Wednesday, May 25, 2011

Sleep Changes in the Older Adult and Some Common Sense Strategies to Improve Sleep

This is my Nephew

This is My Sister

We went to Babies R' Us  during the Easter Break and I saw a storage of baby products that looked like the closing scene of all the boxes of exotic stored things in Raiders of the Lost Ark.



I also took a few pictures:
Are these diapers made of air?

These diapers are more complex than the Kleenex I use when I have a cold, and gloves I put on before during a minor surgical procedure.

Really? What type of baby is this that we have to partially break down their proteins for them before even reaching their stomach?

There are actually more types than this picture shows. My mom says Vaseline and babypowder worked just fine for me... and cost a 20th of the price.

Why am I talking about Babies R' Us and showing you these pictures?
Because, as I was trying to decide what to say about Sleep Issues in the Older Adult, and how things change as we age, I started wondering why our sleep worsens. Now, I'm going to tell you some of the natural reasons our sleep changes with age as we get older, but many of the reasons are also of our own design.
If you notice, the above pictures show the great, expensive, and subtle lengths to which we go to care for our children. I landed on three reasons why this seems to drop off as we age:
Babies: Why do they have care that we do not provide for ourselves as we age?
1.      They have obsessive-compulsive mothers to worry about them. We become mothers and fathers and turn our care outward, toward our children instead of inward. And many of our own mothers and fathers start needing their own care and can't concentrate on us like they used to, or, frankly, we start losing our mothers and fathers.
2.      We are stubborn to the artificial “mothers” in our lives. I find myself "mothering" my patients sometimes. Self-help books are one of the best-selling genres of book and are riddled with common-sense motherly advice.
3.      We give up on ourselves to variable degrees. That sounds awful, but it's kind of true. As we age, we stop daydreaming as much about all the future possibilities for our lives. We get burdened by health concerns, financial limitations, and other stressors of adulthood. In the process, we stop taking care of some of our basic needs as well. In the elderly, rates of depression among elderly (60 and above) range from 5% to 15%  depending on the study and measuring tools utilized, and is more common in women, with some studies saying mild depression can be found in up to 44% and major depression, which could lead to suicide present in 2-4%. Of course, much of it is due to situational things such as medical illnesses, disorders of sleep just being one of the many. But much of it is indirectly through our own ability to cope with the burden of increasing medical concerns on our hearts… which ironically leads to hopelessness and us doing less than we should to be good stewards of our health… thus leading to further health issues that might have been avoided.
What I want to talk about today in this blog:
  1. How sleep naturally changes with age.
  2. Common things that interfere with our sleep as we age.
  3. What are some things we can do to help improve our sleep.
  4. When should I see a sleep specialist?
How sleep changes with age.
1.      There are 3 stages of sleep during the night, and REM sleep.
a.      Stages 1, 2, and 3 are progressively deeper stages of sleep and serve many functions, but overall, is necessary for restoring the body. For instance, growth hormones peak during delta (stage 3) sleep. Delta (stage 3) sleep is the deepest sleep.
b.      REM (Rapid Eye Movement) sleep is dreaming sleep and is needed as well. REM sleep plays a role in the reorganization, restoration of brain processes that mediate the flow, structure and storage of information. This includes things like problem-solving, memory consolidation, information processing, and creativity. About 50% of the sleep cycle of the newborn is REM or quasi-REM kinds of sleep.
***Interesting facts: Apnea is often worse during dreaming sleep.
***Also, antidepressants often markedly lessen the amount of dreaming sleep we have.... This does NOT mean that antidepressants improve apnea.
2.      Stage 3 sleep is maximal in childhood (25-40% of their night). This is the deepest sleep and most difficult to be awoken from (why children sleep so soundly). It is also the most common place for sleep walking to occur (which is why they do this too).  As we age, Stage 3 sleep decreases (5-10% in elderly) and is replaced by Stage 1 and Stage 2, so that we have less deep sleep and more of lighter Stage 1 of sleep, which makes it easier for us to keep partially awakening and more difficult to get into that deep sleep of childhood. This is natural. The actual amount of net sleep need does not change over a lifetime. You are born with that, and your lifestyle, work requirements, habits cannot change that. Studies suggest that in older populations, you are more likely to get greater amounts of stage 3 sleep if you consolidate your sleep into night only (no daytime naps), and are active with light exposure during the day.
3.      But Dr. Kirk, I sleep all day… doesn’t that mean I need more sleep?
Maybe you don’t really sleep all day. Maybe you waffle among the lighter stages of sleep and wakefulness all day… and then all night as well because you did that all day. You could be sleeping all day from other causes, but in the natural healthy state, older people can get into the seeming pattern of sleeping all day because of this natural change in Stage 3 sleep and how we respond to it. In the past, when we fought for our food and worked in the village into older ages in less civilized society, the extra daytime activity helped us get that deeper sleep at night.
4.      Sleep efficiency decreases.
a.      We wake more during the night (Children once to twice. Adults: 5 or more) These are the memorable awakening. Children average 10 MILD arousals per hour of sleep and the elderly up to 27 MILD arousals per hour.
b.      We do not remember all our awakenings The hippocampus is the part of the brain that helps us lay down new memoriesm, and shuffle them away into longer-term storage in other parts of our brain. This is less likely to remember that we awoke during the night (unless we do something like get some water or use the restroom) than it does when we’re younger.

