Prime Time

POSTED: Sunday, Jan. 25, 2009

Sleepless in seniority: Some live with disorders for decades before seeking medical care

It was the sight of the tree coming toward her that made Penny Schons realize her future depended on getting a better night's sleep.

Schons, now 64, had battled fatigue for years. She'd often dozed off grading papers during her years as an elementary school teacher in Sedro-Woolley, and lately it was becoming difficult to even read or watch television at night without dropping off.

It's all part of getting older, she figured.

That was until Mother's Day, 2005, when Schons drifted off to sleep while driving home through Newhalem and woke up as her car was heading toward a tree. Luckily, she wasn't going very fast, she says, and was able to avoid it.

But she couldn't avoid the reality that her problems staying awake were more than just a nuisance.

"It was a very scary experience," Schons says. "I decided I had to get some help."

STRUGGLING WITH SLEEP

People often live with sleep disorders for decades before seeking medical care, says Dr. Murali Maheswaran, director of sleep medi-cine at Skagit Valley Medical Center. They assume symptoms like hypertension, depression, heart trouble, obesity, joint pain, acid re-flux, anxiety, memory loss, fatigue and poor sleep itself are simply signs of advancing age.

"Unfortunately, people don't realize the symptoms and problems they have during the day are connected to everything that happens during the night," Maheswaran says.

Many seniors believe the old wives' tale that older people need less sleep, says Dr. Zachary Webb,director of sleep medicine at North-Star Medical Specialists in Bellingham. But new studies suggest that older folks need the same amount of sleep as adults, he says, about seven-and-a-half to eight hours per night.

Studies show many people are struggling with sleep disorders without realizing it, says Dr. Francisco Vega, medical director of the sleep center at Island Hospital in Anacortes.

A recent annual poll by the National Sleep Foundation found that about two-thirds of Americans have symptoms of a sleep problem like insomnia or sleep apnea, he says, but fewer than 10 percent had actually been diagnosed with a disorder.

People function so long with sleep disorders that they often think the experience is normal because they don't have anything to com-pare it to, Maheswaran says. They're also often hereditary; Schons, looking back, thinks her father had the same symptoms.

'YOU'RE KIND OF TORTURED'

Schons' physician in Omak, where she lived at the time, diagnosed her with sleep apnea, a breathing disorder in which the airway col-lapses during sleep, cutting off oxygen to the brain and forcing her to wake up over and over during the night to regain her breathing.

Sleep apnea, one of the most common of dozens of sleep disorders, usually comes with loud snoring, punctuated by long pauses in breathing. Even if they've slept all night, people with sleep apnea can feel like they've hardly slept at all, groggy from a night of their brain being yanked out of the kind of "slow-wave" sleep the body needs to feel rested, says Dr. Robert Price, medical director of the Sleep Disorders Center at United General Hospital in Sedro-Woolley."You're kind of tortured by that inability to get slow-wave sleep," Price says of those who suffer from sleep apnea.

Schons was afraid to drive long distances again until she felt confident she could stay awake behind the wheel. And if she wanted to see her daughters in different parts of the state, she had to do something.

"One of the most frustrating things for me was, as a widow, how am I going to manage this if I can't actually drive?" Schons says, "be-cause I can't expect my children to handle all of it."

But people with sleep apnea there are not just tired. They're are also more prone to heart disease, high blood pressure and stroke, Price says.

Sleep apnea has such a dramatic impact on the brain, Vega says, that stroke patients who have it - and many do - typically have a better recovery if they're also treated for sleep apnea.

Sleep apnea also raises the body's resistance to insulin and glucose levels and hinders the natural appetite suppression system, says Vega, which altogether can exacerbate obesity and diabetes.

A BETTER NIGHT'S SLEEP

But while sleep disorders can make other health problems worse, getting a better night's sleep can also make them better, as Schons found.

Soon after her diagnosis, Schons began sleeping with a mask attached to a Continuous Positive Airway Pressure machine, which keeps air flowing through her airway at night. It also creates some white noise that helps her sleep away from home, she notices.

