April 2016  |   Archive

Everybody Needs a Good Night’s Sleep ... Especially an Older Body!

Ever since my days as a sleep-deprived internal medicine resident, I’ve tried to take seriously the complaints about sleep—or the lack of sleep. I felt the mental dullness along with the physical and emotional strain that limited sleep creates. When my older patients complain of waking four and five times nightly for trips to the bathroom, I remember the impact of the middle-of-the-night beeps from old-time pagers. Ironically, during any given overnight shift, several of the nurses’ calls that woke me up were for sleeping pills for the patients. I handed out sleeping pills in those days far more often than I’d like to admit. But now that I’m a seasoned geriatrician, I know a bit more about sleep in the elderly and a bit more about how to help without harming. So I invite you to “think like a geriatrician” about one of the most common complaints among older adults.

Sleep is one of life’s most precious commodities. Our bodies require sleep for adequate function, healing and repair, and growth. When we are sleep deprived, there are notable effects on cognition, immune function, physical abilities, and emotions. In primary care settings, complaints about sleep are all too common. Sleep complaints are frequent in later life, with self-reported insomnia affecting as many as 60% of the older population at any given point in time.1

First, let’s review what constitutes normal sleep for older adults. Most adults need about seven to nine hours of sleep per night, and typically we need the same amount we did when we were younger. What often changes is when we sleep. Remember “early to bed, early to rise …”? Older adults go to sleep—and wake up—earlier.

Many people believe poor sleep is a normal part of aging; it is not.

Older adults who believe they are not getting enough sleep and cannot function normally for a period lasting more than two to three weeks should talk to their primary care physicians. Most primary care physicians can diagnose sleep disorders and offer suggestions and treatments that can improve sleep.

The most common sleep disorders among older adults are the following:

• insomnia;

• sleep-disordered breathing, such as snoring or sleep apnea; and

• movement disorders, such as restless leg syndrome and periodic limb movement.


Insomnia is the inability to fall asleep or to remain asleep throughout the night.

If you have insomnia you may have one or a combination of the following symptoms:

• taking a long time (more than 30 to 45 minutes) to fall asleep;

• waking up many times each night;

• waking up early and being unable to get back to sleep; and

• waking up feeling tired.

What Causes Insomnia?

Insomnia is caused by many things. Short-term insomnia may be due to a change in personal circumstances such as losing a loved one, moving, or being hospitalized.

Long-term insomnia, lasting more than one month, may be due to acute pain, neurologic conditions such as Parkinson’s disease or dementia, depression, caffeine stimulants, consuming alcoholic drinks, changes in sleeping or waking, or medications.

Sleep-Disordered Breathing

Snoring is caused by a partial blockage of the airway passage from the nose and mouth to the lungs. The blockage causes the tissues in these areas to vibrate, leading to the noise produced in snoring. Sleep apnea occurs when a person stops breathing for 10 or more seconds multiple times throughout the night.

Obstructive sleep apnea is common in older adults and in people who are overweight. It occurs when air entering through the nose or mouth is partially or completely blocked.

Central sleep apnea is less common and occurs when the brain does not send the proper signals to the muscles that control the breathing process.

Both obstructive and central sleep apnea can increase a person’s risk for high blood pressure, strokes, heart disease, and cognitive problems.

Movement Disorders

Two movement disorders that may disrupt sleep are restless leg syndrome and periodic limb movement.

Restless leg syndrome affects more than 20% of people aged 80 and older; it is characterized by an uncomfortable feeling in the legs such as tingling, crawling, or the feeling of pins and needles.

Periodic limb movement causes an individual to kick or jerk one or both legs many times during sleep.

Primary Care Evaluation of Sleep Disorders

Diagnosis of a sleep disorder may include several steps, such as the following:

1. Ask patients/caregivers to keep a sleep diary for one to two weeks to develop a picture of sleep habits, voiding/drinking habits, and exercise schedules.

