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What We Now Know About Poor Sleep in Older Adults

Why sleep is so important for good health and what we've been doing wrong


The more experts have learned in recent years about older adults and sleep, the more they realized how little they actually knew.

Recent research in the field has shown that nursing-home practices have been misguided for decades, that it soon will be possible to diagnose and alter sleep patterns to help treat or prevent dementia — and that, yes, we should be getting a good night’s sleep at all ages.

Five or Six Hours Isn’t Enough

“We have really taken for granted that ‘Aw, seniors don’t need that much sleep.’ No, [on the contrary] they need seven to eight hours,” said Sue Ann Guildermann, director of education for Empira, a consortium of 24 skilled nursing homes in Minnesota. “And that’s true for everyone. People who do not sleep seven or eight hours [a night] are going to die sooner. Issues like insulin management, cardiovascular problems, cancer, immune diseases are all more prevalent in people who don’t get enough sleep.”

For older adults, problems mount not just because of the quantity of sleep but the quality. It turns out that this trend need not be inevitable nor inexorable, according to Dr. Alon Y. Avidan, a neurology professor and the director of the UCLA Sleep Disorders Center.

“What we’ve known all along is that people who are older, their efficiency of sleep drops for a variety of reasons,” Avidan said. “They might not be sleeping less, but their ability is disrupted, often because of medical issues and medications. When those medical issues are addressed, sleep patterns improve, particularly for people with underlying memory problems.”

Nursing homes have decades and decades of practice at waking up patients every two hours.

— Sue Ann Guildermann, Empira

Let Them Sleep

That’s why Guildermann is spreading the word — via PowerPoint presentations at national and international sleep conferences — on measures that can be taken now to change practices and even the setting for older adults.

“The biggest change in nursing homes is the awareness of the importance of undisturbed sleep at night,” she said. “Nursing homes have decades and decades of practice at waking up patients every two hours.”

That’s particularly problematic, she said, because it takes close to two hours of undisturbed sleep to reach the restorative REM (rapid-eye movement) cycle. During REM sleep, the body becomes more relaxed and the brain more active. It’s a time of what Guildermann calls “mental, psychological and emotional repair.”

Fragmented sleep can cause cognitive changes, she added: an increase in forgetfulness, confusion and dementia-like behaviors.

Red Light, Blue Light

In addition, older adults — or anyone, for that matter — need to “see the light” in terms of understand light’s role in sleep. “For decades, we thought the key was brightness of light,” Guildermann said, “but it’s actually the color of the light.”

Before sleep, exposure to certain colors of light can be problematic. Blue/purple light (think TVs, laptops, iPads, cell phones) has rapid wavelengths, which prompts the body to produce more of the hormone serotonin, which basically peps us up and is not conducive to slumber. Orange/red light (now available in LEDs) prompts the production of melatonin, the yin to seratonin’s yang, which helps us sleep. As we age, our ability to make melatonin fades.

At Empira’s nursing homes, “we have made it darker at night, and what light they do have is orange/amber/red light,” Guildermann said, “and we are having phenomenal results.”

Fewer Pills and Fluids at Night

What patients consume in the evening is changing as well.

People over 65 make up about 13 percent of the population, but take 40 percent of the sleeping pills. These meds need to be tailored to the situation, which might involve problems getting to sleep (sleep-onset latency, or SOL); frequent waking up during the night (wake after sleep onset, or WASO) or total sleep time, Guildermann said.

Empira gives different medications depending on a patient’s needs, and has cut back on sleep medications overall, Guildermann said.

In addition, Empira patients are getting fewer fluids after the evening meal, to reduce bathroom trips during the, er, wee hours.

Scientific Advances

Current and future studies should provide decidedly more help.

After decades of tying countless electrodes to subjects in sleep studies that proved faulty, researchers have developed a device called the Actiwatch. This is wrapped around the wrist — the FitBit is a commercial offshoot — and measures quality of sleep and all activity therein.

“This is cutting edge, a complete assessment of wake and sleep patterns,” Guildermann said, calling it “the biggest advancement in my career.”

Avidan is particularly excited about the ongoing investigation of the recently discovered glymphatic system, which cleans out toxins. “It’s basically the brain’s garbage disposal, and is particularly functional during sleep.”

The glymphatic system might even prove effective in treating the beta-amyloid plaques that are a primary component of Alzheimer’s disease.

“The data in lab animals about glymphatics has certainly opened the door to more research into human studies,” said Avidan, who co-authored the book Geriatric Sleep Medicine with fellow UCLA researcher Cathy Alessi.

Patterns that May Forecast Dementia

Much of the current work about sleep and older adults is about finding signals in sleep patterns that could be precursors for cognitive disorders. That’s especially true for hard-working men and post-menopausal women between ages 45 and 65, said Max Hirshkowitz, chairman of the board for the National Sleep Foundation.

“That’s when we are at the peak of our professional powers, and we tend to work a lot,” said Hirshkowitz, a retired professor who helps sleep researchers at Stanford University. “People often get less sleep than they should. Most men start to gain weight, and the possibility of sleep apnea and other disorders increases. And sleep disorders have a huge impact in terms of producing disease.”

Respiratory Disturbance Variables

That’s why he and Avidan are looking to deep research on Respiratory Disturbance Variables (RDV) — breathing problems that disrupt sleep.

“If I were to diagnose RDV [in a patient],” Avidan said, “I can predict that 10 years down the road, the patient will probably get serious neurodegenerative disease. We can do this as early as age 30, 40, 50, well before the neurodegenerative disease. It opens a brand new pathway to potential treatment or to prevent patients from developing dementia.”

After decades in which most sleep-disorder research was focused on children and soldiers, all options are being explored. Even aromatherapy, Guildermann said, “which for years was put into a kind of voodoo-science category.”

The Importance of Education

Perhaps the biggest issue now is getting all this sleep research into the hands of the individuals and organizations that can put it to use.

Avidan stressed the importance of people knowing that “sleep problems are a reversible condition.”

Guildermann is loathe to retire because she is constantly traveling — “I swear I could be on a plane every day going somewhere” — to share the practices that her company has adopted. “It’s just barely getting out there.”

For his part, Hirshkowitz sees some progress on the awareness front.

“In the last five to 10 years there has been a recognition that sleep is not merely a biological phenomenon but the foundation of health,” he said. “People are starting to understand that between sleep, exercise and nutrition, those are the biggest components of health. If you could convince people that getting good sleep would make them more beautiful and sexy, it would be sold. But they really are starting to value sleep more.”

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