In the next fifty years, the aged will make up a progressively greater proportion of the general population and medical scientists are learning that sleep may provide a key to the health and wellbeing of this group. Many older people are very healthy and have normal sleep; however, a significant number of older adults have sleep problems that are often linked to other factors including underlying medical conditions.
To address these issues, NSF—in cooperation with the National Institute on Aging, National Institute on Mental Health, National Center on Sleep Disorders
Research, American Association of Medical Colleges, and the Canadian Institutes of Health Research—recently convened a Congress on Sleep, Health and Aging in Washington, DC. Prior to the Congress, NSF asked several of the speakers to comment on issues related to sleep, health and aging.
The speakers included:
- Sonia Ancoli-Israel, PhD
Professor of Psychiatry, University of California, San Diego, CA and Director of the Sleep Disorders Laboratory, Veterans Affairs San Diego Healthcare System
- Virend K. Somers, MD, DPhil
Professor of Medicine, Division of Cardiovascular Diseases and Division of Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN
- Michael V. Vitiello, PhD
Professor and Senior Scientist, Sleep Research Group, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA
What are the changing characteristics of sleep as we age?
Dr. Vitiello: We find that sleep tends to get shorter, we see less sleep, on average, even in healthy non-complaining older adults compared to younger individuals. We also see increased fragmentation of sleep; older people wake up more often and for longer periods of time during the night. Their sleep becomes shallow; that is we see less delta (or slow wave) sleep (when growth hormone is produced), which is the classic sleep hallmark of aging. Interestingly, men lose much more slow wave sleep than women, but women report more sleep disturbances than men. That's a puzzle: why don't the epidemiological and subjective data match up?
What is the impact of age-related health problems on sleep? What conditions are mostly associated with sleep deprivation and sleep disorders?
Dr. Somers: Most age-related diseases will affect sleep and will be affected by sleep. For example, painful conditions like arthritis or back pain will affect how patients sleep by causing arousal during the night. Sleep-related breathing disorders, which tend to be more frequent in older individuals, may affect quality of sleep, cause sleep deprivation and exacerbate conditions like high blood pressure. Other considerations are disease processes that have a relationship with sleep, such as heart failure, when symptoms of shortness of breath become worse. Patients may have sudden episodes of shortness of breath during the night that occurs when they are lying flat. That's why people with heart failure have to sleep with the head elevated.
Heart failure disturbs sleep, and disturbed sleep can contribute to daytime tiredness and fatigue that is so characteristic of heart failure patients. Disease affects sleep quality, and sleep quality affects the disease.
Dr. Vitiello: I think of disturbed sleep in the elderly as a layer cake. One layer is associated with the process of aging per se. A second layers are the health and psychosocial burdens that can contribute to sleep disturbance. A third is the primary sleep disorders such as sleep apnea or restless legs syndrome that appear with increasing frequency in older individuals. A fourth layer of course is related to sleep hygiene, the various behaviors people have around sleep that can either increase or decrease its quality.
What should healthcare providers ask their older patients about their sleep problems?
Dr. Ancoli-Israel: First, they need to understand that disturbed sleep can be a major issue. The fact that they're 80 or 90 years old shouldn't preclude the possibility of sleeping well. If they don't sleep well, it's the physician's job to figure out why. First, ask whats causing the problem.
Do you require less sleep as you get older (as is commonly believed), or do you just get less sleep?
Dr. Ancoli-Israel: That's a big debate in our field. Many of us do believe the need for sleep doesn't change. There are two ideas: (1) if you look at older healthy adults, they're sleeping about the same amount as when they were younger; (2) when you study older adults, many are sleepy during the day, and we believe that sleepiness during the day almost always means the person is not sleeping enough at night, suggesting that the older adult has lost some of the ability to get the sleep they need. We have to do more research to determine if the need for sleep changes or not. Regardless, it is clear that the ability to sleep for many older adults changes. Circadian rhythms, sleep disorders, medical problems, and changes in lifestyle can contribute to poor sleep. The important question is, why do adults have trouble sleeping, and what can we do about it?
If it's medication, try changing the times they take it, the dose or an alternative that doesn’t disturb sleep. If it's pain, get the pain under better control. Poor sleep at any age is a problem. Just because somebody is older doesn't mean they weren't meant to sleep better.
Dr. Somers: The key questions should be part of a standard sleep history: Does the patient sleep well? How long do they sleep? Do they have problems breathing during sleep? Is there daytime somnolence (falling asleep when it's important to stay awake)? These are the kinds of questions that help guide us in determining how the patient's health is being affected by sleep. Simple sleep hygiene, such as getting the TV out of the bedroom, making the room darker by reducing ambient light, and avoiding strenuous mental and physical activity just before sleep can help. It's important that we teach the doctor about these hygienic measures, and doctors need to share them with their patients, in particular their elderly patients, who are more susceptible to the development and the consequences of disturbed sleep.
Dr. Vitiello: The first thing doctors should do is never assume a sleep complaint is simply because the patient is getting old. They should determine whether that person feels their daytime function and quality of life is impacted by their sleep complaint. They can have poor sleep, but if they're functional during the day, it may be OK. But if poor sleep interferes with function, that's a problem. You may have to educate the patient that sleep changes with age and eight hours may not be an achievable goal. You may have to address health conditions; there may be depression or a sleep disorder present that can be treated. The doctor should also examine the patient's sleep hygiene.
There are behavioral techniques that have been shown to be extremely effective in combating certain sleep problems. This should be the first line of attack, and pharmacological therapy should be a fallback method of treatment.
This article was published in the Spring 2003, Volume 5, Issue 2 of sleepmatters.
