By JUDD MATSUNAGA, Esq.
As a kid, we would run around all day, stay up late, then fall asleep out of sheer exhaustion. We’d sleep uninterrupted until morning, and then fall asleep again two or three times, hitting the snooze button on the alarm. Not anymore. At 64 years of age, I rarely will sleep through the night, usually having to get up once or twice to use the restroom.
How about you? It’s probably not realistic to expect that as you get older, you’ll sleep as long or as soundly as when you were younger. In fact, experts do believe that “normal aging” brings on some changes to sleep. Basically, older adults tend to get sleepy earlier in the evening and tend to sleep less deeply than when they were younger.
Studies have found that we all experience changes with their sleep as we age. Sleep becomes lighter and more fragmented, with less time spent in deep REM sleep. Aging is also associated with a shift in the circadian rhythm, so that many older adults find themselves sleepy earlier at night and hence wake up earlier in the morning. Lighter sleep means it’s easier for aging adults to be disturbed by any other sleep-related disorders or chronic medical conditions and medications.
In addition, older adults often experience “secondary” sleep difficulties, which means that the sleep problems are being caused by an underlying health problem. Many people diagnosed with Alzheimer’s have additional chronic health problems that may be associated with sleep difficulties. Treating such problems can help improve sleep. Common causes of secondary sleep problems include:
• Heart and lung conditions, such as heart failure or chronic obstructive pulmonary disease.
• Stomach-related conditions such as gastroesophageal reflux disease
• Chronic pain from arthritis or another cause
• Urinary conditions that make people prone to urinating at night, such as an enlarged prostate or an overactive bladder
• Mood problems, such as anxiety or depression
• Medication side-effects, and substances such as alcohol (which is known to disrupt sleep).
Alzheimer’s and other neuro-degenerative diseases change sleep. The brain deterioration associated with various forms of dementia tends to affect the way the brain sleeps. In most cases, this causes less deep-sleep time, and more awake time at night. Problems with the circadian rhythm system (the body’s inner system for aligning itself with a 24-hour day) also become more common in dementia.
In short, most aging adults develop lighter sleep as they age, and many older adults have health problems that prompt night-time awakenings. Sleep-related disorders such as sleep apnea are also common in aging. Seniors with Alzheimer’s and other dementias are likely to be affected by any of these factors that change sleep in older adults, plus dementia brings on extra changes that make night-time awakenings more common.
Insomnia is very common, and it becomes even more common with aging. One study found that 23-24% of older adults reported symptoms of insomnia. Insomnia means having difficulty falling asleep or staying asleep, despite the opportunity to do so (e.g., being in bed), and experiencing decreased daytime function because of this. Insomnia has been associated with anxiety, depression, fatigue, worse quality of life, cognitive decline, and a variety of other worse long-term health outcomes.
Sleep problems also commonly drive family caregivers crazy, because when your spouse or parent with Alzheimer’s doesn’t sleep well, this often means that you don’t sleep well. As a caregiver, you may simply want to know: “Isn’t there a medication we can give in the evening, to help my parent (or spouse) sleep better at night?”
It’s true that sleeping pills, sedatives, and tranquilizers exist, and they are often prescribed to help keep people with dementia quieter at night. These include antipsychotics like Olanzapine, Risperidal, and Quetiapine, benzodiazepines such as Lorazepam and Temazepam, sleeping medications like Zolpidem, or even over-the-counter sleep aids (which usually contain some form of sedating antihistamine).
Unfortunately, all these medications are likely to cause concerning side-effects in people with dementia, namely a worsening sleep cognition and increased fall risk. The antipsychotics have also been associated with a higher risk of dying. Last but not least, comprehensive scientific review articles conclude that in clinical trials, these drugs do not conclusively improve sleep.