After several months, she was able to cut back on one of her three blood pressure medications, one that kept her heart rate low even when she was exercising. Even though she walked regularly, she hadn't been able to lose weight.

But without that medication, which she dropped after consulting with her primary care physician, she's been able to lose some weight, she says. Another payoff: Losing weight can help alleviate her sleep apnea.

"Now, my blood pressure is pretty well under control, almost all the time," Schons says.

Terri Gotelaere, manager of the Sleep Disorders Center at United General, has seen it happen before. Patients often see their high blood pressure drop after they begin treatment for sleep apnea, she says, which can lead to a reduction in their blood pressure medica-tion. She's also seen people who no longer need anti-depressants.

People are glad to cut back on their pills, Gotelaere says. But they're really glad to regain some activity in their lives, she says.

"If it's an exercise program or just walking around with their grandkids," Gotelaere says, "it makes their day because they're exercis-ing again."

But while sleep apnea is one of the most common sleep disorders, it's not the only one. In fact, there are over 90 sleep disorders.

Sometimes, people have more than one sleep problem, Maheswaran says. They may think they have insomnia because their mind seems to race at night, but actually they're kept awake by an uncomfortable, restless feeling in their arms and legs. Not necessarily the twitchy, whole-body jerk some people experience as they're dropping off to sleep, but more of a fidgety, itchy or even burning feeling.

"A lot of times, they can't even describe it," Maheswaran says. "They just know it's uncomfortable."

LYING AWAKE

Chronic insomnia is the most common sleep disorder that affects seniors. About one-third of people over the age of 65 have chronic insomnia, Webb says.

Insomnia is caused by poor sleep habits, Webb explains. Napping during the day and following irregular bedtime and waking hours, for example, can throw off a person's sleep schedule. These irregular sleep cycles tend to occur after people retire and start sleeping in because they no longer have to get up for work at a certain time every morning.

Also, drinking alcohol, caffeine or using nicotine can cause insomnia, Webb says. For most people, one alcoholic drink with dinner is okay, but for others, just one cocktail can affect sleep. Alcohol acts as a sedative that initially causes people to feel drowsy, but leads to lighter sleep in the second half of the night.

People who deal with chronic insomnia can worsen the problem by spending more time lying awake or watching TV in bed when they can't sleep, which leads to negative conditioning to be awake in bed, Webb says. It creates a habit of being awake in bed and associating the bedroom with being alert, he explains.

Medical conditions, such as heart disease, gastrointestinal and prostrate problems, can also cause insomnia, as can psychiatric disor-ders, such as depression and anxiety, he says. Insomnia can also be a side effect of some medications, such as blood pressure and diu-retic medications, as well as antidepressants, Webb says.

"But they are not strong inducers of insomnia, and I wouldn't recommend going off them" without consulting with your physician, he adds.

Lack of exercise is another cause of insomnia. While it's not known why this is true, studies show getting exercise improves sleep quality, Webb says.

Additionally, other sleep disorders, such as sleep apnea, restless leg syndrome, periodic limb movement disorder, and rapid eye movement (REM) sleep behavior disorder can lead to insomnia as a side effect, Webb says.

'WORRIES ARE WORSE AT NIGHT'

It's important to deal with insomnia because it has been shown to reduce quality of life in those who experience it chronically, Webb says. Insomnia is associated with an increased risk for depression, an increase in falls and reduced cognitive ability. Studies also suggest it can contribute to cardiovascular disease and weight gain.

For those who experience insomnia, there are several treatment options. Webb says he prefers to begin with behavioral modifications before trying medications.

First, treating any medical problem that is contributing to the insomnia is necessary. Then he recommends insomniacs change their daily behaviors that lead to sleeplessness. Avoid or decrease napping during the day, avoid or limit alcohol, tobacco or caffeine in the afternoon and evening, and try to exercise (but not within four hours of bedtime), he suggests. Insomniacs should also stop or limit fluid intake within four hours of bedtime so they won't need to get up during the night to use the bathroom.

