Healthy Living magazine gathered three Eisenhower Medical Center physicians to discuss insomnia and sleep disorders in the elderly and to dispel some myths about what works and doesn’t work with regard to sleep problems. The participants were Board Certified Neurologist Reza Nazemi, MD, Eisenhower’s Section Chief of Neurology, Mohammad Mojarad, MD, Board Certified Pulmonologist, and Philip Shaver, MD, a Board Certified Cardiologist who served as moderator.
DR. SHAVER: Dr.Nazemi, there are a number of neurological disorders that can lead to insomnia. Would you discuss some of these?
DR. NAZEMI: There are many physical conditions that can cause insomnia, as well as psychological disorders that contribute to insomnia in older people. As far as the neurological conditions are concerned, a very distinct one that occurs in patients with dementia, mostly patients with Alzheimer’s disease, is called Sundown phenomena. These are patients who become extremely agitated, restless, confused, combative, and unmanageable late in the afternoon or evening.
DR. SHAVER: What can be done?
DR. NAZEMI: There is a misunderstanding that sleeping pills may help this situation, but in most cases, they don’t. Restraining is usually counterproductive. Anti-psychotic medications may help. It may also help to get the patient involved in some kind of activity with exposure to bright light. Sometimes, giving the patient stimulant drugs in the morning works much better than sedating them at night. For example, taking Provigil® in the morning may help promote alertness, which may allow these patients to fall asleep later at night. MYTH Insomnia in the elderly is normal.
DR. SHAVER: What can you tell us about restless legs syndrome?
DR. NAZEMI: Restless legs syndrome is one of the leading causes of insomnia. Our patients describe an irresistible feeling like crawling, cramping, or itching that forces them to move their legs.
DR. SHAVER: There is the thought that some patients may respond to iron therapy.
DR. NAZEMI: It has been known that restless legs syndrome could be due to iron deficiency anemia. The iron deficiency may not be detectable as a serum iron, but is better detected by a blood test called a serum feritin since the iron deficiency is in the cerebral spinal fluid.
DR. SHAVER: Parkinson’s patients often suffer from restless legs syndrome.
DR. NAZEMI: Yes. Parkinson’s medications are very effective on restless legs syndrome, and are now helping the majority of patients who are suffering from this.
FACT As we age, deep sleep changes to a more superficial sleep.
DR. MOJARAD: Patients with sleep disorders can have movements of all of the limbs including the legs.
DR. SHAVER: So everybody who kicks at night doesn’t have restless legs syndrome?
DR. MOJARAD: Correct. It’s a relatively normal phenomenon.
DR. NAZEMI: In dealing with restless legs syndrome, the first step is to make an accurate diagnosis. In severe cases, clinical description by the patient or the family would be adequate. However, sleep studies usually confirm the condition. It is the responsibility of the physician to accurately diagnose, and to exclude various conditions which may cause excessive leg movements, such as neuropathy, lumbar nerve root impingement, Parkinson’s disease, iron deficiency, etc.
MYTH As we age, we need less sleep.
DR. MOJARAD: Good sleep habits are also important. In general, the bedroom should not be used for watching TV or reading books. It’s better to use the living room for watching TV or reading. When you’re ready to go to sleep, go to the bedroom.
DR. SHAVER: There are ten basic rules for a good night’s sleep:
- Sleep only as much as you need to feel rested.
- Keep a regular sleep schedule. Get up at the same time everyday.
- Avoid forcing sleep. Go in another room.Watch something relaxing.When you’re sleepy, go back to bed. If you’re still awake 20 minutes later, get up again. Repeat, until you fall to sleep.
- Exercise regularly, but not 4 to 6 hours before bedtime.
- Avoid caffeine beverages after lunch.
- Avoid alcohol near bedtime.
- Avoid nicotine near bedtime.
- Don’t go to bed hungry.
- Adjust the bedroom environment. If you have to get up, don’t turn on the bathroom light. Use a night light.
- Don’t bring your worries to bed.
Let’s discuss hypnotics. Hypnotics are drugs that help us go to sleep. I see a trend that concerns me — more and more older patients are using Ativan® to fall asleep which has a very long half-life. There is a real risk of falling when they get up at night and drowsiness the next day.
FACT Sleep efficiency does decrease with age.
DR. MOJARAD: Experts agree that the more you use these kinds of medications at night, the more you believe you can’t sleep without them. I prefer to see if we can change the patient’s pattern of sleep by changing their lifestyle a little without using a medication.
DR. SHAVER: There is a class of hypnotic drugs known as Ambien®, Sonata®, and Lunesta®. Ambien and Sonata are approved for 35 days. Lunesta is approved for chronic therapy. Interestingly, these drugs have a different onset and duration and must be tailored to the patient’s sleep problem. How about antihistamines like Benadryl® which is the primary ingredient in Tylenol® PM?
