This class of medication has a high addiction potential. They are considered minor tranquilizers that are used to decrease anxiety and induce sleep. The side effect profile is a concern in the older population: dizziness, daytime drowsiness, muscle weakness, headache, blurred vision, nausea, memory loss, slurred speech and decreased appetite.
Non-benzodiazepine hypnotics focus solely on inducing sleep. They also have a dependency risk, but lower than the previous category, and fewer side effects. The common medications in this class are Ambien, Sonata and Lunesta. While the side effects are similar to the benzodiazepines, additional reports of diarrhea and/or constipation have been reported. The dependency risk for Ambien is high if taken longer than two weeks, Sonota and Lunesta have medium risk for dependency. There is another drug Rozerem that works on the melatonin receptors. The side effect profile is minimal – dizziness and daytime drowsiness as well as having a low dependency risk. This is a better option in the older population.
One final option to discuss is Cognitive Behavioral Therapy (CBT). This process works to unlearn negative associations with falling/staying asleep and adjust the mindset. Components of CBT can include but are not limited to: Establishing a more rigid sleep schedule, gradual removal of bedroom activities that conflict with sleep (TV, eating), keeping a sleep diary and relaxation techniques. According to the Tuck article “most elderly individuals with sleep disorders receive between four and 12 CBT sessions.”
This therapy is covered by many insurances, check with your carrier. CBT is available in Colorado Springs.
Talk To A Medical Specialist
Sleep is an integral part of good health. If you have sleep disturbance make an appointment to discuss your concerns with you primary care provider. Together you can decide what option to achieve restful, restorative sleep is best for you.
[By Elizabeth Allen, Nurse Practitioner, AgeWell Medical Associates, PC, Colorado Springs, CO]: