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Nonpharmacologic Approaches to Insomnia in Older Adults
This review discusses options for nonpharmacologic management of insomnia in older adults. A proposed model provides insights into the multidimensional nature of insomnia as a geriatric syndrome and provides a framework for evaluation and treatment. Practical nonpharmacologic interventions (sleep hygiene, sleep restriction, stimulus control, relaxation techniques, cognitive interventions) have demonstrated effectiveness in older adults and may be considered as a component in a multifaceted approach to improve sleep quality. Interventions to help strengthen circadian rhythm regulation are also outlined. While the article discusses insomnia in the general elderly population, suggestions for special populations, such as individuals with cognitive impairment or those in long-term care, are also explored. (Annals of Long-Term Care: Clinical Care and Aging 2010;18[8]:36-42)
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The Magnitude of Sleep Disruption in Older Adults
Sleep disruption is a significant problem for older adults. Several changes in sleep architecture have been noted with age. The most prominent change in sleep for older adults is an increase in the number of nighttime awakenings.1 Reductions in sleep efficiency (ratio of time in bed asleep to time in bed), total sleep time, and the amount of time spent in deep or slow-wave sleep are common. While a weakening of the suprachiasmatic nuclei (the brain’s biologic clock) may explain some of these changes in the context of normal aging, it is more likely that declines in sleep in an elderly individual are due to changes in health and well-being. Age, cognitive status, and medical burden appear to predict subsequent declines in sleep efficiency.2 Sleep becomes increasingly disrupted with declines in physical health,3 and strong links have been found between anxiety4 and depression5 and disrupted sleep.
Getting a good night’s sleep for long-term care (LTC) residents proves to be more challenging than for community-based older adults. While 4% of community-based older adults meet the diagnostic criteria for insomnia, it is estimated that 6% of LTC residents meet the criteria, and 17% report at least one of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision criteria.6While insomnia is a significant problem in LTC, fewer than 25% of residents with insomnia receive treatment.7 Primary complaints include difficulty falling asleep and difficulty staying asleep, and studies of sleep in nursing homes (NHs) demonstrate very fragmented sleep.8 The result is that, despite residents spending more time in bed than community-based samples, sleep efficiency is considerably lower (48-72%).9
Sleep problems can be even more challenging for individuals with dementia. Some 19-54% of individuals with dementia experience problems with sleep, characterized by decreased total sleep time, less slow-wave and rapid eye movement (REM) sleep, and frequent nocturnal awakenings.6,9 Sleep-related disorientation, referred to as confusional arousals, as well as agitation and wandering, may accompany nocturnal awakenings. Abnormal movements such as stereotypic repetitive flexion of the legs and/or dream enactment may be noted. Sleep disruption may be also due to damage to the neuronal pathways related to the suprachiasmatic nuclei. Medication used to treat dementia can contribute to sleep disruption: donepezil may increase REM sleep, decrease REM sleep latency, or increase nightmares, while galantamine may decrease REM sleep latency and slow-wave sleep. Comorbid illnesses and primary sleep disorders can also contribute significantly to sleep dysregulation.
