Sleep problems are a relatively common healthcare complaint. Insomnia (i.e., difficulty initiating or maintaining sleep) is one of the more common sleep problems. While approximately 30% of the general population experience insomnia symptoms at some point in their lifetime, 6-10% experience chronic insomnia that leads to clinical distress and daytime impairment (Morin et a., 2006; Ohayon, 2002). While research reports increasing prevalence rates of insomnia symptoms with age, the need for sleep does not decrease with age (Mander, Winer, & Walker, 2017) and remains essential for healthy aging into older adulthood (Ravyts & Dzierzewski, 2022). As such, it is important to understand the potential risk factors, assessments, and treatments for sleep difficulties, such as insomnia, in older adults.

While poor sleep is not a guaranteed outcome of aging, older adults may experience sleep disruptions or poor sleep quality related to normative age-related changes in sleep architecture (Ohayon et al., 2004). Even with these age-related changes, researchers hypothesize that the increased incidence of medical conditions and medication side effects are more prominent risk factors for sleep difficulties in older adults (Rybarczyk et al., 2013; Li, Vitiello, & Gooneratne, 2022). One relevant issue regarding late life sleep difficulties is nocturia, or an increase in nocturnal urination. It is believed that with increasing age, the greater likelihood of nocturia is due to co-occurring decreases in antidiuretic hormone (ADH) (i.e., hormone that supports the regulation of water in the body), gradual loss of bladder capacity, lighter and more fragmented sleep, and potential medication side effects. Nocturia can co-occur with other sleep disorders, such as sleep-related breathing disorder (e.g., obstructive sleep apnea) and insomnia disorder in older adults (Vaughan & Bliwise, 2018). Overall, the increased likelihood of medical problems in an older population and potential subsequent impact on sleep has diagnostic indications as well. The majority of adults over age 60 with insomnia have “comorbid insomnia,” or insomnia that co-occurs with (but is not secondary to) other psychiatric or medical conditions (Lichstein & Rybarczyk, 2010). For example, common psychiatric conditions comorbid with insomnia include depression, bipolar I disorder, and anxiety. Common medical conditions comorbid with insomnia include chronic pain, arthritis, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Although this is not an exhaustive list, it should be noted that, while these conditions commonly co-occur with insomnia in older adulthood, they are not exclusive to this age cohort (Barczi & Teodorescu, 2017).

Assessment of insomnia and sleep difficulty is particularly important in older adults. Research has demonstrated that older adults may perceive poor sleep to be a normal part of aging or may rate sleep as a lower priority than other medical conditions and age-related concerns (Brouwer, van Exel, & Stolk, 2005). As such, it is essential that clinicians consider sleep a “vital sign” and appropriately assess sleep in patient care visits (Grandner & Malhotra, 2015). While there is no standardized way of evaluating sleep or insomnia in older adults, a clinical interview with subjective questionnaires is an important first step. Clinical interviews typically examine history; biopsychosocial and environmental factors; frequency, severity, and chronicity of symptoms; degree of impairment; and, if appropriate, corroborating information from a bedpartner or caregiver (e.g., Duke Structured Interview for Sleep Disorders; Edinger et al., 2009). Subjective questionnaires may include broader questions of sleep disorder symptoms (e.g., Sleep Disorders Symptom Checklist-25 [SDS-CL-25]; Klingman, Jungquist, & Perlis, 2017) followed by tailored assessments based on reported symptoms (e.g., Insomnia Severity Index; Morin, 1993; Bastien, Vallières, & Morin, 2001). One or two-week sleep diaries are often a vital part of assessment and can provide insight into severity and frequency of disturbances, as well as when these disturbances occur during the sleep period (e.g., The Consensus Sleep Diary; Carney et al., 2012). This may be particularly relevant as older adults are more likely to report problems with early morning awakenings than younger cohorts (Boyle et al., 2023).

In addition to interviews and self-report measures, there are times when objective assessments are warranted. Actigraphy devices are typically worn on the wrist and record physical activity or movement, from which sleep variables can be calculated. Actigraphs may also be used in conjunction with sleep diaries and can be useful in assessing insomnia or circadian rhythm disorders (Smith et al., 2018). Other sleep disorders, such as sleep-related breathing disorders (e.g., obstructive sleep apnea) or sleep-related movement disorders (e.g., periodic limb movement disorder) may be assessed through polysomnography (PSG). PSG involves an in-lab study that typically occurs overnight. Sleep diagnostic variables are captured through an electroencephalogram (EEG; brainwave activity), an electromyogram (EMG; muscle activity), an electrooculogram (EOG; eye movements), an electrocardiogram (ECG; heart rate and rhythm), an airflow sensor (nasal or oral airflow), a thoracic belt, an abdominal belt, and pulse-oximetry (blood oxygen). Measuring brainwaves (EEG) is essential for the identification of sleep stages and time spent in each stage during a sleep period. Specifically, this helps determine presence, staging, and timing of rapid-eye-movement (REM) sleep (i.e., stage where dreaming occurs) or non-rapid-eye-movement (NREM) sleep (i.e., stages N1, N2, and N3). Eye movement (EOG) and muscle activity (EMG) further support identifying REM sleep. EMG also supports the diagnosis of sleep-related movement disorders. Additionally, the thoracic and abdominal belts capture movements within the thoracic and abdominal areas to assess respiratory effort, which is useful in diagnosing sleep-related breathing disorders. A microphone may be used to capture snoring and a camera may be used to view body position and ensure patient safety during the assessment. Additional measures or variables may be used or scored depending on the presenting concern of the patient (Pandi-Perumal, Spence, & BaHammam, 2014). The Home Sleep Apnea Test (HSAT) is a modified form of this objective assessment and can be used to assess for obstructive sleep apnea within the patient’s home environment (Kapur et al., 2017).

