5.02 Sleep in older people
Episode 5.02
Sleep
Presented by: Dr Jo Preston, Dr Iain Wilkinson, SJ Ryan
Faculty: SJ Ryan, Wendy Grosvenor, Edda Hensler
Broadcast Date: 20th February 2018
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Social Media this week
https://twitter.com/skipbidder/status/957798665577431043 pain in german hospitals
ADDITIONAL RESOURCES
http://www.sleepeducation.org/news/2013/08/07/sleep-and-growing-older%20Obstructive
Sleep Council UK: https://sleepcouncil.org.uk/
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Main Show Notes:
Learning Outcomes
Knowledge:
- To understand the basics of normal sleep architecture and how this is affected with increased age.
- To recall some of the common conditions affecting sleep
- To understand how poor sleep can affect older adults
Skills:
- To recognise when sleep may be affected older adults function
- To be able to ask questions to identify the problem
Attitudes:
- To appreciate that disrupted sleep is not a part of normal ageing
- To appreciate that each person may have a different cause for the sleep disruption
Definitions:
The resting state in which the body is not active and the mind is unconscious.
Cambridge Dictionary
Normal physiology of sleep & changes with age.
Conventional wisdom says we should be getting 8 hours of sleep a night but NHS guidance says most people need between 6 and 9 hours to feel refreshed and function well both physically and mentally.
The Great British Bedtime Report 2013 by the Sleep Council
Decreased ability to sleep is less a function of age and more a function of other factors that accompany aging, such as medical and psychiatric illness, increased medication use, advances in the endogenous circadian clock and a higher prevalence of specific sleep disorders.
Sleep Disorders in the Older Adult – A Mini Review. Niekrug & Ancoli-Israel, Gerontology 2010
In a large epidemiological study of sleep, Foley et al. found that over 50% of older adults had complaints of insomnia, but that chronic sleep disturbances were associated primarily with indications of poor health. At follow-up 3 years later, of the 2,000 survivors with chronic insomnia at baseline, about 50% had no symptoms and improved sleep was associated with improved health
Foley et al in Sleep 1995 and 1999
A secondary analysis of a study into an Alzheimer’s population, which used rigorous exclusion criteria for physical and psychiatric conditions (so labelled healthy), found that sleep complaints were rare with two cohorts totalling nearly 3000 participants showed a prevalence of around 2%.
Sleep complaints cosegregate with illness in older adults: clinical research informed by and informing epidemiological studies of sleep. Vitiello et al, Journal of Psychosomatic Research 2002
Its topical, with Researchers at University of Surrey are doing research on sleep in older adults.
SomnIA is a four year NDA Collaborative Research Project (CRP) which addresses practice and policy relevant issues arising from the nature, impact and management of the sleep-wake balance in later life. It will extend and ‘join up’ strategically targeted areas of sleep research relevant to understanding and improving autonomy, active ageing, and quality of later life.
http://www.somnia.surrey.ac.uk/
Sleep Architecture
Changes in sleep architecture do occur with age but are considered normal age related neural degeneration rather than pathological.
A large meta-analysis of 65 overnight studies representing 3,577 subjects across the entire age spectrum reported that, with age the percentage time of rapid eye movement (REM) sleep decreased while the percentages of light sleep (stage 1 and stage 2 sleep) increased.
When only reviewing studies of elderly participants, slow wave sleep remained constant after age 60 with no significant continued change with age.
Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: developing normative sleep values across the human lifespan. Ohayon et al, Sleep 2004
Circadian Rhythms
These control normal variations in things like hormone levels, sleep wake cycles and core body temperature and generally operate on a 24 hour loop. They usually depend on two things
- Endogenous clock: Hypothalamic suprachiasmatic nucleus
- External stimuli such as light
With age, circadian rhythms become weaker, desynchronised and decrease in amplitude e.g. increased frequency of night time waking and daytime sleepiness.
Nocturnal secretion of melatonin decreases with age potentially leading to reduced sleep efficacy and increasing circadian related sleep disturbance. Melatonin can be attempted to reset this. No convincing studies on its use but can be useful and relatively few side effects so may be worth a try.
Phase Advance of circadian rhythm is common > Fall asleep earlier (7-8pm) and wake up 8 hours later (3-5am).
- Going to bed later doesn’t reset this.
- Bright light therapy early evening can as it is the strongest cue for circadian rhythm.
- Avoid bright lights in the morning.
- Light box works for both healthy and institutionalized older adults.
External cues may be weaker or missing entirely. Healthy older adults usually get about 60 minutes of bright light per day. A person with Alzheimers living at home may only get 30 minutes and those in a nursing home may not get any.
The ability to get the needed sleep can change with age though, many reasons for this including
- Medical or psychiatric illnesses
- Life changes (e.g. retirement, bereavement, decreased social interactions)
- Environmental changes (e.g. including placement in a nursing home)
- Polypharmacy.