2. Verify caffeine use and alcohol consumption; these can affect sleep.

3. Ask about any medications or herbals, including over-the-counter medications.

4. Ask about emotional status, assessing for signs of depression and/or anxiety.

5. Perform a physical exam for signs of other diseases, such as Parkinson’s disease, COPD, stroke, or heart disease, that could affect sleep.

6. If you cannot identify the reason for the insomnia, you may need to refer patients to a specialist or sleep center for a more complete evaluation and testing.

A good sleep diary template is available at https://sleepfoundation.org/sleep-diary/SleepDiaryv6.pdf.

Upon review of the sleep diary and completion of the other aspects of evaluation, you will have an idea of what is creating the sleep disturbance.

Suggestions to Improve the Ability to Sleep/Sleep Hygiene

In many cases, practicing good sleep hygiene will help increase total sleep. Suggestions include the following:

• Keep a regular schedule—go to sleep and wake up at consistent times, aiming for seven hours total.

• Do not nap during the day.

• Exercise for at least 30 minutes each day and at consistent times each day. Try to finish your workout at least three hours before bedtime.

• Get natural light in the afternoon daily.

• Be careful about what you eat and drink after dinner. Don’t drink beverages with caffeine late in the day: “Only sips after six.”

• Don’t drink alcohol or smoke. Even small amounts of alcohol make it harder to stay asleep and nicotine in cigarettes is a stimulant. No nightcaps!

• Create a comfortable place to sleep. The room should be dark, well ventilated, and quiet.

• Consider buying a new pillow or mattress.

• Develop a bedtime routine. Do the same things each night to tell your body it is time to wind down.

• Sleep only in your bedroom. After turning off the light, give yourself 15 minutes to fall asleep. If you are still awake after 15 minutes, get out of bed and do a quiet activity such as reading or listening to music. When you are sleepy, go back to bed.

From a treatment standpoint, it’s advisable to work with nonpharmacologic strategies first.

If these strategies prove unsuccessful, and additional treatment is needed, consider the following agents:

• Melatonin in doses of 3 to 10 mg taken three to five hours before the desired time of sleep onset has been reported to be effective in some patients with insomnia. It does not appear to be effective when taken at bedtime. Circadin, a sustained-release formulation of melatonin, is approved for use in Europe; one study found it to be more effective than placebo for use two hours before bedtime in patients ≥65 years old.2 Melatonin is available only as a dietary supplement in the United States; the hypnotic dose has not been established and the purity of these products is unclear.3

• Trazadone, an older antidepressant, used at low doses of 50 to 100 mg has been found to make some people drowsy.

• For patients with any signs or symptoms of depression or anxiety, consider a selective serotonin reuptake inhibitor such as Sertraline in 25 to 50 mg at bedtime.

• Another option for patients with depression and low appetite is the antidepressant Mirtazapine. At its lowest dose range, 7.5 mg, it has been found to make some people sleepy and is known to stimulate appetite.

For more information on sleep disorders and other health information of interest to older adults, visit the National Institutes of Health Senior Health website at http://nihseniorhealth.gov or the National Sleep Foundation at www.sleepfoundation.org.

— Rosemary Laird, MD, MHSA, AGSF, is a geriatrician, executive medical director of senior services for Florida Hospital at Winter Park, and past president of the Florida Geriatrics Society. She is a coauthor of Take Your Oxygen First: Protecting Your Health and Happiness While Caring for a Loved One With Memory Loss.



  1. Foley DJ, Monjan AA, Brown SL, Simonsick EM, Wallace RB, Blazer DG. Sleep complaints among elderly persons: an epidemiologic study of three communities. Sleep. 1995;18(6):425-432.
  2. Wade AG, Ford I, Crawford G, et al. Nightly treatment of primary insomnia with prolonged release melatonin for 6 months: a randomized placebo controlled trial on age and endogenous melatonin as predictors of efficacy and safety. BMC Med. 2010;8:51.
  3. Drugs for insomnia. Med Lett Drugs Ther. 2015;57(1472):95-98.