SLEEP WELL, FEEL BETTER

by Ralph A. Pascualy, M.D. and Sally Warren Soest

We often assume that it is normal for older people to get less sleep during the night than younger people. This assumption often is further explained by the assumption that “older people don’t need as much sleep.” In fact, both of these assumptions are open to question.

It is true that people over 50 years of age typically do get less than seven hours of sleep during the night, compared with eight hours for people 19 to 30 years old. This is partly because older people awaken more often during the night and partly because they usually wake up earlier in the morning. However, older people also appear to take more frequent daytime naps than young people, so an older person’s total amount of sleep during a 24-hour period may be very close to the eight hours obtained by a younger person.

However, the quality of sleep that older people get is not as good as it is in younger people. The quality of the sleep is diminished when a night’s sleep is broken up by wakefulness. Older people’s sleep is lighter and more fragmented by periods of wakefulness than is the sleep of younger people.

Older people experience less deep sleep. They get almost as much REM sleep as younger people, but it is less intense.

Older people may be attempting to compensate for sleep lost during the night by napping. In some individuals naps may make up for the amount of sleep lost, but they do not make up for the loss of sleep quality at night. In fact, in some people naps may simply compound the problem, both by making the person less sleepy at night and by confusing the person’s internal clock.

The significance of these differences between the sleep of older people and younger people is not understood. No one knows exactly why we need deep sleep and REM sleep, so the meaning of the decrease in these stages of sleep with age remains to be discovered.

The majority of older people are healthy and have few, if any, complaints about sleep disturbances. Even though their sleep may be more fragmented than it was when they were younger, they do not appear to be unduly bothered by it. However, some older people do have serious sleep problems. Unfortunately, they may be discouraged from seeking help by certain myths about sleep and aging.

• Feeling sleepy is not “just part of getting old.” Do not accept this explanation by family physicians, or even your own rationalizations that tell you that being sleepy during the day is “just part of being old.” If you are drowsy to the point that it affects your ability to drive alertly for at least an hour, to read for 30 minutes or more, or to sit and socialize with family, the odds are that you may have a treatable sleep disorder.
• Disturbed or poor sleep is not normal. Do not accept explanations that claim that disturbed or poor nighttime sleep is “normal.” Although most elderly people agree that their sleep is not what it used to be, most do not believe that poor sleep is significantly interfering with how they feel or function.

If you think your quality of life is being diminished by sleeping difficulties, do not hesitate to seek help and do not be discouraged by those who would make light of your complaints.

Sleep apnea is one of several medical conditions that can seriously interfere with the sleep of older people. Sleep apnea has been reported in as many as 30 percent of the healthy elderly adults who have been studied. It probably results from the gradual loss of tone in the muscles in the upper airway that occurs with increasing age.

The sleep apnea seen in healthy older people is usually very mild or moderate. In many cases it is not severe enough, or is barely severe enough, to qualify as clinical sleep apnea (i.e., more than five apnea events of 10 seconds or more during an hour, or a total of 30 or more apnea events during a night).

The consensus seems to be that a mild degree of apnea in otherwise healthy older people does not normally call for treatment, provided they feel well rested. However, a suspicion of sleep apnea should not be ignored. Drowsiness and loss of mental alertness are the worst enemies of the healthy senior citizen, whose goal should be to remain as active and alert as possible. Apnea episodes contribute both to fragmentation of sleep and to a decrease in the oxygen content in the blood, which can lead to daytime drowsiness and loss of alertness. Seniors with other kinds of sleep disturbances, such as restless legs, show less daytime drowsiness. This suggests that sleep apnea may be a particularly significant cause of the daytime drowsiness seen in seniors.

If you are an older person who suspects that apnea is significantly disturbing your sleep and is causing drowsiness during the daytime, you may want to contact a sleep center for an interview and potential testing. If your snoring is disturbing your spouse or partner, but you are otherwise sleeping well and have a minimal amount of apnea, Somnoplasty™ may be effective.

