Improve Health by Improving Circadian Rhythms and Sleep

Welcome back everybody. Today we are talking about circadian rhythms and sleep in older adults. I'm your host, Dr. Donnelly Snipes. We're going to develop an understanding of how circadian rhythms regulate pretty much all bodily functions. Explore how sleep and circadian rhythms, they're different, they're not exactly the same. Explore how they can worsen cognition, blood sugar regulation and mood issues. And develop strategies to manage residents circadian rhythms and improve their sleep to improve each piece of life. And if you remember from the last session, peace stands for physical, interpersonal, emotional, cognitive and environmental. Circadian rhythms are our natural body rhythms. Our body runs on what you will think of like a clock. And I talk a lot about the body factory. So I want you to think about a factory that has multiple shifts. And if the middle day shift shows up at 8am, you know it's going to throw things out of whack. And if the evening shift shows up four hours late, that's going to be a problem too. So circadian rhythms regulate the shifts of all the different departments in our body. They regulate sleep. Cortisol, which is our stress hormone. Cortisol is supposed to peak in the morning and then gradually decline throughout the day. It peaks in the morning to give us energy to get out of bed and get on with our day. Cortisol in itself is not bad. It is helps provide energy. It is a stress hormone. But a little bit of stress is necessary. Or we just like laze around and binge on Netflix for our entire lives. We need something to wake us up and get us out of bed. Now we start to see problems with cortisol when people are drinking a lot of coffee, which keeps the cortisol levels up. Cort. High cortisol means low melatonin. High cortisol means difficulty getting to sleep. Circadian rhythms regulate sex hormones. So we do have a natural eb and flow. Estrogen, Testosterone, progesterone, dhea, they are all involved in libido and procreation, but they are involved in so much more. And we do need to recognize that we have cyclical rhythms of our sex hormones and they regulate our neurotransmitters. Now this is something a lot of people don't realize. Serotonin, which most people think of as your antidepressant drug, not exactly, but it does help with mood regulation. But it also regulates heart rate, it regulates breathing, it helps regulate blood pressure. I mean, it's involved in a lot of stuff. But serotonin is also the precursor to melatonin. So if your Serotonin is not working well. You may not be able to make melatonin, which will help you get to sleep, but serotonin helps you modulate your mood throughout the day, and then it gets broken down to help you go to sleep. Synthesis making serotonin is highest in the morning, so your body's actually making it mainly in the gut first thing in the morning. And if your gut is unhealthy, then you're going to have a problem. We'll talk about that in nutrition. But we do want to recognize that serotonin goes up and is made when cortisol goes up. You're preparing for the day, and serotonin levels tend to go down at night as it's broken down to make melatonin and as cortisol goes down, dopamine, that is our perseveration neurochemical. I want to do it again. That was fun. I, I want to do it again. It gives us motivation to do things. Now, dopamine is often paired with endorphins, which is why a lot of people think it's our reward neurochemical, because when we do something pleasurable, our brain, we get a hit of the endorphins and our brain goes, yeah, I want to do that again. So dopamine activity is also higher during the day, which supports attention and learning and motivation to do things that are going to make us happy and things that are going to help us survive. GABA is the other neurotransmitter that is regulated in part by circadian rhythms, and it goes up at night. It is our natural calming chemical, basically our natural Valium, if you will, and it helps relax us. It's activated when we activate that vagus nerve and the parasympathetic nervous system, and it helps us get good quality sleep. Circadian rhythms also regulate digestion and appetite. It regulates our hunger and our satiation hormones. Now, my son, when he was a baby, you could set your watch by him because he would get hungry. And to a certain extent, I'm the same way. So the apple doesn't fall too far from the tree, but I get hungry. And he would get hungry pretty much within 10 or 15 minutes of the same time every single day, because the circadian clock starts release, releasing the hunger hormones and tells you, hey, it, it's time to eat. It peaks before meals because it wants to motivate us to eat. Disrupted circadian rhythms alter our, our digestion and alter our hunger and satiation, which can result in appetite dysregulation, which can mean depending on the person, they're hungry all the time or they're not hungry most of the time. So you don't get those windows where your body's saying time to eat, time for breakfast, time for lunch. Circadian rhythms and this is really important for those who are insulin resistant or have diabetes or which is approximately 40% of our population. Circadian rhythms regulate our blood sugar as well. I mean, yes, eating impacts that, but insulin and glucagon are both regulated by circadian rhythms to align with glucose metabolism and feeding and fasting cycles. Insulin sensitivity. Our body, when we get up in the morning, is more prepared to take in carbohydrates because it's been, you know, using