Introduction
From the wealth of available sleep aids that are heavily marketed to older adults, the impression is that a good night’s sleep diminishes with age and medicinal or herbal sleep aids are essential. The truth is that aging per se has little negative impact on sleep1. However, there are many factors, related and unrelated to aging, that may perturb sleep and hinder one to sleep better. This blog is about modifiable factors making sleep better.
Sleep Complaints
Several recent reviews on sleep in the older adult report that a high percentage (up to nearly 50%) of older adults have sleep complains relating to difficulty falling asleep and staying asleep2-4. Significantly, delving deeper reveals that poor health and associated issues, not age per se, is the main driver of sleep complaints. In fact, sleep problems fell to 18% when factors such as “poorer self-rated health, elevated depressive symptomatology and increasing number of physical disabilities, respiratory symptoms and nonprescription medication …. and use of prescription medication” were accounted for5.
Notably, many of these complaint-related factors are, in fact, modifiable. Importantly, when removed or mitigated, various aspects of sleep improve such as time to fall asleep, duration of quality sleep, fewer interruptions, feeling rested the next morning. The modifiable factors making sleep better that need evaluation and change are:
1. Diseases/disorders not adequately treated such as cardiopulmonary diseases (conditions that affect normal breathing), gastric reflux disorder (gastric contents enters esophagus causing chest pain) and chronic pain (such as osteoarthritic pain)
2. Prescription medications known to negatively affect sleep e.g. beta blockers (anti-hypertensives), bronchodilators (generally for chronic obstructive pulmonary disease), antidepressants (anxiety/depression)
3. Use of sleep aids: prescription or over-the-counter (OTC)
4. Behavioral factors: poor sleep hygiene, daytime napping, excessive use of alcohol and caffeine
5. Life style choice: reduced physical activity
Therefore, there is scientific evidence to support the aforementioned factors as sleep disruptors and additional evidence suggesting a way toward better sleep.
Diseases/disorders
# 1 – Related to certain diseases/disorders. Probably the most difficult to quickly resolve are sleep issues relating to specific medical conditions. The top three sleep disrupters are diseases affecting adequate breathing, reflux of gastric contents and conditions producing chronic pain. Clearly, these are prominent factors that affect sleep in many way. Specifically, a resolution comes with discussion between patient and doctor to prescribe therapies that promote better breathing, quiescent gastrointestinal tract and no pain with therapies that also promote restful sleep. Such therapies, pharmacological and non pharmacological exist6-8.
Prescription Medications – Modifiable Factor making sleep better
# 2 – Several prescription medications stand out as enablers of poor sleep. Specifically, the drugs in the class of beta-blockers e.g. Lopressor® are able to reduce effects of melatonin, the natural sleep hormone, disrupting sleep9. Also, antidepressants e.g. Prozac®, Pristiq® elevate the levels of neurotransmitters, serotonin and norepinephrine to stimulate the brain and alter sleep10. Additionally, bronchodilators e.g. Proair® if taken too close to bedtime will produce a stimulatory effect as well11. Importantly, drugs from other classes with difference mechanisms of action are available to lower blood pressure, relieve depression and assist with breathing to aid with sleep. However, as with #1 modifiable factor, physician-patient discussion is essential to put these changes into effect.
Sleep Aids – Modifiable Factor making sleep better
#3a – Prescription Sleep Aids to Avoid. The benzodiazepine class of drugs (examples: Xanax®, Valium®, Librium®) and are widely prescribed as sleep aids12. Many reviews report only a modest effect on sleep coupled with a great potential for dependence, both physiological and psychological12. Thus, these drugs are contraindicated in the older adult because they increase the risk of falls, daytime sedation, memory concerns and car accidents. Hence, physician-directed slow benzodiazepine withdrawal is highly recommended for those already taking benzodiazepines13. Another class called Z-drugs e.g. Lunesta®, Sonata®, Ambien® have similar problems as the benzodiazepines and additionally may cause complex sleep behaviors resulting in sleep walking or other unusual behavior that may cause injury (FDA.gov)
A third class is the barbiturates e.g. Fiorina®, Pentothal®, Seconal®, although used less frequently, nevertheless, these drugs are still prescribed as sleep aids. For the older adult, barbiturates are considered potentially inappropriate medications (PIMS). A panel of experts with a thorough review of the literature has made this recommendation14. This is based on evidence of eventual tolerance to sleep, physical dependence and risk of overdose.