Approximately 40 percent of older adults experience involuntary leg movements associated with sleep. In restless legs syndrome, a person has an uncomfortable or achy feeling and an urge to move the legs. This may interfere with falling asleep. Periodic leg movements (nocturnal myoclonus) are kicking motions that occur repeatedly during sleep. These may awaken the sleeper, but often they do not and are more disruptive to the bedmate. If you or your bedmate experience either of these disorders, talk with a sleep specialist about possible treatment.

Some less healthy older adults are bothered by medical problems that affect sleep (e.g., pain from arthritis, respiratory problems, frequent urination, or leg cramps).

Depression is another condition that can affect sleep. The symptoms

of depression often are attributed to “just getting old” - insomnia; pessimism; loss of interest; decreased energy; poor self-esteem; poor sexual functioning; increase in health complaints, such as constipation, back pain, abdominal pain, headache; social withdrawal; decreased appetite; and weight loss.

However, it is not true that aging inevitably leads to these difficulties. Healthy older adults who are not depressed do not routinely experience these symptoms. If depression is the cause of symptoms such as poor sleep, it is the depression that needs to be treated, not simply the symptoms.

The treatment of medical problems and depression that interfere with sleep is best carried out in consultation with a sleep specialist, as explained later, because some treatments can further interfere with sleep.

The most common sleep complaint among healthy older people is that they awaken numerous times during the night. People sometimes become worried about this pattern, and the worry itself - that they’re “not getting a good night’s sleep” - keeps them awake.

If you are a senior who is somewhat bothered by frequent awakenings during the night and drowsiness during the day, and you doubt that you have a serious sleep disorder, here are some helpful things that you can do for yourself.

1. Practice good “sleep hygiene.” That is, try arranging your daytime life so that you promote good sleep:

a. Eat regular meals.

b. Get more exercise every day (but don’t exercise right before bedtime).

c. Go outside for a while every morning. Your biological clock needs light signals to regulate your sleep-wake cycle everyday. Indoor light is not bright enough to work very well. Morning light, even on a cloudy day, can reset your sleep-wake rhythm and help you get better sleep.

d. Eliminate daytime naps. They often are more the result of boredom than sleepiness. Find something active to do instead of napping.

e. Plan evening activities - with friends or by yourself, either outside or in the home. Look forward to a full evening.

f. Limit your caffeine intake (coffee, tea, cocoa, cola) and use alcohol moderately (alcohol actually interferes with sleep).

g. Limit your fluid intake after 7 p.m. so that you will have less need to urinate during the night.

h. Make yourself get out of bed and get dressed at a specific early hour every morning (say, 6:30 or 7 a.m.).

i. Learn relaxation techniques to relieve the tension or worries that may be keeping you awake.

2. Reassure yourself that brief nighttime awakenings are normal and that you probably are actually getting enough sleep. This knowledge alone may release you from worrying about getting a good night’s sleep. That, in turn, will probably let you sleep better.

3. If these suggestions are not effective, strongly consider seeking help.

If you try these suggestions in a disciplined way for several weeks and decide they are not helpful, make an appointment to discuss the problems with your doctor. If the symptoms are not resolved, ask your doctor about a referral to a sleep clinic.

If you have a medical problem that seems to be interfering with your sleep, check with a sleep specialist for ideas about a solution that will help you sleep better.

Sometimes the treatment for one medical problem may conflict with the treatment for another. For example, some drugs taken for heart problems can make sleep apnea worse. “Sleeping pills” nearly always make sleep apnea worse, as does alcohol. Barbiturates and some antidepressants have side effects that can affect sleep. A sleep specialist is likely to know more about these effects on sleep than your family doctor does, and the two of them should work together to find the most appropriate way of improving your night’s sleep.

If sleep apnea is a moderate to serious problem or if you have other conditions, such as arrhythmias (irregular heart rhythms), congestive heart failure, or respiratory problems, that are aggravated by sleep apnea, the sleep specialist may recommend treatment for your apnea. The type of treatment will depend on the kind of apnea and the severity

of the problem.

• Older people often get as much total sleep in 24 hours as young people do.

• However, the sleep of older people may be of poorer quality; that is, broken up by periods of wakefulness.

