Blackburn J.A., Dulmus C.N. (Editors). Handbook of gerontology: evidence-based approaches to theory, practice, and policy

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most frequently venous insufficiency in lower limbs, hypertension, and os-

teoarthritis (Chokroverty, 1994; Loiselle et al., 2005).

LEEP

PNEA

The rate of sleep apnea in the elderly is estimated to be as high as 62% (Lugaresi,

1993). Sleep apnea is the “absence of respiration” (Hauri & Linde, 1996, p. 201).

While sleeping, breathing stops for a few seconds. This is caused by the collapse

of the trachea, which prevents the passage of air, which stops breathing (Hauri &

Linde, 1996). Muscles relax and become flaccid during sleep. The muscles in the

trachea can become so flaccid that the trachea actually collapses and breathing

stops. Individuals begin to choke and awaken, muscles contract, rigidity in the

trachea is restored, and breathing resumes. This cycle can occur many times dur-

ing the night. Symptoms include loud snoring, choking while asleep, cessation of

breathing, frequent awakenings, frequent nighttime urination, daytime sleepi-

ness, forgetfulness, morning headache, insomnia, night sweating, and gastroin-

testinal reflux, which causes coughing and aspiration (Chokroverty, 2000; Hauri

& Linde, 1996; Piccone & Barth, 1983). Precipitating factors include nasotracheal

abnormalities, overbite, enlarged tongue and tonsils, tissue that blocks the air-

way, obesity, alcohol use, medications, medical conditions, menopause, old age,

large neck size, and genetics (Chokroverty, 2000). Sleep apnea can have very seri-

ous effects. It causes insomnia, daytime sleepiness, impaired concentration, fa-

tigue, high blood pressure, increased stroke risk, decreased concentration,

cognitive problems, attention deficits, and higher risk for myocardial infarction

and other cardiac problems (Chokroverty, 2000; Piccone & Barth, 1983). The de-

generative process of aging results in anatomical and physiological changes in the

lungs. The airway becomes smaller due to changes in supportive tissues. Addi-

tionally, the elderly have smaller diameter bronchi, resulting in decreased air

passage. The lungs do not expand and contract as effectively as when young, and

individuals experience increased difficulty breathing (Avidan, 2005). Sleep apnea

is more serious in individuals who have underlying physical conditions such as

cardiac disorders, cerebrovascular problems, and metabolic disorders, all of

which are more common in the elderly (Lugaresi, 1993).

IRCADIAN

HYTHM

ISORDERS

Circadian rhythm sleep disorders are caused by disruption of the sleep-wake

cycle. Any lifestyle, psychological, or physical condition can disrupt this cycle.

For young adults, disruptions of normal sleep-wake cycles are most commonly

caused by jet lag and shift work. For the elderly, the most common causes are ill-

nesses, hospitalizations, physical discomfort, and daytime napping. Many com-

plain that they are not sleepy at night but are very sleepy at inappropriate times.

The elderly experience physical, social, and environmental changes and are more

susceptible to temporary changes in schedules and living conditions that can dis-

rupt normal sleep-wake cycles. Chronic disruption of normal cycles will result in

random sleep periods that further upset the cycle. Individuals are sleepy during

the day and early evenings, but not sleepy at bedtime (Billiard, 1993).

Sleep Disturbances 237

EUROLOGICAL AND

SYCHIATRIC

ONDITIONS

The elderly have high rates of depression, adjustment disorders, and anxiety. Old

age is a time of major life changes. Family members and friends have died, and

many feel lonely. Living situations can change drastically. Individuals may have

to leave the home in which they lived for many years and move to an assisted liv-

ing situation or a smaller, more manageable home. They may have to live with

family members because they are not able to care for themselves properly or can-

not financially afford to do so. Retirement can be traumatic. Retirees who have

spent their entire adult lives working suddenly have no reason to get up in the

mornings. Many may have been forced into retirement and suffer overwhelming

feelings of loss, decreased stimulation, loss of income and status, and feelings of

betrayal and rejection. Other conditions are social isolation, boredom, and inac-

tivity. Depression caused by both physical and social changes experienced by the

elderly is common. One of the primary symptoms of depression is disrupted sleep

with insomnia, frequent awakenings, and reduced quality of sleep (Ito et al.,

2000).

