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230

CHAPTER 9

Sleep Disturbances

MARY ANN LEITZ

ACK OF SLEEP

and poor quality sleep have major negative effects on all indi-

viduals, but especially the elderly. The rate of sleep disorders is much

higher for the elderly and escalates in intensity and frequency due to dete-

rioration of physical and psychiatric status that occurs with normal aging. Sleep

problems cause health problems, mood disturbances, decreased energy, emo-

tional instability, and inability to concentrate and negatively impact personal re-

lationships. A relationship between illness and sleep disturbances has been

established; individuals who do not receive adequate sleep have higher rates of

illness and immunity to ward off communicable illnesses drops (Leitz, 2005; Mar-

tin, Shochat, & Ancoli-Israel, 2000).

Sleep disturbances are one of the most frequent complaints reported to physi-

cians by adults. Surveys of physicians find that approximately 10 million Ameri-

cans annually identify sleep disturbances as the main reason they visit their

doctors. Sleep disturbances are the most frequent complaint of the elderly to

their physicians, and physicians write most prescriptions for sleep medication

for the elderly (Hauri & Linde, 1996; Morgan, 1987; Roth, 1993). Patients report

overall decreased number of hours of sleep, decreased levels of satisfaction with

the quality of sleep, problems falling and staying asleep, more frequent awaken-

ings during the night, earlier rising, and more need for daytime naps. Overall

they report a decrease in level of satisfaction with their sleep quality (Martin

et al., 2000).

Sleep disturbances thus are very common. According to a 1993 Harris poll, as

many as half of all adults felt sleep deprived (Hauri & Linde, 1996). Ito et al.

(2000) studied the rate of sleep disturbances in 518 (255 men and 263 women) 65-

year-olds. Findings indicated that 50% of the sample reported sleep disturbances.

The most frequent problem reported was falling asleep. Researchers also found a

relationship between depression, poor health, and sleep disturbances: The

greater the number of sleep problems, the more depressed and ill subjects felt.

Subjects specifically reported shorter sleep periods, increased awakenings, easy

arousal, daytime fatigue, and feeling the need for a daytime nap (Roth, 1993).

Sleep Disturbances 231

Studies have indicated that sleep problems of even short duration have a nega-

tive impact on functioning. A study of adults living in Los Angeles (Chokroverty,

2000) found that as many as 33% of subjects reported having some type of sleep

disturbance that resulted in feelings of fatigue and sleepiness during the day. In

a sample of college students (N = 1,414), Ban and Lee (2001) found approximately

40% reported problems sleeping, with measurable loss of productivity, difficulty

concentrating, increased number of accidents, increase in mood disturbances,

and an inability to complete assigned academic projects. These findings are sup-

ported by Heuer and Klien (2003), who studied volunteers who were sleep de-

prived for only one night. Findings indicated that subjects exhibited decreased

learning capacity and inability to complete assignments the next day.

NORMAL SLEEP

Falling asleep is a process that involves complicated, intricate interactions be-

tween neurological and chemical processes. Gradually and slowly, the con-

scious mind is isolated from the external environment, and motor functions and

alertness to surroundings are decreased (Dement & Vaughan, 1999; Hauri &

Linde, 1996).

Sleep needs vary among individuals, but a range of 4 to 8 hours of sleep a night

is considered necessary for normal functioning (Dement & Vaughan, 1999; Hauri

& Linde, 1996; Van Dongen, Maislin, Mullington, & Dinges, 2003). However, sleep

is easily disturbed by many different physical and emotional problems. The older

the individual, the more likely he or she is to have the type of problems that di-

rectly impact sleep. Approximately 50% of individuals 60 years old report chronic

sleep problems, and 100% of those 90 and older experience sleep disturbances.

The quality of sleep also deteriorates with age. The elderly are more likely to re-

port frequent nighttime awakenings and describe themselves as light sleepers

who are easily awakened (Martin et al., 2000).

The elderly experience the same sleep disorders as young adults but at higher

rates. They experience more obstructive sleep apnea, restless leg syndrome, and

periodic limb movement disorders. Sleep for the elderly is further complicated by

other conditions frequently found in this age group, including chronic pain, fre-

quent urination, arthritis, inactivity, Alzheimer’s disease, and Parkinson’s dis-

ease (Asplund, 2004; Dement & Vaughan, 1999; Foley, Ancoli-Israel, Britz, &

Walsh, 2004). They also experience an increase in psychological and environmen-

tal stresses that may interfere with sleep.

