Sleep Issues 2018-02-11T19:48:43+00:00

Sleep problems are a relatively common healthcare complaint, with 5% to 10% of the general population reporting insomnia causing significant distress or daytime impairment (Ohayon, 2002). Prevalence rates for older adults are higher, estimated between 15% and 35%, though it has been found to be as high as 50% in some studies (Buysse et al., 2011; Ohayon, 2002).  Advancing age is a risk factor for insomnia symptoms due to normative age-related changes, as older adults have generally lighter and more fragmented sleep patterns (Buysse et al., 2005).  Researchers hypothesize that increased medical problems and medication side effects are the primary reasons for these higher rates of sleep difficulties in older adults (Rybarczyk, Lund, Garroway, & Mack, 2013; Vitiello, 2006). Notably, there are minimal to no differences in prevalence rates of insomnia symptoms between healthy older and younger patients (Ohayon, 2002).  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 anti-diuretic hormone (ADH), gradual loss of bladder capacity, lighter and more fragmented sleep, and potential medication side effects (Jennum, 2002). Although bladder volume remains consistent throughout sleep, it is common for older adults with nocturia to use incorrect post-hoc reasoning, misattributing the urination sensation as the cause for their nighttime awakening (Pressman, Figueroa, Kendrick-Mohamed, Greenspon, & Peterson, 1998).  Cognitive behavioral interventions for sleep can help individuals adjust beliefs about nocturia as the reason of their sleep difficulties.

The increased likelihood of medical problems in an older population and 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 other psychiatric or medical conditions (Lichstein & Rybarczyk, 2010).  In the past 15 years, there has been an increasing presence of older adults with comorbid insomnia included in treatment studies in the cognitive behavioral treatment for insomnia (CBT-I) literature.

Assessment of insomnia and sleep difficulty is typically based on clinical interview, however objective measurement tools are available as well.  Clinical interviews typically examine history, environmental factors, degree of impairment, and sometimes corroborating information from a bed-partner interview (e.g., Duke Structured Interview for Sleep Disorders; Edinger et al., 2009). One or two-week sleep diaries are often a vital part of assessment, and there are numerous publicly available diaries online (e.g., American Academy of Sleep Medicine diary, 2010).  More objective evaluation tools include actigraphy, a motion-sensitive wrist worn device, and polysomnography (PSG), or sleep study.  PSG is considered the gold standard for measuring sleep disturbances; the evaluation assesses brain and eye movements, muscle activity, and heart rhythm during sleep (Buysse, Germain, & Moul, 2005).

The most well-established treatment for insomnia is cognitive-behavioral therapy for insomnia (CBT-I), with main treatment components including sleep restriction, stimulus control, cognitive therapy, and sleep hygiene (Morin et al., 2006). This evidence-based treatment is typically effective for 70% to 80% of patients and has good long-term efficacy in reducing insomnia symptoms (Edinger et al., 2001; Morin et al., 2006). CBT-I has short-term outcomes comparable to pharmacotherapy, however CBT-I maintains longer therapeutic benefits after treatment termination (Riemann & Perlis, 2009). There is also good evidence that CBT-I is as effective for older adults compared to their younger counterparts (Irwin, Cole, & Nicassio, 2006; see Rybarczyk et al., 2013 for a review).  In response to the high need for more CBT-I trained clinicians to increase dissemination and accessibility of the treatment, a brief behavioral treatment for insomnia has been recently developed and shown to be an effective intervention for chronic insomnia in older adults (Buysse et al., 2011).

Written by Andrea Garroway, MS & Bruce Rybarczyk, PhD

GENERAL

Ancoli-Israel, S., & Cooke, J. R. (2005). Prevalence and comorbidity of insomnia and effect on functioning in elderly populations. Journal of the American Geriatrics Society, 53(S7), S264–S271.

Ancoli-Israel, S., & Cooke, J. R. (2005). Prevalence and comorbidity of insomnia and effect on functioning in elderly populations. Journal of the American Geriatrics Society, 53(S7), S264–S271.

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Buysse, D. J., Germain, A. & Moul, D. E. (2005). Diagnosis, epidemiology, and consequences of insomnia. Primary Psychiatry, 12(8), 37-44.

Buysse, D. J., Germain, A. & Moul, D. E. (2005). Diagnosis, epidemiology, and consequences of insomnia. Primary Psychiatry, 12(8), 37-44.

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Jennum, P. (2002). Sleep and nocturia. British Journal of Urology International, 90(S3), 21–24. doi: 10.1046/j.1464-410X.90.s3.6.x

Jennum, P. (2002). Sleep and nocturia. British Journal of Urology International, 90(S3), 21–24. doi: 10.1046/j.1464-410X.90.s3.6.x

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Morin, C. M., LeBlanc, M., Daley, M., Gregoire, J. P, & Merette, C. (2006). Epidemiology of insomnia: Prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors. Sleep Medicine, 7, 123–130.