Alzheimer’s disease and dementia can also cause sleep disturbances in the el-

derly due to neurological deterioration. Dementia can be caused by other condi-

tions, but 70% of all dementias are caused by Alzheimer’s disease, a progressive

neurological condition that gradually destroys the brain. As the disease progresses

and destroys more of the brain, sleep patterns and circadian rhythms are dis-

turbed. Confusion, agitation, and aggression are common symptoms of middle-

stage Alzheimer’s. Alzheimer’s and dementia are characterized by quiet, restful

days and extreme agitation, restlessness, and delirium during the night (Hauri &

Linde, 1996; Morley, 1993).

Sleep disturbances in the elderly are more resistant to treatment than those in

younger adults; some can be so resistant that they are never resolved. However,

the elderly are not without options. There are strategies that can be used to fight

these frustrating and debilitating conditions.

UNIVERSAL MEASURES OF PREVENTION FOR

SLEEP DISTURBANCES

Sleep disturbances in the elderly may not be avoidable. However, there are strate-

gies that may help manage these problems.

LEEP

SSESSMENTS

It is very helpful for the elderly, or their caregivers, to complete detailed sleep

assessments. Sleep assessments and diaries should be as detailed as possible.

Individuals should write down all daily activities, food eaten, physical condi-

tions, medical treatments and medications taken, and a detailed description of

their moods and feelings for each day. For example, they should write down the

type of food they ate, the way the food was prepared, and the amount eaten

(Chokroverty, 2000; Dement & Vaughn, 1999). A careful assessment provides a

clear picture of the individual’s day, which is used to identify and analyze any

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problem areas. In addition, a detailed sleep diary or sleep log should be main-

tained for an entire 24-hour period, including awake periods. Sleep logs should

record hours of sleep, quality of sleep, number of nighttime awakenings, feelings

on awakening, when one feels tired and when one feels rested, and periods of in-

sufficient sleep. These two records can be combined and used to provide a clear il-

lustration of an individual’s day and can also be used to evaluate the improvement

or deterioration of conditions and treatments that affect sleep (Chokroverty, 2000;

Dement & Vaughan, 1999).

LEEP

YGIENE

Developing good sleep hygiene is very effective in aiding sleep for all adults, but

especially for the elderly. Sleep for the elderly can be elusive and easily dis-

rupted. Good sleep hygiene can help induce sleep, increase relaxation, and help

the elderly fall asleep. There are several strategies that can be used to improve

sleep hygiene. For the elderly these include improvement or maintenance of

health status by maintaining a healthy diet, compliance with their medical regi-

men, physical exercise approved by their physician, reduction of stress, continued

social interactions, and mental stimulation (Chokroverty, 2000; Hauri & Linde,

1996; Piccone & Barth, 1983). Additionally, the elderly should avoid napping un-

less they are ill because it reduces sleep debt and can disrupt circadian rhythms

(Dement & Vaughan, 1999; Piccone & Barth, 1983). Short rest periods may be

needed due to physical problems or to recover from exertion and exercise. How-

ever, rest periods should not be longer than necessary and sleep should be

avoided (Martin et al., 2000). Bedrooms should be pleasant, uncluttered, neat, and

clean. At night the room should be dark to enhance production of melatonin and

quiet to reduce external stimulation and prevent arousal. The temperature in the

room should be comfortable. Usually it is more conducive to sleep to have the

room slightly cooler than in the day (Piccone & Barth, 1983). It is important to

have good supportive and comfortable mattresses and pillows. It is especially im-

portant for the elderly to have a mattress that supports their body without caus-

ing pressure points that can lead to bed ulcers and skin breakdowns. It is

important that the elderly maintain a sleep ritual. A sleep ritual is a set routine

that individuals follow every night before they go to bed. It signals the body and

brain that they are preparing for sleep (Chokroverty, 2000; Piccone & Barth, 1983).

