Getting a Good Night's Sleep

My 78-year-old mother has been living with me for 2 years. Over the past several months, she has complained of increasing difficulty getting a good night's sleep. Some nights she awakens around 3 or 4 AM, is up for the rest of the morning, and then catnaps throughout the day. Sometimes, she says she is up and down all night. She is usually fairly active and involved but is becoming less so as she is always too tired. She is scheduled to see her nurse practitioner to talk with her about this problem, but is there anything we could be doing in the interim?

 

As an individual ages, there are several normal changes that occur in sleep patterns. In general, nighttime sleep becomes lighter, there are more frequent and longer periods of wakefulness, and there is decreased total sleep time. The internal clock also appears to shift so that elderly persons often retire to bed earlier in the evening and awaken earlier in the morning.

 

While the ability to sleep may be reduced with age, the need for sleep is not. Sometimes, recognizing that sleep patterns do change with aging and accommodating those changes can ensure adequate rest. However, when sleep requirements are not met, excessive daytime sleepiness and fatigue occurs, daily function suffers and the person's quality of life and health status are slowly eroded.

There are many potential causes that can contribute to sleep disturbances in the elderly, including emotional stress, medical or psychiatric illnesses, prescribed and over-the-counter medications (including alcohol and caffeine), primary sleep disorders such as sleep apnea (a sleep-related breathing disorder) or periodic leg movements during sleep (rhythmic jerks of the lower leg) and poor sleep habits.

Depending on the person and the causes, sleep problems can range from merely annoying to life-threatening (as with undiagnosed sleep apnea). Assessment of a sleep problem generally includes a comprehensive sleep history, review of current sleep hygiene practices, a medical history and exam, medication review and, in some cases, a psychiatric history. If possible, it would be helpful to the practitioner for your mother (with your help) to keep a daily sleep diary for at least 2 weeks recording information such as you have already provided: 

  • What time does she go to bed?

  • What time does she fall asleep?

  • How often does she awaken during the night and for how long?

  • Can she identify what awakens her? (need to use the bathroom? unpleasant dreams?)

  • What time does she wake up in the morning?

  • How often and for how long does she nap in the day?

  • Does she snore?

  • How alert is she during the day?

In many cases, sleep can be improved by following practical Sleep Hygiene Tips. However, in some cases, medications may be indicated.  One of the older anti-depressants, trazadone (desyrel) is commonly used at low doses for sleep problems in elders.  Other sleep medications such as ambiem are indicated for short-term use and may cause memory problems when used for extended periods of time.  Over-the-counter preparations which usually contain antihistamines such as Benadryl (diphenhydramine) should not be considered completely safe as they can produce undesirable and even deleterious side effects in elders. If your mother's sleep does not improve with simple sleep hygiene tips, talk with her health care provider who may consider medications or referral to a sleep specialist if sleep apnea or restless legs is suspected.

Some elders erroneously accept excessive daytime fatigue and decline in function as part of the normal aging process. You and your mother have astutely recognized that her sleep complaints and changes in daytime function deserve evaluation and intervention by a health care professional. Thank you for sharing this question with us as I am hopeful our response will help other silver feathered night owls!

Sleep Hygiene Tips

Taken from Primary Care of the Older Adult: A Multidisciplinary Approach, Mosby, Inc., 2000.

  • Establish a relaxing routine and follow it every night before bed.
  • Go to bed and get up at the same time each day.
  • Avoid alcoholic beverages before bedtime (can cause awakenings).
  • Avoid tobacco, caffeine, and decongestants (often in over-the-counter cold preparations) within 8 hours of bedtime.
  • Maximize exposure to bright light, preferably sunlight, every day.
  • Schedule exercise for each day but avoid right before bedtime.
  • Keep your bedroom quiet and dark with the temperature in a comfortable range.
  • Use the bed only for sleep and sexual activities. Do not read, watch TV, or talk on the phone in bed.
  • If unable to fall asleep in 30 minutes, get up, do something else, and return to bed when drowsy.
  • A small snack such as warm milk or cheese may help to promote sleep.
  • Avoid daytime naps.
  • Talk with your health care professional about snoring as it may indicate sleep apnea.

If there's an Eldercare topic you'd like to see addressed in "Caregiver Query", e-mail Kathy Fletcher at krf8d@virginia.edu. Remember, any information provided is not a substitute for consultation with your health care provider.