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Aging in the Land of Nod

category_bug_geriatrician.gif [EDITORIAL NOTE: The TGB Geriatrician is a semi-monthly column written by Dr. Bill Thomas for Time Goes By to give us the information we need to help us navigate the health issues of aging. Dr. Thomas also writes his own blog at Changing Aging.]

The comments about age-related changes in sleep patterns posted in response to Pinnacle of Adaptation, my last column here, reminded me of a patient I wrote about early in my practice.

”She slept an average of 16 hours a day, mostly in blocks of three to four hours at a time. It was clear that she was not distinguishing between night and day and that caused all kinds of problems for her caregivers. I saw the patient regularly and the good news is that, over the next three months, she started sleeping ten hours a day, almost all of them at night! Still, she was prone to napping in the middle of the day. I told the family not to worry; napping is normal at her age.”

Her mother and father were relieved by the changes, having a newborn baby in the house can be tough! It turns out that how we sleep changes as we age. Toddlers do not sleep in the same way a newborn does, nor does the 80-year-old experience sleep the same way a 30-year-old does.

So what do we need to know about age-related changes in sleep patterns? Not surprisingly, older people are more likely to develop sleep-related, medical disorders than younger people. Here are a few of the more common disorders along with their definitions:

  • Nocturnal Leg Cramps: This involves sudden, painful cramping of one or both calf muscles during sleep. The cramp can last for as many as 10 minutes, and the resulting pain from the cramp can last for much longer.
  • REM Sleep Behavior Disorder (RBD): The person is in REM (dreaming) sleep and acts out violent dreams through body movements and sounds. This disorder generally occurs in older men, but can occur in others as well.
  • Sleep Bruxism: Also known as teeth grinding during sleep, sleep bruxism is when a person involuntarily grinds or clenches their teeth while sleeping. This can lead to teeth wear and jaw discomfort. The method for treating teeth grinding is usually a mouth guard that is worn during sleep.
  • Sleep Talking: This usually occurs during a sleep/wake transition of the sleep cycle. The person can utter sounds or even entire sentences. The sleeper generally does not remember doing this in the morning.

  • Sleep Apnea: Changes in upper airway muscle tone during sleep make breathing difficult. The person experiences shortness of breath, wakes up, breathes and falls back asleep. The pattern can recur hundreds of times a night.

Most of these "parasomnias" have effective treatments you can discuss with your doctor.

Much more common are sleep-related problems that are caused by medications and medical conditions. It's always a good idea to tell your doctor about how you are sleeping even if she doesn't ask and even if you are sleeping well. Few physicians pay enough attention to sleep-related issues and patients are wise to raise the issue.

Sometimes small changes in medical treatment can make a big difference in how I sleep. I remember being a doctor-in-training and prescribing a "water pill" to a patient of mine. It was the right drug and the right dose, but the trouble was that I told her to take it in the evening. She was up half the night running to the bathroom because her doctor (me) didn't know what he was doing.

There are normal, age-related changes in sleep and sleep patterns. The most important thing is to understand what is normal and what is not normal. Here is a short list of normal changes:

  • Sleep efficiency is the ratio of the total time we spend in bed (not counting amorous adventures) and the total time we spend sleeping. Sleep efficiency generally decreases with age.

  • Daytime napping increases with age. It's normal. Enjoy it. Get used to it. Take pride in it. In medical school we used to joke that medical training also teaches students the value of a good nap. I still enjoy a mid-day nap when the opportunity arises.

  • Phase Advance is the fancy medical term for the experience of going to bed earlier in the evening and waking up earlier in the morning. The sleep phase advances as we age. Many older people fall asleep early in the evening, yet awaken much earlier than desired in the morning and cannot fall back to sleep easily.

Changes in sleep can be merely annoying or they can represent a symptom of a more serious medical situation (heart failure, depression, etc.) Sometimes not even your doctor can be sure which is the case. The general rule I follow is that when changes in sleep patterns are merely annoying, they are usually normal. When the changes cause real distress or are combined with other non-sleep related symptoms, it's time to make an appointment with your doctor.

