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SUBJECTIVE AND OBJECTIVE QUALITY OF SLEEP: SLEEP AMONG INFANTS AND THE ELDERLY.

An infant is known to sleep considerably more than a mature person. However, even at this early age there are differences in the need for sleep and in the amount of sleep. The number of hours needed can even vary between ten and thirty-two. Many sleep difficulties that later trouble adults can have their origin in infancy.

An infant who is a short sleeper, for example, if coerced to sleep by parents in the erroneous belief that an infant must after all sleep 20 hours, can acquire even at such an early age a complex about being unable to sleep. The child is simply subjected to being trained against its individual biological clock and, in effect, is taught to regard sleep as a problem.

In the beginning, a newborn baby wakes up only when it is hungry, wet, cold, or when it is otherwise disturbed. This condition, called "wakefulness of necessity," (Kleitman) has been contrasted with "wakefulness by choice." As the cerebrum develops, the child learns with increasing regularity to do his sleeping at night, to adjust to the rhythm of the social life of his environment, and to remain awake during the day.

The sleep-wakefulness rhythm is evidently the result of an inborn physiological, periodically changing cycle of activity. Even among adults this cycle is manifested in variations in the degree of feeling awake during the day, mental alertness, and bodily (physical) efficiency.

A familiar practice among young people is the tendency to shift the day-night rhythm toward the direction of late night hours or even toward the early morning hours. Interestingly enough, this can especially be observed among vivid dreamers. The habit conceals dangers, however, which mainly consist in diminished mental productivity and an impaired ability to concentrate. Thinking really requires a rested brain. The assertion of greater mental efficiency during the evening and night hours so often made by students after having shifted day into night (advancing) can at best be supported by the observation there is less distraction and disturbance at night than during the day. For the rest, however, the assertion is a fallacy.

Among older persons, the time spent in sleep is significantly/shortened, and the character of sleep also changes. The elderly person sleeps less and more superficially, and he does more napping. While the

relation between synchronic and asynchronic sleep among infants amounts to 50%, this relation increasingly changes during different phases of life, and among the elderly the REM portion of sleep only amounts to 14%.

Aging, among other things, is also a question of the regulatory capability of the vascular system and is therefore related to the elasticity and condition of the walls of the blood vessels. Leo Buerger, a doctor famous for having conducted research in vascular diseases, made the statement more than 50 years ago that "a person is as old as his blood vessels." It may be assumed that changes in sleep brought about by age are related to these changes in the blood vessels (arteriosclerosis), particularly to the weakening of the elasticity of the vessels in the brain (cerebralsclerosis). It is important to know this-for one reason, because there are far more elderly people than in earlier generations and, for another reason, because of the widespread habit of eagerly and swiftly reaching for sleeping pills.

One of the most essential components of sleep-inducing medications on the market is barbituric acid. In addition to its welcome characteristic of inducing sleep, it has the problematic side effect of lowering the blood pressure and consequently of supplying areas in which circulation is already weak with even less blood and oxygen. In this context, we wish to recall a phenomenon already mentioned in an earlier passage-namely, that during the night the functioning of organs periodically changes. For example, the pulse frequency changes, and so does perspiration, depth and frequency of breathing, and the blood pressure becomes lower. With these changes in mind, it then becomes understandable why a sleeping pill containing barbiturate acid can have an absolutely disastrous effect on an older person. The chain reaction is as follows: as a result of a sclerosis of old age, there is a lack of circulation within the brain, a condition, aggravated both by the diminished strength of the heart as a result of age and by the physiological lowering of the

blood pressure during the night. A single additional sleeping pill containing barbituric acid then suffices to decrease the supply oxygen to the brain to such an extent that the elderly person can become confused and disoriented, even experience clouding of consciousness (delirious).

The most sensible recommendation to elderly persons having difficulty in sleeping, first of all, is to have a medical consultation to check coronary circulation and the supply of blood to the brain. Then, instead of obtaining a prescription for sleeping pills, it may be indicated that a cardiac stimulant should be taken to improve circulation and medication prescribed to stimulate the flow of blood through the brain. In many instances, a cup of coffee drunk before going to bed, seemingly a "paradox sleep medication," can have a splendid effect.

An explanation to the elderly about the nature and amount of sleep as related to age can be of significant help to them in sleeping by dispelling wrong sleep expectations and by promoting the acceptance of dozing off for shorter intervals. Naps, too, taken frequently by the older person during the course of the day, whether after eating, while reading the newspaper or looking at TV, count as sleep. They lessen fatigue at night and diminish the need for sleep. An increasing lack of movement and physical exertion among the elderly also contribute to their need for less sleep than younger persons have or at least should have. In fact, many sleep difficulties have their origin in a lack of movement and of physical fatigue and in the absence of demarcation between day and night. If someone has already had that first little bit of sleep lying down in the front of the TV, it should not be astonishing if he is wide awake after getting into bed, particularly if we recall the organism's periodically changing readiness to sleep during the night. The first opportunity to fall asleep has already been used during the nap in front of the TV, so there is no

alternative but to wait for the next wave of fatigue.

If the person is aware of this, it will certainly be possible to wait with more composure for the moment of falling asleep without reacting abnormally to being awake at night, and the elderly can learn to accept changes in sleep patterns that come with age.

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