• Factors that can interfere with older people’s sleep include sleep apnea, leg movement syndromes, pain, respiratory problems, frequent urination, medications, and depression.

• Seek help if you are persistently drowsy or if sleep disturbance is decreasing your quality of life.

• If you suspect sleep apnea, go to an accredited sleep center for an interview and possible testing.

• Mild sleep problems often can be solved by a program of good “sleep hygiene,” as discussed in this article.

   

If your car needs new brakes, you don’t take it to a windshield shop. The same is true of sleep apnea.

This is especially important because sleep disorders medicine is a fairly new medical specialty, and few doctors are trained in the field. A survey of medical schools found that the average amount of time spent teaching about sleep was 20 minutes.

Because of managed care and financial arrangements with insurance companies, your doctor may want to send you to someone in his referral group who is not board certified in sleep medicine or does not even practice sleep medicine full time. Find out if your health plan is “capitated”-this means that every time your doctor orders a test it costs the clinic money. In a capitated setting you are more likely to be denied care or to be offered potentially unproven or lower quality services. The doctor often may not consciously be trying to “save” money but may have been too ready to believe claims that some service is “cheaper” and “just as good.” This may sometimes be true, but do you want to be the exception?

Most established specialties, such as pediatrics, obstetrics/gynecology, otolaryngology (ear, nose, and throat), psychiatry, and so on, have their own departments in hospitals and medical schools. Medical students are taught by specialists in these fields, and they learn routines for diagnosis and treatment of illnesses in those areas. After medical school, doctors can spend several years in residency programs perfecting their skills in their chosen specialties. But very few medical schools offer courses or programs in sleep disorders medicine. Consequently, very few doctors are trained to recognize and treat sleep disorders.

In the absence of established departments of sleep medicine in hospitals and medical schools, a number of professional organizations have taken on the role of setting the standards for professionalism in the field. The American Academy of Sleep Medicine (AASM), whose members are accredited sleep centers and sleep specialists, has established the standards for the evaluation and treatment of sleep disorders. Its parent organization is the Association of Professional Sleep Societies (APSS), which also includes the Sleep Research Society (SRS). The APSS coordinates the publication of journals that deal with sleep and sponsors conferences on the latest research and treatments for sleep disorders.

Today these professional organizations are the backbone of sleep disorders medicine and the main source of learning and information exchange for professionals in the field. This will change in time. The field is growing very rapidly. The AASM hopes the major medical schools will have programs on sleep disorders within a few years. However, until systematic sleep medicine training becomes part of the medical school curriculum, the public will have to look carefully to find a qualified sleep specialist.

Because so few training programs have existed, most of today’s sleep specialists have done their residencies in other related specialties. In 1991 the AASM reported the specialties of their members as follows: psychiatrists, neurologists, psychologists (48 percent), pulmonologists (38 percent), and other specialties (14 percent).

These doctors have then gone on to study sleep physiology through additional fellowship programs, graduate courses, or periods of practice at one of the major sleep disorders centers. In 1993 only eight such AASM-accredited fellowship programs in sleep disorders medicine existed. They were located at Stanford University; Georgetown University Hospital in Washington, DC; Mt. Sinai Medical Center in Miami Beach; VA Medical Center in Allen Park, Michigan; Henry Ford Hospital in Detroit; University Hospital at Stony Brook, New York; the Medical College of Pennsylvania; and Crozer-Chester Medical Center in Upland, Pennsylvania.

A physician can earn a sleep specialist credential by passing the certification examination administered by the American Board of Sleep Medicine (ABSM). He becomes a board certified sleep specialist (BCSS). (Before the recent establishment of this board, the credential for a certified sleep specialist was accredited clinical polysomnographer, or ACP.) In 1998 there were approximately 1,100 board certified sleep specialists

in the United States.

Some physicians who have trained in sleep medicine do not choose to become certified. Nevertheless, they may be well informed about sleep disorders. However, as in any medical specialty, a doctor’s board certificate in sleep medicine assures you, the consumer, that the doctor has received special training and is qualified to carry out sleep testing and interpret the results of the tests.