energy throughout the night. It's more prepared in the morning and in the early afternoon to digest and deal with carbohydrates. Our insulin sensitivity, our body's ability to react and effectively use insulin is better during the morning and early afternoon. So that's something important to recognize in terms of eating. For some people, growth hormone peaks during early sleep and supports tissue repair, muscle growth and fat metabolism. Yes, older adults, they ain't growing anymore, but growth hormone, as I'm sure you've seen on tv, they swear by it, slows aging, blah, blah, blah. Well, I don't know that that's necessarily true, but growth hormone is necessary for your body to repair. And whenever you work out and you get tiny muscle tears and then you get sore and that's when your muscle is repairing. So the growth hormone is helping repair your muscles and build those muscles. One of the reasons that adults, older adults, metabolism declines is because of muscle wasting, because they're not doing resistance type activities. And so they don't have those muscles growing and they don't have that repair going on. But when people are under stress, when their circadian rhythms are out of whack, even if they are working out, they're not going to recover as effectively if they're sick, they're not going to heal as efficiently if, you know, a lot of things are not going to happen as effectively and efficiently if the circadian rhythms are out of whack. Thyroid stimulating hormone peaks at night, which I don't understand why, but it does, and declines in a similar pattern to cortisol. So thyroid stimulating hormone peaks at night and stimulates your body to release T4 and get you ready for the day. And then T4 is broken down into the bioavailable form of T3 that helps give you energy throughout the day. So it's kind of priming the system first thing in the morning. If sleep is poor quality, is inadequate, or circadian rhythms are out of whack, the thyroid, thyroid stimulating hormone may be suppressed so then that T4 doesn't get released, and then it can't be broken down. If it's not released, it can't be broken down to make T3. And we start seeing subclinical hypothyroid symptoms. Body temperature is again set by circadian rhythms. It rises during the day and falls at night. When we go into our hibernation state. Your body is not using as much energy to keep you warm because it's using energy to, to repair and clear out all the debris. Your blood pressure is normally lower at night. Another thing that's kind of taking a rest, thinking about the factory first shift and second shift, they are just cranking out products and building up junk and byproducts, building up waste. At night, the cleaning crew comes in and starts moving out all the waste and tuning up the machines and getting everything ready for the next day. So at night, a lot of things that are normally kind of revved during the day are going to be slower, more relaxed at night because the body is focusing most of its energy on repair and restoration. Immune activity increases during sleep to repair and protect the body and brain. Cleaning cycles increase to clear out adenosine and other reactive oxygen species. Again, reactive oxygen species, I'm not exactly sure why they're called that. It sounds like a different type of little insect or something. But this is our oxidative stress. This is the junk, the byproducts, the trash that's left behind from living. And we have to make it. If we don't make it, we're not existing. Our brain and our body can normally clear it out pretty effectively when we sleep, but when we're under a lot of stress, we need help. We need help clearing out that junk. Adenosine is a hormone that builds up in our brain as we move through the day. And it's part of that byproduct junk in some ways. And it builds up to lead to sleep pressure. When it gets to a certain point in our brain when we get very, very sleepy, we get very, very foggy. Well, that's the adenosine. And the adenosine is cleared out when we get good quality sleep, Particularly in that deep sleep area at the beginning of the night. But it's cleared out. If you wake up and you haven't had good quality sleep, you may feel foggy or kind of hungover and because those receptors are still being bound by or clogged up by the adenosine junk. Now, little side note, caffeine can displace some of that adenosine, but that is not a permanent solution and it's not going to do as good of a job as letting your body actually clear out the waste. So adenosine is an interesting, interesting chemical. Sleep is regulated in part by circadian rhythms. And sleep helps regulate circadian rhythms. So it's a bi directional. Like a lot of things, it's a bi directional system. Circadian rhythms help regulate cortisol and melatonin. Remember, cortisol and serotonin peak in the morning. And when cortisol and serotonin decline, melatonin goes up, adenosine is up, sleep pressure is up, everything's wonderful. Deep slow wave sleep occurs early in the night and REM sleep typically early in the morning. Now our wearables are crappy at really accurately picking up deep slow wave, deep REM and non REM sleep. Okay? So encouraging people to monitor their sleep through their watch may actually sleep studies have found, and the sleep foundation actually discourages it because sleep studies have found it actually increases stress and worsens sleep. Because people are looking at their chart and they're going, I didn't get enough deep sleep last night. And then before they go to sleep at night, they're like, okay, I need to