Babies can sleep through a thunderstorm, but older people will awaken at the sound of a pin dropping!
The average old person's circadian rhythm changes such that melatonin-induced sleep occurs earlier, say by 8 or 9 pm, and awakening occurs earlier by 4 or 5 am. The "early to bed and early to rise" phenomenon of the older person is well known. The structure of sleep is altered in older persons; non-REM sleep is shortened , and depth of sleep during this period is decreased, so sleep is fragile. Frequent awakenings also occur because of the urge to pass urine. Distressing symptoms arising from any diseases such as heart and lung disease, or gastric reflux, or joint pains, can cause awakenings.
Medications taken by the older person also disrupt sleep, and it is worth sifting through the drug list and suggest changes. Not many people know that beta-blockers, deriphylline, statins, and steroids, and others, cause insomnia.
In women the menopause is a difficult time as the fluctuations of hormonal levels disrupt sleep.
The average old person's circadian rhythm changes such that melatonin-induced sleep occurs earlier, say by 8 or 9 pm, and awakening occurs earlier by 4 or 5 am. The "early to bed and early to rise" phenomenon of the older person is well known. The structure of sleep is altered in older persons; non-REM sleep is shortened , and depth of sleep during this period is decreased, so sleep is fragile. Frequent awakenings also occur because of the urge to pass urine. Distressing symptoms arising from any diseases such as heart and lung disease, or gastric reflux, or joint pains, can cause awakenings.
Medications taken by the older person also disrupt sleep, and it is worth sifting through the drug list and suggest changes. Not many people know that beta-blockers, deriphylline, statins, and steroids, and others, cause insomnia.
In women the menopause is a difficult time as the fluctuations of hormonal levels disrupt sleep.
Sleep problems range from difficulty in falling asleep, to easy awakening, to not feeling refreshed in the morning after disturbed sleep. The distress of the insomniac is impossible to ignore, but difficult to treat without prescribing sleeping pills. As a result, doctors all over the world drug their older patients with addictive drugs belonging to the class of benzodiazepines. There is no real estimate of what percentage of the older population in India is on the sleeping pill, but a reasonable guess (needs corroboration with hard data) is that it is upwards of one in every 5 older persons in the urban setting.
The problem with sleeping pills is that they silently take over the body and ..... the mind also perhaps, and make the person vulnerable to many killers, and here is why;
a) addiction is almost 100%, with patients needing increasing doses (tolerance); the non-benzodiazeoine sedatives such as zolpidem, and zolpiclone are thought to be less addictive.
b) sleep pattern is destroyed, so one function of sleep, which is to "restore" the body, does not happen;
c) daytime drowsiness occurs because the drug's half-life increases in the elderly because it is stored and later released from the increased fat compartment;
d) postural reflexes are weakened, and falls occur more often;
e) acute agitation occurs when the drugs are inadvertantly stopped when they get ill and are hospitalized, or forget the pills when travelling;
f) but perhaps one of the worst things is that cognitive functions of the brain decline.
In short, one creates a zombie, not immediately, but gradually, whenever one prescribes sedative hypnotics to older people. These drugs should be given for just 7 to 10 days to tide over stressful times, and then discontinued immediately.
a) addiction is almost 100%, with patients needing increasing doses (tolerance); the non-benzodiazeoine sedatives such as zolpidem, and zolpiclone are thought to be less addictive.
b) sleep pattern is destroyed, so one function of sleep, which is to "restore" the body, does not happen;
c) daytime drowsiness occurs because the drug's half-life increases in the elderly because it is stored and later released from the increased fat compartment;
d) postural reflexes are weakened, and falls occur more often;
e) acute agitation occurs when the drugs are inadvertantly stopped when they get ill and are hospitalized, or forget the pills when travelling;
f) but perhaps one of the worst things is that cognitive functions of the brain decline.
In short, one creates a zombie, not immediately, but gradually, whenever one prescribes sedative hypnotics to older people. These drugs should be given for just 7 to 10 days to tide over stressful times, and then discontinued immediately.
The panacea to insomnia is not a magical potion; but a bit of hard work in the consultation room giving tips on how to promote sleep helps a great deal.
So here are some golden rules, or the "sleep-inducing charter".
a) Reduce coffee, tea and other caffiene-containing beverages to the barest minimum, and restrict them to early morning.
b) Milk, and bananas, and carbohydrate -containing foods are rich in serotonin, and provide the right stage for sleep when taken as a bedtime snack. Protein foods should be avoided.
c) Exercise promotes sleep, but should not be taken in the evening hours.
d) Sleep-inducing ritual must be practised religiously. The bed must be seen as a place for sleep alone, and of course intimacy! So reading, paperwork, TV watching from the bed are taboo. Lighting, temperature, tranquillity in the bedroom is important. If the person cannot sleep after 40 mins of lying down, he/she must stop counting sheep, and instead should leave the bed and engage in some restful activity such as listening to soft music, or reading. Normally stimulating activities such as sodoku, crosswords, watching TV etc may induce sleep in some people, but could be counter-productive in others.
e) The time of awakening should remain the same, even if the person feels he/she has not slept enough and is entitled to a late morning.
Instilling these "sleep hygiene" points takes time during the consultation, but can be very effective by encouraging the person to take responsibility for themselves rather than relying on the doctor for a magic potion. Family members are excellant supporters and should be roped in.
A final word: dont be the one to create the zombie; but rather be the caring physician who not only motivates the patient to come off sedatives, but is willing to undertake the hard task of slow and gradual withdrawal.
a) Reduce coffee, tea and other caffiene-containing beverages to the barest minimum, and restrict them to early morning.
b) Milk, and bananas, and carbohydrate -containing foods are rich in serotonin, and provide the right stage for sleep when taken as a bedtime snack. Protein foods should be avoided.
c) Exercise promotes sleep, but should not be taken in the evening hours.
d) Sleep-inducing ritual must be practised religiously. The bed must be seen as a place for sleep alone, and of course intimacy! So reading, paperwork, TV watching from the bed are taboo. Lighting, temperature, tranquillity in the bedroom is important. If the person cannot sleep after 40 mins of lying down, he/she must stop counting sheep, and instead should leave the bed and engage in some restful activity such as listening to soft music, or reading. Normally stimulating activities such as sodoku, crosswords, watching TV etc may induce sleep in some people, but could be counter-productive in others.
e) The time of awakening should remain the same, even if the person feels he/she has not slept enough and is entitled to a late morning.
Instilling these "sleep hygiene" points takes time during the consultation, but can be very effective by encouraging the person to take responsibility for themselves rather than relying on the doctor for a magic potion. Family members are excellant supporters and should be roped in.
A final word: dont be the one to create the zombie; but rather be the caring physician who not only motivates the patient to come off sedatives, but is willing to undertake the hard task of slow and gradual withdrawal.
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