Chronic Insomnia

Sleep Problems

Sleep disorders in the elderly involve any disruptive pattern of sleep such as problems with falling or staying asleep, excessive sleep, or abnormal behaviors associated with sleep.

Causes

Sleeping problems are common in the elderly. In general, older people require less sleep, and their sleep is less deep than that experienced by the young. Some causes of and contributors to sleep disturbances include the following:

• Sedentary lifestyle
• Depression among the elderly (depression is a common cause of sleep problems among people of all ages.)
• Chronic pain caused by diseases such as arthritis
• Chronic diseases such as congestive heart failure
• A need to urinate frequently at night
• Stimulants such as caffeine
• Prescription drugs, recreational drugs, or alcohol
• Neurological conditions
• Alzheimer's disease
• Organic brain syndrome

Symptoms

• Frequent night awakenings
• Difficulty falling asleep
• Early morning awakening
• Confusion differentiating between day and night

Exams and Tests

• History of sleep disturbances and history of contributing factors
• Physical examination to rule out medical causes

Treatment

The relief of chronic pain and control of underlying medical conditions such as frequent urination may improve sleep in some people. Effective treatment of depression can also improve sleep.

Sleep-promoting interventions such as a quiet sleep environment and a glass of warm milk before bed may improve the symptoms. Other ways to promote sleep include the following:

• Have a specific bedtime and awakening time each day.
• Do not take naps during the day.
• Use the bed only for sleep or sexual activity.
• Exercise early in the day.
• Avoid large meals shortly before bedtime.
• Avoid stimulants such as caffeine.

If you can't fall asleep after 20 minutes, get out of bed and do a quiet activity such as reading or listening to music.

The use of sleeping pills, such as benzodiazepines, to promote sleep is usually not recommended on a long-term basis, as these can produce dependence and lead to worsening sleep problems over time if used inappropriately.

However, other sleeping pills, such as Ambien and Lunesta, are relatively safe if used properly.

WARNING: The FDA has asked manufacturers of sedative-hypnotic sleep medicines to put stronger warning labels on their products so that consumers are more aware of the potential risks. Possible risks while taking such medicines include severe allergic reactions and dangerous sleep-related behaviors, including sleep-driving. Ask your doctor about these risks.

Outlook (Prognosis)

Most people see improvement in sleep with treatment or interventions. However, others may continue to have persistent sleep disruptions.

Possible Complications

A complication is alcohol use or drug abuse.

When to Contact a Medical Professional

Call for an appointment with your health care provider if a lack of sleep or too much sleep is interfering with daily living.

Prevention

Eliminating as many causes of sleep disruption as possible and encouraging regular exercise may help control sleep problems.

Until the 1950s, most people thought of sleep as a passive, dormant part of our daily lives. We now know that our brains are very active during sleep. Moreover, sleep affects our daily functioning and our physical and mental health in many ways that we are just beginning to understand.

Nerve-signaling chemicals called neurotransmitters control whether we are asleep or awake by acting on different groups of nerve cells, or neurons, in the brain. Neurons in the brainstem, which connects the brain with the spinal cord, produce neurotransmitters such as serotonin and norepinephrine that keep some parts of the brain active while we are awake. Other neurons at the base of the brain begin signaling when we fall asleep. These neurons appear to "switch off" the signals that keep us awake. Research also suggests that a chemical called adenosine builds up in our blood while we are awake and causes drowsiness. This chemical gradually breaks down while we sleep.

During sleep, we usually pass through five phases of sleep: stages 1, 2, 3, 4, and REM (rapid eye movement) sleep. These stages progress in a cycle from stage 1 to REM sleep, then the cycle starts over again with stage. We spend almost 50 percent of our total sleep time in stage 2 sleep, about 20 percent in REM sleep, and the remaining 30 percent in the other stages. Infants, by contrast, spend about half of their sleep time in REM sleep.

During stage 1, which is light sleep, we drift in and out of sleep and can be awakened easily. Our eyes move very slowly and muscle activity slows. People awakened from stage 1 sleep often remember fragmented visual images. Many also experience sudden muscle contractions called hypnic myoclonia, often preceded by a sensation of starting to fall. These sudden movements are similar to the "jump" we make when startled. When we enter stage 2 sleep, our eye movements stop and our brain waves (fluctuations of electrical activity that can be measured by electrodes) become slower, with occasional bursts of rapid waves called sleep spindles. In stage 3, extremely slow brain waves called delta waves begin to appear, interspersed with smaller, faster waves. By stage 4, the brain produces delta waves almost exclusively. It is very difficult to wake someone during stages 3 and 4, which together are called deep sleep. There is no eye movement or muscle activity. People awakened during deep sleep do not adjust immediately and often feel groggy and disoriented for several minutes after they wake up. Some children experience bedwetting, night terrors, or sleepwalking during deep sleep.

When we switch into REM sleep, our breathing becomes more rapid, irregular, and shallow, our eyes jerk rapidly in various directions, and our limb muscles become temporarily paralyzed. Our heart rate increases, our blood pressure rises, and males develop penile erections. When people awaken during REM sleep, they often describe bizarre and illogical tales - dreams.

The first REM sleep period usually occurs about 70 to 90 minutes after we fall asleep. A complete sleep cycle takes 90 to 110 minutes on average. The first sleep cycles each night contain relatively short REM periods and long periods of deep sleep. As the night progresses, REM sleep periods increase in length while deep sleep decreases. By morning, people spend nearly all their sleep time in stages 1, 2, and REM.

People awakened after sleeping more than a few minutes are usually unable to recall the last few minutes before they fell asleep. This sleep-related form of amnesia is the reason people often forget telephone calls or conversations they've had in the middle of the night. It also explains why we often do not remember our alarms ringing in the morning if we go right back to sleep after turning them off.

Since sleep and wakefulness are influenced by different neurotransmitter signals in the brain, foods and medicines that change the balance of these signals affect whether we feel alert or drowsy and how well we sleep. Caffeinated drinks such as coffee and drugs such as diet pills and decongestants stimulate some parts of the brain and can cause insomnia, or an inability to sleep. Many antidepressants suppress REM sleep. Heavy smokers often sleep very lightly and have reduced amounts of REM sleep. They also tend to wake up after 3 or 4 hours of sleep due to nicotine withdrawal. Many people who suffer from insomnia try to solve the problem with alcohol - the so-called night cap. While alcohol does help people fall into light sleep, it also robs them of REM and the deeper, more restorative stages of sleep. Instead, it keeps them in the lighter stages of sleep, from which they can be awakened easily.

People lose some of the ability to regulate their body temperature during REM, so abnormally hot or cold temperatures in the environment can disrupt this stage of sleep. If our REM sleep is disrupted one night, our bodies don't follow the normal sleep cycle progression the next time we doze off. Instead, we often slip directly into REM sleep and go through extended periods of REM until we "catch up" on this stage of sleep.

People who are under anesthesia or in a coma are often said to be asleep. However, people in these conditions cannot be awakened and do not produce the complex, active brain wave patterns seen in normal sleep. Instead, their brain waves are very slow and weak, sometimes all but undetectable.