Older couples are less likely to share a bed, with 13% those over 55 likely to sleep alone. This increased with certain conditions:
- Heart disease 19%
- Heart problems 15%
- Arthritis 15%
- Depression 15%
- Back Pain 11%
The Great British Bedtime Report 2013 by the Sleep Council
Men are more likely to snore than women, with half of men snoring by time they reach middle age. Potentially related to this is more women are affected by their partners affecting their sleep (31%) compared with men (19%).
The Great British Bedtime Report 2013 by the Sleep Council
A study of adults over 65 found that 13 percent of men and 36 percent of women take more than 30 minutes to fall asleep.
Complications of poor sleep
Not sleeping well can lead to a number of problems. Older adults who have poor night-time sleep are more likely to have a depressed mood, attention and memory problems, excessive daytime sleepiness, more night-time falls, and use more over-the-counter or prescription sleep aids. Poor sleep is also associated with a poorer quality of life.
Many people believe that poor sleep is a normal part of aging, but it is not. In fact, many healthy older adults report few or no sleep problems. Sleep patterns change as we age, but disturbed sleep and waking up tired every day are not part of normal aging. If you are having trouble sleeping, see your doctor or a sleep specialist. There are treatments that can help.
The association between sleep complaints and cognitive decline disappears once depression is controlled for, raising the question of whether poor quality of sleep leads directly to poor cognitive function, or whether poor sleep causes an increase in depressive symptoms which then results in cognitive decline [22]. This finding highlights the importance of accounting for the effects of other variables, such as depression, on sleep and cognitive function when interpreting various study results and potentially contradictory conclusions.
Sleep and Cognition, Chapter 1, Sleep and it’s disorders affect on society.
Sleep Disorders
The most common primary sleep disorders among older adults are Insomnia, sleep-disordered breathing (snoring to sleep apnea) and movement disorders, such as restless legs syndrome and periodic limb movements disorder (PLMD).
Insomnia
Insomnia affects almost half of adults 60 and older.
Taking a long time — more than 30 to 45 minutes — to fall asleep
Waking up many times each night
Waking up early and being unable to get back to sleep
Waking up feeling tired
If insomnia lasts longer than a month, it is considered chronic.
Sleep disordered breathing
Sleep apnoea and snoring are two examples of sleep-disordered breathing — conditions that make it more difficult to breathe during sleep. When severe, these disorders may cause people to wake up often at night and be drowsy during the day.
Snoring is a very common condition affecting nearly 40 percent of adults. It is more common among older people and those who are overweight. When severe, snoring not only causes frequent awakenings at night and daytime sleepiness, it can also disrupt a bed partner’s sleep.
Snoring is caused by a partial blockage of the airway passage from the nose and mouth to the lungs. The blockage causes the tissues in these passages to vibrate, leading to the noise produced when someone snores.
As many as two-thirds of older adults (65 years and older) experience mild to severe symptoms of sleep apnoea, a sleep related breathing problem where the airway collapses during sleep thus making it difficult to breathe.
Two kinds of sleep apnoea: obstructive sleep apnoea and central sleep apnoea. Obstructive sleep apnoea occurs when air entering from the nose or mouth is either partially or completely blocked, usually because of obesity or extra tissue in the back of the throat and mouth. If these episodes occur frequently or are severe, they may cause a person to awaken frequently throughout the night. This may disrupt their sleep and make them sleepy during the day. Central sleep apnoea is less common. It occurs when the brain doesn’t send the right signals to start the breathing process. Often, both types of sleep apnoea occur in the same person.
Obstructive sleep apnoea can increase a person’s risk for high blood pressure, stroke, heart disease, and cognitive problems. The most effective and popular treatment for sleep apnea is nasal continuous positive airway pressure, or CPAP – keeps air passages open by supplying a steady stream of air pressure through the nose while person sleeps. This is often tolerated better than expected and its use has good outcomes in older adults.
Risk Factors for Sleep Disordered Breathing
- Age
- Obesity
- Male gender
- Sedating medications
- Alcohol and tobacco use
- Family history
Effects on daytime functioning and slowing of psychomotor function worse than with insomnia alone.
Neurological conditions
Parkinson’s Disease / Movement Disorders
Two movement disorders that can make it harder to sleep include restless legs syndrome, or RLS, and periodic limb movement disorder, or PLMD. Both of these conditions cause people to move their limbs when they sleep, leading to poor sleep and daytime drowsiness.
RLS (Restless Legs Syndrome)
Restless legs syndrome is a common condition in older adults and affects more than 20 percent of people 80 years and older. People with RLS experience uncomfortable feelings in their legs such as tingling, crawling, or pins and needles associated with the urge to move to alleviate it.
Four Qs to diagnose RLS
- Do you experience the urge to move your legs (and/or other parts of your body) accompanied or caused by an uncomfortable and/or unpleasant sensation in the body part affected?
- Does the urge to move or the uncomfortable/unpleasant feeling start and/or worsen during periods of rest, relaxation or inactivity?
- Is the urge to move or uncomfortable/unpleasant feeling partially or totally relieved by movement?
- Does the urge to move or the uncomfortable sensation worsen in the evening or at night (as compared to the daytime), or does it only occur in the evening or at night?