c.       We try to make up for that inefficiency during the night by sleeping more during the day.
d.      There is also decreased time-in-bed-to-sleep efficiency. This is different than overall sleep efficiency. This tells us that once adults awaken in the night, it takes naturally longer to fall back asleep. See, you can be less efficient by either waking up a large number of times, OR waking up and staying awake. *** This is also different than the bad habit of just hanging out in bed watching television or reading***
5.      Dreaming, REM sleep should stay the same… unless we are on medications that suppress it. Or have some disorder of sleep that doesn’t let us have restful, stable enough sleep to let us get to dreaming sleep.
a.      I see “REM rebound” often during sleep studies
b.      We remember our dreams less as we age, but usually still remember some. When did you last dream?
c.       The amount of time is takes to get to REM sleep decreases with age (90 minutes in youth on average.)
d.      REM sleep is also more evenly distributed throughout the night. REM sleep is normally more present at the end of the night which is why you normally wake from a dream in the morning. Interestingly, this pattern is also more commonly seen in people of all ages who have depression.
e.      There is some soft evidence that those who keep a dream journal, may actually increase the amount of dreaming sleep they have, and no one knows why that might be.
f.        We are unable to regulate our body temperature during REM sleep, so many of us sleep with too many or not enough covers on us we get older, which cause us to more likely waken from sleep during REM.
6.      Time to fall asleep only increases by about 5 minutes on average between youth and age, in healthy individuals. In fact, if we compare 20 versus 80 year-olds, that time increases only about 10 minutes on average.

What are some things we can do to help improve our sleep, then?
We can make some personal changes in an attempt to counteract these natural changes in our physiology:
  1. Spend more “quality time” in bed. Don’t linger in bed at the beginning of the night, but it more okay in the morning. We should still be using bed just for sleep and sex. You go to bed when you are sleepy, but we should be willing in the morning to give ourselves an extra hour if needed, and definitely not short-change ourselves by only giving 6 or 7 hours in bed.
  2. More activity during the day and less daytime naps. You should feel like you earned your sleep at the end of the day. so that we will encourage greater efficiency of sleep and promote the deeper stages of sleep
  3. Exercise isometric not so much aerobic,slow & steady, a little each day(30min)
  4. Get plenty of natural REAL sun during the day. Our brain has special receptors JUST for real natural light (even in many blind people), and it encourages the natural melatonin to be released at night when the sun goes down, to promote sleep.
  5. Use fans and the right amount of covers. General rule of thumb: Too hot at night is actually worse than too cool at disrupting sleep.
  6. Keep a dream journal and mark the date
  7. Worry less about some of these changes since they are in the design

