This is the second of a nine-part print and online series looking at the science of sleep and the vital role of sleep in maintaining overall health.
There's a reason no one ever wakes up after a restful night in bed and says: "I slept like a senior citizen."
As people age, their ability to get a good night's sleep becomes more elusive. And, to add insult to injury, those who might have reached for a sleeping pill to get through the night when they were younger are no longer good candidates for doing so after age 65 or 70.
"There's no question that sleeping pills that are prescribed or taken over the counter are more hazardous to the senior population," said Rachel Morehouse, a psychiatrist and the medical director at Saint John Regional Hospital's Atlantic Sleep Centre in New Brunswick.
The most common over-the-counter sleep medicines, including Tylenol Nighttime and Benadryl, contain the sleep-inducing ingredient diphenhydramine hydrochloride. According to Ariel Green, a geriatric health specialist at Johns Hopkins University School of Medicine in Baltimore, Md., these readily available drugs can cause dizziness, confusion, urinary retention, constipation and dry mouth. Their effects can be more pronounced in older people because they're more likely to have sluggish metabolisms, low body weight and other medical issues, plus interactions with drugs they're already taking to treat those other issues. Even more worrisome, the side effects are often ignored because people mistake them for general problems related to getting older.
The most common prescription sleeping pills are benzodiazepines, also known as the "pam" drugs, such as lorazepam and diazepam. In the 1980s new nonbenzodiazepine "z drugs," such as zopiclone, were marketed as having fewer side effects and being less likely to cause dependence. But they're still risky, especially for seniors.
The biggest risk, according to Dr. Morehouse, is falls.
"Getting up to go to the washroom becomes more common as you get older," Dr. Morehouse said. "And if you've got a sleeping medication on board, and maybe you have trouble with vision and walking generally, that causes you to fall. Then, because you have osteoporosis, you break something and end up in the hospital. Then a whole host of bad things can happen."
Despite the recognition within the medical community that sleeping pills are not ideal for seniors, nearly one-third of people older than 65 in the United States take sleeping pills – both prescription and over-the-counter – according to Choosing Wisely, a U.S. educational initiative led by the American Board of Internal Medicine.
Carolynne Boivin, a 73-year-old who splits her time between Toronto and Thornbury, Ont., has seen the quality of her sleep deteriorate over the past 10 years. Her doctor prescribes her 40 zopiclone a year, and she is aware of the risks of using them too frequently.
"If I could, I would use one every night, but I know that's not the right thing to do," said Ms. Boivin, who has trouble falling asleep and staying asleep several times a week. "I'm a little bit paranoid about becoming dependent on them."
She has tried melatonin, a hormone that can be taken orally to improve sleep, with little effect. Ditto for natural powders and drinks suggested by her daughter-in-law. She has also taken a yoga class focusing on how to get better sleep and does concentration exercises in bed at night – such as counting backward from 100 by 3s.
"If I can become better at concentrating, then, in the middle of the night when I'm awake, I can focus and eliminate some of the mind chatter and get back to sleep faster," Ms. Boivin said. "But usually by the time I'm at 91, my mind is off on a tangent."
Dr. Green, who says she "hates sleeping pills," would agree that Ms. Boivin is on the right path with her non-medicinal attempts at sleep. Dr. Green counsels her senior patients to try lifestyle changes as a first line of offence, such as being as active as possible during the day, seeking exposure to sunlight, limiting alcohol and not falling asleep watching television. She is also a great believer in cognitive behavioural therapy for insomnia, which she said has been shown to be as effective as medication for people who are willing to seek out a therapist and practice this particular brand of talk therapy.
Dr. Green prescribes sleeping pills only as a very last resort. When she does, her mantra is: "The lowest dose possible for the shortest amount of time possible."
"Sometimes there are reasons why we may feel we have to accept the potential risks of prescribing sleeping pills, because the benefits may outweigh them," Dr. Green said. "But it's really rare for my patients that we can't avoid prescribing them."