OTC Drugs
3b. OTC drugs for sleep to avoid. The list of OTC sleep aids is extensive. Those marketed for this reasons include OTC drugs and OTC dietary supplements. Among the OTC drugs are the antihistamines, diphenhydramine hydrochloride (Benedryl®, ZzzQuil®, Simply Sleep®), and doxylamine succinate (Unisom®). OTC drug must show safety and efficacy sufficient for FDA approval. However, for the older adult, antihistamines are considered potentially inappropriate medications14. Antihistamines cause sedation, dry mouth, blurred vision, urinary retention, constipation, confusion, increased heart rate, heat intolerance, hallucinations. These effects are harmful in themselves and are additive to many other medications leading to serious adverse drug reactions. Antihistamines as sleep aids should be avoided.
3c. OTC dietary supplements to avoid. The second group of OTC sleep aids are classified as dietary supplements. They include products such as melatonin, St. Johns Wort, valerian, L-tryptophan. As indicated in the preceding blog (Turmeric) dietary supplements are not regulated in the same manner as OTC drugs. Thus, dietary supplements marketed as sleep aids have not been tested clinically for safety and efficacy15. Reports of published clinical trials on these dietary supplements used proprietary preparations or prescription drugs (as in the case of melatonin). Thus “tested” products are products are not available OTC. The reader can find study details on melatonin and St John’s Wort in my upcoming book coauthored with Dr. Patricia Brown-O’Hara, Drug Use in the Older Adult – A Guide for Nurses, other Practicing Clinicians and Interested Older Individuals.
Behavior – Modifiable Factor making sleep better
#4- Behavioral Changes. Cognitive Behavioral Therapy (CBT) is the gold standard for therapy of insomnia and other diagnosed sleep disorders that exceed the level of sleep complaints. However, aspects of CBT can be practiced effectively to enhance sleep. In the category of sleep hygiene, effective changes include: use the bed for sleep not for work or iphone/ipad perusing, use the bed only when sleepy and if not sleepy, get up for a period of 20-30 minutes and repeat if necessary; get up at the same time each day (use an alarm clock if necessary), establish regular sleeping hours16. Other behavioral changes are to avoid daytime napping11, and avoid elevated consumption of alcohol17, caffeine17, smoking and large meals 2 hours before bed time.
Lifestyle
# 5 – Lifestyle Choice. In addition to behavioral changes, lifestyle changes have become important. One focus is on physical activity. Results of one study in older women (360, one week assessment) showed a positive relation between moderate-vigorous physical activity plus time spent outdoors with longer sleep duration18. A 12 month study with fewer older adults (55+ years, 36 in exercise and 30 controls) performing moderate-intensity endurance exercise (5 days/week; 60 minute sessions, aerobics, resistance, stretch and balance) exhibited reduce sleep latency, reduced number of awakenings and overall feeling of being more rested19. A third study assessed with questionnaires concluded that moderate low-intensity exercise was a significant factor in preventing insomnia 20. While a serious exercise program offers many health benefits (Insight 3 Insight 4), larger clinical trials are needed to rigorously support moderate-intensity exercise as effective in reducing all sleep complaints. For more discussion, check http://sleepwellns.ca/; http://thesleepreset.com; http://lp.stellarsleep.com.
Conclusions
It is unrealistic to blame poor sleep on growing older. Sleep complaints can be minimized or eliminated with review of the modifiable factors making sleep better. These are inadequately treated diseases/disorders, certain prescription drugs, sleep aids (prescription and OTC products), poor sleep hygiene and reduced physical activity.