Anxiety and depression are common problems for the elderly. Many experi-

ence major losses, including the death of a spouse and elderly family members,

loss of home and independence, and other major lifestyle changes, such as finan-

cial problems. With longer life expectancies, the elderly are faced with support-

ing themselves financially for many years after retirement. Many retire between

the ages of 65 and 72 but live for another 25 to 30 years. Although many elderly

persons remain active and healthy, the older they are the more likely they are to

have health problems. This can challenge their independence and cause severe fi-

nancial strain due to the necessity of supporting themselves and also paying for

medical care (Barbar et al., 2000; Dement & Vaughan, 1999; Loiselle, Means, &

Edinger, 2005; Piccone & Barth, 1983). As a result of these financial, physical,

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emotional, and social problems, the elderly frequently experience a lower stan-

dard of living, which results in depression and anxiety.

STAGES OF SLEEP

Sleep is composed of several stages, and we cycle through the different stages sev-

eral times during the night. Sleep is also composed of core sleep and optimal

sleep. Core sleep occurs in the first part of the night and is necessary for normal

functioning and body and brain recovery and healing from the stressors of daily

life. Optimal sleep occurs later in the night and is required to feel rested and en-

ergetic. The amount of optimal sleep determines the quality of sleep. There are

two main stages of sleep: nonrapid eye movement (NREM) sleep and rapid eye

movement (REM) sleep; NREM is further separated into Stages I, II, III, IV.

1. Stage I NREM: Stage I comprises only 8% of the total night’s sleep. There is

a gradual decrease of the level of consciousness and awareness of external

stimuli. Heart rate, respiratory rate, and blood pressure also decrease. Sleep

during Stage I is very light. Individuals sleep are only partially asleep and

are easily awakened by even slight stimulation. If awakened during this

stage, individuals may not even know they had been asleep. The elderly ex-

hibit longer and more frequent Stage I sleep and therefore are more easily

aroused. As a result, they experience poor quality of sleep. They spend less

time in the deeper stages of sleep and as a result do not feel well rested or

benefit from the natural healing that occurs while in deep sleep

(Chokroverty, 2000; Morgan, 1987).

2. Stages II, III, and IV NREM: Combined, these stages comprise approximately

42% of sleep during the night. As individuals cycle through these stages,

they fall into ever deepening sleep, until finally, in Stage IV, sleep is so deep

that it is difficult to arouse individuals. Core sleep occurs in Stages III and

IV, which are the deepest stages of sleep (Hauri & Linde, 1996). Heart rate,

respiration rate, and blood pressure are at their lowest during these stages.

This allows the cardiovascular system to rest, which helps prevent cardio-

vascular diseases. The elderly spend less time in these deeper stages, which

results in their bodily functions being unable to slow to the same level as

younger adults so they do not experience the same healing benefits of sleep

(Chokroverty, 2000; Morgan, 1987).

3. REM: Rapid eye movement sleep accounts for approximately 50% of all

sleep. Dreaming occurs during this stage. Although our bodies are para-

lyzed, eye movement under the closed lids can be seen. The actual function

of dreams has been debated for decades, but it is clear that they are very im-

portant for normal functioning. Individuals who are deprived of dreams re-

port feeling increased fatigue, irritability, and anxiety. Lack of dreaming is

commonly caused by illness or medication and results in increased feelings

of irritability, emotional instability, and feelings of being unable to cope

with everyday demands. When individuals who were deprived of dreams

begin to dream again, the brain appears to make up for lost REM periods. It

has been reported that when dreams do resume, they are much longer,

more bizarre, and more kinetic (Hauri & Linde, 1996). A study in which a

group of subjects were deprived of REM sleep for four consecutive nights

Sleep Disturbances 233

showed that subjects were easily angered, frequently confused, and emo-

tionally labile. When they were allowed to sleep normally, including REM

sleep, subjects experienced longer and more frequent dream periods. They

also reported that their dreams were extremely vivid, sometimes colorful,

and bizarre (Dement & Vaughan, 1999). REM sleep is easily disrupted by

illness, medication, chronic conditions, and sleep disturbances (Dement &

Vaughan, 1999). The length of REM sleep has been found to naturally de-

crease with age so that the elderly experience fewer and shorter REM peri-

ods. The older the individual, the more disrupted the REM sleep. The

natural aging process results in decreased REM periods even if the individ-

ual is in good health. Many health problems associated with aging and

medications to treat these illnesses decrease REM sleep even further (De-

ment & Vaughan, 1999; Morgan, 1987).