For insomnia, Cognitive Behavioral Therapy for Insomnia (CBT-I) is considered the first line of treatment (Qaseem et al., 2016). CBT-I can be completed in 6-8 sessions and core components include stimulus control, sleep restriction, and sleep hygiene. Patients also receive tailored sleep education to support their understanding of insomnia and of the treatment components (Perlis et al., 2005). Supplemental components, such as cognitive therapy and mindfulness, may be essential for improving treatment outcomes in some patients (Harvey et al., 2007; Ong & Smith, 2017). Up to 80% of patients experience at least a therapeutic response to this evidence-based treatment (Morin et al., 2009). Further, CBT-I has also demonstrated good long-term efficacy in reducing insomnia symptoms with one study observing remission rates of up to 74% one year following CBT-I completion and up to 63% two years following CBT-I completion (Beaulieu-Bonneau et al., 2017). CBT-I has short-term outcomes comparable to pharmacotherapy; however, CBT-I maintains longer therapeutic benefits after treatment termination (Riemann & Perlis, 2009). CBT-I can be effectively provided in individual or group settings, in person, or via telehealth (Muench et al., 2022). There is also good evidence that CBT-I is effective for treating insomnia in older adults (Irwin, Cole, & Nicassio, 2006; Rybarczyk et al., 2013; Hinrichsen & Leipzig, 2022). Many older adults are able to complete CBT-I with minimal to no adaptations; however, specific adaptations have been identified for older adults with functional, sensory, or cognitive impairment, increased social isolation, reduced daytime activity, increased risk for falls, and comorbid sleep or medical disorders (Hughes & Martin, 2022).

CBT-I and other behavioral sleep medicine interventions have received growing support from the healthcare community. With this support comes a greater demand for more trained clinicians and more treatment options. Efforts to address these demands include the introduction of shorter but effective treatments. Specifically, Brief Behavioral Treatment for Insomnia (BBTI) may be an effective alternative to treat chronic insomnia in older adults, especially when CBT-I is not available or feasible. BBTI consists of two core sessions and a follow-up session, which focus on tailored sleep education, as well as the evidence-based behavioral components of CBT-I (i.e., stimulus control and sleep restriction) (Buysse et al., 2011). There is also exploration for additional evidence-based treatment options for insomnia, such as Acceptance and Commitment Therapy (ACT) for insomnia. ACT for insomnia utilizes mindfulness and acceptance-based approaches while also maintaining key components utilized in CBT-I (i.e., sleep hygiene, sleep education, sleep restriction, stimulus control). Within an ACT framework, insomnia treatment may also include values-based goal setting and committed action to engage in values-based activities despite insomnia; cognitive defusion in leu of cognitive restructuring; and acceptance of insomnia as a short-term discomfort during the treatment process (Saldana, McGowan & Martin, 2023).

Lastly, efforts to expand access to assessment and treatment of insomnia also include Geropsychologists and other healthcare professionals who work with older adults becoming proficient in CBT-I and other behavioral sleep medicine interventions as they are uniquely positioned to effectively provide these treatments to older adults (Hinrichsen & Leipzig, 2022).

Additions and updates for this article written by Julia T. Boyle, PsyD, DBSM in 2023.

Original article written by Andrea Garroway, MS & Bruce Rybarczyk, PhD.

GENERAL

ASSESSMENT OF SLEEP ISSUES IN LATER LIFE

MEASURES and TOOLS

• STOP Questionnaire—screening tool for patients with obstructive sleep apnea
• Epworth Sleepiness Scale (ESS)—measures excessive daytime sleepiness
• Pittsburg Sleep Quality Index—measures quality and patterns of sleep in older adults
• American Association of Sleep Medicine sleep diary
• Consensus Sleep Diary
• Insomnia Severity Index
• Sleep Disorders Symptoms Checklist

TREATMENT OF SLEEP ISSUES IN LATER LIFE

RESOURCES FOR OLDER ADULTS AND FAMILIES ON SLEEP IN LATER LIFE

• Find an accredited Sleep Center near you
• “How to sleep well over 50”
• NIH Senior Health: Sleep and Aging FAQ
• Sleep Apnea Health Center