The older we get, the harder it seems to be to get a good night’s sleep.
Whether it’s back pain, sleep apnea, or needing to use the bathroom, nights seem to last longer than they used to, with more interruptions and less time down for the duration.
At the same time, sleeping pills, like most medications, become more dangerous after 60. As liver and kidney functions slow, drugs stay in the body’s system longer, meaning more groggy mornings with all the related risks of falls.
In one 2005 paper, for instance, researchers from the University of Toronto found that sleeping pills helped people over 60 sleep a little better compared to a placebo. But that improvement came with nearly 5 times the number of cognitive problems, 2½ times more physical problems, and nearly 4 times more daytime fatigue. On balance, the study concluded that, “in people over 60, the benefits of these drugs may not justify the increased risk.”
But that doesn’t mean people are sentenced to counting sheep for the remainder of their lives.
“I can almost promise people that they’re going to be sleeping better,” said Dr. John W. Winkelman, chief of the sleep disorders clinical research program at Massachusetts General Hospital, and an associate professor of psychiatry at Harvard Medical School.
Maybe they won’t be sleeping a full eight hours when he is done, but they’ll get more shut-eye than they are now, Winkelman said. “That’s why being a sleep doctor is so great: There are so many ways I can help people sleep.”
The need for sleep does not decline in a straight line as we age, said Michael V. Vitiello, a professor of psychiatry and behavioral science, gerontology and geriatrics, and biobehavioral nursing at the University of Washington. The biggest fall-off, he said, is from the teens through age 60. After that, the need for sleep stays pretty stable.
“In the past, we assumed it was a never-ending decline,” Vitiello said. But when researchers factored out health problems and just looked at people aging in good health, they realized that “the changes in sleep that occur from 60-90 are not that great.”
Technically, insomnia is defined as a lack of sleep that interferes with daily life at least three nights a week for three months. Roughly half of Americans over 60 meet these criteria.
Researchers used to think that insomnia was caused by another condition like depression, and doctors had to resolve the depression to improve the insomnia. But now, insomnia is considered a problem in its own right, and treating both the insomnia and the depression will lead to better outcomes than one alone, Winkelman said.
Sleep doesn’t just happen — it has to be made, researchers now realize. People with sleep issues either have trouble making sleep or suppressing their wake system, Winkelman said. “There’s some evidence that people with insomnia make the sleep, but don’t suppress the wake.”
Untreated, insomnia can be dangerous. Sleep problems have been linked to higher rates of depression, suicide, addictions, and congestive heart failure, as well as cognitive problems like Alzheimer’s.
Some people unwittingly make sleep harder for themselves, Winkelman said. Drinking alcohol can disrupt sleep, as can using electronic devices in the evening, drinking coffee after lunch, falling asleep on the couch after dinner, or exercising too late in the day or not at all.
Sleep doesn’t just happen — it has to be made, researchers now realize. People with sleep issues either have trouble making sleep or suppressing their wake system.
Addressing untreated medical problems, such as restless leg syndrome and sleep apnea can also improve sleep.
Behavioral modification can be just as or more effective than medications without the side effects, said Vitiello, a psychologist.
Cognitive behavioral therapy for insomnia (CBT-I) is a six- or eight-week course that teaches people about their sleep habits and what interferes with good sleep, he said. Participants are also taught relaxation exercises and how to adjust their time in bed to their actual sleep schedule, so they are not lying in bed awake for hours. “It gets you to sleep sooner and in a more consolidated fashion,” Vitiello said.
CBT-I has been shown to work as well for people in their 60s as for younger adults, and Vitiello said he has treated people with it well into their 90s.
It can also help with depression, and possibly pain and PTSD. Research is now focusing on ways to deliver the same benefits more simply and in less time, he said, including online programs.
Medication should be a last choice, after trying other approaches, said Dr. Suzanne Bertisch, a sleep medicine specialist at Beth Israel Deaconess Medical Center. In a study published earlier this year, Bertisch and Winkelman showed that 5 percent of people over age 80 take some kind of medication to help them sleep.
More than half of those who took sleep aids used more than one medication and 10 percent used three or more, putting them at risk for medication interactions. Sometimes people start medications in their 40s and are still taking them 20 years later, without realizing that the side effects may change, she said.
Bertisch said she takes a lot of new patients off sleep medications prescribed by internists or family doctors — who don’t have the time she does to delve into the causes of sleep problems. And when she prescribes drugs herself, she said she reevaluates that decision regularly. “I want to see improvement or I start weaning them off the medication,” she said. But pills still have a place among treatments, Winkelman said. Telling people who can’t sleep that they shouldn’t take medication can be paralyzing, he said. “It really leaves them helpless and I don’t think that’s a position we want to leave people in.”