September 19, 2018

Sleep Problems in the Elderly

You may find as you age that your ability to live longer is rewarded with insomnia. It does not seem fair that you worked so very hard to stay healthy and fit, and in return you are much more likely to suffer sleepless nights as you grow older.

But when you look at it from a purely physical point of view, the aging / insomnia relationship makes a lot of sense.

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The effects of aging can make for poor sleep patterns with sleepless nights - Here's What to Do.

Beginning at about 50 years of age, your body begins to grow weaker faster. Both inside and out, your body is simply not as healthy as when you were younger.

Many senior citizens have reported becoming sleepy earlier in the evening than ever before.

This means that they also wake up early. And though there is nothing wrong with that natural cycle, unfortunately poor quality of sleep and insomnia are often also along for the ride.

Women experience hormonal changes in menopause, and both men and women can suffer from the debilitating disease that is Alzheimer's.

Insomnia is a frequent accompanying symptom of both those age-associated afflictions.

Sleep Changes As You Age – Here Is Why

As you age, it is important to understand how sleep changes throughout your life.

Since your body produces lower levels of growth hormone, your natural disposition to enjoy restful slow wave and deep sleep cycles is inhibited.

You produce much less melatonin than when you were younger, meaning rapid sleep cycles and waking up often during the night.

But this insomniac behavior can be treated naturally and effectively.

First off, identify whether there is some outlying cause for your insomnia.

Are you in a situation which provides a lot of stress during the day?

Do you often feel depressed?

Do your personal relationships create anxiety and worry?

These could all be simple causes of anxiety which can be psychologically treated.

Age-Related Insomnia – 6 Tips To Get Better Sleep

You may want to check your diet.

Poor diet can definitely lead to symptoms like acid reflux and GERD, which make it very difficult to sleep properly.

But if you do not suffer from any of those common causes of insomnia, try the following tips to get a better night's rest.

Set a sleep schedule and stick to it.

Go to bed and wake up at prescribed times.

Do not drink alcohol or eat for at least 3 hours before you go to sleep.

Check your medications.

If sleeplessness is a symptom, ask your doctor if you can take that particular medicine earlier in the day.

Falling asleep with the TV on is a no-no.

It may take you some time to break yourself of this habit, but your mind subconsciously pays attention to the sound of the television after you have fallen to sleep, causing poor sleep patterns.

Listen to your body.

If you find yourself feeling drowsy on a consistent basis earlier than you have gone to sleep before, adjust your bedtime accordingly.

Create bedtime rituals.

A relaxing bath or soothing music, stress and relaxation management techniques like mindfulness meditation, and any repeated, calming action can help you get to sleep quicker.

So - sleep problems in the elderly.

Everybody listening knows about sleep deprivation because my hunch is everybody has suffered maybe a night or two maybe many nights with the small baby or someone who's sick or maybe worry about an exam or a business deal and and I think what we probably say right off the bat is when we don't get good sleep we just don't feel like your mind is clear.

And if that comes to pass not just one or two nights but night after night after night I think this little diagram suggest that this then becomes a cascade of problems.

I mean not just that not thinking clearly as you see in bullet two -

cognitive impairment, but irritability short temper you know our judgment may be a wee bit off maybe were a little more sensitive to things but as you kind of scan down list other things are now - other dominoes and now starting to fall our immune system doesn't work as efficiently we get heart rate variability and we're beginning to learn that heart rate variability is a predictor of lots of disease states and lots of symptoms.

Then a bit of a surprise as in terms of a musculoskeletal system have increased reaction time you're quicker faster more nimble no this is more along the lines of a twitch your hyper-vigilance not fine motor tuning in fact as you can see decreased accuracy muscle aches and then much more ominously you know this is persistent sleep deprivation gross depression he might say

I'm grown

I'm an adult no

no throughout our life span you know we're producing growth hormone which has a lot to do human growth hormone which has a lot to do with cellular repair and the velocity of agent risk of obesity decreased temperature and that's just with sleep deprevation.