The elderly should engage in quiet time before they go to bed, such as watching

television, reading, or listening to music; this helps the brain and body to relax

and prepare for sleep. Any stimulating activities or conversations should be

avoided during this period (Hauri & Linde, 1996). It is even more important for

the elderly to have stimulating days with regular social contact to minimize isola-

tion, depression, and anxiety. Active lives also increase sleep debt and reduce the

tendency to nap.

SELECTIVE MEASURES FOR THE PREVENTION OF

SLEEP DISTURBANCES

Universal measures are generally effective in preventing sleep disturbances, but

older individuals may need to use more specific and aggressive preventive mea-

sures. Most elderly develop many of the conditions that are identified risk factors

Sleep Disturbances 239

for sleep disturbances. Neurological conditions such as restless leg syndrome

and periodic limb movements that are present in young adults increase in inten-

sity and frequency with age. Therefore, strategies should be more focused and

aggressive.

NSOMNIA

The easiest technique to prevent insomnia is to develop good sleep hygiene. If the

elderly are unable to follow these steps themselves they should enlist someone to

help ensure that their environment is conducive to sleep (Dement & Vaughan,

1999). The elderly benefit from stress reduction techniques such as gentle exer-

cises and stretches, deep breathing, meditation, warm baths, and massage, which

may also reduce pain and stiffness from conditions such as arthritis. It is espe-

cially important for the elderly to treat depression, which is a very common cause

of insomnia. They should obtain any needed psychiatric treatment, maintain

good social contacts, adequate exercise, and diet, and continue as many enjoyable

activities as possible (Dement & Vaughan, 1999; Ito et al., 2000).

LEEP

PNEA

Sleep apnea is very common in the elderly. They can use the same techniques that

are used by younger adults, which include maintaining normal weight, treating

sinus, throat, and respiratory problems, and avoiding tobacco, alcohol, and drugs

(Hauri & Linde, 1996). Surgical treatments to remove excess tissue and restruc-

ture the throat should be performed only if absolutely necessary. Surgery and

anesthesia always carry risks, and these risks are greatly increased for the elderly

(Chokroverty, 2000; Dement & Vaughan, 1999). Elderly persons have obtained en-

couraging results by using nasal continuous positive airway pressure (CPAP).

This method is a very effective and conservative treatment for sleep apnea. A

small mask is worn over the nose while sleeping; a machine connected to the

mask forces air into the throat while sleeping. This prevents the trachea from be-

coming flaccid and collapsing. However, careful evaluation and assessment for

the appropriateness of CPAP must be conducted by a physician. The CPAP is not a

cure and must be used properly every night, which necessitates training. Users

must understand the equipment, know how and why it is used, and be willing to

cooperate with treatments (Martin et al., 2000). Less drastic methods involve oral

appliances that push the jaw forward, holding the airway open. These devices do

reduce snoring and sleep apnea but are not as effective as the CPAP method. Oral

devices must also be prescribed by either a physician or a dentist and must be

properly fitted, which requires several office visits and can be very costly. These

devices must also be used nightly. Weight loss, reduction in alcohol intake, and

avoiding tranquilizers and narcotics are also effective in reducing sleep apnea

(Martin et al., 2000).