It is unclear exactly causes restless legs syndrome, it has been linked to a variety of conditions. Some of these conditions include iron deficiency, kidney failure and dialysis, pregnancy, nerve abnormalities, and movement disorders. CHECK FERRITIN
PLMD (Periodic Limb Movement Disorder)
Periodic limb movement disorder, or PLMD, is a condition that causes people to jerk and kick their legs every 20 to 40 seconds during sleep. As with RLS, PLMD often disrupts sleep — not only for the patient but the bed partner as well. One study found that roughly 40 percent of older adults have at least a mild form of PLMD. Most people develop restless legs syndrome after age 45. Women are nearly twice as likely as men to develop the disorder. If you have a family member with restless legs syndrome, you are more likely to develop the symptoms before you are 45 years old. More than half of people with restless legs syndrome have a pattern of it in their family, as the risk is about three to six times greater.
Both RLS and PLMD can be treated with dopamine agonists such as pramipexole or ropinirole.
REM Sleep Disorder
More common in men over the age of 50. 50% may develop PD or MSA within 3-4 years
REM sleep, or rapid eye movement sleep, is the most active stage of sleep where dreaming often occurs. During normal REM sleep, the eyes move back and forth beneath the eyelids, and muscles cannot move. In more severe forms of REM sleep behaviour disorder, the muscles become quite mobile and sufferers often act out their dreams.
Dementia / Delirium
19-44% complain of sleep disturbance, which includes abnormal night time behaviours such as confusion, agitation and walking around. This can lead to excessive daytime sleepiness which is linked to carer strain and increased rates of institutionalisation.
In care homes, severity of dementia is seen to correlate with severity of sleep disordered breathing.
Increased exposure to bright light shown to reduce agitation
Tips for improving sleep in the nursing home
- Determine cause of sleep problem and initiate specific treatment
- Limit naps to 1 h in the early afternoon
- Adjust medications
- Avoid all caffeine
- Improve environment
- Keep the environment dark at night
- Keep the environment bright during the day
- Keep the environment quiet at night
- Match roommates
Example of staff wearing pyjamas at night on a ward…. Star and garter homes.
Factors influencing sleep associated with increased age
Nocturia
Many factors can cause insomnia. However, the most common reason older adults wake up at night is to go to the bathroom. Prostate enlargement in men and continence problems in women are often the cause. Unfortunately, waking up to go to the bathroom at night also places older adults at greater risk for falling.
Timing of carers
For those who are dependent on others to get in and out of bed.
Many older people also have habits that make it more difficult to get a good night’s sleep. They may nap more frequently during the day or may not exercise as much. Spending less time outdoors can reduce their exposure to sunlight and upset their sleep cycle. Drinking more alcohol or caffeine can keep them from falling asleep or staying asleep.
Reduced Exercise
Regular exercise is recognised to contribute to a good night’s sleep.
The Great British Bedtime Report 2013 by the Sleep Council
A small study of 17 people looked at sleep hygiene with (10) and without (6) exercise and found significant improvements in quality of sleep and daytime function.
Aerobic exercise improves self reported sleep and quality of life in older adults with insomnia. Reid et. al Sleep 2010
Management Options
Investigations
Helpful to keep a sleep diary for a week
Overnight sleep study, also called a polysomnogram, and/or a sleepiness, or a nap test – measures brain waves, heart rate, breathing patterns and body movements.
A common sleepiness test is the multiple sleep latency test. During this test, the person has an opportunity to nap every two hours during the daytime. If the person falls asleep too quickly it may mean that he or she has too much daytime sleepiness.
Sleep Hygiene
The term “sleep hygiene” refers to a series of healthy sleep habits that can improve sleep. These habits are a cornerstone of cognitive behavioural therapy, the most effective long-term treatment for people with chronic insomnia. CBT can help address the thoughts and behaviours that prevent person from sleeping well. It also includes techniques for stress reduction, relaxation and sleep schedule management. Benefits of CBT maintained at 3, 12 and 24 months compared with sedating medications.
Medications
Review medications may contribute including
- Antihypertensives: alpha and beta blockers
- Respiratory drugs like theophylline
- Hormone treatments like steroids
- Psychotropic medications
- Antidepressants such as SSRIs and atypicals
No evidence of effectiveness of medications to improve sleep overall and there is concern for harm e.g. falls.
Curriculum Mapping:
This episode covers the following areas (n.b not all areas are covered in detail in this single episode):
| Curriculum | Area | |
| NHS Knowledge Skills Framework | Suitable to support staff at the following levels:
| |
| Foundation curriculum | Section
2.1 2.2 | Title
Patient as centre of care Communication with patients |
| Core Medical Training | Neurology (Sleep) | |
| GPVTS program | Section 2.03 The GP in the Wider Professional Environment
Section 3.05 – Managing older adults
| |
| ANP (Draws from KSF) | Section 9: CGA | |
| Geriatric Medicine Training Curriculum | Presentations of other illnesses in older adults |