get good deep sleep tonight. And they get themselves all stressed out. What does that do? Makes their sleep even worse. So we want people to judge their sleep by how quickly they fall asleep, how many times they awaken, how quickly they get back to sleep, and how they feel in the morning. If somebody's falling asleep in less than 10 minutes, it's a general rule that that may mean that the person is sleep deprived. Doesn't always mean that some people just fall asleep quickly and easily. And you know, I envy them. If it takes more than 30 minutes to fall asleep, then they may have some difficulty converting over. There's something blocking their melatonin from kicking off their sleep. Is something altering their circadian rhythms? But you know, those are just general numbers. Every person is unique and individual. How long you sleep? 7 to 9 hours, even for older adults is important because that gives your body time. That's the night shift. You gotta let the night shift work their entire shift to do their job. Now a lot of older adults especially, and I shouldn't say that older adults and younger adults that have young children at home, they don't sleep through the night. If your kids are waking, you're up, your dogs are waking you up, or you gotta pee every 30 minutes, it's going to disrupt your sleep architecture. You don't want to have to be doing that. And we're going to talk about ways to address that. But it is important to understand that the quantity and quality of our sleep are both important. Sleep stages follow circadian cues and are essential for tissue repair, hormone regulation and immune balance. When people aren't getting adequate quality sleep, their gonadal hormones and their thyroid hormones are gonna be out of whack, which means their mood and their energy is potentially gonna be out of whack. Now what out of whack looks like differs for different people, but generally it tends towards irritability because it's stressful. When the body notices something's out of whack that's stressful, that's registered as a stressor in the brain. So people tend to be more in fight or flight. Physically poor sleep increases sympathetic activation. We are more stressed. Our brain is actually dumping more cortisol and more blood sugar to try to help us stay awake and alert so we don't get attacked by the hungry lion. It's a primal survival mechanism. As a result of ongoing activation of the stress response, we see increased inflammation and neuroinflammation, reduced immunity, increased infections, increased pain, reduced energy. Well, no, no, duh. If you're not getting good sleep, then you're probably not going to feel very energized. And increased blood sugar. Every time cortisol goes up, blood sugar gets dumped. And when blood sugar gets dumped, then insulin's got to kick in as well. Interpersonally, as a result of being a little bit stressed, we see reduced patience and possibly social withdrawal due to reduced energy and irritability. When I'm tired, I don't have the energy to deal with peopling. You know, it's just me and my cats and, or my dogs and I'm good with that. So you may see social withdrawal in people who are perpetually sleep deprived because they just don't have the energy for it. And again, reduced patience is kind of a no brainer. When you're feeling tired and your stress response is activated, that stress bucket is all but full with water because it didn't get dumped the night before. It is easier to be irritable emotionally. People have stronger emotional reactions, increased anger and anxiety, and more moodiness, or what we call emotional ability. It's harder to manage your feelings. You're having more surges of Adrenaline, more surges of stress hormones when they happen. A lot of people will report increased brain fog, partly because of the inflammation, partly because of the adenosine not getting cleared out and reduced executive functioning. Planning, reasoning, concentrating, all of those adulting sort of things in, involved in thinking. It doesn't mean that the older adult or the, or the person is cognitively impaired. It doesn't mean that they're developing dementia. It may mean they're not getting good sleep. So let's look at some of the easy things before we start pathologizing what's going on and say, hmm, is this person not getting good quality sleep? Are they malnourished? Are they hypothyroid? Those are three of the things that I rule out first before I start looking at neurodegenerative issues even in older adults. Now. Yeah, we get there. But it is important to not freak people out and let people know, hey, there may be some very simple things that are contributing to your forgetfulness, that are contributing to your difficulty thinking clearly. So let's take a look at those first before we start getting totally freaked out. Poor sleep increases delirium, moodiness, irritability, confusion, and possibly creates hallucinations when longer term. And when I say longer term, what I'm talking about is a few days, a few days of no sleep and people will start hallucinating a few days to a couple of weeks of minimal sleep, like a few hours. Some people will start getting more moody, having hallucinations and, and other things. So if you've got an older adult who's only sleeping, or a younger adult, we went through this with my son who's only sleeping three hours a night, and then they start evidencing signs of cognitive decline, confusion, irritability, and, and hallucinations. You know, let's take a look at what's going on there and why are they only getting three or four hours of sleep a