One special population of older adults are spouses assuming the role of caregivers for an individual with dementia; they often work in an overburdened schedule, similar to a rotating shift worker but without much predictability. Subsequently, sleep disturbances (eg, frequent nighttime awakenings, shorter sleep time, increased wake time after sleep onset) are very common.10 The quality of the caregiver’s sleep is directly related to the degree of cognitive impairment and nighttime activity of the person being cared for, but also to the caregiver’s age and mental and physical health. These, in the end, may become one the strongest factors in deciding to institutionalize the affected individual.11
Not surprising, daytime sleepiness was found to be a significant problem,12 with daytime sleep interfering with participation in daytime activities and socialization, and increasing the likelihood of nighttime awakenings. A significant part of the day may be spent “dozing,” particularly in the case of institutionalized older adults or those with dementia, to the point of daytime sleep becoming equal in duration to that of nighttime sleep. In addition, with more medical illnesses and impairments, many older adults spend longer time in their rooms, in bed, and rarely go outdoors where they would be exposed to natural light. For example, there appears to be a correlation between severity of dementia in an individual and levels of light exposure: the more severe the dementia, the less amount of light received. Community-dwelling elderly persons with mild dementia were reported to receive less than 30 minutes of bright light exposure per day, while for a NH resident, light exposure was reported to average 10 minutes per day. Diminished light exposure does influence the circadian rhythm regulation, resulting in early-morning awakening and fragmented sleep. Other environmental factors that have an effect on circadian rhythms, such as physical activity and regular social interaction, are often deficient as well.13
Consequences of Insomnia and Disrupted Sleep
In recent years, insomnia has been the object of increased investigation due to its biopsychosocial, clinical, and therapeutic importance. Insomnia has been linked to daytime sleepiness, diminished cognitive ability including attention and memory, disturbances in psychomotor functioning, and slowed response time.14,15 Slowed response time is particularly important because it can affect driving ability and increase the risk of falls.16 Other impairments associated with insomnia include inability to enjoy family and social relationships, increased incidence of pain, decreased ability to accomplish daily tasks, poor self-rated health, and increased consumption of healthcare resources.17 In a study of sleep and mental health in elderly persons without depression, insomnia was found to be the strongest predictor of depression at 3-year follow-up.15,18 Insomnia has been shown to be associated with poorer psychological and social well-being, leading to a lower quality of life.19 Particularly in males, insomnia was found to be the strongest predictor of both mortality and NH placement.20
In a longitudinal study of more than 6000 men and women age 65 years and older who were cognitively intact at baseline, chronic symptoms of insomnia were found to be a significant and independent risk factor for cognitive decline in men without depression.21 Chronic insomnia in older adults is associated with impairment in memory, specifically reduced performance in learning rate and in temporal order judgment, as well as significantly reduced resistance to proactive interference.22 An association between insomnia and hypertension was described, with insomnia subjects characterized by less pronounced nocturnal fall in both systolic and diastolic blood pressure as compared with controls.23 Sleep duration recently was found to be a risk factor for the development of diabetes in elderly men, with both short (< 5 hr) and long (> 9 hr) sleep durations associated with an increased incidence of diabetes, producing a U-shaped distribution of risk.24
Evaluation
The etiology of insomnia in older adults is often juxtaposed against medical conditions (comorbid insomnia). Prior management approach to insomnia suggested that if insomnia occurred within the context of comorbidity, the primary medical illness should be the focus of treatment. However, this does not account for the more complex nature of insomnia. In the context of a medical condition or other sleep disruptor acting as a precipitating event, insomnia develops because of predisposing conditions (eg, high trait anxiety) and perpetuating factors (eg, inactivity, excessive napping during the day). Moreover, it is likely that in most cases of insomnia among older adults, there are multiple precipitating factors, both behavioral and physiological. The Figure illustrates the multifactorial nature of comorbid insomnia. Factors such as preexisting medical conditions and psychiatric illness, including sleep disorders, and medications to treat these disorders, age-related changes in sleep architecture, circadian effects (eg, irregular sleep/wake cycle, limited light exposure, excessive time in bed), host factors such as an increased tendency to hyperarousal, a personality prone to worry, and “lark versus owl” disposition can all interface and contribute to insomnia. Environmental factors and poor sleep habits can perpetuate problems with insomnia. The complexity of insomnia described in the Figure provides us with insights as to why medications alone may not be effective or can lose effectiveness over time.
A thorough evaluation is required to determine the specific factors contributing to insomnia in each older adult. To identify important contributors, a complete sleep history should be obtained, including a review of ongoing and past medical conditions, psychiatric illnesses, and a review of past and current medications. A physical examination and laboratory evaluation as indicated from the history are recommended to support the history and active health problems.
Standardized Tools for Assessing Sleep Symptoms
A diagnosis of insomnia is made from subjective reports of ability to sleep, sleep disruption, or unrefreshing nature of sleep associated with daytime consequences. While sleep polysomnography is an objective method that may be used for measuring sleep initiation and maintenance variables, insomnia by itself is not currently considered an indication for polysomnography. If indicated, a nocturnal polysomnogram may provide important information about the presence of other sleep disorders commonly found in aging adults (eg, sleep-related breathing disorder, limb movement disorders) that may contribute to insomnia.
Sleep Diary
A sleep diary is a semistructured or structured form used by patients for recording sleep/wake activity. It can vary in complexity from a simple log marking bedtime, nighttime awakenings, and morning wake times to a more detailed diary of daytime activities that may influence sleep. Sleep diaries should be completed for one to two weeks. Once a baseline sleep pattern is established, sleep diaries can be used by the patient and provider to monitor treatment progress and symptom reoccurrence.
