As people age, symptoms of insomnia often creep in. They may toss and turn for hours, struggling to fall or stay asleep. Frequent nocturnal and early morning awakenings are very common in older adults. This, in turn, contributes to higher rates of depression, social isolation, and physical health issues. The combination of insomnia and depression can be quite disruptive to an older adult’s quality of life.
“Poor sleep can lead to poor daytime functioning, including difficulty with memory, irritability, and daytime sleepiness,” said Douglas Kirsch, MD, medical director of sleep medicine at Atrium Health in Charlotte, North Carolina, and a past president of the American Academy of Sleep Medicine.
Over time, sleep deficiency has been linked to an increased risk for not only depression but also anxiety, hypertension, type 2 diabetes, heart attack, falls and accidents, substance abuse disorders, and premature death. It also may be a risk factor for Alzheimer’s disease.
“Chronic insomnia takes a toll on overall health,” said Josepha A. Cheong, MD, professor of psychiatry at the University of Florida College of Medicine and a staff physician and psychiatrist at Malcom Randall Veterans Affairs Medical Center in Gainesville.
Research shows that sleep plays a role in storing memories and has a restorative function.
“Lack of sleep impairs reasoning, problem-solving, and attention to detail, among other effects,” Cheong said, adding that during sleep the brain’s cerebrospinal fluid works to “flush” metabolic waste that accumulates during the day.
Behavioral Therapy: A Proven First-Line Intervention
The good news is that treating insomnia can help alleviate depression and related problems.
“Insomnia is a risk factor for depression,” said Natalia S. David, PsyD, DBSM, a health psychologist who specializes in behavioral sleep medicine at the University of Texas Southwestern Medical Center’s O’Donnell Brain Institute in Dallas. “Therefore, reducing insomnia in older adults should be a focus of clinical attention.”
Cognitive behavioral therapy for insomnia (CBT-I) is the first-line and gold-standard treatment for insomnia, as recommended by the American Academy of Sleep Medicine.
“Insomnia is very hard to treat with medication, which is why behavioral and cognitive interventions are preferred, with results durable vs medication alone,” David said.
Sleep hypnotic medication should only be used to treat acute insomnia — with a duration of less than 3 months. Relying on this medication on a long-term basis can cause more sleep issues, potentially resulting in addiction and cognitive impairment. David said research indicates that those who used sleep medication had a twofold greater risk of developing dementia.
Breaking the Vicious Cycle of Insomnia
Kathleen Primm, 68, who lives in Keller, Texas just outside Fort Worth, took David’s 7-week CBT-I course earlier this year, which was recommended by Primm’s sleep medicine doctor.
Primm said she suffers from anxiety, and her doctor noted that she has mood fluctuations as well. Her sleep issues intensified during the COVID-19 pandemic. Even though she didn’t nap during the day, she could only sleep 2-3 hours at night.
“It was just a vicious circle,” the substitute elementary special ed teacher said of her insomnia. “But I took the course and thought it was very beneficial.”
After implementing behavioral changes, Primm gradually weaned off of sleep medication and is now able to get up to 8 hours of rest each night.
She also learned not stay in bed longer than 20 minutes if she couldn’t fall asleep. Instead, she went into her living room, cleared her mind and did breathing exercises, inhaling and exhaling until she felt relaxed enough to go back to bed and fall asleep. She also listened to a mobile phone app that plays soothing rainfall.
A recent randomized clinical trial by UCLA’s David Geffen School of Medicine found that CBT-I prevented depression in community-dwelling adults aged 60 years and older with insomnia. In 291 older adults without depression but with insomnia disorder, 2 months of CBT-I “resulted in a decreased likelihood of incident and recurrent depression during 36 months of follow-up compared with an active comparator control, sleep education therapy.”
CBT-I teaches people practical methods to sleep better. One commonly used technique is called sleep compression, Kirsch said. By selecting a limited and personalized time window for sleeping — often less than the patient allocated previously — the clinician guides the individual’s sleep in becoming more efficient. Gradually, that window is extended to a more typical amount of sleep time, he said.
The process often follows a 6- to 8-week course for most patients, but it may take longer in some difficult cases. At times, medications and CBT-I are used jointly for patients who need both types of therapy to sleep well. Recently, there has been interest in assessing the use of telemedicine to conduct CBT-I, particularly given the limited number of trained therapists, Kirsch said.
A free mobile phone app, CBT-i Coach, provides different tools to establish improved sleep habits, as well as to identify potential factors that may be causing insomnia.
CBT-I does not involve using medications and is considered effective, said Cheong, who is certified in geriatric psychiatry and serves a director of psychiatry for the American Board of Psychiatry and Neurology. She adds that about 70%-80% of patients with primary insomnia experience improvements with CBT-I, falling asleep sooner after going to bed and awakening less during the night.
“If practiced consistently, CBT-I produces sustained results over time,” she said.
Identifying the Signs of These Overlapping Disorders
Geriatricians often encounter patients with sleep disorders, which affect women more commonly than men.
“Sleep disorders are complex, particularly in older adults, because many factors can affect sleep, such as medications, sleep apnea, and even changes that come with normal aging,” said Yoon Hie Kim, MD, MPH, a geriatric medicine specialist at Duke Health in Durham, North Carolina. “Numerous medical conditions also can disturb sleep, including neurocognitive disorders, pain, nocturia, and restless legs syndrome.”
Despite the prevalence of sleep disorders and depression in older adults, they are likely to be underdiagnosed in this age group. Sleep disorders affect as many as half of the older population, whereas depression varies across settings and occurs at higher rates in nursing homes, Kim said.
“These conditions may not be very evident to the patient, but they can be the root cause of many issues that affect daily functioning,” she said.
Depression in older adults may be difficult to recognize because they may have different symptoms than younger people. For some older adults with depression, the main symptom isn’t sadness or depressed mood — it’s a feeling of numbness or a lack of interest in activities, hobbies, or socializing, said Michelle Drerup, PsyD, director of behavioral sleep medicine at Cleveland Clinic in Ohio.
Other common symptoms include unexplained or aggravated aches and pains, weight loss or loss of appetite, feelings of hopelessness or helplessness, lack of motivation, sleep issues and loss of self-worth (worries about being a burden, a sense of worthlessness or self-loathing), fixation on death or thoughts of suicide, and neglecting personal care (skipping meals, forgetting medications or disregarding personal hygiene), Drerup said.
The symptoms arising from sleep disorders and major depressive disorder can overlap and may include fatigue, mood changes, daytime sleepiness, and decreased concentration.
“It’s critical for sleep and mood to be assessed when someone is undergoing an evaluation for cognitive impairment, as improving sleep and mood symptoms may result in improvement in function,” Kim said. “A wellness visit that is focused on preventive care can be a good place to systematically screen for sleep or mood disorders.”
Susan Kreimer is a New York-based freelance health journalist.
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