You may feel hesitant to ask a doctor about his training and qualifications, but this is especially important in a new field such as sleep disorders medicine. “Are you board certified in sleep medicine?” is a perfectly legitimate question. If the doctor appears surprised by your question, you can pleasantly remind him that it is your body he is dealing with. Or you can call the American Board of Sleep Medicine (507-287-9819) and ask whether a particular doctor is certified in sleep medicine, or find a list of accredited sleep specialists on the ABSM Web site.

You might also ask your sleep doctor if he is a member of the AASM. Although membership in a professional group is not mandatory, it indicates something about his involvement in the field and may suggest how well he keeps up with current sleep research. If you are reluctant to ask a doctor these questions, call his office and ask his nurse. If she can’t answer your questions, ask her to find out and call you back.

Finally, it is not advisable to embark on a treatment program for a “sleep disorder” before having undergone thorough sleep testing at an accredited sleep disorders clinic. This is particularly true if the treatment involves surgery. Seek a second opinion.

An accredited sleep center is one that has met the standards established by the AASM. As of summer 1998 there were nearly 400 accredited sleep centers and laboratories in the United States. In addition, there were thousands of nonaccredited sleep labs nationwide. No one knows the exact number of nonaccredited sleep labs, but the AASM had received more than 3,000 requests from sleep labs for information about earning accreditation.

A nonaccredited sleep lab may be good, but you have no way of knowing. Your family physician also is unlikely to be intimately familiar with the details of quality sleep medicine and may just be referring you to someone in his group. However, a very wide range of quality exists, all the way down to some “street corner” sleep labs that are not reputable. The AASM has neither the funds, the staff, nor the mandate to “police” the entire field of sleep medicine beyond its own membership. And so far no other organization or agency is keeping an eye on the quality of sleep testing that goes on in the non-AASM-accredited labs.

As a prudent consumer, if you want some assurance of professional standards in this new field, you may want to choose one of the sleep centers accredited by the AASM.

The standards for accreditation are broken down into two categories: full-service sleep centers and specialty labs.

The requirements for accreditation for a full-service sleep center ensure that the center is able to deal professionally with the full range of sleep disorders. Here are the primary AASM requirements for a full-service sleep center:

• It must have an AASM-accredited clinical polysomnographer (M.D. or Ph.D.) on staff to read and interpret the results of sleep recordings.
• It must have a full-time physician with expertise in sleep physiology.
• It must have trained technicians to administer the sleep tests. Sleep centers are encouraged to have at least one technician who is accredited as a registered polysomnographic technologist.
• A private room must be provided for each patient, with sound, light, and temperature control and easy communication with the attendant.
• The facilities, testing procedures, and patient care must meet standards set by the AASM.
• The sleep center must pass inspection by a two-member accreditation team every five years or it will lose its accreditation.

   

The standards for accreditation of a specialty lab are similar but tailored to a less extensive sleep testing role. Specialty labs usually deal primarily with pulmonary medicine (breathing disorders), and the diagnostic testing they do is mostly for sleep apnea rather than for the full range of sleep disorders.

The requirements for a specialty lab include the following:

• It must have at least one pulmonary specialist on staff.
• The staff must demonstrate knowledge of the practices and procedures of sleep disorders medicine.
• The physical surroundings, facilities, testing procedures, and patient care must meet AASM standards similar to those for a full-service sleep center.

     

The AASM will mail you a booklet listing the 300-plus accredited sleep centers in the United States. Write to the AASM at the following address. Include a large, self-addressed, stamped envelope.

American Academy of Sleep Medicine

1610 14^th Street NW, Suite 300

Rochester, MN 55901-2200

(507) 287-6006

www.aasmnet.org

American Board of Sleep Medicine

(507) 287-9819

www.absm.org

      

You should discuss the problem with your family doctor. If he or she is unwilling to refer you to a qualified specialist, or is actually the source of the denial, you should call your Human Resources Department, union representative, or health plan agent and learn the steps you need to take to appeal the denial. If that fails, write to your state insurance commissioner, whose office can be found by calling your state capital’s government information number. All states have an individual or office that supervises insurance plans and HMOs. Because of well-publicized abuses, insurance commissioners are very interested in identifying these types of problems.