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DEAR DR. ROACH: I am 90 years old and cannot sleep at night. I have tried taking two or three times the dosage of most over-the-counter drugs to no avail. A doctor put me on a prescription medicine, but it didn't work. Is there an alternative, or must I spend the rest of my life sleepless? -- D.J.

ANSWER: At the age of 90, you need careful consideration about treatment for sleep troubles as some of the common treatments that aren't too bad for young adults can lead to significant problems in older adults.

First off, the OTC sleep medications, which are most commonly diphenhydramine (Benadryl), are not great choices for anyone. I especially worry about them because they suppress the most important types of sleep, cause confusion, and increase the risk of falls and motor vehicle accidents. When taking them above the recommended doses, these side effects become more likely.

Prescription medications also have risks including tolerance and dependence. In older people, cognitive impairment and delirium are not uncommon. Most of the advertised prescription sleep medicines are inappropriate for older adults. Accordingly, nonmedication treatments such as sleep hygiene and cognitive-behavior treatment for insomnia are preferred over medication.

DEAR DR. ROACH: My wife who is 78 years old recently underwent a lithotripsy procedure, along with a stent being placed in her urinary tract. She had several urinary tract infections in the recent past. Within 24 hours of the procedure, she had convulsions and could not stand up or support her own weight. I immediately recognized that this reaction was due to a UTI since it has happened in the past. Upon being hospitalized, she was diagnosed with a UTI and sepsis (a blood infection).

My question to you is: Should her urologist have scheduled a urine test prior to the procedure to make sure that she did not have any existing infections? After confronting her urologist about this, he said the test is normally unnecessary. What do you think? -- R.S.

ANSWER: It is standard procedure to perform a urine test prior to urological procedures such as lithotripsy, which is a procedure to break up stones. At least 9% of such people will have a urine infection. People with stents are at a higher risk, as are people with large stones.

The American Urological Association recognizes that serious complications, including sepsis, may result from treatment if a urine infection is present. It sounds like her urologist was in the wrong here if the facts are as you presented them.

DEAR DR. ROACH: We are among the fortunate people to have a hot tub on our deck. I understand the recommended time to spend in the water is about 15 minutes. We keep it between 37-38.5 degrees Celsius (98.6-101.3 in Fahrenheit). My 77-year-old husband sometimes stays in the tub for 90 minutes or even up to 120 minutes. Is this causing any negative effects on his body? -- K.M.

ANSWER: If your husband has no symptoms, it's unlikely to cause harm. With hotter hot tubs, often around 40 degrees Celsius (104 in Fahrenheit), many people will become dizzy or lightheaded as the blood vessels in the skin open up and the volume inside the heart goes down.

After 90-120 minutes, there is a danger of hyperthermia (having too high of a body temperature). Most people will naturally learn to keep part or most of their body out of the hot tub if they feel too warm. Some older people have a hard time recognizing this.

You should also follow your hot tub manufacturer instructions to keep the water free from bacteria.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.

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