References
1. Ohayon MM, Carskadon MA, Guilleminault C, Vitiello MV. Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: Developing normative sleep values across the human lifespan. Sleep. 2004;27:1255–1273.
2. Miner B, Kryger MH. Sleep in the Aging Population. Miner B, Kryger MH.Sleep Med Clin. 2017 Mar;12(1):31-38.
3. Stephan Y, Sutin AR, Bayard S, Terracciano A. Subjective age and sleep in middle-aged and older adults. .Psychol Health. 2017 Sep;32(9):1140-1151.
4. Min Y, Nadpara PA, Slattum PW. The association between sleep problems, sleep medication use, and falls in community-dwelling older adults: results from the health and retirement study 2010. J Aging Res. 2016;2016:3685789.
5. Foley DJ, Monjan AA, Brown SL et al. Sleep complaints among elderly persons: An epidemiologic study of three communities. Sleep. 1995;18:425–432
6. Pain Haack M, Simpson N, Sethna N et al. Sleep deficiency and chronic pain: potential underlying mechanisms and clinical implications. .Neuropsychopharmacology. 2020 Jan;45(1):205-216.
7. Shaheen NJ, Madanick RD, Alattar M et al. Gastroesophageal reflux disease as an etiology of sleep disturbance in subjects with insomnia and minimal reflux symptoms: a pilot study of prevalence and response to therapy. Dig Dis Sci. 2008 Jun;53(6):1493-9
8. Sharafkhaneh A, Jayaraman G, Kaleekal T et al. Sleep disorders and their management in patients with COPD. Ther Adv Respir Dis. 2009 Dec;3(6):309-18
9. Mayeda A, Mannon S, Hofstetter J et al. Effects of indirect light and propranolol on melatonin levels in normal human subjects. .Psychiatry Res. 1998 Oct 19;81(1):9-17
10. Wichniak et al., Effects of Antidepressants on Sleep Curr Psychiatry Rep. 2017 Aug 9;19(9):63.
11. Tatineny P, Shafi F, Gohar A, Bhat A. Sleep in the Elderly. Mo Med. 2020 Sep-Oct;117(5):490-495
More References
12. Holbrook AM, Crowther R, Lotter A et al. Meta-analysis of benzodiazepine use in the treatment of insomnia. CMAJ 2000;162(2):225-33
13. Pottie K, Thompson W, Davies S, et al. Deprescribing benzodiazepine receptor agonists: evidence-based clinical practice guideline. Can Fam Physician 2018; 64(5):339–351
14. By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023 Jul;71(7):2052-2081.
15. Culpepper L, Wingertzahn MA. Over-the-Counter Agents for the Treatment of Occasional Disturbed Sleep or Transient Insomnia: A Systematic Review of Efficacy and Safety. Prim Care Companion CNS Disord. 2015 Dec 31;17(6):10.4088/PCC.15r01798.
16. Sejbuk M, Mirończuk-Chodakowska I, Witkowska AM. Sleep Quality: A Narrative Review on Nutrition, Stimulants, and Physical Activity as Important Factors. Nutrients. 2022 May 2;14(9):1912.18.
17. Thakkar MM, Sharma R, Sahota P. Alcohol disrupts sleep homeostasis. .Alcohol. 2015 Jun;49(4):299-310. 18. Gardiner C, Weakley J, Burke LM, et al. The effect of caffeine on subsequent sleep: A systematic review and meta-analysis. Sleep Med Rev. 2023 Jun;69:101764.
18. Murray K, Godbole S, Natarajan L, et al. The relations between sleep, time of physical activity, and time outdoors among adult women. PLoS ONE. 2017;12:e0182013
19. King AC, Pruitt LA, Woo S, et al. Effects of moderate-intensity exercise on polysomnographic and subjective sleep quality in older adults with mild to moderate sleep complaints. J Gerontol A Biol Sci Med Sci. 2008;63:997–1004.
20. Tsunoda K, Kitano N, Kai Y et al. Prospective study of physical activity and sleep in middle-aged and older adults. Am. J. Prev. Med. 2015;48:662–673.