Sleep disorders are among the most common problems ailing the elderly. In the West, sleep disorder is one of main cause for sending the elderly to nursing homes. There are critical physical changes that affect their nature of sleep and other sleep related conditions.

The elderly can be affected by various organic diseases that directly or indirectly affect sleep, and the nature of sleep. They complain mainly of disruptive sleep. Chances of insomnia also increase with age due to depression, which is the main cause of insomnia and is the most common in the elderly people.

How our sleep changes in the old age?

Before explaining sleep changes in the elderly, we have to mention the levels of normal sleep and its stages, since we sleep at a specific time (usually at night) and wake up at a specific times (usually daytime).

The biological clock, or the circadian rhythm, defined by the exposure to light and the levels of the melatonin hormone is responsible for organizing sleep in the human body.

Normal sleep is divided into two main sections: the first is the REM stage; the second is the NREM stage that includes four stages; the first, the second, third and the fourth.

The sleep usually starts from the first stage and gradually moves to the deepest stages. The third and the fourth stages are referred to as the deep sleep and have a significant role in the rejuvenation of the body.

Middle and old aged people spend a limited time in the deep sleep stages and this gradually decreases with age. For example, a 70-year-old man spends very limited time in the deep sleep while for others that age, the stage might be absent altogether.

The elderly are mostly affected by disruptive sleep that sometimes results from organic factors and other times the causes are unknown.

The elderly have short and frequent naps during the daytime that increase. The biological clock of the elderly causes them to sleep early at night and wake up at odd timing in the morning and night. For example, an old man might sleep at 9 pm, but will wake up by 2 am.

These changes are a result of various bodily changes discovered recently. The melatonin (sleep hormone) decreases with age, also the elderly lead a sedentary lifestyle and inactivity during day, leading to a lack of exposure to the external light. This could affect the quality of sleep.

Do the elderly sleep for fewer hours than as compared to their young age?

There is a difference of opinion between medical specialists of sleep, regarding this topic. While many of them believe that the sleep during the day does not change over the time, despite the few hours of sleep at night (and daytime naps), others believe that the need for sleep decreases with age.

What are the common medical problems that affect the sleep of the elderly?

Many medical problems can affect the sleep quality directly or indirectly at an older age. They include:

• Arthritis and osteoarthritis
• Stomach acidity and acid reflux into esophagus
• Urinary tract disorder
• Heart and respiratory chronic diseases
• Peripheral atherosclerosis
• Parkinson’s, Alzheimer's and others diseases

The medical problems listed above indirectly affect the sleep making it disturbed and causing insomnia. The elderly are the most vulnerable to be affected by some or the other kind of sleep disorders. Chances of snoring also increase with age.

Sleep apnea affects 28% of men and 24% of women over 65 years of age. Potential infection of nocturnal myoclonus syndrome and periodic limbs movements during sleep is likely to increase with old age.

A study showed that about 45% of the elderly complain of periodic limbs movement.

How could we help the elderly, who are affected with sleep disorders?

The elderly with insomnia or excessive sleepiness during daytime need an assessment by a specialist or a physician to define the causes of sleep disorder, i.e. if it is an organic disease or depression or any other sleep disorders. The treatment is prescribed for each patient based on the status of clinical diagnosis, and sometimes a sleep study is required.

Generally, the following are recommended for the elderly:

• Regular exercises suitable as per the age and ability of the person.
• Regular sleep and waking up schedule, particularly the waking up time.
• Avoiding naps as far as possible or limiting them to only one nap in a day not exceeding half an hour.
• Exposure to light particularly before sunset to delay the circadian rhythm (biological hour) and consequently the sleep time.
• Avoiding stimulants such as coffee as far as possible, particularly in the evenings.
• Avoiding use of sleeping pills, and taking them only after consulting a doctor, as they increase the possibility of sleep apnea.

Ahmed BaHammam, FACP, FCCP
Professor of Medicine
Director, University Sleep Disorders Center
College ofMedicine, King Saud University