How Sleep Changes with Aging

Cathy Alessi, MD

Director, Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Health Care System

Professor, David Gaffen School of Medicine at UCLA

How Sleep Changes with Aging

Cathy Alessi, MD

How sleep changes as people get older

1. Sleep is lighter – there is less deep sleep

2. It may takes longer to fall asleep

3. Sleep may be less ‘efficient’ – more time awake during the time in bed at night

3. There may be more awakenings at night

5. Napping during the daytime is more common

6. There are some differences in sleep between men and women.

National Sleep Foundation (NSF) 2003 Sleep in America Poll

• National survey of older adults living in the US, aged 55 – 84 years

• Random sample, N=1506 telephone interviews

Men

(N=634)

Women

(N=872)

Total sleep time on weeknights 7.0 hrs 7.0 hrs

Total sleep time on weekends 7.1 hrs 7.1 hrs

Difficulty falling asleep 14% 21%

Awake a lot during night 32% 34%

Wake up feeling unrefreshed 24% 29%

Source: www.sleepfoundation.org

Women have more difficulty falling asleep than men (The Cardiovascular Health Study, N = 5201 adults aged > 65 years)

0

5

10

15

20

25

30

35

% of participants

66-69 70-74 75-79 80-84 85+

Age, in years

Men

Women

Prevalence in women > men (p<.0001)

Prevalence increased with age from 66 years to 85+ years in men (p=.008), but not women

Newman et al, JAGS 45:1-7, 1997

Both older women and older men have frequent nighttime awakenings (The Cardiovascular Health Study, N = 5201 adults aged > 65 years)

56586062646668707274

% of participants

66-69 70-74 75-79 80-84 85+

Age, in years

Men

Women

Prevalence in women = men

Prevalence increased with age from 66 years to 85+ years in men (p=.002) and women (p=.02)

Newman et al, JAGS 45:1-7, 1997

Insomnia is more common in women than in men throughout adult life (Zhang and Wing. Sleep 29:85-93, 2006)

Age group Risk of insomnia in women compared to men

15 – 30 yrs 1.28

31 – 64 yrs 1.46

> 65 years 1.73

* N = 16,524 to 39,658 participants available for analysis to determine risk ratio by age categories

Sleep and menopause

Frequency of ‘hard time sleeping’ due to hot flashes/night sweats may persist

(from 2007 National Sleep Foundation poll on sleep in adult women; among the 536 women aged 45 – 64 years)

4548

18 2017

101288

13

0

10

20

30

40

50

60

Perimenopausal(n=132)

Postmenopausal(n=260)

Never

Rarely

Few nights a month

Few nights a week

Every/almost everynight

Percent of respondentsSource: www.sleepfoundation.org

Hormone replacement therapy may not improve sleep in postmenopausal women

(Hays et al. NEJM 348:1839-1854, 2003)

• Data from the Women’s Health Initiative (WHI)• N = 16,608 postmenopausal women, intact uterus, 50 – 79 years old• Estrogen (.625 mg)/medroxyprogesterone (2.5 mg) vs. placebo• Sleep measure = 5-items, 0 – 20 scale where higher score is better

Insomnia Rating Scale Estrog + prog Placebo

∆ year 1 - baseline ↑ 0.5 + 3.7

(N = 7497)

↑ 0.1 + 3.6

(N = 7146)

∆ year 3 - baseline ↑ 0.4 + 4.4

(N=635)

↑ 0.1 + 4.0

(N=618)

The authors conclude that the statistically significant improvement in insomnia was not clinically significant.

Management of sleep disruption associated with hot flashes

• Hormone replacement therapy– Most effective treatment for hot flashes– Long-term use increases risk of breast cancer, stroke, heart disease and

vascular dementia (Women’s Health Initiative)– Probably not appropriate in menopause-related insomnia unless clearly

related to frequent and severe hot flashes

• Sleeping environment and bedclothes (keep cool)• Antidepressants

– SSRIs

• Gabapentin• Other modalities:

– Acupuncture, yoga, phytoestrogens (soy and red clover), herbal treatments (e.g., black cohosh)

Example:

60 year old woman has trouble sleeping. She wakes up frequently during the night and in the early morning, and has difficulty falling back asleep. She admits to feeling ‘down’ and has dropped prior interests and activities.

Mental health issues can affect your sleep

• Depression– Takes longer to fall asleep– Waking up during the night– Waking up early in the morning– Light sleep– Less total sleep

• Bereavement• Anxiety and stress

Example

A 75 year old woman with Parkinson’s disease reports trouble sleeping at night. She admits feeling sleepy during the daytime, and her daughter reports she frequently dozes off during the day.

Insomnia cause by medical and neurological illnesses

• Neurological disorders, like Parkinson’s disease

• Chronic pain

• Neuropathy

• Cough, shortness of breath

• Gastroesophageal reflux

• Nighttime urination

Some medicines and other agents can cause problems with sleep

• Medicines associated with insomnia:– Some depression medications– Some asthma/emphysema medications– Corticosteroids (e.g., oral prednisone )– Some decongestants (e.g., pseudoephedrine)– Some stomach acid blockers (e.g., H2 blockers like cimetidine)– Some hypertension medications (e.g., some beta-blockers)– Some memory medications (e.g., anticholinesterase inhibitors like donepezil)

• Other agents that can cause insomnia:– Alcohol– Caffeine– Nicotine

• Drugs associated with daytime sleepiness:– Pain medications– Some depression medications– Some hypertension medications (e.g., clonidine)– Antihistamines (e.g., diphenhydramine)

Example:

A 75 year old woman with hypertension reports trouble sleeping at night, and feeling sleepy during the day. Her husband reports she snores loudly, and sometimes making choking noises while asleep.