Insomnia Severity Index
The Insomnia Severity Index is a 7-item questionnaire used to assess the severity of insomnia, satisfaction with current sleep, sleep interference, and the patient’s and others’ concerns with the sleeping problem. Scores range from 0-28, with scores greater than 8 suggestive of insomnia.25
Pittsburgh Sleep Quality Index
The Pittsburgh Sleep Quality Index is a 19-item questionnaire with a high test-retest reliability and good validity.26 It is an effective instrument in measuring the quality and patterns of sleep in the older adult. It differentiates “poor” from “good” sleep by measuring seven areas: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction over the previous month. The patient self-rates each of these seven areas of sleep. Scoring of answers is based on a 0-3 scale, with 3 reflecting the negative extreme on the Likert Scale. A global sum of 5 or greater indicated a “poor” sleeper and resulted in a sensitivity of nearly 99% and specificity of 84% as a marker for sleep disturbances in patients with insomnia versus controls.26
Epworth Sleepiness Scale
The Epworth Sleepiness Scale is a self-estimate of sleep propensity in different circumstances and is commonly used to estimate the degree of sleepiness in patients with insomnia, obstructive sleep apnea, narcolepsy, and hypersomnia.27 Patients rate how likely they are to doze off or fall asleep in eight different situations commonly encountered in daily life.
Scores vary from 0-24, with scores higher than 10 indicative of significant daytime sleepiness.
Caregiver Reports
Caregiver reports have been used, although not tested, to diagnose insomnia in situations when use of self-assessment tools such as sleep diaries and self-report sleep questionnaires are not possible (eg, persons with severe cognitive impairment, NH residents). Because the above noted tools are designed as self-report measures, there are major limitations when someone other than the patient is reporting the symptoms, such as a caregiver.
Actigraphy
Actigraphy provides objective data when evaluating insomnia complaints. Actigraphy is not an alternative to the nocturnal polysomnogram but may be invaluable in evaluating activity-wake patterns, particularly since it is deployed over multiple consecutive days and is done in a patient’s usual environment, minimizing negative effects from sleep in a laboratory. One of the most successful areas of use is the LTC setting; there are major limitations in obtaining self-reported data, as well as the feasibility of polysomnographic testing, in this population.28 Actigraphy is usually employed for a period of 7-14 days and may assist with the differential diagnosis, guide treatment recommendations, and assess results. Some devices have a light sensor, which may help in identifying more accurately the bedtime and wake-up times, and provides information about timing of light exposure; it may be used also in tracking adherence to light therapy and recommended dim-light period. Actigraphy should not be used alone, but rather in conjunction with a sleep diary to guide scoring and interpretation of data.
Options for Management of Insomnia
Since medical and psychiatric conditions have a significant influence on sleep, optimizing management of underlying disorders should be part of the first step, as it may improve sleep disruption. For example, treating depression, managing pain, and ruling out acute illness such as urinary infections may address disrupted sleep problems. Since medications can increase arousal, contribute to sleepiness, or negatively influence the circadian rhythm, modifications in the timing of medications (eg, antidepressants) may also enhance sleep.
Hypnotics can decrease time to fall asleep and wake time during the night, but there are concerns about extended use in the older adults due to risk of side effects. For example, 30% of older adults who receive a new prescription for benzodiazepines (BZDs) report at least daily use 2 months later.29 Discontinuation of BZD treatment for insomnia can be a difficult task. In a sample of older adults followed for a 2-year period, approximately 43% of the individuals had resumed BZD use.29
Insomnia in late life tends to be chronic and recurring,30,31 so long-term disease management strategies are needed. Cognitive behavioral strategies have been reported to be most effective in managing insomnia over time.32,33
Components of Cognitive Behavioral Therapy for Insomnia
Cognitive behavioral therapy for insomnia (CBT-I) is a multidimensional approach that combines psychological and behavioral therapies to treat insomnia. These include sleep hygiene, sleep restriction, stimulus control, relaxation techniques, and cognitive therapy. CBT-I use for a specific patient may include different degrees and components of these therapies.
