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Sleep and Aging: Disturbed Sleep-Part II

(12/2/16)- A new report, the results of which were published in a recent edition of the journal JAMA Psychiatry, concluded that chronic insomniacs can be helped by online therapy.

The study was led by researchers at the University of Virginia, where doctors recruited 303 people ages 21 to over 65 over the internet. Half of them were randomly assigned to receive education over the internet, including education and advice on insomnia.

The other half got a 6-week focused online therapy product called SHUTI. Some of the researchers and the university received payments from SHUTI This group received cognitive behavior therapy

(11/25/14)- Since sleep deprivation continues to be one of the most pressing problems of an aging population, we are repeating this article because it is even more pertinent today.

(2/23/02)-As a group, the elderly are most likely to report disturbed sleep and the use of some form of remedy to help them sleep. Question a family practitioner, who has about 300 registered patients 65 years or older, and you will find anywhere from 53-77 of these individuals suffering from insomnia. In a general population, according to the Epidemiological Catchment Area Study, the reported incidence of insomnia is 7.3%. Ascoli-Isreal reports that, if sampling techniques are correct, "8 million elderly people experience symptoms of insomnia, more than one million new cases of insomnia occur each year in those older than 65 and 1.3 million cases of insomnia resolve each year."

While a lot is known about sleep, it is still an essential biological process whose function remains unknown despite the slew of research being conducted. Certain things are knownabout sleep. It is ubiquitous i. e. found in all species of mammals, birds and reptiles. Sleep has been preserved throughout evolution. This is despite the fact that it is a potentially dangerous behavior. Animals cannot forage for food, take care of their young, procreate or avoid the dangers of predation during sleep. Sleep deprivation studies tell us that the maintenance of being awake becomes increasingly difficult after one day. The pressure to sleep becomes overwhelming after 48 hours of being awake. Studies have shown that rats when kept awake for 17 days die, and scientist are not sure why this happens.

In an attempt to define sleep in a universal manner, scientist have used the following behavioral criteria:

Sleep involves

  1. A prolonged period of quiescence.
  2. A reduced responsiveness to external stimuli.
  3. Rapid reversibility as opposed to hibernation, which is not easily reversible.
  4. Homeostatic regulation; there is an increased need to sleep following deprivation.
  5. Sleep appears to be independently regulated, not completely tied to circadian rhythms, but has more complex regulations.
  6. In many regions of the brain, gene expression is higher during waking time, than in sleep. (See Cirelli & Tonino J Sleep Res 1999; 8 (Suppl. 1): 44-52.).

As individuals get older, the character of their sleep changes. The first thing seen is the changes in stage 4 or EEG slow wave activity. Other changes follow, including timing of sleep and wakefulness, reduced nocturnal sleep consolidation and a reduction in REM later in the aging process. Thus sleep, as we age, is generally lighter, shows less rapid eye movement sleep and more arousals occur. Other conditions also manifest themselves: sleep apnea and myoclonic jerks become more prevalent. With dementia, one sees an increase in wandering at night, disturbed sleep and day-night reversals. There may be some relation between these changes and the deterioration in the suprachiasmatic nucleus of the hypothalamus, which controls the circadian rhythms. Circadian rhythms are biological cycles of about 24 hours that include sleep/wake, body temperature and melatonin secretion cycles.

Sleep circadian rhythm and sleep homeostasis, two neurological processes, appear to play the key part in the regulation of sleep timing and sleep structure. Dijk and colleagues (Sleep 2001; 24:565-577) hypothesized that changes in these two processes contribute to the age-related changes in sleep timing and sleep consolidation. They state: "Sleep of older people is interrupted frequently by awakenings and this deterioration of sleep continuity is present at all circadian phases and appears to be related primarily to a reduction of the consolidation of non REM sleep. It remains to be established whether age-related reductions in slow wave and/or sleep spindle activity are associated with age-related attenuation of non REM sleep related inhibition of arousal from sleep."

Disturbances of sleep in nursing home residents appears to be a complex issue, involving both internal and external permutations i. e. aging, less than optimal environment, poor health, anxiety and depression, comorbidity, and decreased exposure to bright light. Ancoli-Israel and colleagues (J Am Geriatr Soc 2002; 50:282-289) suggest that bright light (>2000Lux) may be a synchronizer of circadian rhythms and directly influence secretion of melatonin, sleep/wake patterns and other circadian rhythms. They concluded their study with the following statement: "Increased exposure to morning bright light delayed the acrophase of the activity rhythm and made circadian rhythm more robust. These changes have the potential to be clinically beneficial because it may be easier to provide nursing care to patients whose circadian activity patterns are more socially acceptable."

The role of melatonin in sleep is ambiguous. Melatonin is a hormone produced by the pineal gland during the hours of darkness. Its plasma level in the body varies with the time of day, reaching a peak between 01:00-05:00 h and becoming barely detectable by 09:00-10:00 h. While melatonin plasma levels are reported to be lower in older people, there is much variation among older people. Some older people have relatively high levels of melatonin, others have reduced levels and a few have no evidence of melatonin secretion. Baskett et al (Sleep; 2001; 24(4): 418-424) concluded: "Older people with age-related sleep maintenance problems do not have lower melatonin levels than older people reporting normal sleep." The effects of these different levels are still uncertain. This is also true for melatonin supplements. The research literature is full of conflicting results. Women may have more favorable results than men. Most improvements in sleep using melatonin are with controlled release melatonin and involve improvement in sleep quality/efficacy and sleep latency."

Insomnia involves problems of insufficient or non-restorative sleep despite an adequate opportunity to sleep. It can take the form of difficulty falling asleep or difficulty staying asleep. It can be transient insomnia defined as no more than a few nights of difficulty, short-term insomnia (less than about three weeks) or long-term (more than three weeks). The first two occur in individuals with no history of sleep abnormalities. Long-term or chronic insomnia appears to occur in one-third to two-thirds of individuals who have a recognizable psychiatric illness, with depression the leading symptom. It thus would appear that one-third of the elderly though in good health have chronic insomnia.

One of the favorite home remedies for insomnia is use of alcohol. It would appear that alcohol in low-to-moderate amounts initially promotes sleep, but in the long run it disrupts and fragments sleep. This may be the result of partial body tolerance of alcohol, withdrawal symptoms during the night or consequences of drinking i.e. gastric irritation, headache. Alcohol has been indicted as a potential culprit in increasing sleep-related breathing disorders by increasing muscle atonia in the upper airways, resulting in airway obstruction, hypoxemia and fragmented sleep.

The other remedy used is prescribed medications. While these may help in the short run, many older individuals become dependent upon them. The research literature indicates, in older persons, that these sedatives may lead to falling, driving accidents and impaired memory. This could be a case of the secondary effects proving worse than the problem of insomnia.

Morin and colleagues conducted a four-arm research experiment in which they compared a prescribed medication (Restoril) alone, Restoril plus cognitive-behavioral therapy sessions, cognitive-behavioral sessions alone and a placebo. The researchers concluded that cognitive-behavioral educational approaches are an effective long-term management technique for older persons with insomnia.

Please also see: Sleep-Part I

 

FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE "How to Select a Nursing Home"

 

Harold Rubin, MS, ABD, CRC, Guest Lecturer
updated December 2, 2016

http://www.therubins.com

To e-mail: hrubin12@nyc.rr.com or allanrubin4@gmail.com

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