night? One thing that I've seen in a lot of older adults and a lot of adults with developmental disabilities who may be in group homes and just home all day long is that they may only sleep a few hours at night, but then they take a two or three hour nap in the middle of the afternoon. That is horrible. Horrible for your circadian rhythms, horrible. You want to keep naps to under 45 minutes when at all humanly possible, unless otherwise recommended by your doctor. Because once you get past 45 minutes, you start actually kicking off an actual sleep cycle and that confuses your circadian rhythms. It's like almost like calling in the night shift in the middle of the day for two or three hours and everybody's going, what are you doing here? Why? So it is vitally important that we look at people's sleep and examine how their sleep and circadian rhythms may be contributing to whatever physical, interpersonal, emotional, cognitive symptoms or issues that they're having environmentally. When people are stressed, there's a greater awareness or focus on the threats and things that irritate them. A lot of us, when we are sleep deprived, we feel like that curmudgeonly old person that used to, you know, yell at the kids to get off my grass. That's, that's the stereotypical thought of a, of a grumpy, grumpy person. But it happens because we tend to be in fight or flight. Our stress bucket is full up to the top and it doesn't take much to overflow. And we're trying to make sure that we're safe. We're spending all of our energy scanning to make sure that we're safe. We also see increased sensory sensitivity due to an act hyperactivated stress system. Interesting. So when people are sleep deprived, they may actually be more sensitive to temperatures, to smells especially, and even sounds than when they are not sleep deprived. Sounds that don't bother me most of the time will grate on my last nerve when I'm sleep deprived. We have neighbors out here and they were actually, they had their lawn service out mowing their lawn earlier, and I call it the weaponized lawnmower because it's just this constant drone in the background and it drives me nuts. But I live in the, and, and I accept, and all that stuff we were talking about. But we do tend to be more sensitive to irritants when we are already sleep deprived, when we are already stressed. Causes of these disruptions, incontinence or frequent nighttime urination. Now, incontinence. Have them talk with their doctor. Maybe they're going to wear Depends or something. Maybe they're going to have a catheter, I don't know. It's important to manage incontinence effectively to prevent UTIs or frequent nighttime urination. If they are getting up 2, 3, 4 times a night to go to the bathroom, that's disrupting everything. Even if they're not turning on all the lights, it's still disrupting their sleep architecture, encouraging them to drink less after a certain time. And that time is dependent on the person. For some people, they need to start sucking ice chips at 5 in the afternoon. For other people, they're good until 7. It just depends. They're going to have to try experiment and figure out when they need to quit ingesting the majority of their fluids in order to be able to sleep through the night. And encourage them to try to urinate before bed. Even if they don't think they need to, encourage them to just try because that will clear out the bladder as much as possible. Gastric reflux Other pain disrupts sleeping A lack of routine as we talked about before, routine is one of those things that helps set our circadian rhythms. And if our routine is out of whack, then we are likely not going to get the cortisol when it's supposed to be high and low when it's supposed to be low, which means it's going to negatively impact our sleep. As I mentioned earlier, sleeping too much during the day can also impair your ability to get to sleep. You as I mentioned, you can start getting into an actual sleep cycle which confuses the circadian rhythms. But if you get into that deep sleep area, you may be clearing out some of the adenosine that started building up and then you know you're not fully adenosine loaded, if you will, when it's time to have the greatest amount of sleep pressure, when it's time to go to bed and it can make it difficult to go to sleep or stay to sleep. Poor lighting if it's too dim during the day or if it's too bright at night is going to mess with your circadian rhythms. Ensuring having people turn on their night vision or night mode on their mobile devices if they are determined to use them. They have devices that you can plug into regular TVs that turn down the blue light at night, you know, put that yellow hue over it, which some people find truly annoying. But other people are willing to accept the yellow to improve their sleep. So if you are working with somebody who likes to watch TV before they go to sleep, consider getting one of those adapters that turns on the the blue light blocking on the television. You can. There are also screens that you can get that you can fold down over the television or there used to be. It's been a while since I looked at those medication schedules not timed for the residents or the person that you're working with. If you are an in home caregiver, we want to time the medication for the person that you're serving. There was one assisted living facility I was working at and this particular patient, the medication was being handed out at 10 in the morning and or 10 at night, 6 in the morning, 2 in the afternoon, and then 10 at night or something. Anyway, it