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Improving Sleep Quality in Older Adults with Non-drug Approaches

Dementia Prevention

Sleep

A paper published by Mind Science Centre found that community-based activities including tai chi, mindfulness practice, art therapy, and music reminiscence therapy improved overall sleep quality and decreased sleep disturbances in older adults (Rawtaer, 2018).

Sleep issues in the Elderly

Poor sleep quality is quite commonly reported in older adults. After all, ageing is associated with changes in sleep physiology. Older adults have increased risk of physical and psychological ailments including depression and anxiety which also may lead to sleep difficulties.

While common, it is not to be disregarded. Poor sleep quality is associated with adverse consequences including poorer quality of life, cognitive and physical decline, as well as increased risk of depression and falls.

Learn more from three experts: Prof Kua Ee Heok, A/Prof Tan Chay Hoon, and Dr Yap Kai Zhen as they discussed the topic of sleep issues in elderly in our recent webinar on Memory & Medications.

Are sleeping pills the only solution for sleep issues?

Often, people turn to sleeping pills to help get some shut eye. As noted by A/Prof Tan Chay Hoon, “Many eldery people have sleeping problems and many of them take sleeping pills.”

This, however, is not a sustainable solution. Long-term use of sleeping pills may lead to tolerance or dependence, leading to rebound insomnia when one stops taking the medication. Past research also reported residual daytime sedation, cognitive impairment, and increased risks of falls in those who continually use sleeping pills (Rawtaer, 2018).

Adding on, Dr Yap Kai Zhen mentioned, “It is important to not use over-the-counter treatment for sleep issues as they may have other side-effects.”

Dr Yap explained that sleeping issues may stem from other underlying medical conditions. Therefore, it is a good idea to seek medical attention to treat the underlying cause rather than resorting to over-the-counter drugs.

What about melatonin?

Melatonin is a hormone that naturally exists in our brain. It is produced as a response to darkness and helps mediate your circadian rhythms (internal clock) and sleep.

There are many kinds of melatonin supplements available over the counter, with varying doses. A/Prof Tan mentioned that if all non-drug approach does not work for you, you can try melatonin supplements. However, it is important to always be careful and aware of what is advertised and to pay close attention to the side effects.

Non-drug approaches should be the first line of defence

Prof Kua, A/Prof Tan, and Dr Yap all highlighted that in terms of helping with sleep-related issues for older persons, the recommendation is always to try non-drug methods first. These can include:

Avoiding taking naps in the daytime
Taking less caffeine
Exercising
Gardening & other nature-related activities (park prescription)
Doing mindfulness practice to prevent your mind from wandering around
Having a conducive habit of sleep:
- Turning down the lights
- Avoid stimulating activities just before bedtime
- Avoid the use of mobile phones before bedtime

For persistent cases, psychotherapy approaches such as cognitive behavioural therapy has shown good results in treating those with insomnia. Unfortunately, such therapies are yet to be well accepted in the Singapore older adult population. The stigma for such psychological interventions remains persistently.

There is a glaring need for new interventions to improve sleep quality. These interventions need to be more than just effective. It needs to be acceptable and accessible.

Recommended activities to improve sleep quality

This need prompted researchers at Mind Science Centre to embark on a study to evaluate the impact of community-based psychosocial interventions in improving sleep quality in older adults. These include:

Tai chi exercise,
Mindful Awareness Practice (MAP),
Music reminiscence, and
Art therapy (AT)

These activities were curated by a group of experts including doctors, nurses, psychologists, tai chi masters, and mindfulness practitioners. Our programme is special in that it incorporates mostly activities with a strong eastern influence to ensure that it is more appealing to people in Singapore.

For our study, activities were run weekly for 10 weeks, fortnightly for 18 weeks, and monthly for the rest of the year. Each session starts with health education talks on disease management and healthy lifestyle, followed by a combination of the 4 activities mentioned above. To further stray away from the stigma, the programme was held at our research centre located inside Jurong Point Mall (Rawtaer, 2018).