DR. MOJARAD: They were not made for insomnia. They’re long lasting and stay in your system, making you drowsy the next day.
DR. SHAVER: Let’s discuss insomnia as it relates to other medical problems.
DR. NAZEMI: There are many reasons for sleep problems including neurological disorders, cardiac disease, congestive heart failure, respiratory diseases, emphysema, asthma, gastrointestinal problems, muscular and skeletal disorder, chronic pain, and urological disorders.
DR. SHAVER: It is very common to see insomnia in depression.
DR. NAZEMI: Medication is another important factor. Cardiac and pulmonary medications, bronchodilators, stimulants, antidepressants can make it difficult to sleep.
FACT As we age, our biorhythms change. Our core body temperature starts decreasing earlier in the day, which leads to sleep.
DR. MOJARAD: Also, sleep apnea (cessation of breathing during sleep) can make several medical conditions worse, including diabetes, high blood pressure, obesity and coronary artery disease.
DR. SHAVER: There are a lot of heavy snorers who don’t have sleep apnea. How can we decide who is likely to have sleep apnea?
DR. MOJARAD: Snoring by itself is not a sign of sleep apnea. But, if you add snoring to conditions such as obesity or hypertension, then sleep apnea will be more likely.
DR. SHAVER: What options do you offer these patients?
DR. MOJARAD: The diagnosis of sleep apnea is made in the sleep lab. We look at the pattern of sleep using the electroencephalogram, the pattern of the breathing, air flow measurements, and movement of the chest, abdomen, legs and jaw muscle contractions. If sleep apnea occurred, we can determine whether it was due to obstruction of the upper airway, which is the most common form of sleep apnea, or it was due to a lack of a command from the brain to breathe. When the diagnosis of sleep apnea is made, we must determine the severity. We can evaluate the number of times the upper airway obstructs per hour and sleep is interrupted. The most common type of treatment may be either CPAP, or less commonly, surgical treatment. Oral appliances may also be used for less severe conditions.
DR. SHAVER: What do you mean by CPAP?
MYTH An afternoon nap won’t interfere with falling asleep at night.
DR. MOJARAD: CPAP means continuous positive airway pressure delivered by a mask that gives a continuous flow of air through the nose or the mouth. This will prevent collapse of the throat areas keeping the upper airway open. Unfortunately, about 50 percent of patients cannot tolerate CPAP. We encourage them to try different types of masks to find the most comfortable one. We suggest trying the appropriate mask for at least a week or two to acclimate to the pressure and discomfort. If the sleep apnea is severe, we may recommend a surgical option. This is usually an extensive procedure, but can be effective. All of this expertise is available at Eisenhower Medical Center.
FACT Any medical condition can potentially cause insomnia.
DR. SHAVER: How about weight loss?
DR. MOJARD: Weight loss is effective, and a significant number of patients with adequate weight loss may experience desirable outcomes.
DR. SHAVER: How about oral appliances in these patients?
DR. MOJARAD: Oral appliances are useful in patients who do not have severe sleep apnea. These devices bring the lower jaw forward to increase the size of the upper airway in the throat.
DR. NAZEMI: There’s a very interesting phenomenon that we’re seeing, especially when we do the polysomnogram sleep studies. Many patients experience sleep apnea or louder snoring while they are lying on their back. Sewing a tennis ball in a pocket on the back of the sleeping garment may deter the patient from lying on his back. There are also commercially available T-shirts with a pocket in the back that can hold a tennis ball.
FACT Exposure to light, in the late afternoon or early evening, helps re-establish your internal clock, so that you can fall asleep later in the evening.
DR. MOJARAD: One final comment. People who suspect that they have sleep apnea by feeling sleepy during the daytime should be very careful driving. Fatal car accidents as a result of sleep apnea have occurred. Please avoid placing yourself or others in danger by driving or operating machinery if you have this condition. It’s important to seek medical attention to confirm whether or not you have a sleeping disorder.
DR. SHAVER: It is never normal, at any age, to fall asleep involuntarily when you should be awake.
DR. NAZEMI:I think a very keen physician should ask all of these questions: “How do you sleep?” “Do you feel drowsy?” “Do you snore?” “Do you kick?” First, we have to heighten the physician awareness of sleep disorders, and then make the community aware that there is help here.
RECOMMENDED WEB SITES
National Sleep Foundation: www.sleepfoundation.org, and www.drowsydriving.org Society for Light Treatment and Biologic Rhythms: www.sltbr.org American Sleep Apnea Association: www.sleepapnea.org Restless Legs Syndrome Foundation: www.rls.org