ESTLESS

YNDROME AND

ERIODIC

IMB

ISORDERS

Individuals who have these disorders in old age probably had them in milder

forms when they were younger. Although these conditions cannot be avoided,

their intensity and frequency can be reduced. Effective strategies include regular

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exercise, gentle stretching before bedtime, and walking during the day. The phys-

ical status of the elderly may necessitate that they take several short, slow walks

during the day instead of one long walk. Short, slow walks are effective in mini-

mizing restless leg syndrome and periodic limb disorders. However, any exercise

must be approved by their physician. Other strategies that help are massage,

warm baths, and heat/ice compresses (Hauri & Linde, 1996). New medications

have been shown to be effective in reducing periodic limb movements and rest-

less leg syndrome. These medications actually reduce the number of leg kicks

and movements during the night. Sedatives and hypnotics have been used in the

past; however, these medications do not actually reduce the movements, but

make arousal more difficult so the individuals do not awaken. As with all med-

ications, careful management and prescribing must be used with the elderly.

Medications must be taken correctly and may need supervision to prevent im-

proper use, accidental overdose, and interactions with other medications. A care-

ful medical assessment must be made by the physician to determine the

appropriateness of the medication and to supervise medication use, side effects,

and treatment outcomes (Martin et al., 2000).

EDICAL

, N

EUROLOGICAL

AND

SYCHIATRIC

ONDITIONS

To prevent sleep disturbances secondary to other conditions it is necessary to

treat the underlying condition. A thorough assessment by a physician is required

to determine any precursors or conditions that may be present. Because sleep dis-

turbances are secondary symptoms, treating the primary condition will resolve or

reduce sleep problems (Chokroverty, 2000; Hauri & Linde, 1996; Martin et al.,

2000). Medications and treatments to treat either the underlying conditions or the

secondary insomnia must be prescribed and carefully monitored by physicians.

Medications can improve sleep, but they can have serious side effects and drug

interactions. Medication ordered for the elderly to treat both the underlying con-

ditions and secondary sleep disturbances should be prescribed in the smallest

possible doses of the mildest medication. Additionally, care should be taken that

the elderly are not taking duplicate medications to treat the same conditions or

medications that will interact with medications for other conditions. The elderly

do not always take their medication reliably as prescribed by their physician.

Often they are confused about what they are taking and for what reasons. They

may ignore drug reactions or interactions, not tell their doctor, or even increase

the medication, thinking they feel ill because they are not taking enough. It is

helpful for the elderly to write down their medications, doses, and frequency as a

convenient tool. Nonmedical approaches may also be considered for the elderly,

including those listed earlier (Morgan, 1987).

IRCADIAN

HYTHM

ISTURBANCES

Circadian rhythms that regulate sleep-wake cycles are themselves regulated by

exposure to light. Circadian rhythm disturbances can be treated in a safe and

conservative manner by using light therapy. Light therapy involves a timed and

regulated exposure to light, either natural sunlight or sunlamp. Exposure to

light in the morning advances the sleep cycle so that individuals become sleepy

earlier in the evenings. This is helpful when individuals do not feel sleepy until

late in the night. Conversely, light therapy used in the early evening will delay

Sleep Disturbances 241

circadian rhythms, which delays sleepiness. This is useful for those individuals

who become sleepy too early in the evening. A problem for even healthy and ac-

tive elderly persons is that they usually have less exposure to sunlight in their

normal days. They tend to stay inside for longer periods of time, and physical

or psychiatric conditions and treatments can prevent individuals from spend-

ing time outdoors. Care should be taken when light therapy is used by the el-

derly. If the elderly are confused or forgetful, or otherwise unreliable, they

should be supervised during light therapy to avoid dangerous and painful

burns. Time spent in sunlight must also be monitored to avoid burns and skin

cancers (Billiard, 1993).

PRACTICE AND POLICY IMPLICATIONS

Sleep disturbances in the elderly can be devastating to their health and overall

physical, social, and psychological functioning. Professionals must become

knowledgeable about specific sleep disturbances and how they affect the elderly.

Additionally, the sensitive and fragile health status of the elderly must be under-

stood and accommodated. Appropriate measures must be recommended and re-

ferrals to a gerontologist must be made when necessary.

