Good Sleep, Healthy Mentation

Good Sleep, Healthy Mentation

By Joanne Kaldy 

In the world of age-friendly, value-based care, sleep plays a significant role. Not only is adequate sleep key to physical health, but it is also important for mental health and well-being. This is especially true for older adults, as lack of sleep can contribute to irritability, mood disorders, and cognitive impairment.

Which Came First?

It is a bit of a chicken-and-egg situation when it comes to sleep and mental health. Poor sleep can negatively impact mental health, and poor mental health can cause or exacerbate problems sleeping. While the relationship between sleep and mental health is complex, evidence indicates that restorative sleep is associated with better mood, a greater ability to focus, and a desire to engage and socialize. At the same time, lack of restorative sleep has been linked to greater psychological distress and higher rates of anxiety and depression.

Some common myths can prevent interventions to help older adults get sleep that contributes positively to their mental well-being. These include the misconception that older adults need less sleep than their younger counterparts and the myth that frequent nighttime waking is normal as people age. Some people even believe that sleep disorders like insomnia and sleep apnea are a natural part of aging, because they occur at greater frequency in older adults. Daniel Haimowitz, MD, FACP, CMD, FPALTC, a Pennsylvania-based gerontologist and medical director, notes that while it can be more difficult for older adults to get a good night’s sleep, it is important for the care team to take steps that enable all individuals to get adequate rest.

Partially due to these myths, older adults may not report sleep problems, so the care team needs to ask questions and listen to what people are saying. This includes asking how much sleep they are getting on an average night, if and when they wake up during the night, if they have problems falling asleep, and if they feel tired during the day. There are also a number of questionnaires that can help evaluate sleep and circadian health. For instance, the Functional Outcomes of Sleep Questionnaire, Pittsburgh Sleep Quality Index, and Sleep Quality Scale can help assess dimensions of sleep. Excessive daytime sleep may be detected via the Epworth Sleepiness Scale and Stanford Sleepiness Scale. The Insomnia Severity Index is used to assess insomnia, and various tools—from the Sleep Disorders Questionnaire and OSA50—can help identify possible sleep apnea.

Not All Sleep Is Created Equal

Demetra Antimisiaris, PharmD, BCGP, FASCP, associate professor emerita at the University of Louisville, observes that even when older adults sleep, it may not be restorative. She explains, “Sleep consists of four main stages, and we cycle in and out of these while we sleep. Stage three is long wave, or deep, sleep, and that’s when your body regenerates the neurotransmitters you need. This and stage four, rapid eye movement (REM) sleep, are restorative.” However, she says, “As we get older, the cycles of stage three and four sleep are shorter, so we don’t get as much restorative sleep.”

Nonetheless, because they are sleeping, older patients may not think about reporting any problems. Instead, notes Dr. Antimisiaris, they may attempt to self-medicate with something like alcohol or over-the-counter products that actually lead to less restorative sleep.

Since people may not realize or report sleep problems, staff can watch for signs that residents aren’t sleeping well and that this may be affecting their mental well-being. These include:

• Yawning, lethargy, and even falling asleep during the day
• Sudden or growing irritability, short temper, anxiety, or anger
• Crying and/or sadness
• Lack of interest in activities and engagement, especially regarding things they used to love; or general social withdrawal
• Cognitive slowing, forgetfulness and/or confusion

“The only real way to get back to restorative sleep is to practice sleep hygiene and foster conditions that trigger the natural chemicals, namely melatonin, that help move us into stage three and four sleep,” says Dr. Antimisiaris. Sleep hygiene, habits, and behaviors that contribute to quality sleep include some basics, such as keeping a consistent sleep schedule, not napping during the day, getting some daytime exercise (even 10 minutes of walking can help), limiting caffeine intake (especially late in the day), going to bed only when you are tired, and avoiding large evening meals or late-night snacking.

Another aspect of sleep hygiene to keep in mind is light exposure. Getting sufficient light in the early hours of the day triggers wakefulness hormones and suppresses sleep-inducing hormones like melatonin, while avoiding electronic devices at bedtime is critical for improved sleep. Having a relaxing bedtime tradition is important, although this may differ significantly from person to person.

Ensuring appropriate sleep hygiene, especially in a way that promotes mental well-being, requires a person-centered approach, Anna Fisher, RN, PhD, a Nebraska-based clinician and educator, stresses. “You need to know what comforts and calms someone. Some individuals like to sleep with a light or a fan on at night. Some find the background noise of a TV or radio comforting. Music may be relaxing to some people, while others like things to be perfectly quiet when they go to bed,” she says.  “We need to know what type of relaxation technique resonates with each person, then provide it to the best of our ability.”