Yawn. I think I'll take a nap.

EDITORIAL NOTE: You can subscribe to The TGB Geriatrician column by email by clicking here. Subscribe to the daily Time Goes By blog by email or RSS in the upper right corner of this page.

[At The Elder Storytelling Place today, Brent Green's story, Saving Us, is most appropriate for the 64th anniversary of D-Day today.]


Clinton: Refusing to Leave the Stage

In retrospect, anyone following the Democratic primary campaign for the past five months could have predicted it: Senator Clinton won’t leave the stage even when she has lost the contest. Why would someone who broke the rules, invented six new ways to interpret votes and can’t count exit the stage gracefully when her opponent is awarded the prize?

The only person Crabby Old Lady is more tired of than Senator Clinton is President Bush, but at least, in the waning days of his term, we don’t have to see much of him. Clinton, on the other hand, will not get out of the country’s collective face.

The candidates’ speeches Tuesday night said it all. Senator Obama’s was all about “we.” Senator Clinton’s was all about “me.” “What does Hillary Clinton want?” she asked with her id exposed almost as much as her husband’s when, earlier that day, he – a former president! - crudely referred to a journalist as a “scumbag”.

In addition, after Senator Obama had won the necessary number of delegates Tuesday, Clinton campaign manager Terry McAuliffe had the brass to introduce Senator Clinton as “the next president of the United States,” leaving open the implication that she’s not done yet. And she is not.

Although it took the strong urging of her Congressional supporters (who, it was reported by at least one news source, were contacted by Clinton campaign operatives asking them to intervene with Clinton), late Wednesday, Senator Clinton sent an email to supporters announcing an event in Washington, D.C. on Saturday when she will "suspend" her campaign and pledge her support for Senator Obama.

Senator Clinton has still not used the word "concede," and the suspension, rather than withdrawal, allows her to technically remain a candidate.

In her obstinate refusal to observe what may be the only courtesy left in politics - concession and pledged support immediately following a loss - Senator Clinton has kept the media spotlight on herself, tainting the historic moment of celebrating the first major-party candidacy of an African-American for president. From the first woman candidate to nearly gain the nomination, her behavior is especially contemptible.

Is Crabby Old Lady the only person who has had enough of both Clintons?

[At The Elder Storytelling Place today, Mort Reichek tells another tale of his experiences in India in MEMOIR: Meeting My Boyhood Idol on Chowringhee.]


The Ups and Downs of Aging

category_bug_journal2.gif Often, it seems, there is no accounting for one’s emotional tone. For no apparent reason, sometimes, there is a general irritation when even a twittering bird might be annoying. On other days - dark and gloomy and sunshiny alike - a sense of elation prevails although there is no event, past, present or future, to cause it.

More often, nowadays, I live with sense of well-being that is a few notches above neutral, in a state where there is time to note the freshness of a breeze through an open window, to pause in amusement at the serious demeanor of the cat at his bath or to enjoy, for a moment, the satisfaction of a sparkling kitchen after a clean-up.

Small pleasures, to be sure, but they arrive now with a frequency I don’t remember in my youth. In those days, perhaps into my forties and even fifties, my emotional temperature was more volatile and seems to have been not much in my control. The highs were as out of proportion for the circumstances as the lows, although I don’t think I recognized the disparity, and a minor disappointment could dampen my mood for days.

I can’t think where to look for the information, but I recall reading somewhere that emotions become less charged as we age. It’s hard to believe, however, when a politician’s – or a president’s – idiot actions send me off in high dudgeon.

Although the serenity I would like to achieve one day is far from - and may forever be beyond - my grasp, I do more easily now take the time to smell the flowers, as it were, and find more pleasure in the ordinary than when I was young.

Some of my newfound contentment may be due to choosing my obligations now rather than being subject to others’ demands on my time in exchange for a paycheck. Or, maybe it is related to getting old.

