Sleeping through the ages: A solid snooze gets harder with time

If you’re getting older and thinking that you’re not sleeping as well as you used to, you’re probably right.

Sleep experts say a host of small biological changes can leave people in their 50s, 60s and older feeling less refreshed after a night in bed, even though there is some evidence that they need slightly less sleep than younger people.  The nature and quality of sleep itself changes over time, and physical ailments and the medicines used to treat them can make things worse.

This matters not just because people who haven’t slept well feel bad but because inadequate sleep is associated with serious medical conditions  like obesity, diabetes, heart disease, and depression.

“It’s essential that you rest.  Your body needs that opportunity to rest, to dream, and to rejuvenate,” said Eric Sztejman, a sleep expert with Virtua Pulmonology in Marlton.

Poor sleep is also associated with dementia, but it is unclear whether poor sleep in later life is primarily an early symptom of dementia or a risk factor for it, experts said.

Some age-related sleep problems are fixable.  Some, you’ll just have to learn to live with.

Bob Miles, a 59-year-old real estate appraiser and music TV show host from Chalfont, was a great sleeper in his 20s.  In his mid-40s, he learned he has sleep apnea.  About seven years ago, he had surgery to correct physical problems that were affecting his breathing at night. His apnea was cured. Then he started waking for two hours in the middle of the night, a routine that made his 7:30 a.m. work start time downright miserable.

 

Camera icon Janet Miles
Bob Miles is coping with insomnia.

Like sleep apnea, insomnia increases with age. Miles has tried multiple medications. He’s now taking one that helps him sleep all night but leaves him so groggy during the day that he takes a short nap at lunchtime and another after work.

“I’m still hanging on for life in the day time,” said Miles, who added that he feels fine while on vacation, when he can spend more time in bed.

A patient at an Abington-Jefferson Health sleep center, Miles worries that he may just have to accept this.  “I don’t know if they’ll ever have a 100 percent cure,” he said.

Sleeping through the years

The need for sleep changes throughout our lifetimes, with children needing the most.  The National Sleep Foundation recommends 14 to 17 hours for newborns, 9 to 11 hours for 6- to 13-year-olds, and 8 to 10 hours for older teenagers.  People aged 18 to 64 need 7 to 9 hours and those 65 and up need 7 to 8.

Some people may sleep more because of illness or medications they’re taking. Many of us need a little less during the summer than during the winter.

There are some adults, known as short sleepers, who can get by with six hours or so, but many people who sleep that little are actually more tired than they realize, sleep experts said.  “Everybody would like to be a short sleeper,” said Nalaka Gooneratne, a geriatric sleep expert at Penn Medicine. “We all want to believe that about ourselves.”

If you’re falling asleep on the bus or in front of the television, you’re probably not sleeping enough, he said.  Irritability and poor concentration can also be signs of sleep deprivation.  Miles’ doctor at Abington, John Khoury, said women with sleep apnea are more likely than men to feel run down rather than overtly sleepy.

Michael Grandner, director of the sleep and health research program at the University of Arizona, said there is a difference between how people subjectively experience sleep and the objective quality of their sleep.  Eighteen to 24-year-olds are most likely to complain about sleep, but that may have more to do with their natural body rhythms — they are programmed to want to go to sleep later — and their erratic schedules than with how well they’re sleeping.

“I don’t think sleep is objectively worse at that age,” said Grandner, who previously worked at Penn.  “It’s probably the best it’s ever going to be.”

Sleepless in midlife

In middle age, many people are pushing themselves as they work full time, raise kids, and try to keep up with social media or the latest TV show worth binge watching.  Their primary sleep problem is their own choices, experts said, and they are the ones most at risk for sleep-related health problems. Grandner said the relationship between short sleep and health is “a little weaker” in older people.

The architecture, or structure, of sleep changes as we age. It takes longer to fall asleep. Sleep itself is shallower, with less time in slow-wave or deep sleep, especially in men over 60.  Overall, Gooneratne said, people over 65 spend 25 to 75 percent less time in deep sleep than children and 10 to 50 percent less than those in middle age.

On top of that, sleep becomes much more fragmented as people get older.  You might awaken slightly only a couple times a night at 40, said Karl Doghramji, a Jefferson Health sleep expert.  By the time you’re over 60, it could be 20 to 30 times.  And the body clock that determines your natural sleep cycle — not the one your work may require — begins to change so that your body wants to go to sleep and wake up earlier.  This may mean you need an earlier bed time.

