Insomnia

Trouble sleeping.  Tossing and turning.  Keeping you up at night.  Insomnia affects up to 25% of older adults.

Most of us can recall a time when sleep was slow in coming, disrupted by frequent wakening or cut short too early for us to feel rested.  Often this is temporary and associated with a clear cause, like stress (either positive or negative), illness, or a major lifestyle change. 

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How is insomnia classified?

Insomnia is the term used when a sleep pattern occurs repeatedly and causes dissatisfaction on the part of the individual. So, if you are a poor sleeper, but it doesn’t bother you (although it may bother your partner or other family members!), it’s not technically insomnia.

Insomnia can be classified as:

• Initial (trouble falling asleep, or increased sleep latency)
• Middle (waking throughout the night and not being able to return to sleep)
• Terminal (which sounds deadly, but really isn’t, and refers to waking early and being unable to fall back asleep),

Some individuals report all three of these patterns.

Diagnostic criteria

The other criteria for the diagnosis of insomnia disorder is that it interferes in a significant way with daily function, either in social or occupational domains.  Insomnia can only be diagnosed if one has trouble sleeping despite having ample opportunity to do so (so not due to a new baby in the house or a medical residency call schedule), and is part of a pattern of at least three nights per week, for at least three months. Symptoms of sleep deprivation can include irritability, daytime sleepiness,  fatigue, mood changes and trouble with concentration and memory.

Stressors that affect sleep patterns

Aging, even normal aging, affects sleep patterns.  Sleep efficiency goes down as we age, meaning that seniors spend more time in bed but less time sleeping (you can calculate your sleep efficiency with this equation: time asleep/time in bed).  Sleep efficiency in younger people is around 95%, for seniors, it’s closer to 80%. 

As we age, we also experience more nighttime awakenings, less REM sleep and less stage 3 sleep (the deep sleep that precedes REM).  Seniors are more likely to retire earlier and get up earlier in the morning (Ever been to a long-term care facility around 8 PM?  Most residents are tucked up in bed, often before the sun has even set).  Add to this the increased likelihood that an older adult has a medical issue that affects sleep (like sleep apnea, chronic pain, depression, dementia, restless legs, medication use) and it’s easy to understand why sleep challenges are so common in the senior population. 

Treatment of insomnia

The good news is that insomnia is a treatable condition, however a “sleeping pill” is not usually the only answer, or the best answer.  Older adults who use sleeping pills (most commonly in the benzodiazepine, or “-pam” family) have an increased risk of falls, broken bones, medication interactions, and, paradoxically – insomnia.  Many older adults on sleeping pills can have symptoms in keeping with Alzheimer’s disease as a side effect of these drugs. 

I have seen many an individual have dramatic improvement in memory performance when the sleeping pills have been discontinued, and often improvement in sleep as well.  Insomnia treatment must be tailored to the individual and in order to develop a management plan, it will be important to get a clear idea of what is contributing to the sleep disturbance.  A management plan that includes medication adjustment and non-pharmacological treatments is most likely to be most successful.