Symptoms of insomnia often creep in with age. You can toss and turn for hours and have trouble falling asleep or staying 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 problems. The combination of insomnia and depression can be quite detrimental to an older adult’s quality of life.
“Poor sleep can lead to poor daytime functioning, including memory difficulties, irritability, and daytime sleepiness,” said Douglas Kirsch, MD, medical director of sleep medicine at Atrium Health in Charlotte, North Carolina, and past president of the American Academy of Sleep Medicine.
Over time, lack of sleep has been linked to an increased risk of not only depression, but also anxiety, high blood pressure, type 2 diabetes, heart attack, falls and accidents, substance use disorders, and premature death. It can also be a risk factor for Alzheimer’s disease.
“Chronic insomnia takes its toll on overall health,” said Josepha A. Cheong, MD, professor of psychiatry at the University of Florida College of Medicine and resident 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 thinking, problem-solving, and attention to detail, among other things,” Cheong said, adding that during sleep, the cerebrospinal fluid works to “flush out” metabolic waste that accumulates during the day.
Behavioral therapy: A proven first-line intervention
The good news is that treating insomnia can help relieve depression and related issues.
“Insomnia is a risk factor for depression,” said Natalia S. David, PsyD, DBSM, a health psychologist specializing in behavioral sleep medicine at the O’Donnell Brain Institute at the University of Texas Southwestern Medical Center in Dallas. “Hence, reducing insomnia in older adults should be the 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 difficult to treat with medication, so behavioral and cognitive interventions are preferred, with durable results compared to medication alone,” David said.
Sleeping pills should only be used to treat acute insomnia – lasting less than 3 months. Long-term reliance on this drug can lead to more sleep problems, potentially leading to addiction and cognitive impairment. David said research shows those who took sleeping pills were twice as likely to develop dementia.
Break the cycle of insomnia
Kathleen Primm, 68, who lives in Keller, Texas just outside of Fort Worth, took David’s 7-week CBT-I course recommended by Primm’s sleep medicine specialist earlier this year.
Primm said she suffers from anxiety, and her doctor noted that she also had mood swings. Her sleep problems worsened during the COVID-19 pandemic. Although she did not take naps during the day, she could only sleep for 2-3 hours at night.
“It was just a vicious cycle,” the assistant elementary school teacher said of her insomnia. “But I did the course and found it very helpful.”
After implementing behavior changes, Primm gradually weaned off the sleeping pills and is now able to rest for up to 8 hours each night.
She also learned not to stay in bed for more than 20 minutes if she couldn’t fall asleep. Instead, she went into her living room, cleared her head and did breathing exercises, breathing in and out until she felt relaxed enough to go back to bed and fall asleep. She also heard a cellphone app that plays soothing rain.
A recent randomized clinical trial from UCLA’s David Geffen School of Medicine found that CBT-I prevented depression in adults aged 60 and older with insomnia. In 291 older adults without depression but with insomniac disorder, 2 months of CBT-I “resulted in a reduced likelihood of incidents and recurrent depression during 36 months of follow-up compared to an active comparator, sleep education therapy.”
CBT-I teaches people practical ways to sleep better. A commonly used technique is called sleep compression, Kirsch said. By selecting a limited and personalized window of time to sleep—often less than the patient was previously assigned—the clinician manages the patient’s sleep more efficiently. Gradually, that window will be widened to include a more typical sleep time, he said.
The process often follows a 6 to 8 week course in most patients, but may take longer in some difficult cases. Sometimes drugs and CBT-I are used together in patients who need both forms of therapy to sleep well. Recently, there has been interest in evaluating the use of telemedicine to perform CBT-I, particularly given the limited number of trained therapists, Kirsch said.
A free mobile app, CBT-i Coach, offers various tools to establish improved sleep habits and identify potential factors that may be causing insomnia.
CBT-I does not involve drugs and is considered effective, said Cheong, who is board certified in geriatric psychiatry and serves as director of psychiatry with the American Board of Psychiatry and Neurology. She adds that about 70-80% of patients with primary insomnia experience improvements with CBT-I, fall asleep earlier after going to bed and wake up less during the night.
“If practiced consistently, CBT-I produces sustainable results over time,” she said.
Identifying the signs of these overlapping disorders
Geriatricians frequently encounter patients with sleep disorders, which affect women more often than men.
“Sleep disorders are complex, especially 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 geriatrics specialist at Duke Health in Durham, North Carolina. “A number of disorders can also disrupt 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 up to half of the elderly population, while depression varies by environment and is more common in nursing homes, Kim said.
“These conditions may not be very obvious to the patient, but they can be the root cause of many problems that affect day-to-day functioning,” she said.
Depression in older adults can be difficult to spot because they can 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 the Cleveland Clinic in Ohio.
Other common symptoms include unexplained or worsening pain, weight loss or loss of appetite, feelings of hopelessness or helplessness, lack of motivation, trouble sleeping, and loss of self-esteem (worries about being a burden, feeling worthless, or self-esteem). revulsion), fixation on death or suicidal thoughts and neglect of personal hygiene (skipping meals, forgetting medication or disregarding personal hygiene), said Drerup.
The symptoms resulting from sleep disorders and major depressive disorder can overlap and can include fatigue, mood swings, daytime sleepiness, and decreased concentration.
“It’s crucial that sleep and mood be assessed when someone is undergoing screening for cognitive impairment, because improvement in sleep and mood symptoms can lead to improvement in functioning,” Kim said. “A wellness visit that focuses on prevention can be a good place to start systematically looking for sleep or mood disorders.”
Susan Kreimer is a New York-based freelance healthcare company journalist.
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