Morin, C. M., LeBlanc, M., Daley, M., Gregoire, J. P, & Merette, C. (2006). Epidemiology of insomnia: Prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors. Sleep Medicine, 7, 123–130.

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Ohayon, M. M. (2002). Epidemiology of insomnia: What we know and what we still need to learn. Sleep Medicine Reviews, 6, 97–111. doi: 10.1053/smrv.2002.0186

Ohayon, M. M. (2002). Epidemiology of insomnia: What we know and what we still need to learn. Sleep Medicine Reviews, 6, 97–111. doi: 10.1053/smrv.2002.0186

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Pressman, M. R., Figueroa, W. G., Kendrick-Mohamed, J., Greenspon, L. W., & Peterson, D. D. (1998). Nocturia: A rarely recognized symptom of sleep apnea and other occult sleep disorders. Archives of Internal Medicine, 156, 545–550. doi: 10.1001/archinte.1996.00440050103011

Pressman, M. R., Figueroa, W. G., Kendrick-Mohamed, J., Greenspon, L. W., & Peterson, D. D. (1998). Nocturia: A rarely recognized symptom of sleep apnea and other occult sleep disorders. Archives of Internal Medicine, 156, 545–550. doi: 10.1001/archinte.1996.00440050103011

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Rybarczyk, Lund, Garroway, & Mack (2013). Cognitive behavioral therapy for insomnia in older adults: Background, evidence, and overview of treatment protocol. Clinical Gerontologist, 36, 70-93. doi: 10.1080/07317115.2012.731478

Rybarczyk, Lund, Garroway, & Mack (2013). Cognitive behavioral therapy for insomnia in older adults: Background, evidence, and overview of treatment protocol. Clinical Gerontologist, 36, 70-93. doi: 10.1080/07317115.2012.731478

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Vitiello, M. V. (2006). Sleep in normal aging. Sleep Medicine Clinics, 1, 171–176. doi: 10.1016/j.jsmc.2006.04.007

Vitiello, M. V. (2006). Sleep in normal aging. Sleep Medicine Clinics, 1, 171–176. doi: 10.1016/j.jsmc.2006.04.007

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ASSESSMENT OF SLEEP ISSUES IN LATER LIFE

Bastien, C. H., Vallières, A., & Morin, C. M. (2001). Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Medicine, 2(4), 297-307.

Bastien, C. H., Vallières, A., & Morin, C. M. (2001). Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Medicine, 2(4), 297-307.

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Chung, F., Yegneswaran, B., Liao, P., Chung, S. A., Vairavanathan, S., Islam, S., . . . Shapiro, C. M. (2008). STOP questionnaire: A tool to screen patients for obstructive sleep apnea. Anesthesiology, 108, 812–821.

Chung, F., Yegneswaran, B., Liao, P., Chung, S. A., Vairavanathan, S., Islam, S., . . . Shapiro, C. M. (2008). STOP questionnaire: A tool to screen patients for obstructive sleep apnea. Anesthesiology, 108, 812–821.

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Edinger, J. D., Wyatt, J. K., Olsen, M. K., Stechuchak, K. M., Carney, C. E., Chiang, A., … Knauss, F. (2009) Reliability and validity of insomnia diagnoses derived from the Duke Structured Interview for Sleep Disorders. Sleep, 32(A265).

Edinger, J. D., Wyatt, J. K., Olsen, M. K., Stechuchak, K. M., Carney, C. E., Chiang, A., … Knauss, F. (2009) Reliability and validity of insomnia diagnoses derived from the Duke Structured Interview for Sleep Disorders.  Sleep, 32(A265).

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Hays, R. D., Martin, S. A., Sesti, A. M., & Spritzer, K. L. (2005). Psychometric properties of the medical outcomes study sleep measure. Sleep Medicine, 6(1), 41-44.

Hays, R. D., Martin, S. A., Sesti, A. M., & Spritzer, K. L. (2005). Psychometric properties of the medical outcomes study sleep measure. Sleep Medicine, 6(1), 41-44.