Either way, Crabby Old Lady doesn’t seem ready to retire any time soon. As the late Gilda Radner used to say, “there’s always something” to get Crabby’s knickers in a twist.

[At The Elder Storytelling Place today, Leah Aranoff has two poems for us, Now You See It and Oh Blessed Noise.]


Advertising the Agony of Old Age

This story has been rolling around in Crabby Old Lady’s head for several months. She kept meaning to record some hours of prime time television over a few days and then zap through the shows to the commercials with pen and paper in hand to have some hard numbers for you. But it would undoubtedly raise her blood pressure and she never got around to it. So you’ll have to trust her general impression:

According to television commercials, old age is so dangerous or painful or simply annoying, it may not be worth hanging around for. Some say old people are more visible on television these days, but not in any manner Crabby wants to be portrayed.

Mostly, elders appear in commercials for remedies to treat diseases and ailments that range from minor through deadly serious to disgusting. Even that icky, mucus, cartoon character is old and these ads outnumber all other types.

Take a look at this list, typed out off the top of Crabby Old Lady’s head. There are so many commercials and public service announcements broadcast so frequently that any young person watching can only assume old age is agony:

Osteoporosis
Back pain
Aching joints
Loose dentures
Gum disease
Bad breath
Heart disease
Diarrhea
Hair loss
Cholesterol
Diabetes
High blood pressure
Atherosclerosis
Heartburn
Acid Reflux
Restless Leg Syndrome
Alzheimer’s
Incontinence
Arthritis
Insomnia
Erectile Dysfunction

Just to check that her memory isn’t failing, Crabby pulled out a recent issue of AARP magazine to see what they advertise to their readers. Most of the items on the list are represented and the rest of the ads are for insurance.

Crabby wouldn’t be so ticked off if she had ever seen an old person in a car commercial. Not even detergent ads feature elders, as though we don’t wash clothes or dishes in our dotage. And no one old appears in glossy ads for clothing, expensive watches or fancy electronics – none of the glamour stuff.

It’s enough to make a Crabby Old Lady sicker than advertisers believe she already is.

[At The Elder Storytelling Place today, Bill Weatherstone returns after an absence of several months with A Canadian Senior's Survival.]


On the Democratic Delegate Decision

Crabby Old Lady likes rules. They establish boundaries of behavior, guide arbitration in disputes and keep the unscrupulous from taking unfair advantage.

The Constitution and Bill of Rights of the United States are nothing more than rules writ large, and long before we are old enough to appreciate the principles contained therein, we learn the essentials of fair play – and the consequences of ignoring them - on hopscotch grids, ball fields and, in modern times, within computer games.

Woe unto to those who try to cheat, particularly in childhood, where indignation of the majority can earn a malefactor expulsion from the game and even a bloody nose.

Senator Hillary Clinton’s nose was bloodied on Saturday at a meeting of the Rules and Bylaws Committee of the Democratic Party which convened to settle the disputed primaries in Florida and Michigan. On Crabby Old Lady’s personal playing field, she deserved it.

For several weeks, not a word has been uttered by Senator Clinton and her surrogates about the crucial issues of our day – not on the Iraq war, the economy, escalating fuel and food prices, unwarranted surveillance, failing education, crumbling infrastructure and the rest that are imperative to voters’ ability to make a reasoned choice at the ballot box.

Instead, Senator Clinton spoke only to the primary horse race, to the delegate count and popular vote of the two disputed states inventing, in each speech, another new math by which to award her the majority and the nomination, never once addressing the rules set up by the Democratic Party which she and Senator Obama agreed to in writing before the first primary was held.

Here are the simple facts of fair play as Crabby Old Lady sees them:

  • The dates of primaries in individual states were set by the Democratic Party.
  • Michigan and Florida moved up the dates of their primaries knowing that the rules of the Democratic Party would not allow their delegations to be seated at the convention.
  • The time for voters in those states (and presidential candidates) to protest was then, to insist that the states follow the rules, and not to whine afterwards that voters had been disenfranchised.

