May/June 2012

Addressing Sleep Challenges

By Debra Sanders, RN, PhD, GCNS-BC
Aging Well
Vol. 5 No. 3 P. 22

Healthcare providers must ask patients about sleep, sleep routines/patterns, the quality of their sleep, and the impact on daily functioning and quality of life.

It is commonly believed that, as we age, we need fewer hours of sleep and that sleep disturbances are an inevitable part of the aging process. It is true that nearly 50% of older adults complain of difficulty sleeping,1 and older adults utilize 40% of the sleeping pills prescribed in the United States, according to SleepMed, Inc, the largest private sleep diagnostic provider in the United States. However, it is not that individuals require less sleep as they age but that sleeping changes with age.

Experts agree that older adults need seven to eight hours of sleep per night to carry out physiologic processes. Yet aging is often associated with diminished quality of nighttime sleep so that the need for sleep doesn’t change but rather the ability to sleep does, according to the National Sleep Foundation. This decreased quality of nighttime sleep can be attributed to a multiplicity of causes, including chronic conditions, medications, and poor sleep hygiene. Moreover, poor nighttime sleep can lead to increased daytime sleepiness with resultant poorer quality of life and functional abilities as well as increased risk for injury and morbidity and mortality, according to the Institute of Medicine.

In a large epidemiological study of more than 9,000 patients, 42% of older adults reported difficulty falling asleep and staying asleep, particularly older adults with poor health and those with comorbidities.2 Furthermore, according to the National Sleep Foundation, 61% of women report experiencing some symptoms of insomnia a few nights per week. This may be attributable, in part, to hormonal factors.3,4

Despite the staggering reports of poor-quality sleep among older adults, sleep disturbances are underappreciated and underdiagnosed by practitioners caring for these individuals. A 2006 report from the Institute of Medicine indicates that sleep and sleep deprivation are significant public health problems that may have particularly detrimental health and safety repercussions for older adults.5 Healthcare providers must respond with vigilance in identifying and addressing older adults’ sleep health.

Sleep Changes With Aging
It has been well documented that sleep architecture, defined as patterns in which sleep alternates between nonrapid eye movement (NREM) and rapid eye movement (REM) sleep, changes with age.6 Normal sleep progresses through three stages of NREM sleep (N1, N2, and N3), from light sleep (N1) to deeper sleep (N3). REM sleep, although an active form of sleep, is a critical sleep stage in which the brain replenishes itself for wakefulness, processes information, and stores data in memory. Sleep traditionally occurs in 90-minute cycles of NREM/REM sleep throughout our nighttime sleeping, according to the American Academy of Sleep Medicine.

As a person ages, the proportion of time spent in the deeper stages of sleep is reduced while time spent in the lighter stages of sleep increases. Moreover, repeated and frequent nighttime awakenings or arousals can disrupt sleep patterns. Sleep latency, or the amount of time it takes to fall asleep, increases with age, creating longer periods of lying awake before sleep ensues. Sleep efficiency, or the ratio of the amount of time spent in bed to time spent asleep, changes so that more time is spent in bed awake than time actually sleeping.7

There are also notable changes in circadian rhythm, the 24-hour sleep-activity cycle, which tends to weaken with age and become more disjointed. Such circadian rhythm changes can cause older adults to go to bed earlier in the evening and wake up earlier in the morning. Increased daytime napping to make up for lost nighttime sleep only further accentuates the problem by delaying sleep onset and reducing nighttime sleep. Environmental cues for sleep, such as light and dark, can alter an individual’s circadian rhythm. Additionally, the nocturnal secretion of melatonin decreases with age. Melatonin, known to influence the sleep-wake cycle, may further contribute to reduced sleep efficiency (see “Sleep Changes Associated With Aging” below).

Sleep Stealers
Older adults may encounter a multitude of factors that tend to “steal” sleep. Comorbid conditions can become significant causes of nighttime sleep disruption. Chronic conditions such as lung disease, heart disease, and arthritis can cause frequent nighttime awakenings, leading to nonrestorative sleep. Additionally, any condition causing chronic pain can interfere with restful sleep, as can many medications taken for underlying medical conditions and psychiatric illness. Examples of such medications are corticosteroids, beta-blockers, diuretics, bronchodilators, decongestants, antihistamines, serotonin reuptake inhibitors, and tricyclic antidepressants. In addition to these prescription medications, over-the-counter preparations such as cough and cold medications, caffeine-containing products, and nicotine preparations (eg, transdermal patches, gum, inhalers) can be culprits in disrupting sleep.