Obstructive sleep apnea• Typical patient = obese, sleepy, snorer with

hypertension• Prevalence increases with age• Obesity and sleep apnea:

– In middle-aged people, obesity and a large neck are risk factors for sleep apnea

– In older people, even normal weight people can have sleep apnea

Common symptoms of sleep apnea (OSA):

• Excessive daytime sleepiness• Loud snoring, stopping breathing, and

choking sounds during sleep• Morning headache, personality changes• Poor memory, nighttime confusion,

irritability• Hypertension, heart arrhythmias

Sleep apnea is more common as women get olderDancey et al. Chest 120:151-155, 2001

N = 1315 women referred to a university hospital sleep clinic

Age < 45 years

(N=797)

Age > 55 years

(N=518)

Mean age, in years 35 65

Body mass index 30.2 32.2

Neck circumference 35.8 37.1

Apnea-hypopnea index (a measure of sleep apnea)

8.7 17.0

Apnea-hypopnea index was still greater in older women even after adjusting for body mass index and neck circumference.

Treatment of sleep apnea (OSA)

• Main treatment = positive airway pressure (PAP)

• Some patients may improve with:– weight loss– avoid nighttime alcohol, sedatives– jaw or tongue devices

Example

60 year old woman reports “leg cramps” at night. This uncomfortable symptom occurs more in the evening and when resting in bed, and improves with walking.

Restless legs syndrome (RLS)

• Symptoms of RLS:1. An urge to move the legs which is

unpleasant/uncomfortable2. Begins or worsens with rest3. Worse in the evening or night4. Partially or totally relieved with movement

Restless legs syndrome is more common in women than in men

(Rothdach et al. Neurology 54:1064-1068, 2000)

• N=369 participants (173 women, 196 men) in Augsburg, Germany, aged 65 – 83 years

• Restless legs syndrome diagnosed by physicians using International Restless Legs Syndrome Study Group criteria

Group Women, % Men, % Total, %

Overall 13.9 6.1 9.8

65-69 yrs 13.2 12.2 12.8

70-74 yrs 15.2 4.6 9.9

>75 yrs 13.0 3.7 7.4

Treatment of restless legs syndrome (RLS)

• RLS is only treated if it is a significant problem for the individual.

• Low iron level is a cause of RLS in some people.• Commonly used medications for RLS (if it needs

to be treated with a medicine):– Dopamine agonists (such as pramipexole or ropinirole)

– Other medicines (such as gabapentin)

Example:

72 year old woman with Parkinson’s disease reports “bad dreams.” Her husband reports she “thrashes about” while asleep, and he now sleeps in another room because she has hit him during the night.

REM Sleep Behavior Disorder• Major features:

– Vigorous movements during sleep and vivid dreams– Person does not have the muscle paralysis that should

occur during rapid eye movement (REM) sleep– May cause injury to the person or their bed partner– Over 85% of patients with this problem are men

• Causes – Some medications (e.g., some medicines for depression)– Parkinson’s disease, other similar disorders– Unknown cause

Example:

84 year old woman has no sleep complaints, but reports falling asleep early (about 7 pm) and waking early (about 4:30 am). She feels rested during the day, and has no other complaints.

Circadian rhythm changes

• Advanced sleep phase syndrome – When you feel sleepy early in the evening, and wake up

early in the morning

• Delayed sleep phase syndrome– When you stay up very late and wake up late in the day

• Irregular sleep-wake rhythm– When you fall asleep and wake up, off and on several

times during the day and night

Example:

55 year old woman reports trouble sleeping at night and daytime fatigue. She goes to bed at 8:30 pm, and takes 1 hour to fall asleep. She wakes up 2 – 3 times per night, taking 1 – 2 hours to fall back asleep, and gets up for the day at 6 am.

Treatment of Insomnia

• Sleep hygiene

• Behavioral treatments

• Drug treatments

Common ‘sleep hygiene’ measures to improve sleep

• Keep a regular rising time• Go to bed only when sleepy• Decrease or eliminate daytime naps• Exercise (but not right before bedtime)• Use bed only for sleeping or intercourse• Avoid caffeine in the afternoon and evening• Limit or eliminate alcohol before bedtime• Wind down and relax before bedtime• Follow a bedtime ritual, keep your sleeping environment

comfortable• Get out of bed if unable to fall asleep

Tai chi can improve sleep in older people

• At least two research studies have shown that sleep can improve in older adults who practice Tai chi– One study compared Tai chi to low impact exercise

– Another study compared Tai chi to health education

• Both studies reported better self-reported sleep in those who participated in Tai chi

Cognitive Behavioral Therapy for Insomnia (CBT-I)

• A behavioral treatment for insomnia that usually combines:– Stimulus-control therapy– Sleep restriction therapy– Cognitive therapy

• CBT-I may also include:– Sleep hygiene education– Relaxation techniques

Which is better for older people: sleeping pills or cognitive behavioral therapy for

insomnia (CBT-I)?

• Several research studies show that CBT-I works just as well for chronic insomnia as sleeping pills.

• Most patients prefer CBT-I, rather than sleeping pills

• The effects of CBT-I last longer than sleeping pills.

• CBT-I is safer than sleeping pills in older people.

Websites

• American Academy of Sleep Medicine: www.aasmnet.org

• National Institutes of Health, National Center on Sleep Disorders Research:  www.nhlbi.nih.gov/sleep

• National Sleep Foundation: www.sleepfoundation.org

• Sleep Research Society: www.sleepresearchsociety.org