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A good night’s sleep

Yale Medicine Magazine, 2020 - Summer


Good sleep is important. The consequences of missing quality rest accumulate over time; and as geriatricians can attest, it can have serious long-term effects.

This spring, Senator Joe Biden and President Donald Trump were lambasted for appearing to nod off in public. Both men are in their 70s—an age when many people struggle to get sufficient high-quality sleep to remain alert during the day. For the elderly, sleep problems can lead not only to daytime drowsiness, but also to impaired cognition, lowered physical function, and increased dependence on others for activities of daily living like showering. Remedies like sleeping pills can make matters worse.

To untangle these problems and help elders get the sleep they need, Brienne Miner, MD, MHS, HS ’12, assistant professor of geriatrics, cross-trained in sleep medicine. She completed a residency, geriatrics fellowship, and sleep fellowship at Yale. Miner aims to bring together geriatrics and sleep medicine in her clinical and research work.

“Just because you’re older doesn’t mean your sleep should be worse,” Miner said. With better sleep, she explained, the older patient feels and functions better, and their family feels better too. “As a geriatrician, cognition and physical function are things I really care about,” she said. “Those are things that are helping older people to maintain their independence.”

Sleep requirements don’t change with age

Contrary to popular belief, outright sleep disturbance is not a normal part of aging. Still, as people get older, the architecture of their sleep does change. They experience less time in overnight sleep, less time in restorative sleep, and more frequent arousals. Many elderly people also experience medical conditions or other disturbances that make sleeping difficult.

Another common change among older sleepers is advanced sleep phase disorder (ASPD), in which melatonin, the “time for bed” hormone, is released early in the evening. People with this condition may hit the hay around dinnertime, then wake up refreshed at 3 a.m., earning them the nickname “morning larks.” (Their opposites: teenage “night owls,” whose melatonin is released later in the evening, have trouble getting up early for school.)

Amid these challenges, older adults continue to need about the same amount of overnight sleep that younger adults do. For those aged 65 or older, the National Sleep Foundation recommends getting 7 to 8 hours of sleep per night, compared with 7 to 9 hours for younger adults. Older adults who meet the benchmark “tend to have better physical health, better mental health, and better quality of life,” Miner said.

Those who don’t get enough sleep face a host of resultant problems. Sleep symptoms like daytime drowsiness and insomnia, topics of Miner’s research, predict worse physical and mental health-related quality of life. Insomnia also correlates with poor physical outcomes like falls; cognitive problems; psychiatric problems like depression; and trouble carrying out activities of daily living. Miner has also studied hypersomnia, or excessive sleep duration—a risk factor for lowered physical function, loss of independence, cardiovascular problems, and even death.

When everyone’s a light sleeper

All kinds of factors can ruin an elder’s sleep, including medical diagnoses like sleep-disordered breathing or restless leg syndrome; psychiatric problems; medications; lifestyle factors; or some combination thereof. But, Miner said, “I look at that as potentially a positive thing, because it means there are actually a lot of things we can treat.”

Medication is not her first choice, though. Prescription and over-the-counter medications can erode sleep quality. That in turn can lead to drowsiness, memory problems, and strains on caregivers—the latter a potentially disastrous effect if it leads the elder to lose a stable living situation. “Any medication that you are going to use to help these people sleep is going to be sedating, and any sedating medication is going to affect memory. It’s going to increase risk of falls. It’s going to impair mobility,” Miner said.

Instead, Miner takes a meticulous and painstaking approach. She reviews patients’ current medications in case one or more is making matters worse. She considers psychiatric factors: Anxiety and depression can harm sleep quality, which can in turn lead to memory problems. Fortunately, cognitive behavioral therapy can be useful to treat not only those conditions but also insomnia itself. “Poor sleep and psychiatric symptoms are very tightly linked, and in geriatric medicine we think about treating psychiatric symptoms to help people’s cognition,” Miner said.

She inquires about nighttime urination, which can sometimes flag undiagnosed sleep apnea. Many of her patients may also undergo a sleep study. (For wrist-based sleep monitor enthusiasts, Miner has bad news: these devices are inaccurate when compared to gold-standard sleep measurement techniques.)

Finally, she goes over the sleep environment—Is it dark enough? Is it quiet? Are there disruptive people nearby?—and sleep-related behaviors. “It’s all about going to bed at the same time every night, waking up at the same time every morning—having those cues like you take a bath or brush your teeth or put your pajamas on to tell your body it’s time to go to bed,” Miner said. “A lot of times, the solution to [a sleep problem] is really getting down to a routine.” She added that spending too much time in bed to compensate for missed sleep can exacerbate problems associated with sleep deprivation.

While there’s no simple cure for sleep-related problems in the elderly, Miner finds tracking down and addressing their causes gratifying: “People are very, very happy when you help them sleep.”

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