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Matthew J. Edlund M.D.

Barriers to Sleep in the Elderly – Insomnia, Part 1

Getting old is tough, getting sleep tougher.

Insomnia risk increases with age. Most studies claim the inability to get proper rest affects the majority of folks past the age of 65 (Lots of younger people can’t sleep, either.) There are dozens of known reasons people can’t sleep. Here’s some of the most prominent.

Aging Changes Sleep

Take a newborn. Many neonates will sleep blissfully fourteen to sixteen hours, rapidly remaking their brains and bodies. In an infant, REM sleep can approach two thirds of total sleep time.

What a difference aging makes.

By the time someone reaches 65, sleep will have gone down to a bit over seven hours on average (of course, many don’t come close to that.) Not just total sleep time goes down; so does sleep effectiveness and efficiency. Sleep efficiency is a real and important number – sleep time divided by time in bed. When you’re 18, sleep efficiency might be 95% or higher. By the time you’re 65, even if in the peak of health, it might be 80-85%.

So there’s less sleep. The sleep you get is less efficient. Aging also changes biological clocks.

Process S and Process C

Sleep researchers model two major components of physiology as getting us to sleep – Process S and Process C. Process S includes how long we’re up. If you’re awake 25 hours you’re much more likely to sleep than if you’ve awake ten. The power of Process S declines with age. And then there's the powerful biological clock circadian process, Process C.

Process C is a very big part of why we can we can feel fully awake at 9:30 and fully asleep at 10:30. Biological clocks, especially the circadian 24 hour ones, provide much of the drive that puts us to sleep.

And these clocks change radically with age. First, they get earlier. You might want to go to sleep at 12:30 AM when you’re 19, and 10:45 PM when you’re 70. Second, biological clocks become less strong. Their power to put us to sleep declines.

Now add televisions and cellphones. Light is the main time-giver of internal biological clocks. Humans did not evolve with electricity. The bright lights of televisions and cellphones don’t just arouse and keep us up. They also change our internal clocks.

Early morning light shifts our clocks earlier. Night light, especially for most light around 3-5 AM, shifts our clocks later. Electronic devices often confuse our internal clocks. The signals became less coherent. Mess up biological clocks and lots of basic physiologic processes go awry. People get fatter. More diseased. Less productive. And really tired and sleepy.

TV or not TV really is the question.

Illness with Aging

If people could continue the mortality statistics of 11 year old girls, we might live more than a thousand years. The script of aging has different priorities.

Worldwide the biggest cause of insomnia is pain. Arthritis, particularly osteoarthritis, increases with age. It causes lots of sleeplessness.

So do most of the chronic illnesses that afflict humanity. Whether it’s heart disease or cancer, lung disease or gastroesophageal reflux, disease rises with our time on earth. As does what disease treatment can do to sleep.

Medications with Aging

Eighty year olds take a lot more pills than 20 year olds. It’s not a matter of desire.

With time, most of us see creeping waistlines, encroaching blood pressure, creaking joints. As Big Pharma has a large place in the mindset of physician training and in what gets paid for, lifestyle and behavioral regimes that keep people healthier and feeling younger receive short shrift.

Many common medications, like blood pressure pills, antidepressants and statins, can disrupt sleep. Perhaps the most insidious example is sleeping pills.

Sleeping pills do more than cut back on people’s survival. By making people used to the equation pill=sleep, they woefully impede people’s ability to rest.

In the “best” clinical studies, sleeping pills may add 10-15 minutes of total sleep at the outset. That generally does not continue. Nor do sleeping pills produce normal sleep architecture. But what they do extremely well is fake out people. Sleeping pills make people think they slept better than they did.

Because sleeping pills make people forget how often they wake up. Sleep is critical to memory. Many sleeping pills disrupt people’s ability to remember their many awakenings.

Even “perfect” sleepers may awaken briefly 15-20 times a night. But people taking sleeping pills will often awaken dozens of time a night. They just won’t remember it.

Useful when you’ve got jet lag or temporary personal problems, chronic sleeping pill use is far more problematic.

Primary Sleep Pathology

We can’t leave out sleep disorders' effect on with sleep. Sleep apnea with its many not-breathing provoked awakenings markedly goes up with age. The majority of people over 65 have more than 5 apneas or hypopneas an hour. Regular leg kicks, often small movements of legs and arms, also affect the majority of people over 65. Confusional arousals, doing strange things while still asleep, increases a lot with age.

Bottom Line:

Aging makes sleep more difficult to obtain. All the more reason for people to look at some of the dozens of ways to improve sleep - which you can check out in part II.

About the Author

Matthew Edlund, M.D., researches rest, sleep, performance, and public health. He is the author of Healthy Without Health Insurance and The Power of Rest.