Even healthy older adults are more susceptible to the complications and nega-

tive effects of sleep problems. Working directly with the elderly and their care-

givers in helping them understand and manage sleep problems can be very

effective in resolving this devastating problem. While it may be necessary to refer

individuals to specialists in the field of gerontology, clinicians can teach the el-

derly about sleep disturbances and encourage them to maintain a lifestyle that

can minimize these problems. All treatments should be coordinated and inte-

grated into a treatment plan that addresses all of the problems and conditions as-

sociated with sleep problems, and the treatment plan should be incorporated into

individuals’ everyday lives. Professionals who work with the elderly must also

monitor treatments and medications to avoid dangerous complications and inter-

actions. Even if clinicians do not work in gerontology or sleep disturbances, they

must educate themselves so that their clients receive the highest level of care.

It may be necessary for the elderly to be evaluated by a sleep center for a defin-

itive diagnosis. Sophisticated and sensitive diagnosis identifies specific problems

and determines severity and intensity and suggests appropriate treatments.

However, this type of assessment is very expensive and can be upsetting for el-

derly who are depressed, anxious, and emotionally labile. With changes in insur-

ance and third-party payments, sleep studies and treatments may be

unaffordable for many elderly, especially if their only medical coverage is

Medicare. Professionals must support their patients through this process and

must frequently become advocates to obtain needed services. Careful detailed

records must be kept that describe the type of sleep disturbances and the effects

they have on the overall functioning and health of the elderly. This information

can be used to identify needs and craft effective and appropriate treatment ap-

proaches specifically designed for the elderly.

FUTURE DIRECTIONS

Even after decades of sleep research, there is much to discover about sleep. How-

ever, many discoveries have led to improvement, control, and even prevention of

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sleep disorders. As the field of gerontology continues to improve services and

treatments for the elderly, help for sleep disorders will also be discovered. Knowl-

edge of how normal aging interacts with physical and psychiatric conditions in

the elderly will aid in the development of effective and safe measures that specif-

ically target sleep disorders in this age group. It is documented that sleep distur-

bances increase with age and sleep problems are frequently secondary problems

related to illness and normal aging. This makes sleep disturbances in the elderly

difficult and complicated to both prevent and treat. The devastating health and

psychological risk of sleep disorders and the precarious health status of the el-

derly make the prevention of sleep disorders a priority.

CONCLUSION

As this chapter illustrates, the elderly have many of the same sleep disturbances

as younger adults, but their age changes the focus and type of recommended

treatments. They also experience conditions specific to their age group. The el-

derly have many changes in their physical and emotional status which can cause

or exacerbate sleep problems. Treating sleep disturbances in this age group is

complicated and delicate and requires careful assessment and treatment. Sleep

disturbances can be devastating to the fragile health status and social function-

ing of this population and can rob the elderly of the opportunity to experience

satisfying and enjoyable lives.

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244

CHAPTER 10

Sexuality and Intimacy

LINDA J. BROCK and GLEN JENNINGS

EXUALITY IN THE

human is more than biology and reproduction. Whether or

not sexuality is expressed with the genitals, with or without partners, it is

central to human identity and is essential to wholeness in the life experi-

ence. Sexuality includes gender identity and gender roles, attractions and desires,

and sexual behaviors. Yet it also is reflected in sensuality, body image, and sense

of attractiveness. How a person dresses and moves is an expression of her or his

sexuality. Sexuality can be experienced alone through such actions as bathing,

grooming, and application of cosmetics, as well as through genital self-

pleasuring. Sexuality with a partner can be expressed through touching, talking,

eye contact, flirting, kissing, holding hands, sharing erotic poetry, dancing, hug-

ging, cuddling, acts of care and kindness, and the giving of gifts, as well as

through genital contact. Sexuality includes, perhaps most important, the unique

experience of intimacy and love, the creation of a profound connection with an-

other human while being acutely aware of one’s own sense of wholeness as a sep-

arate person.