Hence, the recommendation of experts in geriatrics is that these medications should generally be avoided, and only used as a last resort once behavioral approaches (e.g., setting a routine, more walking, etc.) have been tried. Benzodiazepines such as Lorazepam, Alprazolam, Diazepam, and Temazepam (Ativan, Xanax, Valium, and Restoril) are also habit-forming. It can be a lot of work to wean people off these drugs, but research has proven it’s possible.
But letting them continue to use their Benzodiazepine puts us in a pickle, because it also keeps them from having the best brain function possible, is associated with faster cognitive decline, AND increases fall risk. “Taking physician-recommended sleep medications to treat insomnia may actually increase the risk of falling for older adults,” according to Orfeu Buxton, associate professor of biobehavioral health, Penn State Center for Healthy Aging.
Buxton and his colleagues reported their findings in the Oct. 17, 2017 issue of **Sleep,**
titled “Older adults with insomnia may fall even more when on prescription sleep meds” (www.psu.edu/news/research). Buxton said, “The more likely a person has difficulty sleeping, the more likely they are going to be up and walking around in the dark at night. You might think that if they have a physician-prescribed sleep medication that risk of falling might go down because they would stay in bed, but it doesn’t. It worsens.”
The researchers also found a link between the number of insomnia symptoms and fall risk. The four symptoms of insomnia: (1) trouble falling asleep; (2) waking up during the night; (3) waking up too early; and (4) not feeling rested. All increased the risks of falls for older adults, according to the researchers.
The probability of a fall goes steadily upward from 28% for older adults with no symptoms of insomnia, to 40% for older adults reporting four different symptoms of insomnia, according to the researchers. However, the risk of falls for those taking physician-prescribed insomnia medicine was always higher for older adults with insomnia, even those who had all four symptoms of insomnia.
The exact approach to improving sleep in a person with Alzheimer’s or another dementia will depend on what underlying factors are causing sleep problems. Still, certain general approaches have been found to improve the sleep of many people with dementia. According to gerontologist Leslie Kernisan, MD MPH, here are some non-drug approaches to treating insomnia:
• Outdoor light or bright light therapy during the day. Bright outdoor light helps keep the circadian signals (the body’s inner clock) on track. For seniors who can’t get outside for at least an hour per day, bright light therapy with a special lamp might help. A study found that bright light therapy in Alzheimer’s patients improved sleep.
• Increase daytime physical activity. Research has suggested that walking during the day can help improve nighttime sleep in people with Alzheimer’s.
• Optimize environmental cues for sleep. This means keeping the sleeping environment dark and quiet at night. This is especially important in nursing homes, which have sometimes been found to have staff active at night.
• Establish a regular routine with a consistent wake-up time. A regular routine can help maintain better sleep. The ideal is to have a consistent bedtime and wake-up time, but many experts believe it’s best to start by focusing on a consistent wake-up time.
A research study published in 2005 found that training dementia caregivers to use these techniques in combination did lead to improved sleep of the care recipients with Alzheimer’s. So it’s better to avoid sedatives until you’ve exhausted all other options. Non-drug approaches like those mentioned above usually improve the person’s quality of life overall.
Remember, sleep is important for health, and it’s especially important for family caregivers. The key to successfully stopping sedatives for sleep is to very slowly taper the drug under medical supervision, plus add cognitive-behavioral therapy or other sleep-improving approaches, if possible,
Sometimes additional testing is necessary, such as a sleep breathing study to evaluate sleep apnea. Based on the category of sleep problem, and the underlying causes that have been identified, e.g., difficulty falling or staying asleep, or abnormal breathing patterns during sleep, the doctor should then be able to propose a plan for improving the sleep difficulties.
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Judd Matsunaga, Esq., is the founding partner of the Law Offices of Matsunaga & Associates, specializing in estate/Medi-Cal planning, probate, personal injury and real estate law. With offices in Torrance, Hollywood, Sherman Oaks, Pasadena and Fountain Valley, he can be reached at (800) 411-0546. Opinions expressed in this column are not necessarily those of The Rafu Shimpo.