Sleep Changes as We Age

A Q&A with Dr. Catherine McCall

Catherine McCall, MD is a sleep medicine physician and psychiatrist working at the Seattle VA. She is also the Acting Assistant Professor in the Department of Psychiatry and Behavior Sciences at the University of Washington. Dr. McCall was interviewed about the important questions surrounding how our age relates to our sleep.

Q: Is it normal for sleep to change as we age?
Yes. As we age, we tend to spend less time in deep non-REM sleep (also called slow-wave sleep), and we may get sleepy earlier in the day. Sleep in older adults may be more fragmented due to a variety of issues, including sleep disorders, medical disorders and medication effects. People experiencing menopause also frequently have sleep problems.

Q: Are sleep complaints common in older adults?
Many older adults do not complain of difficulties with sleep or excessive sleepiness. So when they do, it’s important to evaluate these problems and treat them appropriately. Of course, I am a sleep physician and many of the patients who come to my clinic have a sleep disorder. But many older adults do not report or perhaps realize how inconsistent their sleep patterns are.

Q: Are sleep disorders more common as we age?
Yes, many of the sleep disorders that afflict adults are more common as we age, including obstructive sleep apnea and insomnia. These disorders cannot only cause poor quality sleep and daytime sleepiness, but are also associated with other medical problems, neurological disorders and mental health issues.

Q: What are notable sleep-related discoveries surrounding sleep and aging?
One of the most important sleep-related discoveries in recent years is the existence of a process by which metabolic waste products and proteins are washed out of our brain tissue. This process has been called the “glial lymphatic” or “glymphatic” system, and it is most active when we are in deep sleep. Think of it as night janitors coming in to clean up the brain for the next busy day. Researchers have begun to learn that even short-term sleep disruption can interrupt this process and lead to a build-up of proteins in the brain. We are still learning about this, but there is some evidence that untreated sleep disorders such as obstructive sleep apnea may be associated with the later development of dementia, including Alzheimer’s disease.

Q: Is chronic insomnia in older adults normal?
Yes, one major problem that older adults tend to experience is chronic insomnia, which is the difficulty getting to sleep or staying asleep. Having short-term difficulty sleeping is normal, especially in stressful times. For some people, however, this develops into a long-term problem. Often the individual will report lying awake in bed, with racing thoughts and significant anxiety about lost sleep.

Q: What medications are available for insomnia?
In short, medication is not the first line of treatment for insomnia. When insomnia becomes a persistent problem, people will often request a medication from their clinical provider. This becomes more problematic in older adults who are more prone to having side effects from hypnotic medications, including serious risks of falls and excessive sleepiness the next day. People with insomnia may also take over-the-counter supplements such as Benadryl or Tylenol PM. These supplements can help people fall asleep, but can have serious short-term and long-term side effects in older adults such as urinary retention, constipation, dryness, confusion, restless legs and adverse effects on cognition.

Q: What is the best way to treat insomnia?
The gold-standard treatment for insomnia is something called CBT-I “cognitive-behavioral therapy for insomnia,” and it has few to no side effects. It is considered more effective than a medication, especially in the long term, and in older adults. Unfortunately, many providers do not have easy access to providers who can do this type of treatment.

Q: How does CBT-I work?
CBT-I is a therapy that employs several different techniques to address the root causes of insomnia. Chronic insomnia occurs when individuals develop a physiologic stress response called “hyperarousal” that overwhelms their perception of sleepiness. This hyperarousal response often becomes a 24-hour problem that prevents them from sleeping at night or during the day. People with insomnia also form a mental habit of being awake in bed, often with a mind that is actively worrying. CBT-I is designed to reverse these processes, changing bad habits into healthy ones. It helps realign the circadian drive by prescribing regular sleep and wake times, and helps increase “sleep pressure” (the sleepiness that increases the longer you are awake) by avoiding naps and caffeine use later in the day. People in CBT-I keep daily sleep diaries that show approximately when they are in bed and when they are asleep, which helps guide the provider to come up with a “sleep prescription.”

Variants of CBT-I may last anywhere from 4 to 12 weeks, can be delivered individually or in groups, and has been shown to work well via telemedicine. One positive thing that may come out of the pandemic is the ability to connect to a healthcare provider some distance away via video- or telephone-based care, which may eventually increase the availability of this therapy. I recommend patients ask their healthcare provider about referral possibilities for CBT-I treatment.
…………………………………………………………………………
Wendi Kitsteiner is a former high school English and Journalism teacher who has worked as a writer/editor for the RLS Foundation and as an editorial assistant for a cardiovascular researcher at Mayo Clinic. She is currently homeschooling her four children on a farm in East Tennessee.


Facebook
Twitter
LinkedIn

Subscribe for Free

Subscribe to the digital edition of Healthier Sleep for free! Issues are emailed to subscribers at least four times per year. Your email will be used for this purpose only.