How sleep changes with age… due to things other than natural aging?
  1. Medications
    1. There are a long list of medications and substances that potentially (not always) affect sleep negatively:
                                                              i.      Alcohol “nightcaps”: They may help you fall asleep initially, but they cause increased free water release which makes you need to urinate more during the night, and they cause rebound alertness at about 5 to 6 hours later (2 to 3 am).
                                                            ii.      Nicotine in tobacco can cause nightmares, increased latency to sleep as body relaxant but mind stimulant, and withdrawal alertness when it wears off in the night. Smoking and tobacco juice can increase edema in the throat and increase the chance for apnea.
                                                          iii.      Pain medications can cause rebound insomnia when they wear off and increase the amount of relaxation in the throat leading to worsening sleep apnea and therefore more difficulty breathing at night and resultant frequent nighttime arousals.
                                                           iv.      Caffeine can last 6, 8, and 10 hours in some people, and your reaction to caffeine changes unpredictably with age.
                                                             v.      Cold medications like benadryl with antihistaminergic and anticholinergic qualities can not only increase your chance of falls, dry mouth, and constipation, but also can cause prolonged residual drowsiness lasting into the next day. Decongestions have chemicals that not only reduce the swelling in your nose, but also keep you awake at night. By the way, please thrown away your Afrin. Everybody always seems to have worsening congestion as soon as this medication wears off. You should be using saline sprays, the neti pot, and possible low-dose steroid nasal sprays daily instead.
                                                           vi.      Some antidepressants, besides just decreasing the amount of REM sleep, can be themselves, activating. Effexor is a good example of this, and we recommend individuals taking this in the morning to try and minimize this possibility.
                                                         vii.      Some medications for breathing such as albuterol and keep patients awake.
                                                       viii.      Prednisone for some autoimmune disorders can cause brain excitation and insomnia
                                                           ix.      Some cholesterol-lowering medications can cause insomnia and nightmares
                                                             x.      Beta blockers for hypertension and some arrhythmias can cause insomnia.
                                                           xi.      Many more
    1. Everybody’s chemistry is different and this in by no means universally true… it is just something to keep in mind as you look over your medications. BUT you should know EXACTLY why you are on each and every medication. Sit down tonight and go over your list. If you aren’t sure exactly why you’re on it and if it’s helping, ask your doctor just to be sure. Sometimes I see medications on the list and frankly just think, we should stop this one. But stopping some like blood pressure medications, coumadin, ASA, etc… can kill you.
    2. Again, NEVER stop a medication without discussing it with your doctor, but the goal is always simplification of your regimen when possible, and seeing if you can treat two things with one medication when possible. Example: In older people, I see no reason to use Ambien to help them sleep when many people have nerve pain or headaches or something that could be treated with Neurontin/gabapentin or nortritptyline which can both treat the problem AND cause sleepiness to help them sleep if they take it before bed. BUT if it makes you sleep all day too… then that’s a problem. So there has to be a compromise, which I WILL BE THE FIRST to admit can be tricky when you have many things that need to be treated and many doctors on board.
  1. Bad Habits/Poor Sleep Hygiene:
    1. Some of this is already addressed above but one of my biggest concern is regarding late night, in-bed computer watching and computer use and nightlights that are too bright, followed by “twilight” lighting during the day, with the shades drawn and inside lights on… We spent thousands of years as humans being guided by sunrise and sunset and our body has been designed to respond most powerfully to these changes in light. When we manipulate that artificially, we respond very powerfully at a chemical level in our brain and this is ONLY becomes more true as we get older.
    2. Another one is a lack of bedtime ritual. My pre-bedtime ritual: I take a warm shower (not too hot), dim all the lights except enough light to read comfortably, read (next to my bed in a chair) one short article of neurology or sleep medicine or one article in a magazine or one short story in a book collection of them (no more). I do not watch any television or use the computer 45 minutes to 1 hour before getting into bed. By the time I finish reading, my body knows it is time. We are beings of ritual and habit and our body responds to it.
    3. Go to bed at the same time each night. If you control your medication intake, take your medications by alarm, at the same time each night.
    4. Keep your room and bed linens clean. A clean environment has been shown to relax the mind in preparation for sleep. The smell of clean sheets is often associated with bedtime and therefore becomes part of the bedtime ritual as aromatherapy. I use a lavender detergent so I always associate that smell with sleep, but I could just as easily use a similar candle or spray or use some sprigs from the neighborhood plant.

  1. One of the 85+ established Sleep Disorders could be adding to your difficulty sleeping.
    1. Of these, Obstructive Sleep Apnea and Central Sleep Apnea are very common in the population. There are numberous books dedicated to these alone.
    2. Another one is Restless Leg Syndrome and Periodic Limb Movements of Sleep. Also for another discussion in detail elsewhere.
    3. Many of them do not need a sleep study to evaluate but can be addressed by discussing your sleep concerns with your physician.
  2. Common medical co-morbidities that get in the way of your quality of sleep:
    1. Pain from osteoarthritis of the knee or hip or shoulder disrupts sleep in a different way than the disruption of sleep from say, Parkinson’s disease causing abnormal breathing or behavior during REM sleep… These will have to be addressed on an individual basis.
    2. Incontinence causing frequent restroom breaks. In women, it is often due to the trauma of childbearing. In men, it is often due to prostate enlargement. Interestingly, untreated sleep apnea actually causes the body to release a chemical that increases free water release and therefore a need for more restroom breaks during the night.
    3. Heart attacks cause a slight physical change in the human brain, decreasing the presence of a certain neurotransmitter (acetylcholine), which actually increases the presence of insomnia and will also increase, independently, the presence of depression to about 15-30% of individuals.
    4. Stroke patients and post-myocardial infarction patients are more likely to have central sleep apnea, in addition to insomnia.
    5. By the way, keep in mind that pain in the joints of your legs, pain in the muscles of your legs keeping you awake before bed, is very different from cramps, and restless leg syndrome and periodic limb movements keeping you awake or disrupting your sleep once you fall asleep. It is essential to differentiate these since the treatment is different.
When should you see a sleep specialist?
  1. If you are sleepy and taking care of the basics does not help
  2. If you think you have sleep apnea. We often underestimate how much apnea we truly have and how much sleep disruption because of it we have.
  3. If you think you have kicking of your legs WHILE YOU ARE ASLEEP. This is different from Restless Leg Syndrome which occurs WHILE YOU ARE AWAKE.
  4. If you think you have some other disruptor of your sleep and need some help teasing it out.

*** Please note, however, that whomever you see about this should be FELLOWSHIP TRAINED SPECIFICALLY in the Sleep Medicine, NOT just fellowship trained or resident trained in their main specialty. For instance, there are 18 of us with Raleigh Neurology and we are ALL Board Certified in Neurology, but only 2 of us are Fellowship trained specifically in Sleep Medicine.***

I really just want you to try and seek guidance from whoever is helping you keep healthy as an older adult, and hopefully remain optimistic about your ability to be a good steward of your health. I hope this entry has been helpful to you.