Insomnia is a prevalent problem in late life and Pharmacists and Doctors are often approached with elderly patients looking for an instant cure. Sleep problems in the elderly are often mistakenly considered a normal part of ageing. Insomnia, the most common sleep disorder, is a subjective report of insufficient or non-restorative sleep despite adequate opportunity to sleep. Even though more than 50% of elderly people have insomnia, it is typically undertreated, and non-pharmacologic interventions are underused by health care practitioners. The latter very often solves the problem and is as important as proper sleep hygiene.
CAUSES OF SLEEPLESSNESS
Two primary factors control the physiologic need for sleep: the total quantity of sleep (average of ∼8 hours of sleep each 24-hour period) and the daily circadian rhythm of sleepiness and alertness. Sleep requirements and patterns change throughout life, but sleep problems in the elderly are not a normal part of ageing. The progression of sleep across the night is called sleep architecture, and it is displayed as a sleep histogram or hypnogram. Sleep architecture is composed of 3 segments. The first segment includes light sleep (stages 1 and 2), and the second segment includes deep sleep (stages 3 and 4). Taken together, stages 3 and 4 are referred to as delta sleep or slow wave sleep (SWS). SWS is believed to be the most restorative part of sleep. Stages 1 to 4 constitute nonrapid eye movement (non-REM) sleep.
Stress, caffeine, physical discomfort, daytime napping, and early bedtimes are common factors that may interfere with sleeping. Psychiatric disorders are often associated with persistent insomnia. Depression is usually associated with fragmented sleep, decreased total sleep time, earlier onset of REM sleep, a shift of REM activity to the first half of the night and a loss of slow-wave sleep. In manic disorders, a reduced total sleep time and a decreased need for sleep are cardinal features of the condition. Sleep related panic disorders occur in the transition from stage 2 to stage 3. Abuse of alcohol may cause or be secondary to the sleep disturbance. Heavy smoking (more than a pack a day) causes difficulty falling asleep. Excess intake near bedtime of caffeine and other stimulants as found in over-the-counter medicines and prevents causes decreased total sleep time – mostly non-REM sleep. Some medical conditions, like chronic pain, respiratory conditions like asthma, uremia, thyroid disorders and nocturia could be causes of insomnia.
SIGNS AND SYMPTOMS:
Persons having sleep problems may typically complain of difficulty getting to sleep or staying asleep, intermittent wakefulness during the night, early morning awakening, or a combination of these. Difficulty in falling asleep may suggest delayed sleep phase syndrome, chronic psychophysiological insomnia, inadequate sleep hygiene, restless leg syndrome, or childhood phobias. Difficulty in maintaining sleep suggest advanced sleep phase syndrome, major depression, central sleep apnoea syndrome, periodic limb movement disorder, or ageing.
The Epworth Sleepiness scale can be used to determine excessive daytime sleeping.
Sitting and Reading
Sitting inactive in a public place
Riding as a car passenger for one hour continuously
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after lunch (no alcohol)
Sitting in a car stopped for a few minutes in traffic
For each situation, probability of dozing is self-rated as none (0), slight (1), moderate (2), or high (3). A score of ≥ 10 suggests abnormal daytime sleepiness.
In general, there are two broad classes of treatment for insomnia and the two may be combined: psychological (cognitive-behavioural) treated by practitioners with expertise in CBTI and pharmacologic. The latter may be treated with over-the-counter medicines from your local pharmacy with sedating antihistamines which might induce sleep, but it might not treat the intermittent wakefulness during the night which means a visit to your medical doctor is necessary. The possibility of drug dependence should always be kept in mind, and one should be aware of that possibility when using prescribed treatment for insomnia. Newer generations of hypnotics have a much smaller chance of a patient becoming dependent on them and causes less of a “groggy” feeling the next morning although one soon becomes desensitised towards these unwelcome side-effects should they occur.
Good sleep hygiene is very important.
- Go to bed only when feeling sleepy.
- Use the bedroom only for sleeping and sex.
- If you still awake after 20 minutes, leave the bedroom, pursue a restful activity (such as a bath or meditation) and only return when sleepy.
- Get up at the same time every morning regardless of the amount of sleep during the night.
- Discontinue caffeine and nicotine, at least in the evening if not totally.
- Establish a daily exercise programme.
- Avoid alcohol as it may disrupt continuity of sleep.
- Limit fluids in the evening.
- Learn and practice relaxation techniques.
- Establish a bedtime ritual and a routine for going to sleep.
Research suggests that cognitive behavioral therapy for insomnia is as effective as prescribed medication with sustained benefits 1 year after treatment.
WHEN DO YOU KNOW IT IS TIME TO VISIT YOUR DOCTOR?
Persistent insomnias that do not respond to sleep hygiene practice or over-the-counter treatment should warrant a visit to the doctor. Also, if psychiatric disorders like depression or delirium, pain, respiratory distress syndromes, uremia, asthma, thyroid disorders, and bedwetting due to benign prostatic hyperplasia seems to be likely, a visit is necessary.
Before looking at medication as a relief for insomnia, proper “sleep hygiene” should be looked at as a point of departure. Compile a sleep diary for at least two weeks and show it to your doctor or pharmacist and give them a proper history of all your chronic conditions ie pain, diabetes, hypertension, anxiety, depression. Try lifestyle modifications at first and re-evaluate after two weeks. Only then start with a sedating antihistamine obtainable from your pharmacist as a first option, and if insomnia persists, visit your doctor.
Sleep requirements and patterns change throughout life, but sleep problems in the elderly are not a normal part of ageing. Whether older people need less sleep or cannot get the sleep they need, requires ongoing research. There is currently no gold standard for how much sleep is normal in the elderly.
Johann Kruger M.Pharm., M.Phil., PhD., FPS is a Director at Medwell SA – The Home Health Care Specialists and the Head of EDNA Medical Distributors, an incorporated company at Medwell SA. For more information visit www.edna.co.za or www.medwell.co.za