March 22,2021

It’s another one of those bolt upright at 4:30 AM mornings. I don’t worry when that happens as I know it’s perfectly normal at my age. My sleeping patterns are becoming a bit more erratic in general. Some nights I’ll sleep nine or ten hours, some five or six. On those latter nights, my brain is trying to get me into the old patterns of first and second sleep that the human race discarded with the onset of shift work and electric light but which our primitive brains remember all too well. I know I’ll be sleepy again around 6:30, just in time for my first alarm to go off rather than for me to snooze for a few more hours so today is going to be a long day with double clinic and rehearsal to follow.

One of the chief complaints of many of my patients is ‘I can’t sleep’. On gentle probing, I usually find that they sleep just fine, they just don’t sleep in the patterns they think they’re entitled to. We all think we should slumber in a state of complete unconsciousness for somewhere between six and ten hours as that’s what we all remember from our young adult days. Young brains are wired to do that, older brains not so much. We’re all cro-magnons and for the tribe to survive the older adults had to wake up at night, make sure the competing tribe wasn’t sneaking over the hill, scare away the saber tooth tiger, and count the children while the younger adults slumbered to conserve their energies for the mammoth hunt. So older adults naturally sleep less deeply and are conditioned by evolution to have periods of wakefulness. The private letters and diaries of pretty much anyone prior to the mid nineteenth century speak of first and second sleep in such a way that it was clear that it was the norm and the scholars and intellectuals often did their best work in the wee hours between the two periods.

The invention of factories led to the invention of shift work which required sleep be compressed. And then electric light separated our daily cycles from the cycles of the sun. The response in western society was to train everyone from infancy to have a single sleep period of roughly eight hours. This was further reinforced in the latter half of the twentieth century by television programming schedules. So now, the elder population, socialized by all of that, feel something is definitely amiss when they wake up at night just as their brains are designed to do and off they troop to the pharmacy and load up on Unisom, Sominex and Tylenol PM.

The problem with this is that the active ingredient in all over the counter sleep aids (with the exception of melatonin) is diphenhydramine, often known by its original trade name of Benadryl. It’s a pretty benign drug in young adults, which is why it’s been sold over the counter for decades. It’ll make you slightly sleepy and clean up your runny nose while it’s at it as it’s a fairly powerful antihistamine (it’s original use). Unfortunately, it’s also very strongly anticholinergic (meaning that it blocks the action of the neural transmitter acetylcholine – a transmitter that’s used in various ways in the brain, gut, and bladder). In older people, where their neural systems are already in trouble from other processes, this can spell disaster. Acetylcholine is the major neurotransmitter involved in memory processes so blocking it can cause significant memory issues. This is the mechanism by which Alzheimer’s disease causes much of its havoc. I have cured more than one case of ‘Alzheimer’s by taking away the over the counter sleep aid. There’s also some evidence that routine use of diphenhydramine by the elderly can actually cause the brain changes of Alzheimer’s. Other side effects are constipation and urinary continence issues.

There are prescription sleep aids that are relatively safe for older people that can be used. I try not to. I try to get older people to understand and accept their own natural body rhythms. And I’m fine with such tried and true methods as warm milk, chamomile tea, and I don’t mind over the counter melatonin (it’s a natural brain chemical involved in the sleep cycle). I do use sleepers in the demented who become completely divorced from the clock and household routines. It’s not about them, it’s about the family who still need to keep to work and school schedules and really need to sleep when grandma decides that three am is the correct hour for practicing her accordion.

So where are we in Covid land? We’re just about to hit 30 million diagnosed cases. For those of you playing along at home, we hit 10 million on November 9th and 20 million on January 1st so the curve is not as steep as it was this winter but continues to inch inexorably up. Deaths are at 542,000 and are still somewhere between 1000 and 1500 daily. As I write these numbers, which would have been unfathomable a year ago, I realize that I’ve become inured to them. They seem less immediate, less real. Is that because I’ve had my vaccination and am less worried about myself? Am I just burnt out? Is it that the media is moving on to other things and while Covid remains in the background, it’s not front and center in the constant information stream that bombards us all on a daily basis? The vaccines keep rolling out at a fast and furious rate (in Alabama, everyone over 55 and everyone with a chronic health condition is eligible as of today) and a significant portion of the population will have that protection shortly. We’ll have to wait a few months though to know what that really means in terms of viral spread.

The governor of Florida, who has spent most of the pandemic in a state of denial and cooking the books regarding Covid data, has been given a lot of good press recently and has been leading the charge for fully opening up. This has led to the traditional spring break crowds flocking to Florida beach towns. Young people at the beach are, of course, doing what young people at the beach do much to the consternation of their elders. Will this lead to a new surge as they return to their college campuses and towns after exchanging microbes? With luck, the more vulnerable back home will have been vaccinated and less sucspetible and it won’t be as bad as last year. We’ve all heard about the unrest in Miami Beach and the imposition of a curfew. Out of curiosity, I went looking for social media pictures of the beach in Fort Lauderdale and other beach towns to see if they looked similar. Yup, plenty of mingling unmasked young folk there too. The difference is that Miami Beach is a traditional gathering place for young people of color suggesting that America’s systemic racism is rearing its ugly head once again in terms of unequal treatment.

If you decide to go to the beach the next few weeks, just remember it ain’t over until it’s over. Vaccines aren’t fully protective until about six weeks after your first shot. It remains unclear how much the vaccinated can contract and transmit. So wear your mask around other people, keep your hands washed and plunk your beach towel down away from those you don’t know.