Sleep Hygiene
Sleep hygiene measures are often the first form of intervention used (either alone or in combination with hypnotic treatment) to treat insomnia (Table I). Sleep hygiene uses common-sense interventions to promote sleep, such as reducing environmental factors (eg, turning off TV) and intrinsic factors (eg, restricting stimulants prior to bedtime) that can disrupt sleep. Sleep hygiene has been linked to sleep practices and, in turn, to overall sleep quality. Interventions to improve sleep hygiene practices may be less effective than other cognitive behavioral interventions since a study by McCrae et al34 indicated that older individuals with sleep complaints did not necessarily engage in poorer sleep hygiene practices (eg, alcohol, cigarette, and caffeine use; irregular bed and out-of-bed times) than noncomplainers, therefore making sleep hygiene as a single therapy for late-life insomnia questionable in its efficacy.
Sleep Restriction
Sleep restriction utilizes an individual’s natural circadian rhythm and homeostatic sleep drive to regulate sleep and wake patterns (Table II).35 Sleep restriction interventions focus on limiting time in bed and daytime napping, and warding off unintentional dozing. Usually based on sleep diaries kept for two weeks prior to the intervention, the amount of time spent in bed is reduced to an amount closer to the estimated actual time sleeping. Once sleep efficiency (total sleep time divided by time spent in bed) improves, the time allowed in bed may be gradually increased in small increments until the individual’s optimal sleep time is obtained or sleep efficiency falls.
Stimulus Control
Stimulus control interventions focus on reducing conditioned behaviors that may interfere with sleep (Table III).36 For example, patients may spend extended hours in bed watching TV or doing other activities, conditioning the body to use the bed as a place for activity instead of sleep. Stimulus control interventions may include pre-bedtime wind down and/or strategies for limiting the time lying awake in bed waiting to fall asleep, as well as during the day.
Relaxation
Relaxation techniques are used to create a relaxation response, help manage anxiety, and prepare the body for sleep (Table IV). These interventions are best suited for individuals who have problems with falling asleep.
Cognitive Interventions
Cognitive interventions address maladaptive sleep-related beliefs or intrusive pre-sleep cognitions and generally require the assistance of a person trained in these therapies. A referral to a trained behavioral sleep specialist may be indicated.
Applicability of CBT-I in Older Adults
Older age was not found to be a barrier to successful treatment outcomes in using cognitive behavioral therapy. A systematic review of the research on the effectiveness of these therapies indicates that any single therapy is not as effective as when interventions are combined.37 Among patients reporting chronic sleep difficulties, long-term hypnotic consumption, and high levels of comorbidity, use of CBT-I was associated with significant improvements in sleep latency, sleep efficiency, and global sleep quality.38 Most improvements in sleep quality were maintained at 3-6 month follow-up. Lower health status at baseline, acute illness episodes, and hospitalizations were the most commonly cited reasons for dropout.38
Stimulus control and sleep restriction techniques have strong data support for reducing wake after sleep onset, increasing sleep efficiency, and increasing total sleep time, and were most helpful in producing improvements over an average 6-month follow-up period.33 Cognitive restructuring and sleep hygiene are less studied and have not demonstrated their utility as stand-alone therapies. A meta-analysis of almost 60 studies assessing nonpharmacologic treatment of chronic insomnia found that an average of five hours of CBT-I therapy was provided.33 Several studies have suggested that more limited interventions and interventions conducted by registered nurses may be helpful to patients with insomnia. CBT-I was found to be helpful when administered in individual face-to-face treatment, in group therapy sessions, or through brief telephone contact.39 Another study using two sessions of CBT-I led to greater improvement for chronic primary insomnia subjects than two sessions of generic sleep hygiene education.40
Efficacy coupled with minimal side effects makes behavioral interventions highly recommended for treating insomnia. However, most data come from research studies employing highly specialized personnel such as psychologists, many of them trained in Behavioral Sleep Medicine (BSM). Factors such as cost, lack of availability of behavioral sleep medicine specialists, and potential problems with patient cognitive status, physical limitations, motivation, and compliance may raise challenges in implementing the use of CBT-I techniques.41
Circadian Rhythm Modulators
As described earlier, the circadian component of sleep physiology can dampen with age. In addition, limited exposure to bright light (≥ 2000 lux/day) can lower melatonin levels, disturbing circadian rhythms, and may predispose individuals to insomnia or perpetuate an existing insomnia.
