The last several posts have been about the importance of sleep and the barriers that older adults face. We’ve all seen ads for expensive beds that will miraculously improve sleep. But buying an expensive bed is not the right way to start. It’s also not the correct first step to ask a health care provider for a sleeping pill. A logical, calm, and customized approach is needed. This post is about finding YOUR path to the best sleep possible.
Sleep clinics consistently start with a sleep journal
Journals examine sleep patterns over a period of days. It does more than track number of hours asleep and awake. The journal clarifies what aspect of sleep is most troublesome. Sometimes it uncovers a disorder such as sleep apnea or restless leg syndrome. It also investigates daytime wakefulness, diet, exercise, medications, mood, and activities. Use the information to make needed changes.
A useful sleep journal/diary is attached at the bottom of this post.
Problem solve root causes
Insomnia is often caused by underlying emotional or social distress. Address these issues first. Frailty is a major transition point in life; one that most of us will experience. Elders face loss of loved ones and mental and physical decline. The living situation is often disrupted. This can result in isolation, anger, despair, anxiety, and depression. The first step is to provide compassion, support, and connection. Seek help and work on solutions.
Physical problems also make it difficult to fall and stay asleep. Pain, shortness of breath and urinary frequency all need optimal management.
Problem solving for frequent urination at night
- Limit fluid intake after 3 PM.
- Avoid coffee and alcohol late in the day.
- Avoid diuretics (“water pills”) later in the day.
- Review all medications carefully. Anticholinergics, antihistamines, antidepressants, and inhaled bronchodilators can all result in urinary problems.
- Men should sit on the potty and relax to help bladder emptying.
- Set up a nighttime urination schedule.
- For prostate problems seek medical care.
Disorders such as sleep apnea have specific treatments. Alzheimer’s Disease will be discussed in my next post. Lastly, always review medications for side effects.
A routine that works for you
Have you ever read a “do’s and don’ts” for good sleep. These are general guidelines. However, it’s more important to find and stick with a routine that works for you. For instance, a common suggestion is to make the bedroom dark and quiet. The more important message is that the environment should feel safe and relaxing. For some people that may be with a soft light on. Some patients like to fall asleep with the TV on. It helps them wind down and shut down thinking. For some people it is a signal to fall asleep, just like reading a book. Radio or some soft music can also serve as background white noise. If possible, turn things off after a person has fallen asleep. This results in less interference in the circadian rhythm.
Another common suggestion is to avoid naps. This is good advice for most adults, but elderly people have more fragmented sleep. An early afternoon siesta can supplement overall sleep time and restore energy. Babies nap but no one ever warns that a nap will keep a baby from sleeping at night.
The following general suggestions do make sense:
- Stick to a regular routine and schedule.
- Avoid alcohol and caffeine late in the day.
- Make every day an enjoyable day.
- Get the right amount of physical activity. Physical activity helps establish a circadian rhythm.
- Get a generous amount of sunlight every day. This also helps the body maintain a good circadian rhythm.
- Make sure the bedroom and bed are comfortable. Just like the Three Bears make everything, including the room temperature, just right.
An extra touch
Standard medical advice to promote good sleep is frequently not enough. Here are some tried and true and alternative approaches.
Show love and provide emotional and physical comfort. Have a bedtime chat or share a prayer. Give a gentle touch, hug, or massage. A stuffed toy or precious memory provides comfort for some people. Staying at the bedside until a person is asleep helps when a person is anxious.
"Rock-a-bye baby" is a lullaby we all know. Lullabies are not just for babies. Sound therapy soothes the mind. Try some favorite songs, melodies, nature sounds and piano sonatas.
Make warm milk or herbal tea a bedtime routine. Warm milk contains tryptophan which converts to melatonin. Chamomile tea contains flavonoids which have a calming effect. Valerian, also available as a tea, has been known for its calming effect for thousands of years.
Many natural plant extracts are available as a scent or a lotion. Lavender is used in aromatherapy to help people relax.
Melatonin is a hormone and antioxidant produced in the brain. It increases in the evening to promote sleepiness. However, production decreases with age. This can lead to difficulty falling and staying asleep. Melatonin supplements are widely used as a sleep aid, especially in older adults. They are available over the counter and safer than sleeping pills. Melatonin, taken in the evening, gently promotes sleep. Its long-term usefulness as a “snooze vitamin” is uncertain. There is no evidence that a dose higher than 6 mg works better. Higher doses may result in restlessness, vivid dreams, nightmares, daytime sleepiness, and morning grogginess.
Ramelteon (Rozerem), is a prescription drug that enhances the effect of melatonin. It decreases the amount of time needed to fall asleep. It is different from other sedatives and has less potential for dependency. More information is needed about its long-term effectiveness and safety in older adults.
Sleeping pills. Health care providers are hesitant to prescribe traditional sedatives to older adults. Side effects include confusion, impaired coordination, and falls. They are often habit-forming. Long-term use of sedatives is linked to cognitive impairment. Non-prescription sleeping pills are a special concern and should not be used in the elderly
Orenxin receptor antagonists are a new class of medicine for insomnia. There is evidence that they are safer for older adults but more studies are needed. Suvorexant (brand name Belsomra) is in this class.
Antidepressants are often prescribed for patients who have anxiety/depression and insomnia. Use of these medications should be carefully reviewed with a provider. Narcotics and muscle relaxants are used for both pain relief and sedation. Their use in older patients is especially problematic.
Acupuncture has been shown to improve sleep quality and duration in some people. It has not been well studied in older adults.
Cannabis/Marijuana has been promoted for sleep. Cannabis is only legal in certain states. The use of cannabis for older adults needs more research.
“Counting sheep” is not an effective approach for people with chronic insomnia. Progressive relaxation techniques are helpful but require mental concentration. They are unlikely to be effective for people who have dementia.
Your path to good sleep
Older people CAN get good sleep. However, stressing out will make the problem worse. If a person is wide awake, it’s better to get up and do a relaxing activity until sleepy. Don’t get frustrated. It takes trial and error, time and effort, to find the right routine and schedule.
Bill is an 82-year widower who lives with his divorced daughter. She works full- time and also cares for two of her own grandchildren. Bill is on oxygen for COPD. Breathing is so tough that he gets breathless walking across the room. He barely sleeps at night. His daughter gets up multiple times to help him go to the bathroom. The daughter is fed up. She screams that he just needs to sleep. His response is that things would be better if he were dead.
The family requested a sleeping pill. But we adjusted his meds and reviewed his daily schedule. We had a family meeting to figure out what would make things better. We provided support. Bill ended up with a routine that works for him. He takes long naps both during the day and at night. He prefers to sleep sitting in his adjustable electric lounge chair. The TV is always on. The grandchildren pop in and out but are supportive and respectful. It’s his path to better sleep.
Great article! Looking forward to part 2.
Very thorough and useful info here for the common problem of insomnia – something I fortunately don’t suffer from.