Age Wise: Aging Well by Sleeping Well

M aurice Ohayon and colleagues have reported elsewhere in this issue of the Journal of the American Geriatric Society the results of a cross-sectional telephone survey in over 13,000 subjects age 15 and over in the United Kingdom, Germany, and Italy. The authors observed that insomnia symptoms were reported by more than one-third of respondents age 65 and older but that multivariate models suggested that age per se was not a predictive factor of insomnia complaints after controlling for activity status and satisfaction with social life. Lower levels of social activity and dissatisfaction with life predicted the presence of insomnia complaints. By contrast, level of activity and social interactions had no influence on napping, although increasing age itself was positively associated with napping. The authors conclude that aging per se cannot be considered as predictive for insomnia in older people. Rather, sleep quality in later life is clearly influenced more directly by engagement in life and life satisfaction. If you are old and want to sleep well, stay busy, engaged, and happy during the day. We believe that this report makes a conceptually useful and clinically valuable contribution to our understanding of aging and sleeping. The key observation is that insomnia complaints in later life are more likely in the context of social withdrawal, disengagement, and dissatisfaction with the social aspects of quality of life. The author’s findings lead them to downplay the extent of aging’s direct contributions to sleep complaints, other than noting the greater proclivity of older people to take naps. We have a different perspective on their data; we believe that the relation between sleep and health in later life is bidirectional, not unidirectional. Poor sleep is certainly the consequence of declining physical and mental health. Indeed, such declines may lead to social withdrawal and life dissatisfaction, which may lead to still poorer sleep, but declining sleep quality itself is also antecedent to diminished adaptation in the final years of life. Hoch et al. 1 observed superior sleep quality in a group of very old nuns who had remained engaged in their vocations and who restricted time in bed by 30 to 45 minutes nightly, as compared with an age-equated group of retired, nonreligious women, whose life styles were much less regular. This observation leads us to believe that continuing engagement in life, coupled with stabilizing and curtailing time in bed, is itself associated with better sleep quality. The bidirectional nature of the sleep/health relation is further underscored by a study from Dew et al., 2 who observed that inefficient sleep (i.e., sleep disrupted by insomnia) predicted future declines in subjective sleep quality, fewer regular social activities, higher depressive symptoms, and higher chronic medical burden scores at 1-year follow-up. Poor sleep quality may be the antecedent of diminished activity levels and life satisfaction, as well as being the consequence of them. Age well by sleeping well. So, how does one sleep well in old age? It is important to keep in mind that Ohayon and colleagues are reporting insomnia complaints and not physiological measures of sleep. The continuity and depth of sleep, even in healthy, successfully aging people, deteriorates with age, especially after age 75: 3 an effect of age in addition to declining cognitive status and increasing chronic medical burden. People age 75 and older are especially vulnerable to age-related decay in sleep efficiency. Sleep quality can be protected in later life, however, and this may work to the benefit of continued successful aging and to the compression of functional morbidity. A yearlong program of modest restriction of time in bed (i.e., going to bed 30 minutes later than usual each night), coupled with coaching in healthy sleep practices, led to sustained improvement in polysomnographic measures of sleep continuity and depth—those aspects of sleep most vulnerable to disruption in later life. 4 Age-related declines in sleep continuity and depth can be slowed, maybe even reversed. Here is the hypothesis begging to be tested: Better sleep leads to better functioning in old age, prolonging a successful trajectory of aging and foreshortening functional morbidity. Geriatric medicine and psychiatry should actively pursue this hypothesis within the matrix of the very challenges faced by our older patients themselves, as they confront bereavement, caregiving, chronic medical illness, and the uncertainties of the final years of life. Can one age well by sleeping well? We predict that the answer will be yes, notwithstanding all the ills that flesh is heir to.