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
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ASSESSMENT OF SLEEP ISSUES IN LATER LIFE
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MEASURES and TOOLS
TREATMENT OF SLEEP ISSUES IN LATER LIFE
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RESOURCES FOR OLDER ADULTS AND FAMILIES ON SLEEP IN LATER LIFE
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.