Among the elderly overall, the quality and length of sleep is decreased due to

the changing pattern of sleep, with longer periods in the lighter stages and

shorter periods in the deeper stages of sleep.

CIRCADIAN RHYTHMS

One of the most valuable discoveries in sleep research was the realization that our

bodies function on a 24-hour biological clock, or circadian rhythm, that is regu-

lated by chemical substances that establish sleep-wake cycles (Chokroverty, 2000).

Normal circadian rhythm results in being awake in the day and sleepy in the

night. Sleep-wake cycles are controlled by both internal influences (circadian

rhythms) and external influences (environmental). Circadian rhythms are con-

trolled by hormone levels in the brain that are affected by exposure to light and

dark. Melatonin is the main sleep hormone that is secreted by the hypothalamus,

which causes and controls sleep. It is released in the dark and inhibited in bright

light. Therefore, levels of melatonin are at their highest during the night when

sleeping in dark rooms and lowest in the daylight. Melatonin acts on the brain and

the body to cause feelings of being sleepy, decreases body temperature, decreases

blood flow to the brain, increases relaxation, and induces sleep. The elderly expe-

rience a reduction in the production of melatonin, resulting in disrupted sleep

(Chokroverty, 2000; Dement & Vaughan, 1999; Dunlap, 1998; Green & Menaker,

2003; Pandi-Perumal, Zisapel, Srinivasan, & Cardinali, 2005; Van Someren, 2000).

Sleep debt is another factor of sleep-wake cycles. Energy used to complete

daily activities results in greater levels of fatigue. The more we do during the day,

the more tired we feel in the evening. This energy depletion creates a sleep debt.

Sleep debt is the amount of sleep the body needs to be rested. The greater the

sleep debt, the more sleep is needed (Dement & Vaughan, 1999). As the day pro-

gresses, fatigue increases until individuals feel increasingly tired. Eventually, in-

dividuals become so tired that they begin to focus on their feelings of fatigue and

experience a strong desire to go to sleep (Van Dongen et al., 2003).

Both the level of melatonin and the amount of sleep debt are reduced in the el-

derly. Changes in the aging brain cause decreases in the amount of melatonin

produced. Additionally, melatonin is produced only in the dark. Many elderly

sleep with some type of light on in the room to avoid falls should they get out of

bed during the night. This reduces the amount of melatonin produced by the

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brain. Napping negatively affects both melatonin production and sleep debt.

Many elderly feel the need to nap in the day. Daytime sleep disrupts sleep-wake

cycles and is not as restful as nighttime sleep. Melatonin is not produced during

daylight napping. Napping also reduces sleep debt, so individuals will not feel

tired at night and will not feel the need to sleep. Circadian rhythms are dis-

rupted, so individuals will feel sleepy in the day and awake at night (Loiselle

et al., 2005; Van Someren, 2000).

SLEEP DISTURBANCES IN THE ELDERLY

Sleep disturbances can occur at any age but are more likely to occur in the el-

derly. Psychological and physiological changes that are part of the natural aging

process negatively impact sleep both directly and indirectly. Direct influences

are caused by degeneration of the nervous system and physiological processes

that affect sleep-wake cycles. Indirect causes of sleep disturbances in the elderly

are the result of illnesses and physical conditions. The most common of these are

arthritis, diabetes, increased urination, and dementia. The elderly report spend-

ing more time in bed but less time asleep, with resultant daytime sleepiness and

fatigue. Feelings of daytime fatigue can encourage the elderly to take naps, which

decreases sleep debt, which further interferes with night sleeping. The elderly

are 25% more likely to nap than other adult age groups, with an average of 30

minutes spent napping each day (Martin et al., 2000).

However, sleep disturbances in the elderly are more commonly caused by spe-

cific conditions related to aging, including sleep-disordered breathing, periodic

limb movement, circadian rhythm changes, medical illness and/or medications,

and Alzheimer’s disease and dementia. Treatments that specifically target these

conditions and good sleep hygiene practices help to resolve or at least decrease

sleep problems (Martin et al., 2000).