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MEASURES and TOOLS

TREATMENT OF SLEEP ISSUES IN LATER LIFE

Buysse, D. J., Germain, A., Moul, D. E., Franzen, P. L., Brar, L. K., Fletcher, M.E., . . . Monk, T.H. (2011). Efficacy of brief behavioral treatment for chronic insomnia in older adults. Archives of Internal Medicine, 171, 887–895. doi: 10.1001/archinternmed.2010.535

Buysse, D. J., Germain, A., Moul, D. E., Franzen, P. L., Brar, L. K., Fletcher, M.E., . . . Monk, T.H. (2011). Efficacy of brief behavioral treatment for chronic insomnia in older adults. Archives of Internal Medicine, 171, 887–895. doi: 10.1001/archinternmed.2010.535

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Edinger, J. D., Wohlgemuth, W. K., Radtke, R. A., Marsh, G. R., & Quillian, R. E. (2001). Cognitive behavioral therapy for treatment of chronic primary insomnia. JAMA: The Journal of the American Medical Association, 285(14), 1856-1864. doi: 10.1001/jama.285.14.1856

Edinger, J. D., Wohlgemuth, W. K., Radtke, R. A., Marsh, G. R., & Quillian, R. E. (2001). Cognitive behavioral therapy for treatment of chronic primary insomnia. JAMA: The Journal of the American Medical Association, 285(14), 1856-1864. doi: 10.1001/jama.285.14.1856

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Irwin, M. R., Cole, J. C., & Nicassio, P. M. (2006). Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age. Health Psychology, 25, 3–14. doi: 10.1037/0278-6133.25.1.3

Irwin, M. R., Cole, J. C., & Nicassio, P. M. (2006). Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age. Health Psychology, 25, 3–14. doi: 10.1037/0278-6133.25.1.3

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Lichstein, K. L., & Rybarczyk, B. (2010). Cognitive-behavior therapy for co-morbid and late-life insomnia. In D. Bussye & M. J. Sateia (Eds.), Insomnia: Diagnosis and treatment. New York, NY: Informa Healthcare, Inc. doi: 10.3109/9781420080803.030

Lichstein, K. L., & Rybarczyk, B. (2010). Cognitive-behavior therapy for co-morbid and late-life insomnia. In D. Bussye & M. J. Sateia (Eds.), Insomnia: Diagnosis and treatment. New York, NY: Informa Healthcare, Inc. doi: 10.3109/9781420080803.030

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Morin, C. M., & Espie, C. A. (2003). Insomnia: A clinical guide to assessment and treatment. New York: Kluwer Academic/Plenum Publishers.

Morin, C. M., & Espie, C. A. (2003). Insomnia: A clinical guide to assessment and treatment. New York: Kluwer Academic/Plenum Publishers.

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Morin, C. M., Bootzin, R. R., Buysse, D. J., Edinger, J. D., Espie, C. A., & Lichstein, K. L. (2006). Psychological and behavioral treatment of insomnia: Update of recent evidence (1998–2004). Sleep, 29, 1398–1414.

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Riemann, D., & Perlis, M. L. (2009). The treatments of chronic insomnia: A review of benzodiazepine receptor agonists and psychological and behavioral therapies. Sleep Medicine Reviews, 13, 205–214. doi: 10.1016/j.smrv.2008.06.001

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Rybarczyk, B. R., & Mack, L. J. (2009). Self-help treatments for older adults with primary and comorbid insomnia. In S. R. Pandi-Perumal, J. M. Monti, & A. A. Monjan (Eds.), Principles & practice of geriatric sleep medicine. (pp. 394–402). New York, NY: Cambridge University Press.

Rybarczyk, B. R., & Mack, L. J. (2009). Self-help treatments for older adults with primary and comorbid insomnia. In S. R. Pandi-Perumal, J. M. Monti, & A. A. Monjan (Eds.), Principles & practice of geriatric sleep medicine. (pp. 394–402). New York, NY: Cambridge University Press.

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Rybarczyk, B., Lopez, M., Benson, R., Alsten, C., & Stepanski, E. (2002). Efficacy of two behavioral treatment programs for comorbid geriatric insomnia. Psychology and Aging, 17, 288–298.

Rybarczyk, B., Lopez, M., Benson, R., Alsten, C., & Stepanski, E. (2002). Efficacy of two behavioral treatment programs for comorbid geriatric insomnia. Psychology and Aging, 17, 288–298.

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Rybarczyk, B., Lund, H., Shamaskin, A., & Mack, L. (2013). Cognitive Behavioral Therapy for Insomnia in Older Adults: Background, Evidence and Overview of Treatment Protocol. Clinical Gerontologist, 36, 70-93.

Rybarczyk, B., Lund, H., Shamaskin, A., & Mack, L. (2013). Cognitive Behavioral Therapy for Insomnia in Older Adults: Background, Evidence and Overview of Treatment Protocol. Clinical Gerontologist, 36, 70-93.

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RESOURCES FOR OLDER ADULTS AND FAMILIES ON SLEEP IN LATER LIFE