As a behavioral sleep health specialist, I am compelled to write about the existential challenge of our moment: the war we are waging against the COVID-19 pathogen and the need to protect our vulnerable populations. This blog is about the impact of the pandemic on the sleep of older, single individuals, beyond 65 years of age, dwelling in independent living environments where constant caregiver attention is not available or necessary.
The vast majority of senior living residences are now subject to mandated lockdowns, creating social distancing between the general public and elderly resident to curb community transmission of the COVID-19 virus. Even family members may be denied access except in cases of emergency. Residents hearing or reading about the COVID-19 mortality rates in aging individuals may not even go outside for fresh air when given the opportunity. Fear, confusion and helplessness fester in people living alone.
Add to the mix sustained exposure to artificial indoor light in the living space and the loss of mood protective direct natural light exposure. Constant bombardment by news outlets and in-house gossip fuels anxiety about the COVID-19 virus, and coupled with sadness and grief about loss of mobility and lack of direct contact with family members, creates an elevated risk for clinical depression and/or anxiety.
When mixed anxiety and depressive states emerge, natural sleep suffers. Seniors still need 7-8 hours of sleep in the 24-hour period. Scientific research has shown that under the best of circumstances aging means an erosion in the quantity and continuity of deep, slow wave sleep needed for cognitive and physiological restoration. Nocturnal sleep is already more piecemeal in older people due to a combination of chronic medical conditions that may cause pain or breathing difficulties, gastro-intestinal disturbance, and degenerative changes in joints. Worries about being safe from infection further de-stabilize sleep. Hans Selye’s general stress adaptation model applies. When people are unduly alarmed personal antennae become more sensitive. This alerting response can be useful, but if the threat does not go away it becomes challenging to separate the wheat from the chaff and really know what one rationally needs to avoid or do. When anxiety floods the mid-brain and our emotional brain, especially a structure called the amygdala, reasoning and problem-solving falter. Restorative and consolidated sleep can be a defense against not just the inevitable exhaustion and physical/mental vulnerability, but a strategy to combat mild cognitive deterioration that can accompany aging. Without the benefit of routine deep sleep for cleansing toxic proteins from brain tissue, the prospect of developing more serious cognitive impairment exists, opening a pathway to Alzheimer’s and related dementias. Waking up in the middle of the night when one is depressed or feeling hopeless can be a risk factor for suicide.
Trying to keep a routine under the current circumstances is harder, as the hours and days blend together. The mind-body harmony of the circadian clock is thrown off kilter. The elderly tend to wake up earlier in the morning than younger individuals. The entire waking day may be advanced relative to the schedule of younger people involving earlier meal times, including dinner, and a tendency to nod off very early in the evening right after the last major food intake of the day. Older individuals are probably less efficient in manufacturing melatonin, the sleep hormone, in the pineal gland, and therefore may have more difficulty following light and darkness cues for sleep onset and offset. Tendencies to nap during the day, as a strategy to offset boredom from reduced social and community activity, weaken the biological drive for sleep. Together with lack of exercise during the day, the older person’s core body temperature may not elevate sufficiently and drag down efforts to remain alert and productive.
Providing single seniors with adequate social stimulation during the day is going to be a challenge for the near future because of the shelter in place orders around the country. If possible, daily face time interactions with family and friends would be a welcome event. However, encouraging your loved one to keep a steady routine, to exercise in the hallways by walking, doing stretches in the apartment space or on the grounds of the residence, as well as providing exposure to natural light, blue and green wavelengths, from sky, water, grass and/or trees, sharpen the circadian rhythm and clarify the differences between waking and sleeping states. Studies suggest seniors sleep with fewer awakenings following a day of bright illumination. Self-guided yoga can help with balance, centering, flexibility and anxiety reduction. Exposure to bright light sources and/or e-devices with blue wavelength in the evening can delay the circadian and homeostatic signals pointing to imminent bedtime. and encourage the resident to stay up later and perhaps increase chances for social connection online or over the phone with others who might be otherwise occupied during the day. For seniors fortunate enough to have a smart phone or computer, access to social media may enliven the day and ward off loneliness, despair, boredom and feelings of abandonment.
No one approach fits all single seniors coping with the extended impact of quarantine. The risks of infection and mortality created by close public interaction outweigh other considerations, but it is possible to fine tune one’s circadian clock and activity schedule such that sleep becomes an ally in the fight against viral assaults, boosting immunity and providing necessary energy for daily tasks. Well rested seniors have better attention spans, focus and sustained concentration. For more serious cases of depression, formal mental health evaluation may be needed, addressing risk of self-harm and substance misuse, and pointing the way to more systematic interventions, including appropriate medication and counseling, as well as cognitive-behavioral and environmental approaches to modify sleep and circadian processes.