Tuesday, March 1, 2011

Insomnia in the Elderly: Symptoms, Causes, and Treatment

What is it?

Insomnia (in-som-nee-uh) is having trouble getting to sleep or staying asleep. Insomnia is also the feeling that you are not getting enough sleep. People over 65 years of age are more likely to have problems with sleep.

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Adults need 7 1/2 to 8 hours of sleep each night. As people age their need for sleep actually stays the same or only decreases slightly (6 1/2 to 7 hours a night). Normal sleep happens in several stages. There are times in the night when you sleep lightly and do not dream. There are also periods of deep, dreamless sleep. Throughout the night you have several periods of active dreaming called REM (rapid eye movement) sleep. But, sleep patterns change as we grow older. The amount of time you spend in each type of sleep changes.

Insomnia can be a serious problem for older adults. A lack of sleep can cause difficulties that mimic symptoms of Alzheimer’s disease: slower response time, increased falls, decreased memory, attention and cognitive performance. Depression and dementia sometimes follow insomnia. All too often, people respond to such difficulties by staying indoors, resting more and sleeping during daytime hours. This results in a decreased ability to sleep at night, and the cycle repeats.  

Shallow non-REM sleep is typical in older adults. When sleep is disrupted, as is common with the elderly, the deep stage 3 and 4 slow-wave sleep cycles (SWS) are difficult to achieve and maintain. It takes time for the body to shift into SWS, and any disturbance, whether the sleeper actually wakes or not, throws the body back into a lighter sleep phase. Current scientific evidence indicates that these SWS cycles are the most restorative phase of sleep and are necessary for proper daytime brain functioning, as well as hormone regulation. Since these hormones affect glucose regulation, a lack of SWS sleep may affect glucose homeostasis and could therefore be a contributing factor to the development of type 2 diabetes, which is an increasing problem for older adults. 

Signs and Symptoms

You may have one or more of the following symptoms of insomnia.
  • Harder time falling asleep.
  • Awaken more often (3 to 4 times each night) and have greater memory of being awake.
  • The difference between being asleep and awake is sudden. This can make you feel like you are a light sleeper.
  • Feel as though you are not getting enough sleep because less time is spent in deep, dreamless sleep. But, your total sleep time may not have changed.
  • "Internal clock" shifts so that you go to bed earlier in the evening and wake earlier in the morning.
  • Confusion between day and night.
Causes

 Many things can cause insomnia in the elderly. Most of these causes can be treated. The causes of insomnia in the elderly are divided into 4 groups.

Physical Causes

  • Cardiovascular disease.
  • COPD, asthma, or other lung problems
  • Long-term pain.
  • Bladder or prostate problems.
  • Epilepsy.
  • Sleep apnea.
  • Dementia or Alzheimer's disease.
  • Joint disease, like arthritis or bursitis.
  • Gastroesophageal reflux.
Environmental/Behavioral Causes

  • Noise.
  • Late-night eating.
  • Late-night exercise.
  • Inactive lifestyle.
Drugs-related Causes

  • Caffeine (coffee, tea, cola drinks, chocolate, some cold medicines).
  • Alcohol.
  • Nicotine.
  • Some antidepressant medicines.
  • Stimulant medicines.
  • Medicine schedule. Taking some medicines at night may cause you to wake up at night, like diuretics (water pills). 
Mental Causes

  • Anxiety.
  • Depression, caused by
    • Retirement.
    • Loss of personal identity.
    • Death of spouse, family member, or friends.
  • Stress.
    • Financial problems.
    • Belief that you are in poor health.

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Medical Care

  • Tests: You may need one or more of the following tests to plan your treatment.
    • Health history: Visit your family doctor and explain the problems you are having in necessary details. Doctor may ask questions about your sleep habits as well as questions about your past and current medical history. He also will check what medicines you take regularly, including over-the-counter medicines. You may also be asked questions about your life style and about any stresses you have.
    • Physical checkup: You will have a physical checkup to make sure that something physical is not causing your insomnia. The physical checkup may include one or more of the following tests.
      • EEG sleep studies.
      • Overnight oximetry.
      • Overnight polysomnography.
      • Mini-mental state exam.
      • Cardiopulmonary exam.
      • Upper airway exam.
      • Neurologic exam.
      • Musculoskeletal exam.
      • Blood or urine lab tests.