It is important to understand that “bedtime” means different things to different people. For instance, some people like to stay up late and watch TV or read. Others prefer to retire early and go right to sleep. These individuals, says Dr. Haimowitz, should be able to go to bed and wake up when they want to. This also means, whenever possible, not waking them up to take medications and not making them eat breakfast at a specific time. These interruptions not only negatively impact sleep, but they also can contribute to agitation, frustration, and irritability, when individuals feel like they lack control and that their preferences are ignored or disrespected.

Understanding Underlying Causes

There are many possible causes of sleep problems. For instance, for new residents, the change in their living situation may be disrupting their sleep, as well as contributing to mental health issues such as anxiety and depression. A new bedroom, a strange bed, different sounds and smells, and other elements can make it hard to go to sleep or stay asleep; and this change—along with problems sleeping—can contribute to depression, anxiety, cognitive changes, and self-imposed isolation.

Dr. Haimowitz suggests working with the family up front to identify ways to make their loved one feel more comfortable and sleep better in their new home. This might mean favorite pillows and/or blankets, a sound machine or radio they used at home to help fall asleep, or a nighttime cup of chamomile tea as they have always had. If the person was used to sleeping with a pet, a lifelike stuffed animal or a mechanical one that simulates breathing or purring might help them relax and fall asleep.

Understanding the person’s background can also help identify causes of sleep issues. For instance, a past trauma may make it upsetting for someone to be awakened at night or to be in the dark. If a person is having nightmares, night terrors, or similar problems, a psychiatric evaluation may be useful. “Any type of past trauma can strongly influence how safe a person is going to feel at night. If something triggers their fears and anxiety, they may not want to go to bed; or if they get to sleep and a loud noise or something else awakens them abruptly, it may be especially upsetting to them,” says Dr. Fisher. She also stresses the importance of assessing for pain, as this can impact both mental health and sleep.

Several medications can negatively impact sleep. They may cause insomnia, altered sleep cycles, or even vivid dreams or nightmares. Among the most common contributors are corticosteroids such as prednisone or oral steroids, cholinesterase inhibitors, statins, opioids, stimulants such as amphetamines and methylphenidate, pseudoephedrine, and other medications with stimulant properties. These medications can affect sleep in various ways. They can alter neurotransmitters that regulate sleep-wake cycles, reduce deep sleep cycles, or cause side effects—such as pain, coughing, or nausea—that make it difficult to sleep.

Even alcohol or over-the-counter medications for sleep, such as diphenhydramine (found in products like Tylenol PM®), are not recommended for use in older adults due to anticholinergic properties, which can negatively alter sleep cycles; the perception is that these products are helping sleep when, in reality, restorative sleep is impacted. “As there are so many medications that can interfere with sleep, it is worth having the pharmacist conduct a medication review of anyone who is having sleep issues,” says Dr. Antimisiaris.

Mental illness or issues can also disrupt sleep patterns and cause poor sleep. For instance, schizophrenia often causes insomnia or hypersomnia and circadian rhythm disturbances. These issues may appear even before the person is diagnosed. People with this illness may also exhibit restless leg syndrome, sleep apnea, or narcolepsy.

Depression negatively impacts sleep, often causing insomnia or hypersomnia. Depression, anxiety, and post-traumatic stress disorder (PTSD) are associated with frequent nightmares, with up to 70% of people with one of these conditions reporting chronic bad dreams. Therefore, it is important to determine if someone has a mental illness diagnosis that might be affecting their sleep. However, Dr. Haimowitz stresses the importance of digging into the underlying causes of sleep disturbances and not making assumptions.

Identifying the root causes of the sleep issue can help determine the appropriate intervention. It might actually be something fairly simple. As Dr. Fisher says, “It could be light and noise in the hall at night, and it’s waking someone up; or maybe their bed is uncomfortable, or their pajamas aren’t fitting right. Once we know why someone is having trouble sleeping, we can address it in a person-centered way and contribute to their quality of life, as well as their physical and mental health.”

Beyond Sleep Hygiene

In addition to sleep hygiene, there are other nonpharmacologic interventions for sleep issues, even when the person has a concomitant mental health issue. For instance, Cognitive Behavioral Therapy, an evidence-based psychotherapy approach designed to help people identify and change thoughts and behaviors, can help improve sleep quality and reduce mental health symptoms.

While there are medications that can help promote sleep, Dr. Antimisiaris says, they should only be used when nonpharmacologic interventions have failed. “There are really only two sleep medications—mirtazapine and temazepam—that are recommended for use in older individuals, and these should be started on a trial basis and carefully monitored. They should be used in the lowest effective dose and for as short a period as possible,” she explains. Over-the-counter products such as melatonin may be helpful, she says, but they should be used cautiously as well, and individuals should consult a clinician before taking anything to help them sleep.

Joanne Kaldy is a freelance writer living in New Orleans, LA.