•The elderly
By Trisha Macnair
Changes to normal sleep as we get older
Typical sleep patterns vary throughout life, but they also vary from person to person so it can be difficult to say what’s ‘normal’ for an older person.
However research does suggest that in later years, people tend to need slightly less sleep. A study carried out by the Surrey Sleep Research Centre at the University of Surrey and Harvard Medical School in the USA found that when people were allowed to sleep as long as they wanted to, older people took an average of 1.5 hours less sleep than young adults. Those over 60 settled into about 7.5 hours a night compared to 9 hours among people in their twenties.
Some experts suggest that this might be because the elderly need less sleep, perhaps because they’re less active, but others argue that older people need as much sleep as ever (and would be healthier) but are having their sleep disturbed for a variety of reasons.
All adults go through different phases of sleep during the night. These include a number of episodes of rapid eye movement or REM sleep (dream sleep) during which muscles are relaxed but the brain is very active, interspersed with non-REM sleep where the brain is less active but the body moves around.
Within non-REM sleep we also go through different phases, cycling down into restorative deep or ‘slow-wave’ sleep and back up again several times in the night. But older people tend to have only one period of deep sleep each night, usually in the first three or four hours of the night, and after that, they may wake up more easily.
An increase in sleep problems as you age
Some sleep problems, especially insomnia, also become more common as we get older. At the same time we’re more likely to be suffering from chronic health problems which can interfere with sleep.
As a result many older people follow a much more broken pattern of sleep. This is compounded by the gradual reduction in production of hormones such as melatonin and growth hormone which help to keep our daily rhythm going. People who are retired may be tempted to nap in the afternoon to make up for disturbed nights.
While napping can be the answer for some, it leads to problems for others. Some people just spend increasing amounts of time dozing in their armchair during the evening (and sometimes even sleeping in it right through the night) which isn’t the best way to get the rest that the body needs.
Common diseases that disrupt sleep in the elderly include:
Depression and anxiety: depression is common in older age and those affected may have problems getting to sleep (this is more typical with anxiety where worries may keep them awake) or with waking in the early hours of the morning and being unable to get back to sleep.
Chronic pain: painful conditions such as arthritis are widespread once we reach our 70s and frequently disrupt sleep.
Dementia: this can disrupt the normal daily pattern of activity. Some people with dementia become more confused and disinhibited as afternoon turns to evening (a problem known as ‘sundowning’) and may become very unsettled, wandering or shouting out, when everyone else is turning the lights down for sleep.
Respiratory and heart disease: conditions such
as chronic obstructive pulmonary disease (also known as COPD or more commonly chronic bronchitis) and heart failure can cause discomfort or breathing problems which disrupt sleep.
The need to visit the toilet: as we get older we often find it harder to last through the night without a visit to the toilet. This may be because of problems with the prostate gland in men, decreased strength of the muscles in the floor of the pelvis (to hold up a filling bladder) in women, or because the bladder becomes increasingly ‘twitchy’ and likely to empty.
Sleep disorders that are common in older people include:
Insomnia, which affects as many as one in three older people to a degree that reduces their well-being or ability to carry out normal activities, and is often more persistent than in younger people.
Sleep apnoea, where sleep is constantly interrupted as the lungs fail to draw enough oxygen-containing breath through the breathing tubes. As we get older, the tone in all our muscles grows weaker, and the airways are more likely to collapse under the pressure of layers of fat in the face and neck. The end result is poor quality sleep, reduced daytime performance and an increased risk of heart attack and stroke.
Restless legs syndrome. Although common, few people know about this condition until they develop it. It causes an intense prickly or crawling sensation in the lower legs which causes people to move their legs in search of relief. The cause is unknown but it may be linked with disease of the nerves, kidney disease, Parkinson’s disease, anaemia, and certain medicines. Some people have periodic limb movement disorder, where the legs repeatedly jerk. These conditions may respond to the types of drugs used to treat Parkinson’s disease, which increase levels of the neurotransmitter (or nerve message chemical) dopamine.