  • Treatment Options: You may want to try some of the following things to help you sleep better.
    • Set a bedtime routine for yourself. Sticking to this routine will help good sleep habits develop with time.
      • Go to bed and get up at the same time every day. But, try not to go to bed until you feel sleepy.
      • Read or watch television before bedtime. This may help you feel sleepy and allow you to fall asleep naturally.
      • Take a hot bath before going to bed.
      • Avoid heavy eating late in the evening. But, a light bedtime snack may help. A glass of warm milk causes sleepiness naturally.
    • Make sure that your bedroom is quiet, peaceful, and comfortable.
      • Do not turn your bedroom into an office or den.
      • Make sure your mattress is comfortable.
      • Try to make your bedroom as sound-proof as possible so that noises do not wake you. Use earplugs or eye shades if necessary.
      • If you have a bedroom clock, make sure it does not tick or hum because this can awaken you.
      • Several studies show that listening to soft music at bedtime help older people sleep better. You may try that as well.
    • Avoid taking naps during the day.
    • Avoid stimulants such as caffeine and tobacco within 6 hours of sleep.
    • Exercise regularly so that you will be tired naturally at bedtime. But, do not exercise 3 hours before bedtime.
    • Avoid alcohol before bedtime. Alcohol may make you sleep but it can wake you up later in the night.
    • Many people find that they "worry" about things when they are in bed. Try to deal with your worries before going to bed for the night. Try to turn off your mind. Focus on peaceful and relaxing thoughts. Play soft music or relaxation tapes. Ask your caregiver for help with relaxation training or stress management.
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  • Medicine: You may be prescribed some sleeping medicine for a short time to set up regular sleep patterns. But, avoid taking sleeping medicines for long periods if at all possible. These medicines can be addicting and some have side effects, such as confusion. Do not take sleeping pills given to you by friends. Do not take over-the-counter sleeping pills or medicines that cause insomnia, like some cold medicines.

    • Always take your medicine as directed by your physician. If you feel it is not helping, call him/her for clarification or necessary adjustments. Do not quit taking it unless your doctor tells you to.
    • Keep track of what medicines you are taking and when you take them. Learn why you take each medicine.
    • If you are taking antibiotics, take them until they are all gone even if you feel well.
    • If you are taking medicine that makes you drowsy, do not drive or use heavy equipment.

When medications are needed - after non-pharmacological options have been tried - those that have FDA indication for insomnia include barbiturates (pentobarbital, phenobarbital, secobarbital), benzodiazepines (quazepam [Doral], temazepam [Restoril], triazolam [Halcion]), zaleplon (Sonata), and zolpidem (Ambien).
Barbiturates are rarely used for elderly insomnia because they are dangerous, habit-forming, and have many CNS adverse effects including agitation, confusion, hyperkinesia, ataxia, nightmares, nervousness, hallucination, dizziness, and thinking abnormality.

Benzodiazepines are commonly used with adults. However, they are dangerous in the elderly. Elderly who take benzodiazepines are at an increased risk of serious adverse effects including oversedation, dizziness, weakness, unsteadiness, increased falls, mental confusion, dependence with withdrawal symptoms, lack of recall of events while on medication, amnesia, memory impairment, disorientation, nausea, change in appetite, headache, sleep disturbance, and agitation.

Zolpidem is a newer and safer treatment for short-term insomnia and should be used for 1-month-maximum. However, many seniors end up taking it for years. It can cause depression, behavioral changes, decreased respiratory function, dizziness, daytime drowsiness, drugged feelings, amnesia, diarrhea, headache, and nausea.

Zaleplon is the newest drug for short-term treatment of insomnia. It is very short-acting (2-4 hours). Zaleplon's adverse effects include drowsiness, dizziness, hallucination, tremor, vertigo, amnesia, paresthesia, depressed respiratory function, anorexia, and depersonalization. Zaleplon is useful for people who have an occasional problem falling asleep or waking up during the night, and for people who travel through time zones. However, these are not the usual complaints of the elderly.

Antihistamines are commonly used as treatment for elderly insomnia, though this is not an FDA indication. Diphenhydramine (Benadryl) is the active ingredient in over-the-counter sleep preparations such as Tylenol PM and others. Its use in the treatment of insomnia in the elderly is not recommended.


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