Treating Insomnia Part II - Sleep in the Elderly

What to do when sleep gets harder.

Posted Feb 02, 2017

Insomnia afflicts the majority  of Americans over 65. It makes many people miserable, but can be aided or even erased by relatively simple techniques. Insomnia's causes are many and complex, including changes in body clocks, types of illnesses, effects of medications, and the process of aging itself (see part I.) Fortunately, most treatments of insomnia, like CBT-I,  works across populations young and old.

         Biological Clocks and Exercise

As people age, the internal clocks that help put us to sleep became less powerful.  We go to bed earlier, and have a harder time to sleeping through the night.  One simple way to help fix the biological clock this is to take a morning walk.  Because of light’s multiple effects, it’s best to walk it at around the same morning time each day.

Light resets clocks.  Morning light can reset your biological clock earlier, a real problem if you want to get to bed at 7 PM.  Yet morning light is surprisingly effective in treating depression, a major cause of insomnia in all ages.  Light also stimulates immunity.  One study showed regular morning walkers experiencing half the number of colds and half the severity.  Walking also decreases the risk of heart attack, stroke, and many cancers, major causes of death, debility - and insomnia. Walking also  helps people with arthritis (motion is lotion,) though often painful when first engaged. Worldwide, pain is a big reason why people wake at night. For those with restless legs and periodic leg kicks – the latter includes the majority of people over 65 – walking in the evening can help you sleep. 

Humans are built to walk.  Every bit counts.  For those who cannot walk, morning light outdoors or through a window can be helpful.  In darker climes, lightboxes are often effective, and are far cheaper than in the past.  Thirty minutes with a lightbox while eating breakfast, reading, exercising or any other preferred actvity, can help mood, and produce useful behavioral results in those with dementia.

         Waking in the Middle of the Night

It’s normal for anyone to wake in the middle of the night. Most languages have terms for “first” and “second” sleep.  Yet lots of people, especially older folks, find waking at night especially unnerving.

This emphasis on the popular American “lie down and die” model of sleep, with absolutely no interruptions, is wrong.  It’s normal to wake up at night.  The most important part is getting back to sleep smoothly and easily.

Having a separate reading/listening space, like a comfortable  easy to reach chair, can be used as part of the pre-sleep ritual - and to help people get back to sleep. When people wake up and can’t return to sleep for a subjective 10-15 minutes, they can get up and move to this chair. There they can read and/or listen to music, until they’re sleepily ready to return to bed.  Reading and music that takes people far away, obtaining relaxed states of consciousness, are preferred. Sleep specialists who tell people to read the phone book or insurance forms should be forced to try such failing techniques themselves. Reading historical fiction or art history, poetry or travel texts, biographies or memoirs, listening to Thomas Tallis rather than ACDC,  gives people the chance to de-arouse.  We generally need a relaxed state to begin our way to sleep.  From there, biological clocks can take over.

         Medication Lists

Many people in their eighties are on twelve or more medications.  Most physicians are presently too rushed and engaged by checklist medicine to consider drugs' effects on sleeplessness or sleepiness. Often the tradeoffs are complex. For insomniacs, sitting down with your general physician and asking what each drug does to sleep is usually a good idea.  It’s important also to recognize that sleeping pills are often the cause of insomnia, rather than its effective treatment.  Behaviorally addicting people to the idea that pill = sleep is highly lucrative to Big Pharma. It can make life easier for general physicians.  It’s also a public health disaster.

         Treat Pain

Pain is the leading cause of insomnia worldwide.  Yet treating chronic pain is difficult.  The emphasis should be first on keeping people physically robust, and emphasizing physical, mental, and social capacity. The more people move – and can move – the better their sleep.  Next, treating pain preventively, as for example, having people on NSAIDS take them at the beginning of the night, is important.  Recent studies in animals showing opiates increasing pain responses are very worrisome.  Cognitive behavioral approaches take a lot of time and effort, but are often worth it, particularly as depression and anxiety often worsen pain.

         Consider Primary Sleep Pathology

Sleep apnea and leg kicks cause a lot of insomnia.  Historically, sleep apnea specialists have been happy to give people CPAP/BiPAP/AutoPap devices, and then forget the majority of them will remain insomniac. Lots of people cannot tolerate a device at night, especially as we grow older. The treatment of the rest of sleep – beyond the income producing sleep study – is critical to overall health.  Seeing patients with sleep apnea and leg kicks through group treatment can help, particularly as educational measures often help alleviate insomnia.

         Bottom Line

Treating insomnia demands knowledge of multiple cognitive and behavioral techniques, sleep medicine, general medicine, and the interactive effects of medications.  Most physicians are daunted by the challenges. Basic actions by patients, to have regular sleep rituals, to keep as physically active as people, to get light at appropriate times, to learn simple CBT –I,  become even more necessary as the medical care system approaches its next phase of national dysfunction.