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Nalaka Gooneratne is a geriatric sleep expert at Penn Medicine.

To top this all off, older people have a much harder time making up for what experts call “sleep debt” than younger ones.  A college student can sleep all morning on Saturday and Sunday and often nap easily if he didn’t get enough sleep at night.  This is typically not true for elders and is an argument, experts said, against older people doing shift work.

Sleep apnea becomes more common starting in the 40s.  It worsens with age as muscles weaken.  Grace Pien, a Johns Hopkins University sleep expert who focuses on women, said apnea increases three-fold after menopause.  While women complain more about sleep after menopause, she said, studies have shown they actually sleep longer and more deeply than premenopausal women. In general, she said, women need a little more sleep than men and, at all ages, they are more likely to have insomnia or be dissatisfied with their sleep.

A less common but serious problem that can start in the 50s and 60s, Khoury said, is acting out dreams, often violent ones.  Sleep apnea can cause this, but it is often a sign that someone is at high risk for developing Parkinson’s disease or Lewy body dementia.

Gotta go … all the time

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Ariana Smith is a urologist at Penn medicine.

Another big problem that is rare in the young but common among seniors is waking frequently to urinate.   Known as nocturia, this is  considered “clinically relevant” if you’re up two or more times a night, said Ariana Smith, a Penn Medicine urologist.   It develops in both men and women, usually after 50, and affects 30 to 60 percent of those over 70.

Many older men think this is caused by enlarged prostate and is just a normal part of getting older.  But Doghramji said many actually have sleep apnea.  Of those, about half no longer have nocturia if they use a CPAP machine.  That was the case for one of his patients, Jeffry Marlowe, 78, who sought treatment because his snoring bothered his wife.  He was getting up two to three times a night before apnea treatment.  Now the  suburban Philadelphia man often doesn’t get up at all.

Camera icon Judy Marlowe
Jeffry Marlowe feels better after treatment for sleep apnea.

Smith said there are plenty of other reasons why elders of both genders have night time urination problems.  A common issue is edema, or swelling in the legs.  When people lie down, that fluid dissipates and eventually is expelled as urine.  Diabetes can make people urinate more often. People who are waking frequently may go to the bathroom to prevent a trip later on.  The chemical signals in young people greatly diminish urine production at night.  Those signals weaken as we age, so older people are producing more urine while also trying to sleep.

Smith said it’s often helpful to stop eating and drinking about three hours before going to bed.  If your legs swell, wearing compression stockings or elevating the legs before bed can also help.

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Karl Doghramji is a sleep expert at Jefferson Health.

Experts said the end result of all of this is that older people feel less refreshed by sleep than younger people do.  To combat that, they may spend more time in bed or take afternoon naps.  Doghramji said he has had patients who will spend 12 to 14 hours in bed, but only sleep for four.

Naps are controversial, experts said.  Some, like Grandner, like them, especially short power naps for sleep-deprived younger people. Sztejman urges patients to stop taking them.

Experts generally agree that older people need the structure of regular bed times and awakening times seven days a week.  Exercise and interesting activities during the day make seniors sleep more soundly at night.  Use the bed for sleep and sex only.  If you can’t sleep, do something else for a while so your body doesn’t come to associate sleeplessness with being in bed.  That’s often how insomnia starts.

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Eric Sztejman is a sleep expert with Virtua Health.

Gooneratne said it’s difficult to increase deep sleep, although exercise can make a small difference.

Doghramji agreed that feeling you got after a good night’s sleep when you were young may be impossible to recapture.   Sleep is good at fixing sleepiness, he said, but it doesn’t necessarily help the kind of fatigue that many older people feel.

Plus, the brain systems that keep us from feeling sleepy during the day weaken as we age.  People often feel better when they compress the amount of time they spend in bed.  That increases sleep efficiency, or the percentage of time in bed when we’re actually asleep. But it only goes so far.

“Older people cannot produce as great a sleep as they had when they were young,” he said.

There’s a silver lining:  If you live long enough, your sleep complaints will likely go away. “I can’t remember anybody with insomnia over 85,” Sztejman said.