was, it started at 10 and then the last dose was at 10 at night. And she was, she was already asleep. They were waking her up to give her her medication at 10 at night because she wanted to go to sleep at 8:30 and that was truly disrupting to her, her sleep schedules. Apnea, chronic stress, trauma, and aging all increase the risk of sleep apnea. So if you have an older adult that has apnea, make sure that they're getting that addressed. CPAP machines are wonderful. You, there are apps you can get on mobile devices that they can record themselves at night so they can hear if they're snoring and if they're gasping. And that is an easy free way to do early screening for sleep apnea. If you ask the person, do you wake up gasping? And they say, no, okay, well, that's fine. Not everybody wakes up. My husband has never awakened when he's been gasping. You know, most of the time I'm, he'll like stop breathing. And I, I hear it and I start counting and I'm like, okay, come on, breathe, breathe, breathe. Finally, I'll just nudge him, I mean, kick him and he'll start breathing again. But, you know, it's kind of stressful for me waiting for him going, okay, are you going to start breathing again? But he doesn't realize it. And, and that's my point in that whole story is you may be working with people who've got sleep apnea who have no clue. And addressing that in and of itself does wonders for people's mood, for their energy, for their healing, for their immunity, for their inflammation. Oh, my gosh, it's just wonderful. Relationship issues within the facility. If you're in a facility or within the family. You know, sometimes we go to bed if we've had a fight with our kids or whatever, and we dwell on it and we toss and turn and we feel bad and we're angry, but we're anxious, and it's just all kinds of. It disrupts sleep. If you're going to sleep and you're distressed, you're probably not going to sleep as well. And distrust of staff, whether it's staff that you're not sure if staff's going to just barge into your room or you don't trust the staff that's there. Obviously this is overnight staff. And when I say staff, you know, originally I wrote this for people who are working in residential facilities. But even if you're caring for a loved one, maybe you're caring for your mom or your dad and they may have a distrust of that, that you're not going to come into their room at night. If they have dementia, if they start developing some paranoid delusions, thinking that you're going to come in and harm them or something that will also disrupt their sleep emotionally. All of our stress feelings, anxiety, restlessness, anger, grief, guilt, resentment, if you're feeling distressed, that's triggering that stress response, that's increasing cortisol, that's impairing your ability to get good quality sleep. Now, are we going to go to sleep sometimes when we're feeling grief stricken or depressed? Yeah, we are. But it's important to try to be at a place where we feel as grounded or calm as possible so we can get good quality sleep and we can pick up dealing with whatever it is tomorrow morning because it's still going to freaking be there. Ruminations, especially those that activate the stress response, are going to impair sleep. And when sleep starts getting bad, then our circadian rhythms start getting off. Because remember, they set each other. Helping people figure out how to manage those ruminations at night. Write them down, you know, have a red light by their bed, because red light doesn't destroy the night vision nearly as much. A red light by their bed where they can jot something down or have a recorder. A lot of older adults, because not only do they need the red light and the pen and the paper, they also need to find their glasses. It can be a whole thing. If they have a recorder app on their phone that's, you know, recording right there front and center so they don't have to try to find the stupid app. I know I scroll to find mine. They can just press it. They can say don't forget this or whatever they need to get out of their head so it quits bouncing around in there. Sundowning tends to get worse at for most people after three or four o' clock in the afternoon if they're going to experience sundowning, and that's a result of changes in because of the circadian rhythm changes that are happening with the hormones and the neurotransmitters and everything else. People who are in early stages of dementia will start having more difficulty with sundowning. Helping them feel safe and empowered is the most important thing. Their reality is their reality. Trying to argue with them is like trying to argue with somebody with schizophrenia who's telling you the sky is purple and the squirrels can read your mind. I am not that is their reality. I'm not going to convince them of anything different. If they're in a florid psychotic episode. Somebody who is sundowning, who is determined that they need to go to do something convincing them that they're retired and they're living in an alf and they don't need to do that anymore. That's not their reality. At that moment in time. At that moment in time, they're back in that body of the person who is needing to do that. So a lot of times it's better to address and distract. Anticipate address and distract is better. If somebody every night thinks that they need to go feed the chickens, that's what we do every night at our house. So it's one of those things that, you know, I'll probably be doing until the cows come home. If, if I were sundowning and I was just determined I needed to go feed the