So back in the 1970's it was popular for just a sunspot of time for radio disc jockeys they would have a fundraising, and they try to stay up as long as they could. 24 hours - 48 hours - 72 hours and right around 48 to 72 hours they began to actively hallucinate and essentially looked and felt psychotic.

So you know that's kind of at the far end behaviorally of the effects of sleep deprevation.

So we know that not getting regular refreshing sleep can have all sorts . . .

a real spectrum of symptoms and all sorts of problems for us mere mortals. So, I love to ask medical student psychiatry residents - even fellow doctors the simplest of questions but you know we all know that the simplest of questions is often the hardest of questions.

So say - "What are the functions - plural - of sleep?"

And usually just putting a plural on it kind of stuns most people.

So medical students will often give me that kind of deer in the headlights and they'll say well the function of sleep is to - is to - to rest. Of course you say what can we actually make that into a sentence perhaps - instead of just a single word.

But it's just so elegant,

so ingenious,

so brilliant what the Creator has designed for us mere mortals with sleep.

Because it's not simply to rest.

Number one as you can see it's energy conservation.

So you know if you think of ourselves for just a minute as a machine it's generally not good for machines to continuously run.

And then going back to the disc jockeys that are not getting any sleep after a while energy conservation conservation really wears thin and bad things happen.

But wait, there's more and and this is up by the way all these pieces are are now evidence-based and documented.

We know that when we intentionally sleep-deprive college students, after two or three days we can look at their immune system and see that it's beginning to tumble and that they're much more likely to acquire viral illness or bacterial illness.

So somehow, someway magically mysteriously during sleep our immune system reboots. But wait - there's more. This is like an infomercial.

When we sleep and this is easily measured lots of evidence there's hormonal restoration.

So this is when our body reboots hormonally.

Particularly, as I mentioned earlier human growth hormone, which again to reinforce, has a lot to do with cellular aging and cellular repair.

So if that's damaged or slowed down we're going to see cellular repair diminished and cellular aging accelerated.

And then the last one - no the fourth bullet

I should say very near and dear to my heart as a psychiatrist is memory consolidation.

So every day we have billions maybe trillions of bits of information coming our way.

The vast majority is noise and we have to kind of sort out what's important, what do we want to keep it short term storage, long-term storage - What what will help us survive and there's again good evidence you know taking college students and sleep depriving them and asking them to do memory functions we just see them perform awful.

So we think sleep has a lot to do with memory consolidation.

But the most exciting thing absolutely the most exciting thing this is very new as you can see science 2013 so we know about the lymphatic system in our body it's from the neck down and what the lymphatic system does is it sort of parallels blood vessels and veins and it removes waste products.

Brilliant quite fascinating there no there's no lymphatic system in our brain this enclosed capsule that weighs three pounds and takes up twenty-five percent of the energy requirements of our body every second of the day.

So this very recent finding that in our brain there's something called a glymphatic system.

And the short story is - this is actually built into the cerebral spinal fluid and during the day when we're awake the CSF (cerebral spinal fluid) is relatively inactive.

Relatively slow moving but at night when we sleep the CSF switches over into a far faster paced, far broader spectrum of coverage.

And we think that that is the built-in lymphatic system if you will of our brain. But wait there's more! There is now evidence that the glymphatic system perhaps has a lot to do with clearance of beta amyloid plaque production.

So one of the potential targets in terms of Alzheimer's research is - is there any way to perhaps amplify this glymphatic system that appears as we age to be less robust. So this is a new finding stay tuned but exciting finding that here is a clearance system for waste products in the brain that may actually have some benefit in terms of dementia.

And then, the last little bullet there's a movement afoot, mostly from the folks that study sleep. As sleep deserves to be studied.

We spend a third of our life in it. And when I went to medical school in my four years of medical school we got one hour on sleep - and i think i got 70 hours on the kreb cycle.