Getting help for sleep problems as we get older
Many people struggle on for years with poor sleep but it can contribute significantly to deteriorating health with age and increase the risk of problems from falls to depression. There are many things you can do yourself to improve your night’s sleep. These include:
Making sure the bedroom environment is peaceful, not too hot or cold and has a comfortable bed.
Following a regular routine: babies aren’t the only ones to thrive on routine – try to get to sleep and get up at regular times.
Avoiding stimulants such as coffee or tea, heavy food, cigarettes, intense exercise or alcohol (which induces an unhealthy artificial sleep) close to bed time.
Getting some exercise for at least 30 minutes earlier in the day.
Try simple remedies such as herb pillows or herbal teas, or a very light snack such as a mug of warm milk before bed. Yoga and relaxation techniques also help.
If problems persist, talk to your doctor. They should help you to identify any underlying health problems interfering with sleep, and look at what treatments or strategies might help.
Sleeping tablet use in the elderly
Many older people turn to sleeping tablets to help them sleep. These should be a last resort and ideally not used long term but to tide someone through a period of disrupted sleep. Modern sleeping tablets are generally safer but still not without problems, and tend to cause a somewhat artificial sleep pattern. As does alcohol – even though many older people swear by a nip of sherry or whisky at night, alcohol can help you get off to sleep but many wake you up again later.
Sometimes a short course of the hormone melatonin is used in older people (especially those with dementia) to ‘reset’ the body clock and restore a normal sleep pattern.
Depression in the elderly
Causes of depression
Older people are more likely to blame their depression on events or social circumstances. But while the death of a partner or friends, or coping with a chronic illness are important contributory factors, there are real biological changes that account for depression.
Brain-imaging studies have shown that in depression the brain circuits responsible for regulating mood, thinking, sleep, appetite and behaviour all fail to work properly. The chemicals that brain cells use to communicate with each other, called neurotransmitters, become out of balance. This happens in young and old alike and is always abnormal.
Several conditions can lead to depression in the elderly, including heart problems, low thyroid activity (hypothyroidism), vitamin B12 or folic acid deficiency and cancer.
Many drugs also cause, aggravate or trigger depression, including beta-blockers, blood pressure drugs, heart drugs such as digoxin, steroids and sedatives.
Depression often occurs after a stroke, and getting it treated may be critical to restoring normal abilities.
Who’s affected by depression?
Depression is much more common in the years after retirement, when people may struggle to adjust to a new role and routine in life.
It’s then less likely for the next decade until people are in their mid-70s, when factors such as chronic illness, frequent loss of peers and friends, and increasing restrictions on mobility may be factors.
Depression symptoms in the elderly
Depression has a different pattern of symptoms in older people compared with the young. Anxiety is particularly common, as is the slowing of thought and activity.
Older people also tend to have more bodily symptoms, although it can be difficult to work out whether these are signs of depression or part of the increase in general illness seen with age. Older people are more likely to battle with weakness, for example, as well as headaches, palpitations, loss of interest in sex, abdominal or back pain, shortness of breath and constipation. Imaginary illness and hallucinations are also more common.
Deterioration in mental function can occur with depression at 18 or 88, but young people have greater mental reserves, so these problems often show up more in older people. However, it’s important to separate the effects of depression from those of conditions such as Alzheimer’s disease.
Treating depression
If you or a friend or relative has problems with bleak moods, get help from your GP as soon as possible or talk to the Samaritans.
Antidepressant drugs can help to restore the balance of neurotransmitters in the brain, while social support and psychotherapy can help to deal with many of the triggers of depression.
Studies have shown that over 80 per cent of people with depression improve when given the appropriate treatment with a combination of medication, psychotherapy and other measures. However, it can take longer for older people to respond to treatment – on average, it takes 12 weeks to achieve remission. In elderly people in particular, research has shown that a combination of psychotherapy and antidepressants is extremely effective in preventing depression from recurring.
Dealing with social isolation is another important part of treating depression. The health benefits of being part of a family or tight community are well known.
Self-help remedies may be worth a try but beware of interactions with prescribed or over-the-counter medicines – St John’s wort, for example, is increasingly self-prescribed and may help with mild to moderate depression but it can interfere with other drug treatments.
Always talk to your doctor before trying any complementary remedies.
•Culled from BBC Health