Dr. Bill Thomas (a.k.a., “Dr. Bill”), nationally renowned geriatrician, author, and Lifespark Independence Officer, has a lot to say on the subject of sleep, starting with the sober observation that Americans, independent of age or region, have poor sleep hygiene. “As a nation, we’re not getting enough healthy, restful sleep, and the problem gets worse with age,” he said. “After years of sub-par sleep habits and poor-quality sleep, older people are suffering the consequences.”
Sleep deficiency at any age can lead to chronic health conditions, including diabetes, heart disease, kidney disease, hypertension, stroke, obesity, and depression, but in older adults, poor quality sleep adds to their risk of cognitive decline, disorientation, delirium, and falls. While good sleep hygiene by itself won’t resolve chronic disease, studies have shown that healthy, restful sleep fights damaging inflammation, strengthens immunity, and improves mental health, resulting in better health outcomes.
Reframing “normal”
One of the challenges for older people is a misperception of what “normal” sleep should look like in later life. “We have no problem accepting that between the ages of 17 and 87, our bodies keep changing, but for some reason, we believe that how we slept as adolescents is how we should sleep in our 80s, and anything short of that is seen as abnormal,” Dr. Bill said.
To help older clients understand what normal sleep looks like in later life, and to get a clearer picture of their current sleep patterns, Dr. Bill suggest framing the conversation around sleep efficiency, sleep fragmentation, and phase advance, three key elements of sleep.
- Sleep efficiency is the ratio of hours spent sleeping to hours spent in bed. “Sleep efficiency is usually quite high in younger people and decreases naturally with age,” he said. “Unfortunately, this change causes some people to reach for a sleeping pill when, in fact, lower sleep efficiency is normal in older individuals.”
- Sleep fragmentation is defined as repeated, short sleep interruptions during the night. “Barring an underlying sleep disorder, like sleep apnea or restless legs syndrome, older people tend to experience several sleep episodes during the night, with periods of wakefulness in between,” he said.
- Phase advance is a shift in the sleep cycle that causes older people to wake up earlier and go to bed earlier. “Older clients will tell me that something must be wrong, because they get sleepy, when everybody else is just getting started, and wake up when the world is still fast asleep, but again, this is normal in later life,” he said.
Basics of good sleep hygiene
According to Dr. Bill, getting better sleep boils down to a few simple things, done well. “First of all, the bed ought to be used only for sleep and intimacy and nothing else,” he said. “Not for eating, not for watching TV, not for scrolling through Facebook, not for reading—except maybe a few pages before drifting off to sleep.” If an individual is already struggling with decreased sleep efficiency, and they’re using their bed for other activities, it will only increase the problem.
“Second, get the television out of the bedroom,” he said. “So many clients tell me that having the TV on helps them sleep, but in fact, the blue light emitted from TVs, smartphones, computers, and tablets disrupts our natural sleep cycles.” His advice is to limit exposure to screens at least an hour before bedtime.
“Third, recognize that alcohol before bedtime interferes with healthy, restful sleep,” he said. “A drink or two might make it easier to fall asleep, but alcohol disturbs REM sleep, which is the deep, restorative phase of sleep.” A general rule of thumb is to avoid alcohol a few hours before bedtime.
As for caffeine, it varies from person to person, he said, adding, “If caffeine interferes with sleep, that’s a problem; but if it doesn’t, no reason not to enjoy it.”
Napping done right
A big fan of naps himself, Dr. Bill differentiates between two types of naps. “The first is the healthful 20-minute midday nap, terrific for individuals who get plenty of restful sleep at night,” he said. “It’s great for extending alertness, elevating mood, and boosting memory without disrupting the sleep cycle.”
The second is common among people with disturbed sleep patterns and significant daytime drowsiness. “These individuals often take long naps, up to two or three a day, to try to make up for their lack of sleep at night,” he said.
Long nappers may also experience something called sleep inertia, described as a feeling of grogginess, disorientation, and cognitive impairment after awakening, which can last anywhere from 15 minutes to a few hours before fading. Longer naps and sleep inertia may be signs of poor sleep hygiene or an underlying health condition.
Effects of sleep medications
In select cases and for some individuals, using a sleep aid can be a short-term strategy, Dr. Bill said, but the risks for older people often outweigh the benefits. “There’s an increasing amount of evidence that sleep meds cause transient amnesia, that instead of helping people sleep better, the drugs just make them forget they were awake.”
The two classes of medications most often associated with iatrogenic amnesia are benzodiazepines and anticholinergic drugs. The negative effects of these drugs on memory are particularly pronounced in frail and older people for whom polypharmacy is a common problem. “Unlike sleep meds, good sleep hygiene has no known negative side effects and it doesn’t cost anything,” Dr. Bill said.
Uniquely personal
Ultimately, sleep is very personal. “People need to figure what works for them and do that consistently,” he said. “But if your older clients are having difficulties with sleep, you might consider asking them about their sleep habits and their use of sleep medications.”
For healthy, restful sleep, Dr. Bill offers the following prescription: “Wake up in the morning, refreshed and ready to enjoy the day. Get some physical activity, which is associated with better sleep at night. Take a 20-minute nap in the middle of the day. Stay up and out of the bedroom until it’s time to retire. No TV, no light, no distractions.”