Lifestyle issues such as shift work, family or marital discord, frequent travel, or stress and upheaval can disrupt sleep. Alcohol, which can aid an older person in relaxing and falling asleep, can disrupt sleep three to five hours following ingestion, thus contributing to restless sleep. Additionally, the use of other substances such as caffeine or nicotine in the hours preceding bedtime can impair nighttime sleep.

The sleep environment itself may not promote a restful environment. Noise level, lighting, and bedroom temperature can be obstacles to a good night’s sleep (see “Sleep Hygiene Tips for Patients” below). And sleep disorders such as obstructive sleep apnea, restless leg syndrome, and REM sleep-behavior disorder may be contributors to lost sleep. Sleep “stealers” such as these may impede physical and mental functioning during daytime or awake hours and contribute to a host of negative consequences for the older adult.

For institutionalized older adults or elders with dementia, sleep can present some particular challenges. Factors such as unfamiliar people and environments, light, noise, disruptions by staff or other residents, and changes in previous or usual routines can impair sleep patterns.8 Sleep disruption experienced by individuals with Alzheimer’s dementia is estimated to be as high as 40% and commonly characterized by difficulty falling asleep, multiple arousals from sleep, early morning awakenings, and overall fragmented sleep-wake patterns. Sleep disruptions increase as dementia severity progresses.9

Consequences of Poor Quality Sleep
Poor-quality nighttime sleep can have numerous effects on an older adult and, in fact, has been linked to significant morbidity and mortality in older adults.1,5 Excessive daytime somnolence caused by a lack of restful sleep may lead to increased daytime napping and falling asleep at inappropriate times during the day, affecting awake time functioning, quality of life, and social and occupational functioning and potentially increasing depression, anxiety, and cognitive deficits. In addition, older, sleepier adults may experience balance issues and ambulatory and vision difficulties, creating safety concerns and increasing the risk of falls.10 This increased risk of falls is a strong predictor of placement in assisted-living or nursing home facilities.1

Healthcare Providers’ Role  
Comprehensive assessment and identification of sleep disruptions in older adults is essential to intervening with an individualized plan of care. Healthcare providers must ask older patients about sleep, sleep routines/patterns, and quality of sleep as well as the impact on daily functioning and quality of life. Bloom et al11 identified several questions to ask older adults in the initial assessment and screening process (see “Initial Assessment Questions” below). Survey tools can aid in risk stratifying those who may need additional counseling or referral for polysomnography (overnight sleep study).

The Epworth Sleepiness Scale, a well-known short assessment tool used to rate daytime sleepiness, can be helpful in assessing daytime sleepiness in the present as well as to trend sleepiness over time (www.stanford.edu/~dement/epworth.html). The Functional Outcomes of Sleep Questionnaire measures the impact on daily activities of disorders of excessive sleepiness across five domains: activity level, vigilance, intimacy and sexual relationship, general productivity, and social outcome.12 The Pittsburgh Sleep Quality Index can assess sleep quality and disturbance over a one-month time period across seven domain scores: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction.13

Additionally, healthcare providers need to explore existing conditions and medications that may influence elders’ sleep patterns. Over-the-counter preparations and herbal products need to be addressed to determine their potential influence on sleep. Providers should strongly encourage older adults to engage in positive sleep hygiene strategies. Good sleep hygiene enables better-quality sleep, contributing to overall functioning and quality of life. Although education about sleep hygiene may not be indicated as the sole therapy for severe chronic forms of insomnia, behavior change to facilitate better sleep habits is foundational in the overall treatment plan.

Pharmacologic interventions for sleep should be reserved for cases in which nonpharmacologic management is ineffective, for short-term use, or until further evaluation by a sleep specialist can occur. Although several of the newer sleep medications (eg, Sonata, Ambien, Lunesta, Rozerem) may have a better safety profile than prior hypnotics, the National Institutes of Health State of the Science Conference on Insomnia14 cautions practitioners about their long-term use without concomitant behavioral therapy.

Referral to a sleep specialist for more extensive evaluation and polysomnography should occur if the treatment plan is ineffective or the sleep problem is more severe or complex than initially indicated.5 The healthcare provider in tandem with the sleep specialist occupies pivotal positions that can impact an older adult’s sleep health.