Quantifying sleep quality

Sleep quality was measured through the Pittsburg Sleep Quality Index (PSQI). It is a 19-item self-report measure of sleep quality over the past month. The PSQI test consists of 7 components:

Sleep disturbances
Sleep quality
Sleep latency
Sleep duration
Sleep efficiency
Use of sleeping medication
Daytime dysfunction

Each component can have a score ranging from 0 to 3. The scores from each component are added together to give a global score ranging from 0 to 21. Higher scores represent greater sleep disturbance. A global PSQI score of more than 5 indicates poor sleep quality.

For this study, the PSQI was made available in English and Mandarin. Trained staff were also present to help. The test was administered at the start of the intervention (T0; pre-measurement) and at 1 year (T1; post-measurement).

For analysis, change scores were calculated as the score at T1 minus the score at T0. Negative change scores thus represent improvements in sleep quality.

Mind Science Centre’s study found improvement in overall sleep quality and decrease in sleep disturbance

Results from our study showed that 48% (73) of participants had some improvement in their overall sleep quality, as indicated by decreased global PSQI scores (mean difference= -0.24).

	Baseline (T0) Mean ± SD	1 Year (T1) Mean ± SD	Mean Difference ± SD
PSQI total score	4.68 ± 3.34	4.45 ± 3.42	− 0.24 ± 4.82
Component Scores
Duration of sleep	0.84 ± 0.93	0.85 ± 0.96	0.01 ± 1.3
Sleep latency	1.13 ± 1.11	1.06 ± 1.08	− 0.07 ± 1.48
Sleep disturbance	1.04 ± 0.58	0.76 ± 0.59	− 0.28 ± 0.85*
Daytime dysfunction	0.24 ± 0.56	0.28 ± 0.59	0.04 ± 0.77
Habitual sleep efficiency	0.63 ± 0.99	0.69 ± 0.99	0.06 ± 1.39
Subjective sleep quality	0.87 ± 0.68	0.81 ± 0.70	− 0.06 ± 1.02
Use of sleep medication	0.04 ± 0.29	0.02 ± 0.15	− 0.02 ± 0.33

*p < .01

Looking at individual components, sleep disturbance was significantly reduced with a mean difference of (-)0.28. Sleep disturbance is a domain that includes:

Difficulty initiating sleep
Snoring
Nightmares
Nocturia (waking up at night to urinate)
Pain
Breathing difficulties

Associated factors: gender & attendance rates

Our study also found that:

Males were associated with greater improvements in overall sleep quality and sleep disturbance.
Those with a higher attendance rate also experience better improvement in their sleep disturbance score.

A point to consider: how much sleep do I need?

While this article has discussed various methods you can try to help with sleeping issues, we would suggest you take a minute to ponder on the following questions:

“What’s your definition of a good quality sleep?”

“How much sleep do you actually need?”

You might have seen in the news or other articles that doctors recommend at least 8 hours of sleep per day. But it is not that simple. Babies sleep for 16 – 17 hours a day, young adults are recommended to have 8 hours of sleep per day. What about older adults?

According to Prof Kua Ee Heok, as we grow older, we do not need such a long sleep. Most older adults can carry on normal activities with 5 – 6 hours of sleep. So, if you can naturally sleep for this recommended period, you don’t necessarily need to attempt to sleep more.

Sleeping pills and its impact on memory

As previously mentioned, prolonged use of sleeping pills may cause you to still feel groggy when you wake up, medically termed residual daytime sedation.

Especially as you grow older, it takes longer for your metabolism to break down these sleeping pills. As a result, you may have some hangover, which affects your concentration. And without concentration and awareness, you will experience difficulties in remembering.

During our webinar, A/Prof Tan shared how one of her patients came in for an evaluation for dementia. The patient’s daughter shared that the patient had gone to the market to buy the exact same time twice in a day because she couldn’t recall going to the market the first time around. But looking at the patient’s history, she had taken sleeping pills the night before and this affected her memory.

Want to hear more from our experts?

Rawtaer, I., Mahendran, R., Chan, H. Y., Lei, F., & Kua, E. H. (2018). A nonpharmacological approach to improve sleep quality in older adults. Asia‐Pacific Psychiatry, 10(2), e12301.

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