SLEEP IN MIDLIFE AND OLD AGE - PART 2

The third sleep change with advanced age is that of circadian timing.


In sharp contrast to adolescents, seniors commonly experience a regression in sleep timing, leading to earlier and earlier bedtimes.


The cause is an earlier evening release and peak of melatonin as we get older, instructing an earlier start time for sleep.

Restaurants in retirement communities have long known of this age-related shift in bedtime preference, epitomized (and accommodated) by the “early-bird special.”


Changes in circadian rhythms with advancing age may appear harmless, but they can be the cause of numerous sleep (and wake) problems in the elderly. Older adults often want to stay awake later into the evening so that they can go to theater or the movies, socialize, read, or watch television.


But in doing so, they find themselves waking up on the couch, in a movie theater seat, or in a reclining chair, having inadvertently fallen asleep mid-evening. Their regressed circadian rhythm, instructed by an earlier release of melatonin, left them no choice.


But what seems like an innocent doze has a damaging consequence. The early-evening snooze will jettison precious sleep pressure, clearing away the sleepiness power of adenosine that had been steadily building throughout the day. Several hours later, when that older individual gets into bed and tries to fall asleep, they may not have enough sleep pressure to fall asleep quickly, or stay asleep as easily.


An erroneous conclusion follows: “I have insomnia.” Instead, dozing off in the evening, which most older adults do not realize is classified as napping, can be the source of sleep difficulty, not true insomnia.


A compounding problem arrives in the morning. Despite having had trouble falling asleep that night and already running a sleep debt, the circadian rhythm operates independently of the sleep-pressure system and it will start to rise around four or five a.m. in many elderly individuals, enacting its classic earlier schedule in seniors.


Older adults are therefore prone to wake up early in the morning as the alerting drumbeat of the circadian rhythm grows louder, and corresponding hopes of returning back to sleep diminish in tandem.


Making matters worse, the strengths of the circadian rhythm and amount of nighttime melatonin released also decrease the older we get. Add these things up, and a self-perpetuating cycle ensues wherein many seniors are battling a sleep debt, trying to stay awake later in the evening, inadvertently dozing off earlier, finding it hard to fall or stay asleep at night, only to be woken up earlier than they wish because of a regressed circadian rhythm.


There are methods that can help push the circadian rhythm in older adults somewhat later, and also strengthen the rhythm. Here again, they are not a complete or perfect solution, I’m sad to say.

Evening light suppresses the normal rise in melatonin, pushing an average adult’s sleep onset time into the early-morning hours, preventing sleep at a reasonable hour.


However, this same sleep-delaying effect can be put to good use in older adults, if timed correctly. Having woken up early, many older adults are physically active during the morning hours, and therefore obtain much of their bright-light exposure in the first half of the day. This is not optimal, as it reinforces the early-to-rise, early-to-decline cycle of the twenty-four-hour internal clock.

Instead, older adults who want to shift their bedtimes to a later hour should get bright-light exposure in the late-afternoon hours. I am not, however, suggesting that older adults stop exercising in the morning. Exercise can help solidify good sleep, especially in the elderly. Instead, I advise two modifications for seniors.


First, wear sunglasses during morning exercise outdoors. This will reduce the influence of morning light being sent to your suprachiasmatic clock that would otherwise keep you on an early-to-rise schedule. Second, go back outside in the late afternoon for sunlight exposure, but this time do not wear sunglasses.


Plentiful later-afternoon daylight will help delay the evening release of melatonin, helping push the timing of sleep to a later hour. Older adults may also wish to consult with their doctor about taking melatonin in the evening.


Unlike young or middle-age adults, where melatonin has not proved efficacious for helping sleep beyond the circumstance of jet lag, prescription melatonin has been shown to help boost the otherwise blunted circadian and associated melatonin rhythm in the elderly, reducing the time taken to fall asleep and improving self-reported sleep quality and morning alertness.

The change in circadian rhythm as we get older, together with more frequent trips to the bathroom, help to explain two of the three key nighttime issues in the elderly: early sleep onset/offset and sleep fragmentation.


They do not, however, explain the first key change in sleep with advancing age: the loss of deep-sleep quantity and quality. Although scientists have known about the pernicious loss of deep sleep with advancing age for many decades, the cause has remained elusive: What is it about the aging process that so thoroughly robs the brain of this essential state of slumber? Beyond scientific curiosity, it is also a pressing clinical issue for the elderly, considering the importance of deep sleep for learning and memory, not to mention all branches of bodily health, from cardiovascular and respiratory, to metabolic, energy balance, and immune function.


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Coach HB

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