Healthcare providers need to query their patients about sleep and take measures to intervene in problematic situations. Significant evidence suggests a need to consider the impact of poor-quality sleep on older adults’ health and longevity. Now the responsibility falls to healthcare providers to become instrumental in assuring that growing older does not necessarily mean sleeping poorly.

— Debra Sanders, RN, PhD, GCNS-BC, is an assistant professor of nursing at Bloomsburg University of Pennsylvania and a board-certified gerontologic clinical nurse specialist.

Sleep Changes Associated With Aging
• Increased sleep latency (time it takes to fall asleep)

• Decreased sleep efficiency (amount of time in bed to amount of time asleep)

• Difficulty maintaining sleep

• Increased nighttime arousals and awakenings

• Decreased time spent in deeper stages of sleep/Increased time spent in lighter stages of sleep

• Increased early morning awakenings

• Changes in circadian rhythm (sleep-wake cycle)

• Increased sleep fragmentation

Sleep Hygiene Tips for Patients
• Try to maintain regular sleep/wake times.

• Establish a bedtime routine (eg, warm bath, relaxing activity).

• Limit daytime napping.

• Avoid caffeine, nicotine, and alcohol close to bedtime.

• Create a sleep-conducive environment (darkened, quiet environment).

• Use the bedroom only for sleep or sex.

• Limit fluid intake in the hours before bedtime.

• Exercise regularly and earlier in the day.

• Avoid eating large meals before bedtime (a light snack is permissible).

• If unable to fall asleep after 30 minutes, leave the bedroom to do a quiet activity; return to the bedroom when sleepy.

Initial Assessment Questions11
• What time do you normally go to bed at night and wake up in the morning?

• Do you have trouble falling asleep at nighttime?

• How many times do you wake up during the night?

• If you wake up, do you have trouble falling back asleep?

• Does your bed partner say (or are you aware) that you frequently snore, gasp for air, or stop breathing?

• Does your bed partner say (or are you aware) that you kick or thrash about while asleep?

• Have you ever punched, kicked, or screamed while asleep?

• Are you sleepy or tired during much of the day?

• Do you usually take naps during the day? If yes, how many?

• Do you usually doze off without planning to during the day?

• How much sleep do you need to feel alert and function well?

• Are you currently taking any type of medicine or other preparation to help you sleep?

References
1. Neikrug AB, Ancoli-Israel S. Sleep disorders in the older adult—a mini-review. Gerontology. 2010;56:181-189.

2. Foley DJ, Monjan AA, Brown SL et al. Sleep complaints among elderly persons: an epidemiologic study of three communities. Sleep. 1995;18(6):425-432.

3. Krishnan V. Gender differences in sleep disorders. Curr Opin Pulmon Med. 2006;12(6):383-389.

4. Soares CN, Murray BJ. Sleep disorders in women: clinical evidence and treatment strategies. Psychiatr Clinic North Am. 2006;29(4);1095-1113.

5. Institute of Medicine. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: National Academies Press; 2006.

6. Vitello MV. Recent advances in understanding sleep and sleep disturbances in older adults. Curr Direct Psychol Sci. 2009;18(6), 316-320.

7. Unruh ML, Redline S, An MW, et al. Subjective and objective sleep quality and aging in the sleep heart health study. J Am Geriatr Soc. 2008;56(7):1218-1227.

8. Koch S, Haesler E, Tiziani A, Wilson J. Effects of sleep management strategies for residents of aged care facilities: findings of a systematic review. J Clin Nurs. 2006;15:1267-1275.

9. Song Y, Dowling GA, Wallhagen MI, Lee KA, Strawbridge WJ. Sleep in older adults with Alzheimer’s disease. J Neurosci Nurs. 2010;42(4):190-198.

10. Kryger M, Monjan A, Bliwise D, Ancoli-Israel S. Sleep, health, and aging. Bridging the gap between science and clinical practice. Geriatrics. 2004;59(1):24-26, 29-30.

11. Bloom HG, Ahmed I, Alessi CA, et al. Evidence-based recommendations for the assessment and management of sleep disorders in older persons. J Am Geriatr Soc. 2009;57:761-789.

12. Weaver TE, Laizner AM, Evans LK, et al. An instrument to measure functional status outcome for disorders of excessive sleepiness. Sleep. 1997;20(10):835-843.

13. Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatr Res. 1989;28:193-213.

14. National Institutes of Health. National Institutes of Health State of the Science Conference statement on manifestations of chronic insomnia in adults, June 13-15, 2005. Sleep. 2005;28(9):1049-1057.