Light therapy attempts to reset the phase of the circadian rhythm relative to the light-dark cycle and also may influence the production of melatonin, which helps synchronize an individual’s circadian rhythm (Table V). Bright light poses a theoretical threat of retinal damage in susceptible individuals (proliferative diabetic retinopathy, moderate or severe macular degeneration, or absence of a natural or artificial lens in either eye). While initially bright white light (a mixed spectrum of wavelengths similar to daylight) was employed to exert light effects on human circadian rhythm, short-wavelength blue light (approximately 460 nm) may have greater phase-shifting properties than the rest of the visible light spectrum; however, there are still questions about whether this is to become the preferred method to influence the biological clock in the elderly.42
Physical activity has been found to be a useful adjunctive therapy and improves total sleep duration, sleep-onset latency, and scores on a scale of global sleep quality.43 Benefits may extend beyond general physical activity (eg, walking); specifically, a program of tai chi improved sleep-onset latency with 18 minutes and sleep duration with 48 minutes as compared with low-impact exercise participants.44
There is emerging evidence that a consistent and structured daily routine may have beneficial effects on the quality of nighttime sleep. Prior work in this area found that subjects with higher levels of lifestyle regularity report fewer sleep problems.45 Increased stability in daily routine was recently reported to predict shorter sleep latency and improved sleep quality, independent of functional status, comorbidities, and age.46 Therefore, interventions designed at regularizing patients’ daily rhythms and maintenance of a social rhythm metric47 would probably be beneficial; these principles already have been applied in patients with bipolar affective disorder with good results (social rhythm therapy).48
Tailoring Behavioral Interventions in LTC
Differences in environment, health, and level of independence on individuals in LTC settings may argue for a distinct approach to CBT-I interventions as compared to those used in community-based older adults. It is likely that some of the aspects of traditional CBT-I, particularly involving the cognitive aspects of this therapy, would not be applicable or would be of little value to this population. In this context, behavioral therapies are most useful, and even when used alone, have resulted in positive outcomes with continuation and improvement of sleep patterns for at least two years.31,34 Behavioral interventions to improve sleep in LTC settings must be tailored to the specific needs of each resident, and therapies should be chosen to target behaviors that are most likely to impact the individual resident’s sleep problems. While use of sedatives is not encouraged, use of short-acting non-BZD agents has been advocated by some in selected cases in conjunction with behavioral therapies to optimize treatment effectiveness of both.49 It has been suggested that once individuals experience success with behavioral strategies, they may gain the confidence to comfortably taper hypnotic use without relapse. Predictors of relapse include insomnia severity, psychological distress, and number of drug-free weeks.
Specific Aspects in Individuals with Dementia
Because of frequently undesirable side effects of pharmacologic agents in individuals with dementia, CBT-I would be an ideal intervention to implement. Obviously, there are limitations with regard to the cognitive aspect of this therapy in a person with dementia. Therefore, behavioral and environmental interventions appear most feasible and have included reducing day in-bed time, increasing social and physical activity, and altering the environment to make it more conducive to nighttime sleep. However, interventions that require changing established bedtime and waking routines and keeping a person with dementia awake during the day can be challenging for family caregivers and institutions to achieve.50
One of the most successful interventions was reported in the Nighttime Insomnia Treatment and Education for Alzheimer's Disease (NITE-AD) program, which encompassed an 8-week combined intervention that included sleep hygiene education, daily walking (30 min), and increased light exposure (1 hr using a light box). This was associated with a 32% reduction in time spent awake during the night as compared with controls, with effects maintained at 6-month follow-up.51
Conclusions
In light of the multiple interfaces of sleep with many other factors including comorbidity, lifestyle, and environment, as well as increased risks with sedative agents, due to the favorable benefit/risk profile, nonpharmacologic measures should be considered as the first line of therapy in any plan for optimal long-term control of insomnia. This may translate to better sleep-related outcomes with the benefit of potentially lowering the risk of side effects from hypnotic therapy by using lower doses than otherwise needed. In the end, a multicomponent strategy employing carefully considered interventions and goals of therapy will likely provide most benefits while minimizing unwanted effects.
Acknowledgment
The authors would like to express their sincere thanks to Cynthia Phelan for her very useful suggestions in crafting this article. The authors report no relevant financial relationships. Dr. Teodorescu is Assistant Professor of Geriatrics, Gerontology, and Sleep Medicine, and Dr. Husain is a Psychiatrist and Sleep Medicine Fellow, University of Wisconsin Center for Sleep Medicine and Sleep Research, and the William S. Middleton Veteran Affairs Medical Center, Madison.
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