At bedtime, insomniacs should be sure they keep a regular sleep-wake cycle seven days a week, meaning they go to sleep and wake up at the same time every day, he says. He also recommends people limit their bedroom activities to sleep and intimacy only, in order to avoid negative conditioning.

If people must read in bed before lights out time, limit reading time to 10 minutes, he says. And try not to watch TV in bed, as well. Keep the bedroom dark, cool, and quiet, and don't watch the clock while you are trying to fall asleep. If a person can't fall asleep within 20 minutes, the best thing to do is get out of bed, go into another room and either watch TV or read until they are drowsy again, Webb says.

For some people, Webb recommends using medications to treat insomnia. And while some people use over-the-counter sleep aids, Webb says these probably aren't the best choice for older adults because they generally include an antihistamine with potential side effects of confusion, constipation, urinary retention and dry mouth. If necessary, there are certain prescription medications that can be used for older adults, he says.

To prevent insomnia altogether, Webb recommends using the same behavioral modifications. "Tips for treating the problem also help it from starting," he says.

He also recommends that people in general should try not to bring their worries to bed. "If you do, realize that worries are worse at night," he says. As a solution, Webb suggests people instead make a to-do or "concerns" list to deal with the following day.

45 TIMES AN HOUR

Sleep problems tend to get worse - or just more noticeable - as people age, Maheswaran says. People who power through their workdays with caffeine and deadlines may realize only after they retire that they're exhausted. And the hormonal changes that come with menopause can also bring on insomnia and sleep apnea.

Plus, says Price, we simply lose the ability to drop into that deep, slow-wave sleep as we get older.

Treatment depends on what the problem is. Medication can quiet the symptoms of restless leg syndrome. But, like Webb, Mahes-waran says cognitive behavioral therapy is actually a better bet for insomnia that isn't accompanied by other sleep disorders.. Sleeping pills can help put people to sleep for a while, he says, but they can't solve the underlying problem of what's keeping people awake.

And studies show that sleeping pills tend to lose their effectiveness after a few months, Vega says.

Price sometimes puts people with insomnia on something of a sleep diet, delaying their bedtime until they really are sleepy, then gradually moving bedtime earlier as they become better sleepers.

The most common treatment for sleep apnea, the air pressure machine, takes a little getting used to, says Tom Petruzzi, who's been using one since March. But it's worth it, he says.

'HOW I FELT'

Petruzzi, a 70-year-old retired bank executive from Camano Island, used to snore so badly - and stop breathing so often - his wife used to shake him awake. He'd wake up in the morning feeling as tired as he was the night before, but tossing and turning at night didn't feel like a serious-enough medical problem to seek help.

But the problem grew worse, until he had insomnia, too: He was sleeping only a couple of hours a night.

So when he heard Maheswaran speak about sleep disorders at the senior center on Camano Island last year, Petruzzi was ready to lis-ten.

"He was basically describing how I felt," Petruzzi says, "without knowing me."

The proof came when Petruzzi spent the night at Skagit Valley Hospital for a sleep study. As Petruzzi slept, technicians kept track of his breathing, blood oxygen levels and movements in his eyes and limbs.

Afterward, Mahewaran asked Petruzzi to guess how many times he had stopped breathing for 10 seconds or longer that night. Two or three, Petruzzi guessed.

Maheswaran told Petruzzi he had stopped breathing 45 times an hour. Each time, his brain roused from sleep to restart his breathing and keep him alive.

Petruzzi was astonished. He suspects the sleep apnea likely contributed to his vascular disease. He had had a heart attack and bypass surgery at age 47.

At first, Petruzzi balked at the idea of wearing a mask to bed, but he agreed to try it. He was surprised that even the first night felt like the best sleep he'd had in 30 years.

His wife doesn't seem to mind the sound of the machine and the rushing air, he says.

"I think it's probably better than hearing a whole lot of snoring," he says.

Mary Lane Gallagher is a Bellingham freelance writer and former reporter for The Bellingham Herald.

Heidi Schiller is a Seattle freelance writer and journalism graduate of Western Washington University.