From nytimes.com
Insomnia is like a thief in the night, robbing millions — especially those older than 60 — of much-needed restorative sleep. As the king laments in Shakespeare’s “Henry IV, Part 2”: O sleep, O gentle sleep, Nature’s soft nurse, how have I frightened thee. That thou no more will weigh my eyelids down, And steep my senses in forgetfulness?
The causes of insomnia are many, and they increase in number and severity as people age. Yet the problem is often overlooked during routine check-ups, which not only diminishes the quality of an older person’s life but may also cause or aggravate physical and emotional disorders, including symptoms of cognitive loss.
Most everyone experiences episodic insomnia, a night during which the body seems to have forgotten how to sleep a requisite number of hours, if at all. As distressing as that may seem at the time, it pales in comparison to the effects on people for whom insomnia — difficulty falling asleep, staying asleep or awakening much too early — is a nightly affair.
A survey done in 1995 by researchers at the National Institute on Aging among more than 9,000 people aged 65 and older living in three communities revealed that 28 percent had problems falling asleep and 42 percent reported difficulty with both falling asleep and staying asleep. The numbers affected are likely to be much larger now that millions spend their pre-sleep hours looking at electronic screens that can disrupt the body’s biological rhythms.
Insomnia, Dr. Alon Y. Avidan says, “is a symptom, not a diagnosis” that can be a clue to an underlying and often treatable health problem and, when it persists, should be taken seriously. Dr. Avidan is director of the sleep clinic at the University of California, Los Angeles, David Geffen School of Medicine.
So-called transient insomnia that lasts less than a month may result from a temporary problem at work or an acute illness; short-term insomnia lasting one to six months may stem from a personal financial crisis or loss of a loved one. Several months of insomnia are distressing enough, but when insomnia becomes chronic, lasting six months or longer, it can wreak serious physical, emotional and social havoc.
In addition to excessive daytime sleepiness, which can be dangerous in and of itself, Dr. Avidan reports that chronic insomnia “may result in disturbed intellect, impaired cognition, confusion, psychomotor retardation, or increased risk for injury.” Understandably, it is often accompanied by depression either as a cause or result of persistent insomnia. Untreated insomnia also increases the risk of falls and fractures, a study of nursing home residents showed.
There are two types of insomnia. One, called primary insomnia, results from a problem that occurs only or mainly during sleep, like obstructive sleep apnea, restless leg syndrome (which afflicts 15 to 20 percent of older adults), periodic limb movements or a tendency to act out one’s dreams physically, which can be an early warning sign of Parkinson’s disease.
Unless noted by their bed partners, people with primary sleep disorders may not know why their sleep is disrupted. An accurate diagnosis often requires a professional sleep study: spending a night or two in a sleep lab hooked up to instruments that record respiration, heart rate, blood pressure, bodily movements and time spent in the various stages of sleep.
The other, more common type of insomnia is secondary to an underlying medical or psychiatric problem; the side effects of medications; behavioural factors like ill-timed exposure to caffeine, alcohol or nicotine or daytime naps; or environmental disturbances like jet lag or excessive noise or light — especially the blue light from an electronic device — in the bedroom.
Among the many medical conditions that can cause insomnia are heart failure, gastroesophageal reflux (GERD), lung disease, arthritis, Alzheimer’s disease and incontinence. Treating the underlying condition, if possible, often relieves the insomnia.
Regardless of the reason for insomnia, it can become a learned response when people anticipate having difficulty falling asleep or returning to sleep after middle-of-the-night awakenings. They may spend hours lying awake in bed worrying about being unable to sleep, and the anxiety itself impairs their ability to sleep.
The more one frets about a sleep problem, the worse it can get. When on occasion I awaken in the wee hours of the morning and can’t get back to sleep, I usually get up and do something useful, which takes the curse off my insomnia. If I’m worried about forgetting something important, I write it on a pad kept next to the bed, taking care not to turn on a light. (Bright light in the middle of the night can reset your biological clock; if you get up to use the bathroom, use a night light near the floor.)
Nonmedical causes of insomnia are often successfully treated by practicing “good sleep hygiene,” a concept developed by the late Peter J. Hauri, a sleep specialist at the Mayo Clinic. That means limiting naps to less than 30 minutes a day, preferably early in the afternoon; avoiding stimulants and sedatives; avoiding heavy meals and minimizing liquids within two to three hours of bedtime; getting moderate exercise daily, preferably in the morning or early afternoon; maximizing exposure to bright light during the day and minimizing it at night; creating comfortable sleep conditions; and going to bed only when you feel sleepy.
If you still can’t fall asleep within about 20 minutes in bed, experts recommend leaving the bedroom and doing something relaxing, like reading a book (one printed on paper, not on a brightly lit screen), and returning to bed when you feel sleepy.
Many people mistakenly resort to alcohol as a sleep aid. While it may help people fall asleep initially, it produces fragmented sleep and interferes with REM sleep, Dr. Avidan and others report.
For those who still need help with insomnia, cognitive behavioural therapy has proved most effective in clinical trials, though finding a specialist may be challenging in some parts of the country.
Sleeping pills can be problematic, especially for older people who are more sensitive to their side effects, including daytime hangover. Even short-acting drugs like zaleplon (Sonata), zolpidem (Ambien) or ramelteon (Rozerem) can have side effects.
Alternatives include over-the-counter remedies like melatonin or valerian, which have more anecdotal evidence than research to attest to their efficacy. The brain makes melatonin, the body’s natural sleepiness hormone, in response to darkness.
There may also be some useful dietary aids, like bananas, cherries, kiwis, oatmeal, milk and chamomile tea, though evidence for these is also primarily anecdotal. One friend told me she solved a longstanding sleep problem by eating a banana two hours before bedtime.