TYPES OF SLEEP DISTURBANCES

The most common sleep disturbances in the elderly are disorders that prevent the

onset of sleep or cause frequent awakenings. These include insomnia, circadian

rhythm sleep disorders, restless leg syndrome, periodic limb movement disor-

ders, sleep apnea, and neurological, physical, and psychiatric conditions.

NSOMNIA

Insomnia is the inability to either fall or stay asleep. Insomnia sufferers may be

unable to fall asleep, but then may stay asleep the rest of the night. Others may

fall asleep easily but do not stay asleep or experience early-morning risings.

These individuals also have difficulty getting up in the morning and do not feel

rested after sleep (Piccone & Barth, 1983). There are many causes of insomnia, but

for the elderly the cause is usually poor sleep hygiene, stress, medication, acute

illnesses, inactivity, depression, anxiety, and poor diet (Brostrom & Johansson,

2005; Chokroverty, 2000). Insomnia can be acute, short term, or chronic and can

be learned. A cycle can develop where frustration and anxiety prevent sleep, and

being unable to fall asleep creates more frustration and anxiety. Many insomnia

sufferers even avoid going to bed when sleepy because they fear experiencing the

frustration of being unable to fall asleep. The elderly are frequently caught in this

Sleep Disturbances 235

frustrating cycle. As many as 40% of all elderly report experiencing chronic in-

somnia. Complaints of insomnia increase with age, and the natural aging process

can be the primary cause of insomnia. Insomnia can also be secondary to several

conditions related to the natural aging process and is a common side effect of

chronic pain, neurological conditions, depression, illnesses, and medications and

medical treatments. Daytime napping can cause nighttime insomnia due to de-

creased sleep debt (Chokroverty, 2000; Martin et al., 2000).

OOR

LEEP

YGIENE

Poor sleep hygiene is related to lifestyle and environmental factors that disrupt

and prevent sleep. Poor sleep hygiene found in the elderly includes poor diet, use

of alcohol, drugs, and tobacco, lack of exercise, napping, and bedroom environ-

ment. Sleep hygiene that is conducive to sleep is especially difficult for those liv-

ing in assisted living facilities or with family and for individuals who may not be

able to financially afford a comfortable bedroom (Chokroverty, 2000; Dement &

Vaughan, 1999; Loiselle et al., 2005).

ESTLESS

YNDROME

Restless leg syndrome is a sensorimotor disorder. This condition results in an

overwhelming desire and need to move the legs. Restless leg syndrome occurs

when lying in bed or after sitting for long periods. Young adults may have this

condition, but the severity increases as they age. The elderly can develop this con-

dition due to degenerative processes of aging. Approximately 10% of all adults

suffer from restless leg syndrome, and it occurs equally in men and women. It

tends to run in families and is chronic and progressive. As individuals are resting

they feel a strong urge to move their legs, and leg movements are voluntary. Indi-

viduals are awake and choose to move their legs to get relief (Chokroverty, 2000).

This condition is exacerbated by anxiety, depression, illness, aging, sedentary

lifestyles, and physical illnesses. Common medical conditions that can cause rest-

less leg syndrome include diabetes and diabetic peripheral neuropathy, anemia,

renal failure, liver problems, and medications (Chokroverty, 1994; Loiselle et al.,

2005). The elderly are susceptible to all of these conditions (Chokroverty, 2000).

ERIODIC

IMB

OVEMENT

ISORDERS

Unlike restless leg syndrome, periodic limb movements are involuntary and

occur while asleep. This disorder causes brief severe contraction of the limbs, usu-

ally the legs, and is characterized by myoclonus (contract-release) movements

that can occur every 30 seconds. Movements are unconscious but can awaken

sleeping individuals. Restless leg syndrome and periodic limb movement disor-

ders are related. Approximately 80% of those with periodic limb movement also

have restless leg syndrome. Periodic limb movement disorders occur during

Stage II NREM sleep and can occur alone or in combination with other disorders.

When the elderly do cycle into the deeper stages of sleep, limb movements can

awaken them. Severity and frequency vary (Chokroverty, 2000). The likelihood of

this condition increases with age and is associated with neurological degenera-

tion and physical illnesses (Martin et al., 2000). Causes and exacerbation of peri-

odic limb movement disorders are related to conditions common to the elderly,