The most extreme of the subsequent and varied arguments put forth by Senator Clinton was to give all the Michigan votes – and, therefore, delegates – to her because Senator Obama’s name was not on the ballot. But Obama had removed his name in keeping with Party rules, and if an opponent’s name is not on the ballot, a victory over him cannot be claimed. From Crabby’s point of view, to do so is too similar to the kind of elections held in the Soviet Union to be comfortable.

Although it was too late for Senator Obama to remove his name from the Florida ballot, he – again, in keeping with Party rules – did not campaign there. Senator Clinton did, despite the rules. [UPDATE: See comments below re Crabby's error about Clinton campaigning in Florida.]

The point of campaigning is to set forth a candidate’s political beliefs and policy positions so voters have a basis on which to make their decisions. Because Senator Obama followed the rules, he did not have that opportunity in Michigan and Florida and there is no way to know how many voters he might have persuaded or what the count would have been if the states had held their primaries according to Party rules and normal campaigns had ensued.

To Crabby Old Lady, broken rules equal an invalid outcome which must be ignored in the final tally. In this case, all delegates from Michigan and Florida should not be seated at the convention.

The Rules and Bylaws Committee of the Democratic Party on Saturday did not agree. They gave 69 of Michigan’s delegates to Senator Clinton and 59 to Senator Obama. For Florida, the Committee voted to seat the delegation, but to dock them by giving each delegate only half a vote. The final Florida tally is 34.5 delegates to Clinton, and 29.5 to Obama.

In the end, nothing substantive changed. The Committee decision gave Senator Clinton a net gain of 24 delegates placing her behind Senator Obama by 176. By including the Florida and Michigan delegations, the number of delegates needed to win the nomination was pushed up to 2,118 from 2,026.

As expected, Senator Clinton swept the Puerto Rico primary on Sunday reducing Senator Obama's delegate lead to 155. Two more super-delegates announced for Obama on Sunday and there are 31 delegates at stake in the Montana and South Dakota primaries tomorrow. In the unlikely event Clinton wins all of them, Obama would still be ahead by 124. (Numbers according to CNN. Counts from other organizations vary slightly - three or four delegates one way or the other - not enough to change the outcome.)

But wait – the delegate fight may still not be finished:

“Arguing that the Michigan compromise ‘is not a good way to start down the path of party unity,’ [Clinton campaign operative and Rules Committee member Harold] Ickes warned that Clinton had authorized him to note that she will ‘reserve her rights to take it to the credentials committee’ later. Campaign spokesman Howard Wolfson later affirmed that Clinton will reserve her right to challenge the outcome.”
- Washington Post, 1 June 2008

Although some commentators have dismissed Ickes' statement as political posturing, Senator Clinton herself left the door open:

"In a telephone interview Sunday from San Juan, P.R., Mrs. Clinton still raised the possibility that she would challenge the party’s decision on seating those delegates [assigned by the Party on Saturday]. 'Well, we are going to look at that and make a determination at some point,' she said. 'But I haven’t made any decision at this time.'”
The New York Times, 2 June 2008

Although the Democratic Party selects its nominee through delegate count, Senator Clinton continues to insist that it is the popular vote that matters even though she is still behind and any advantage she has depends on unreported votes in some caucus states and not assigning any of the 238,168 "uncommitted" votes in Michigan to Obama.

Senator Clinton has flouted the rules of her party. Now that its leaders have reached a compromise (however much Crabby is insulted by their willingness to change their own rules at the end of the primary season), this week is the time for Clinton to concede. To threaten to prolong the agony to the convention debases the fundamental principles of the United States and Crabby Old Lady's personal sense of fair play instilled at her mother's knee.

[At The Elder Storytelling Place today, Linda recalls a family tale about one of the yummiest treats summer in I Scream, You Scream...]