And I'm waiting to use the kreb cycle any day now.

Where I always ask all my patients about sleep.

So back on track - there's a movement afoot now, driven by sleep specialist, that maybe sleep should be the fifth vital sign or certainly should be a very early part of inquiry on any exam.

You know -

"How well do you sleep?"

"What time you go to sleep?"

"What time do you wake up?"

"Is it restful?"

"Is it restorative?"

So we'll see what what time will tell - but I hope I'm highlighting the, the incredible importance and the multiple functions of sleep that we don't really consider until we start to think about it.

So, a bit about physiology.

So - this is the wake sleep circuit.

And this circuit is mutually inhibitory, mutually inhibitory.

That is to say when our wake promoting system is active - which you can see on the left side of the screen from 6am to 6pm our sleep promoting system is now decaying.

Ok- and then you know and it's driven primarily by light also by temperature we're mammals after all. And then you can see starting around 6pm our sleep promoting system starts to dim - like a dimmer switch.

And our- I''m sorry our wake promoting system starts to dim and our sleep promoting system starts to come online.

So it's mutually inhibitory and this is a really about hour cycle.

Circadian rhythm if you will - Latin circa around a day.

So, we'll take it a little bit further - this is the the arousal promoting system in our brain. And I'm sorry i couldn't flip this around so on your left hand - I'm sorry you're right hand side looking at this is the frontal lobes and on your left hand side is a cerebellum.

And this wakefulness and arousal promoting system is actually pretty well mapped out. That's the circuitry that you see there. Those are the the brain regions.

And, we're pretty sure it's modulated by a number of neurotransmitters. The usual culprits serotonin, norepinephrine and dopamine all those are less so.

But we now have really abundant and emerging evidence that there's another neruotransmitter called orexin. It was initially investigated because we thought it played a big part in appetite. And then lo and behold we discovered that this orexin neurotransmitter plays an enormous part in wakefulness.

So again you know with light this wake promoting system is quote/unquote "activated" and with darkness it starts to diminish. So that the arousal promoting system - it's as if in our brain we have two clocks if you will - going on.

So, that takes us to the sleep promoting system. Again this is very well mapped out. Kind of the center of activity is what's called the VLPO.

The vilpo - the ventral lateral preoptic area.

And there's the circuitry there and a number of neurotransmitters - dopamine again, but norepinephrine again and serotonin again.

They play very minuscule parts, but really this system is kind of driven by gaba that's a neurotransmitter.

Another neurotransmitter called galanin. And then, believe it or not histamine. Histamine plays a big part in the sleep promoting system.

So, as darkness falls and I think melatonin should be in there but unfortunately i don't see it so another neurotransmitter as darkness falls we see more melatonin secreted we think that plays a part in sleep induction and sleep maintenance.

So, last piece of physiology.

So this is a little sleep histogram from birth to death.

And it's a lot to digest.

But, essentially in the green is the amount of time we spend in wakefulness as we age.

And then, in the red the amount of time we spend in REM sleep.

Again as we age.

And then the amount of time we spend in non-rem sleep and I'll explain that in just a minute.

But if you kind of follow this out since we're talking about sleep problems in the elderly - right away it becomes abundantly clear that as we fall into that last third of our life we spent a lot of time awake not quite so much time in non-rem sleep and REM sleep is really starting to kind of vanish -

OK. Kind of vanish.

Of course if we take it to the other end of the spectrum you know we know that babies sleep a lot and when they sleep they're doing a lot of REM sleeping.

Rapid eye movement.

Of course that's another very mysterious triangle of physiology.

What is it? What are dreams?

How do they come about?

What's the importance of it?

So, what we know is that normal aging sleep -

as all of us age -

some very clear events happen.

Number one - our sleep efficiency goes down.

You say, what heck is sleep efficiency?

