Insomnia in the Elderly

Counting Sheep

‘Aiya! I tried counting to 100, changing my pillow, and changing my sleeping positions, but I still could not fall asleep! It has been like this for the past few months. My neck is stiff and I have a headache. I am going crazy!’

Sound familiar?

You are not alone. It is more common than we think. Nearly 40-50% of Malaysians above the age of 60 struggle with insomnia, particularly women.

Sadly, a good night’s sleep has become a luxury, not the norm.

Why is that so? More importantly, what can we do to stop the sleepless tossing and turning?

Insomnia

What is it?

It is a condition where one finds it hard to go to sleep, stay asleep or even receive good-quality sleep. It can cause us to feel sleepy and sluggish throughout the day, which may take a toll on our daily activities.

Short-Term Insomnia

It is also known as ‘adjustment insomnia’, and lasts no longer than 3 months.

Typically, this type of insomnia will go away when what is bothering you is removed or resolved.

However, poor sleep habits may linger and eventually develop into chronic insomnia.

Chronic Insomnia

Do you have trouble falling asleep at least 3 times a week? Has this been going on for at least 3 months?

If you answered yes to these two questions, you may very likely have chronic insomnia. There are multiple factors as to why we struggle to sleep soundly as we age.

What Causes Insomnia?

Sleep Pattern Changes

As we age, we sleep less. An average adult requires about 6½ to 7 hours of sleep a night. This does not count the time we spend trying to fall asleep.

Our circadian cycle will change too. We will start to feel sleepy around 7 to 9 pm ( early evening), and naturally wake up around 3 to 5 am (dawn).

You may think, ‘Why not try going to bed later then?’

It is not as clear-cut as it seems. As we age, we find ourselves taking a longer time to fall asleep.

We spend less time in dreamless deep sleep, which causes us to wake up multiple times a night. An altered sleep-wake cycle may also cause us to wake up early and abruptly.

Other factors can also disturb our sleep, like the increased urge to go to the toilet or even chronic pain from a medical illness.

Reduced Physical Activity

As we age, our physical activity will also reduce.

A more sedentary lifestyle can also affect our quality of sleep.

Physical Illnesses

Medical comorbidities like these can potentially reduce the quality of sleep

Obstructive sleep apnea
Gastrointestinal Reflux Disease (GERD)
Hyperthyroidism
Heart disease
Cancer
Diabetes
Parkinson’s Disease
Alzheimer’s Disease
Chronic Pain from a medical disease like arthritis, cancer or bone pain.
Depression and anxiety

People with neurodegenerative diseases like Parkinson’s or Alzheimer’s disease may struggle with fragmented sleep patterns. Meaning, they do not follow the normal 24-hour day-night cycle. This results in them sleeping and waking at irregular timings.

Psychological Stressors

Major life changes can also affect one’s quality of sleep.

Life transitions, the death of a loved one, a divorce, arguments and disputes, empty nest syndrome or even a health issue- these are just some of the many reasons that may keep us up at night.

Mental health issues are very much underdiagnosed in the elderly population, partly because they do not want to be a ‘burden’, or because it is still a taboo topic amongst the generation.

However, it is important to seek help and reach out.

Behavioural Causes

Daily habits like smoking, watching television before bed, caffeine intake and excessive consumption of alcohol can cause insomnia.

Do I Have Insomnia?

Here are some questions to ask yourself:

Does it take you longer to fall asleep?
Do you find yourself abruptly waking up early in the morning?
Do you wake up lethargic and not feeling rested?
Do you spend longer time in lighter sleep than in deep sleep?
Do you find yourself sleepy throughout the day and needing naps?

If you answered yes to most of the questions, you might have insomnia.

The Detrimental Effects of Insomnia

It can negatively impact the daily quality of life.

We may experience

Low mood and irritability
Fatigue and tiredness
Trouble remembering or concentrating
Reduced productivity at work
Cognitive impairment

These can increase the risk of falling, fractures and thus more frequent hospital admissions. People who struggle with insomnia are also twice as likely to suffer a heart attack or stroke.

Do Sleeping Pills Really Work?

It is a common assumption that sleeping pills are the best way to ‘cure’ insomnia.

Although it may be a temporary solution, it is only a means to an end.

There are some side effects that come along with sleeping pills.

The ‘Hangover Effect’

Sleeping pills can paradoxically cause drowsiness, difficulty balancing or motor coordination. We might find it hard to concentrate or remember.

80% of people experience this after taking sleeping pills.

Parasomnia

This includes sleepwalking, sleep talking and bed wetting. Taking a higher dosage can increase our risk of this sleep disorder.

We may even find unexplained bruises or cuts after waking up.

Addiction

It is fairly common to develop a dependence on sleeping pills. The more we use, the higher our tolerance toward the pills becomes, and the higher the dosage we need to have a similar effect as before!

Withdrawal symptoms

‘I have been using sleeping pills for a while now. Can I just stop using them?’

Long-term use of sleeping pills can cause severe withdrawal symptoms like lightheadedness, tremors and nausea.

We may experience anxiety, restlessness and shivering. It may differ from person to person, and can possibly be life-threatening.

Rebound insomnia

Insomnia may become worse if you stop taking sleeping pills. It is a common side effect and may last up to 4 weeks at a time.

Other side effects include appetite changes, tingling sensation in hands and legs, constipation, headache, heartburn, nausea, and weird dreams or nightmares.

The elderly are more prone to side effects of sleeping pills, particularly because our kidneys and liver reduce in function over time. They cannot clear the drugs out of our bodies as efficiently as before.

All these symptoms can negatively affect daily activities like driving, our relationships and ultimately, the quality of our life.

Use Sleeping Pills with Caution

Do not mix sleeping pills with other sedative drugs or alcohol. Using them with alcohol can increase the effect of pills, which can cause our breathing to slow down rapidly. This can be fatal.
Always start with the lowest dosage possible!
Avoid daily usage. Only take sleeping pills if necessary.

The Caregiver’s Role

A caregiver’s role is crucial. If you are a caregiver, here are some tips to cultivate good sleep in the elderly.

Encourage a fixed sleep schedule. Try to limit napping time to at least 2 hours before bedtime.
Ensure that the medications they take do not affect their sleep. If they do, it would be advisable to bring it up to his or her doctor during their next check-up.
Keep the bedroom comfortable, clean and safe. Dim the lights, set the room temperature cool enough and make sure it is conducive for a good night’s sleep!
Plan meal times. Encourage a light meal before bedtime. Heavy meals can cause acid reflux or heartburn.
Look out for habits that potentially affect sleep, like smoking or consuming alcohol.
Encourage relaxation techniques for anxiety or stress management. Breathing techniques and stretches can help calm our minds down for a good night’s sleep.
Encouraging exercise (if possible) and healthy social relationships are also important.
Watch out for any signs of depression. Most mental health issues are underdiagnosed in the elderly population.

A Good Night’s Sleep

Sleep hygiene is so important for us to wake up feeling rested and rejuvenated. Relying on sleeping pills may actually cause more harm than good in the long run.

As caregivers, it is important to be patient and mindful of the needs of those in our care.