chickens. But, you know, I don't have any chickens anymore, telling me that, hey, somebody else so and so went to do that. You hired somebody else to go do that. It's. It's been taken care of or what have you that may help settle me down and distracting. Turning my attention to something else. Remember, you hired Susie and Susie went out and did that. Why don't we go brush our teeth or why don't we go play cards or something else? A lot of times people who are sundowning can be redirected, especially once whatever their concern is has been addressed. Environmentally, we need to address noise, whether it's neighbors, roommates, people walking up and down the hall making all kinds of noise. Anybody who's been in a hospital or a hotel knows what that's all about. Some people will wear earplugs. I personally don't feel safe having earplugs in, so I won't wear them. Some people will use noise machines that play white, brown or pink noise. White no noise represents the whole spectrum. I find it too sharp, too loud, too hissy. Pink noise is. Takes out the upper register and just uses the middle and the lower. And then brown noise is the lower end of the spectrum. You can go on YouTube and find a variety of videos that demonstrate white, pink and brown noise. You know, like eight hour videos and find which one seems to help for that person. What can they fall asleep best with? Because having that white, brown or pink noise on will drown out the other sounds that may awaken them. Address allergens. You don't want people getting stuffy, coughing, etc. Blue light at night. Blue light during the day and not at night is important. If you have dim light during the day, do whatever you can. I have a little reading lamp over here. And you can adjust the temperature of the light as well as the brightness of the light. So you can make it more yellow or more white and you can make it brighter or dimmer. And you can also adjust how high above your head or how low to your head it is. The closer the light bulb to your face, the more of the lumens you're actually getting, the more the brightness you're actually getting. So if you need to increase light for somebody, you and you don't want to do it in the entire room or maybe you have like 15 foot ceilings and it's just not practical. Those reading lamps can be exceptionally helpful. Put them next to the easy chairs, put them next to the bed, whatever. So the person can adjust the light as needed and create a sense of safety in the environment. What does the person need? What helps them feel safe? We've got to ask them because I don't know what makes you feel unsafe. Strategies, just kind of wrapping it up. Make sure they've got a routine. What do you do? My, my husband's grandfather is in his mid-90s now and he is determined he is not going to a facility. He's staying in his house where he lived for 50 years with his wife. And he ain't leaving there. Okay, all right, Pop, so that's fine. What is Pop's routine? Pop has the same routine pretty much every day. He gets up pretty much the same time every day by his own clock, his own circadian rhythms. He goes to sleep pretty much the same time every day by his own clock, his own circadian rhythms. So he's work, he has that going for him where those are, are regulated. He eats the same time every day, 4:30, like clockwork. And that helps keep those circadian rhythms set. Unfortunately, he is in a state right now. His wife recently passed and he's just not wanting to do anything. So there isn't a whole lot of activity. He's inside most of the day. Adjusting the lighting artificially is about the best we can do to increase brightness, except for when he takes the dog out to pee. Temperature cooler at night. Get a programmable thermostat so it turns up to whatever temperature you want it to during the day and then down to 72 or 68 at night. Avoid stress before bed. Encouraging people, you know, if they get really riled up playing bingo, then bingo is probably not what they need to do right before bed. And I used to go to the bingo hall with my grandma and I've seen people get riled up. Let me tell you what, If it's something that's relaxing for them, then great. But if it's going to rile them up, not before bed, probably not a time to. If they have a challenging relationship with somebody in their family, probably not a time to call them, you know, an hour before bed or something, they probably need to do that earlier in the day. Whatever is going to increase their emotional stress before bed. Let's not do that. Reducing caffeine. Caffeine has, for most people between a six and eight hour half life. That means what you drink, about half of it will be out of your system in six to eight hours, which means 12. It takes about 12 hours for caffeine to get out of your system. So what you're drinking at noon isn't completely out of your system, and this is oversimplified, isn't completely out of your system until midnight, which means it's impairing your sleep quality. Encouraging older adults to limit caffeine definitely after noon. You know, ideally they'd probably not ingest caffeine, you know, after, after the morning. But we're going to make compromises, make the majority of the fluid intake earlier in the day, make sure they've got good ergonomics sleep in a position that is comfortable. I have a U shaped body pillow, which has been a game changer for me because whichever way I roll, I've got something to put my, put my knee on top of, which is really helpful. And I feel snug as a buck. I like to feel, I like a weighted blanket, I like to be right in that U