Sleep efficiency is simply the amount of time that we are asleep - divided by the amount of time we are in bed.

So my wife will tell you that my sleep efficiency - much to her dismay - is 100%.

As soon as my head hits the pillow - bang I'm out until I wake up

. It disturbs her to no end. She's exceedingly jealous okay.

So normal aging sleep .

. . decreased sleep efficiency -- Icreased fragmentation.

So fragmentation means we fall asleep we stay asleep.

So fragmentation means we wake up - and this isn't just to go to the bathroom and come back and fall asleep quickly.

We wake up but we don't have - we don't go through the stages of sleep which I'll show you in just a bit.

So the third bullet makes sense - if we are less efficient and if our sleep is fragmented total sleep time falls off and you know you can kind of see that here I mean if we add REM and non-rem as we age from let's say age 20 to age 60 there's a significant decrement.

So then lastly, increased daytime sleep and you can see that in the green emerging.

So that's normal aging sleep.

Doesn't mean it's pathologic.

That's sleep over our life span.

So, just a wee bit more -- sleep stage distributions changing say what the heck is that keep tantalizing that's the next slide but we see with sleep stage distributions as we see let's slow wave sleep why is that important because we think slow-wave sleep is where we see hormonal restoration communal funk immune function being rebooted memory consolidation so if we have less that those functions we have left decreased round again that's a little bit more of a mystery or not quite sure is a lot of hunches but nothing solid an increased stage 1 and stage 2 sleep and you say well why is that a problem because stage 1 and stage 2 are actually very white stages of sleep so here's this is a polysomnographic

i can only say that once a day if you or someone you know should be recommended to have a sleep study they'll go to a laboratory hotel bed very nice bedroom and they'll be wired up they'll have a 20 league EEG on their head electrodes on their eyelids so we can measure rapid eye movement of the pulse accidents are up here we have a band around their chest to measure volume have an EKG and have abandoned their leg to measure your muscle tension that's a little bit like the mechanical man and then they're asked to go to sleep and there's one sleeps what we see are stages asleep and actually this is a marvelous to a tremendous instrument because we have parameters about what are normal stages asleep and what are abnormal stages asleep and it allows sleep doctors sleep medicine specialist to to make diagnosis but roughly this is what it looks like this is kind of a short story so we fall asleep and usually have only 46 there's a really quick very quick period around and then it's a bit like a rollercoaster we go through stage one sleep which is very light easily disturbed stage to a bit deeper and then stage doing for that slow wave sleep stage three important okay and then we kind of popped back out to one round again then back down again this is a cycle over the night so usually we have four cycles cycles on order 9220 minutes and that's staging asleep

so what we're gonna sleep we can look at each of these stages what's how much stage 1 stage 2 state street and round and what we have reference ranges what's too little what's too much it's a great a great pickup and what we know again to backpedal as we age ok we see

let's slow wave sleep less around and increase stage 1 and 2 which aren't particularly restorative so that's okay in conclusion the words you're lying to hear when the elderly suffer from insomnia and for purposes of time we're just going to zero in on insomnia and the elderly from here on out because that's the most common diagnosis and I'm also hoping to be invited back for parts 2 3 and 4 lake disorder sleep and dementia and disorders asleep in alzheimer's disease but in the elderly in a general way what we see is as we age there's disruptions in the circadian around-the-clock sleep-wake pathways there's some emerging evidence that insomnia which we've always thought for about 2,000 years is a problem in the sleep promoter not working efficiently now we're getting some evidence that maybe the sleep promoters working just fine but perhaps the wakefulness promoter isn't turning off

so insomnia strangely enough maybe a disorder of excessive wakefulness and i'll explain that and just well actually the third bullet kind of explains that there's some evidence that there's increased levels of erection

erection remember that neurotransmitter in the wake promoter in the cerebral spinal fluid of Alzheimer's patients and maybe that's why they have sleep deterioration no more to come this is an early piece

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tony

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