Each individual’s sexuality is constantly shaped by personal experiences and

societal messages that become attitudes and beliefs, in turn influencing sexual

behavior. Much of sexuality is socially constructed, influenced by culture, time,

place, relationships, and the human need to create meaning, individually and as

a group. Sexuality and the sexual scripts through which individuals act out their

sexuality (Gagnon, 1977; Mahay, Laumann, & Michaels, 2001) emerge from the

confluence of biology, psychology, sociology, ethnicity and culture, religion and

spirituality. Each individual brings these and other elements to bear in differing

combinations and varying ways across his or her life course. Such a broad and

deep definition of sexuality applies to the very end of life and is the assumption

behind this chapter.

Older persons, individuals in later life age 60 and older, constitute a category

spanning more than 40 years, based on life spans that can and do reach 100 years.

It is essential to keep in mind the many differences of this group: birth cohort,

life experiences, ethnicity, socioeconomic level, sexual orientation, health status,

relationship status, and educational level, to name a few (Gott, 2003). Some older

Sexuality and Intimacy 245

persons are frail, dependent nursing home residents; others are active commu-

nity members, working at the peak of their careers. Some live alone after the loss

of a mate; some enjoy stable, committed relationships; and others engage in fre-

quent dating with a variety of partners. Some live in exclusive retirement commu-

nities, traveling and enjoying sports and other leisure activities. Some live on the

edge financially, staying with adult children or other relatives. Older persons

may have university degrees or have dropped out of high school; may have

chronic illnesses, physical or mental disabilities, or be in excellent health. Older

persons may have immigrated, bringing values and meanings from a different

land or, although born here, be a part of the hundreds of different cultures that

make up American society. Older persons are heterosexual, bisexual, gay, lesbian,

transgendered, and intersexed. Generalizing about sexuality and older persons

should be undertaken with great caution.

The study of sexuality and older persons is a largely unexplored and still de-

veloping field (Gott & Hinchliff, 2003). For example, the well-known study of sex-

ual behavior conducted by Laumann, Gagnon, Michael, and Michaels (1994)

interviewed only participants 18 to 59 years of age, excluding older adults en-

tirely. Differences in definitions of both sexuality and older persons, as well as a

variety of often unaddressed confounding variables such as those mentioned ear-

lier, make comparison of the available studies difficult. Much of the available re-

search also tends to privilege (hetero) sexual intercourse as a measure of sexual

activity and legal marriage as a measure of relationship, overlooking other be-

haviors and relationship arrangements. Many studies take a problem-centered

approach to sexuality during later life that misses the opportunity to report pos-

itive information about the sexual lives of people 60 and over. In addition, much

available research focuses more on biological and health-related issues than on a

psychosocial and systemic relational perspective. In this chapter, a strength-

based, positive approach open to the richness of diversity both in individuals and

relationships is used as a lens through which to view the sexuality and intimacy

of older persons.

WHAT WE THINK WE KNOW

Despite the lack of a broad and deep body of empirical data, most societies have

developed beliefs and attitudes about older persons and sexuality. Common as-

sumptions exist across many of the world’s societies that older persons do not,

cannot, or should not engage in sex (Global Study of Sexual Attitudes and Behav-

iors, 2002). The widespread assumption of a sexless old age (Kellett, 2000) is fa-

miliar to those who work with the elderly. Older persons themselves across past

decades have also been well acquainted with the idea that their expression of sex-

uality is not acceptable. Some have internalized this traditional taboo; many oth-

ers may have disagreed but been unwilling to resist it openly (Brock & Jennings,

1999). The stereotype of the sexless older person continues to influence public

policy as well as research agendas (Gott & Hinchliff, 2003).

The limited information available on the sexuality of older persons indicates

changes in, rather than cessation of, sexual activity and sexual desire in later life

(Brecher, 1984; Budd, 1999; DeLamater & Sill, 2005; Dunn & Cutler, 2000). Psy-

chological and social influences on sexuality are especially neglected in research.

When these influences are taken into account, the availability of a partner, health