shaped pillow. I like to feel snug. Not everybody likes that. Some people find it oppressive. But make sure that they're using the proper pillow so their spine stays in alignment. They've got a good mattress so their spine stays in alignment. Talking with a physical therapist, if you're not sure what that means, physical therapists can help you work with the older adult to develop a sleep environment that is ergonomically appropriate. You have people that have osteoporosis who may have started hunching. So they're going to have a slightly different sleeping position than the rest of us are going to have in order to both be supporting their spine and be comfortable. So again, physical therapist can be really awesome. Most insurances, except for Medicare Advantage, which you got to be very careful with But Medicare Part B, most other insurances, you're allowed to go to a physical therapist without a referral from the pcp. Now, always check your plan. But that is something that we want to make sure that older adults are aware of what they can do without having to go to their doctor first. Pay attention to your circadian rhythms. Help older adults develop relaxation activities that they like. And that's the important thing that they like. Do they like listening to old big band music on vinyl? You know, that is really a throwback. But some people, that takes them back to a happy place. When I was very young, I used to go to my grandmother's every Saturday and. And we would watch Lawrence Welk. And I get a happy feeling every time I hear Lawrence Welk to this very day. You know, 50 years later, I get that happy feeling when, when I hear Lawrence Welk. It's relaxing because we would do the same thing every night. We'd eat dinner, we'd watch Hee Haw, we'd play a game of gin rummy while we were listening or watching Lawrence Welkin. Then we'd watch the Love Boat and Fantasy island and I'd go to bed. I remember that 50 years later because it was a routine and it was set address allergies. I've already said that before. Allergens not only will cause people to get stuffy, make it difficult for them to breathe, which is going to wake them up. It can cause them to cough, which will make. Make them wake up. It can also get them to be stuck stuffy in the morning, which is going to potentially impair their hearing and their balance. And see a physician about prostate incontinence or urinary urgency issues. There are a lot of new interventions. They've got to help people strengthen their pelvic floor muscles to deal with some of the urinary incontinence and obvious obviously to deal with prostate issues or. And there are some medications for urinary urgency. Disrupted circadian rhythms will disrupt sleep and vice versa. Disrupted sleep increases brain fog and irritability and inflammation. And increased stress and inflammation worsen blood sugar regulation and cognitive functioning and cognitive decline. So we really. Some of these things. As I mentioned earlier, a lot of older adults still have a big stigma about counseling and mental health. But we don't even have to call it counseling. If we look at some of their lifestyle behaviors, we can identify areas that are actually contributing to their irritability and to their pain and to their restlessness that are physical, they're physiological. And we can Help them address those issues a lot more effectively if we engage them in a way that we've got buy in from them. This is why we need to look at circadian rhythms. This isn't all houy. Let me explain to you why it's important. What types of issues do you see in your facilities in terms of sleep issues or circadian rhythms? I know in some of the facilities that I worked at, it's. That was kind of my battle cry because it was always freezing cold in a couple of these facilities, so there was no cyclical regulation of temperature. It was always kind of dim, especially in the hallways. But even in their rooms it was, it wasn't very bright during the day. And most people were staying in bed all day long every day, so there was no routine. Their body didn't know when it was time to be awake, when it was time to sleep. Um, sometimes they'd even have their blinds drawn, so it was super dark in their room. And then the administrators would get frustrated and be like, they're agitated, they're blah, blah, blah. Well, this is why. Now I understand from another perspective that from a staffing perspective that having people up and about and moving around and engaged in activities all day long, that is staffing intensive. So you've got to find a happy medium in a lot of the ALS and nursing homes between what you can actually afford to do and what the older adults need. So considering that, when you're looking at how your facility is set up, I encourage you, or if you're working with an adult in home, I encourage you to go to that environment and look at it and say, is there anything I can do to help this person improve their circadian rhythms and, or their quality of sleep? Or is there anything that this person needs improvement with in an alf? I can guarantee you there's at least a few people that need circadian rhythm reset and help with sleep hygiene on an individual basis. Like I said about Papa Snipes, he. He's pretty good. You know, he gets up once a night or so to go to the bathroom. But his circadian rhythms and his sleep seem to be relatively, relatively good. And that's not one of the issues that he's dealing with right now. A lot of the other issues with fatigue and low motivation have to do more with, with grief than, than other stuff. It.