Helping older patients get a good night's sleep

Mrs. B. is 81 and came with her daughter to your office with insomnia as her main complaint.

Case history

Mrs. B. lives at home with a health aide. She has a medical history of hypertension, diabetes, mild chronic renal insufficiency with frequent urinary tract infections, an unsteady gait, depression since the death of her husband two years earlier and mild cognitive impairment. She was hospitalized for pneumonia three months before her visit to your office and, since discharge, has had increasing difficulty sleeping. She falls asleep between 1 a.m. and 2 a.m., and after three or four hours, she starts calling for the aide and wants to get up to urinate. She takes several naps during the day and is becoming more resistant to leaving the house. Her aide complains of being sleep deprived and threatens to quit. The daughter gave Mrs. B. a common over-the-counter sleep medication twice, but her mother was very confused and lethargic the following day. They are requesting a sleeping pill.

Discussion

Evidence is building that sleep problems, such as insomnia and excessive daytime sleepiness, are more prevalent in older people. Among the reasons: increasing disease burden, effects of medications, pain, depression, anxiety and limited mobility. Changes in an individual's living situation, such as a move to an assisted living facility or a nursing home because of increasing disability or the death of a spouse, can affect sleep.

Mrs. B.'s mild cognitive impairment also should be considered as a possible cause of sleep difficulties. Alzheimer's disease is well-known for changing a person's sleep habits, notes the National Institute on Aging. Some people with the disease may sleep too much, while others may not sleep enough. Some may wake many times and others may wander or yell, ensuring that the caregiver also will have sleepless nights.

In general, older people need less sleep than younger people, and their sleep is less deep, according to the National Institutes of Health. But insomnia isn't a normal part of aging, and it can and should be treated. Recent studies in the journal Sleep found that getting too little sleep is a risk factor for depression, and it also may perpetuate existing depression in elderly patients. Older adults with poor nighttime sleep are more likely to have attention and memory problems. Lack of sleep also has been associated with an increased risk of obesity, cardiovascular disease and diabetes.

If a medical history, physical examination and review of medications fail to detect any apparent connections with a sleep problem, an exploration of Mrs. B.'s sleep habits should be next. Determine if any of her daytime activities contribute to her sleep difficulties. For example, she should be advised to halt daily naps, or at least reduce their length and frequency. In their place, Mrs. B. should be persuaded to go outside for fresh air and sunlight and, if possible, to exercise and socialize with friends. Just exposure to sunlight may be helpful.

Sleep disturbances may result from disruption of the body's circadian rhythms, which are controlled by light and dark patterns. Since many older people, such as Mrs. B., seldom go outside, they may not be exposed to sufficient sunlight to synchronize their rhythms to the 24-hour day. Age-related changes in the eye also may reduce the amount of light that reaches an older person's retina.

But most importantly, good sleep hygiene should be stressed with Mrs. B. The health aide could establish bedtime rituals -- perhaps a bath and quiet, relaxing activities, or massage of the back or feet. Meditation or prayer can be considered.

A light snack in the evening is preferable to a large meal, and fluids should be restricted a few hours before bedtime to avoid the need to urinate during the night. Caffeine and alcohol also should be limited, as both can hurt sleep quality. The bedroom should be dark, quiet and a little cool. Mrs. B. also could be taught to relax her muscles progressively as a way to ease into sleep. Soft, slow music might help.

In Mrs. B.'s case, an additional disruptive factor may be at work. Her earlier hospitalization may have contributed to her sleep problems, which began after she was discharged.

Some individuals, particularly the elderly, become distressed and confused during a hospital stay that disrupts familiar routines, and they may carry that distress home. For these patients, non-pharmacological interventions that emphasize a return to previous routines and promote a stimulus-controlled environment are effective in producing positive and lasting changes in sleep habits.

The main goals of treatment are to identify and remove the underlying cause of insomnia, prevent progression of transient to chronic insomnia and improve quality of life. Therefore, if sleep-enhancing techniques without medication fail to work, a prescription sleep medication should be considered.

Important factors to weigh when selecting sleep medications for the elderly include the prevalence of depression or cognitive impairment, the potential for hepatic and/or renal impairment to affect drug metabolism and elimination, and the use of other medications -- prescription, over-the-counter, herbal or dietary supplements -- which could trigger drug-drug interactions or adverse reactions.

Options include benzodiazepines, such as diazepam, lorazepam and temazepam; non-benzodiazepines, such as zolpidem, zaleplon or eszopiclone; and sedating antidepressants including trazodone and mirtazapine. Hormones and hormone-receptor agonists such as melatonin or ralmeteon are other possibilities.

Although OTC antihistamines are not approved by the Food and Drug Administration for treating insomnia, diphenhydramine is widely used for that purpose. But the medication's anticholinergic properties pose a high risk of delirium, confusion, urinary retention, constipation and daytime lethargy in elderly people.

All sleep medications should be used with caution, since side effects are frequent and include agitation, ataxia, daytime sleepiness, disorientation, impaired motor skills (which increase the risk of falls), impaired judgment and mood changes. Medications with short half-lives are preferred; they should be prescribed in the lowest effective dose and used intermittently rather than nightly, if possible.

Consider prescribing them for short-term use and for no more than three to four weeks. When discontinuing them, do so gradually and be alert for rebound insomnia.