Sleep Changes in Older Adults and At the End of Life

Sleep is integral to good health, proper functioning, and quality of life throughout your lifespan. While maintaining proper sleep habits and sleep quality is a common concern for parents of small children, as well as for busy students and working adults, it is commonly observed that sleep patterns tend to shift as one age. At the end of life, sleep can often be dramatically affected, which can raise concerns for loved ones and those providing care.

Normal sleep and sleep changes across the lifespan

Although a comprehensive accounting of the physiological purposes of sleep is still somewhat elusive, sleep has at least two distinct purposes – that of physical and mental restoration. This happens via a progression through a nightly sequence of uninterrupted sleep stages that take place over an adequate sleep duration (typically six to eight hours for an average human being).

In order to understand how sleep changes across the lifespan and how it presents at the end of life, it’s good to begin by reviewing the stages of normal sleep.

The first is Stage 1, or transitional sleep – when you’re feeling drowsy. This is generally nonrestorative and a stage from which you are easily woken. It tends to be one of the shortest of the sleep cycles.

Stage 2 is light sleep – somewhat more restorative, and the repeated sleep stage we spend most of our time in across a consolidated sleep period.

Stage 3 is also called slow wave sleep (SWS) – due to the characteristic pattern on an EEG and which is thought to be the most physically restorative of all the sleep stages (e.g., where high levels of human growth hormone production and metabolism occur).

Stage 4 sleep is also called rapid eye movement, or REM sleep – and is typically where dream activity occurs. Also, notably, this is where the EEG characteristically looks most like wakefulness – where the brain is most active and is thought to be the time where mental and cognitive restoration (memory consolidation, etc.) occur.

As we age, a couple of things tend to happen:

1. Our sleep architecture tends to fracture, with more nighttime awakenings.
2. The amount of time spent in SWS & REM sleep tends to decrease, while the amount of time in Stages 1 and 2 tends to increase.

Van Cauter and Plat in their sample of 149 healthy adults noted that the mean percentage of time spent in SWS for younger adults (ages 16 to 25) is 18.9%, but then decreases to 3.4% as we age (36 to 50 years). They noted no further decrease in SWS into old age (e.g., 71 and up), which is a typical pattern – and they also noted further degradation of sleep quality with older adults in time spent awake (e.g., intra sleep arousals) – which caused further declines in REM sleep.

Ironically, as we age, while we may have more time to sleep (due to decreases in responsibilities with children being grown, and being retired from work), a good night’s sleep becomes a more difficult task to accomplish.

Sleep at the end of life: various examples

The last six months of life are difficult to encapsulate in terms of succinctly characterizing what happens with sleep, as it’s very much dependent on what the end-of-life causes might be.

For example, in advanced kidney disease, a heterogenous picture tends to emerge, where increases in the rates of sleep apnea (a specific type of sleep disordered breathing), periodic limb movement disorder / restless leg syndrome, and insomnia are common , and are thought to be connected to some complex chemical mechanisms associated with, among other things, chronic hyper- or hypouricemia.

In end-stage Chronic Obstructive Pulmonary Disease (COPD), severe insomnia and agitation secondary to anxiety and depression are common – which makes intuitive sense given the fact restricted breathing (e.g., the feeling of suffocation) is a key characteristic of COPD.

In advanced dementia, sleep tends to be extremely fractured, with what seems at times to be no apparent sleep cycles evident. Unlike people who are cognitively intact, people with advanced dementia don’t tend to respond well to normal sleep-wake cues, like sunlight, which tends to promote melatonin production, or to other environmental cues (called zeitgebers), like clocks on the wall, bathing in the morning, or eating dinner. Also, the phenomenon of sundowning can occur (also known as nocturnal confusion), which is the characteristic increase in confusion and agitation that commonly begins in the evening and can complicate bedtime routines.

Management of sleep problems at the end of life

Specific medical management of sleep problems is very much dependent on the types of medical issues at play. A common issue in late life is sleep disordered breathing (apnea) – typically treated with positive airway pressure, such as with a CPAP or BIPAP machine.

In end-stage COPD, air hunger (which can exacerbate anxiety and lead to insomnia) is often treated with low-dose opioids, which mildly suppresses the sensation of obstructed breathing, and can increase comfort.

In end-stage kidney disease, a variety of methods of managing the hyperuricemia or other metabolic derangements are potentially useful ways to improve sleep quality.

In end-stage dementia where sundowning and highly disordered sleep-wake cycles are seen, careful use of antipsychotic medications or other sedative agents are used. However, because of side effects, these are used sparingly.

These and other medical / medication management approaches aside, there are several nonpharmacological approaches that are potentially effective despite the presence of advanced dementia or some other end-of-life condition.

These include the promotion of sleep hygiene, which refers to things like having a routine bedtime, avoiding caffeine before bed, a television in bed, or stressful activities before bed. Light therapy can be helpful, which can be applied with the use of commercially available lightboxes, or by taking care to get direct exposure to sunlight in the mornings for at least a half hour to an hour per day.

At the very end of life, keep in mind that sleep eventually becomes much more about conservation (as opposed to restoration). This is a natural part of the dying process. Taking care to understand that comfort for both the care recipient and the family member is, in this author’s professional opinion, of the greatest importance at this stage.