Geriatric populations are simultaneously more likely to have insomnia and less likely to tell their medical team about it.
By Greg Thompson
Older adults tend to have multiple health concerns, and the question becomes: Are the problems causing poor sleep, or is poor sleep causing the problems? Sonia Ancoli-Israel, PhD, has wrestled with the chicken-or-the-egg conundrum, and she finds no easy answers.
“We know insomnia predisposes one to being more susceptible to disease,” says Ancoli-Israel, professor emeritus and professor of research in the department of psychiatry at the University of California, San Diego School of Medicine. “There are memory issues, concentration issues, and reaction-time issues…cardiovascular disease, neurodegenerative disease, cancer, arthritis—all those are comorbid with insomnia.”
Ancoli-Israel contends that many of the symptoms of “very disturbed sleep” can even mimic dementia. If clinicians fail to discern what is actually going on, months could be wasted on incorrect treatments. “That’s one reason why it’s important to evaluate sleep and make the diagnosis of insomnia, if that is in fact the case in older adults,” she says. “Sometimes older adults will report insomnia when in fact they’re phase advanced, which means they get sleepier earlier in the evening and they wake up early in the morning.”
“Early morning insomnia” happens when a person wakes too early and can’t get back to sleep, Ancoli-Israel explains, calling this phenomenon the “biggest complaint” older adults have within the sleep realm.
“Within their circadian rhythm, their core body temperature is rising, and that’s when they’re waking up,” she explains. “It’s actually a normal time to wake up. The question is: What time are they going to sleep? If they are still forcing themselves to stay up later, even though they are sleepy, they end up not getting enough sleep at night and they see that as ‘insomnia.’”
Making the right diagnosis depends on asking the right questions. Inquiring about difficulty falling and staying asleep is not enough. Ancoli-Israel’s checklist includes determining natural circadian rhythms (which likely have changed over time), as well as determining when patients start getting sleepy at night. “That’s probably the key question, because if they are getting sleepy at 8 pm, then they are probably phase advanced,” she says. “If they are not going to sleep until later, that’s where problems start. It’s about listening to their body, but it’s also about physicians asking what the body is telling them.”
If clinicians find multiple comorbidities linked to insomnia, and most likely they will, Michael V. Vitiello, PhD, points out that new thinking is required in light of recent research.
“In the older adult population, chronic insomnia tends to be comorbid rather than uncomplicated,” says Vitiello, professor of psychiatry & behavioral sciences, gerontology & geriatric medicine at the University of Washington, Seattle. “Old wisdom held that when insomnia occurred comorbid with another illness, it was ‘secondary’ and successful treatment of the comorbid illness would typically resolve the insomnia. Research has shown that things are not so simple, and in most comorbid situations, insomnia is a disorder, per se, rather than merely a symptom, and worthy of treatment in its own right.”
Extensive literature has emerged examining the efficacy of cognitive-behavioral therapy for insomnia (CBT-I) to treat uncomplicated and comorbid insomnia. According to Vitiello, recent metaanalyses of CBT-I clinical trials literature have demonstrated that CBT-I is highly effective and has sustained benefit.1-3 “Further they have shown that improving sleep with CBT-I can also result in improvement in the comorbid disorder,”3 adds Vitiello. “This later finding clearly demonstrates that in many cases insomnia is not simply a symptom, but a disorder that can have direct impact on a disorder comorbid with it.”
When diagnosing insomnia in older adults, Vitiello points out that multiple comorbidities and high medication usage are common. Effective care requires individualized assessment and meticulous follow-up. “When considering insomnia symptoms, it is important to distinguish between age-appropriate sleep changes and clinically significant insomnia,” Vitiello says. “Nonpharmacologic therapies, such as CBT-I, should always be the first-line treatment and are highly effective for uncomplicated and comorbid insomnia.”
Don Townsend, PhD, DABSM, founder of Insomnia Expertz PLL in Scottsdale, Ariz, says much of the recent literature points to older adults’ chronic health conditions as the biggest factors in the presence of sleep disorders, including insomnia. “It is extremely common for me to work with older adults who have three to five chronic health conditions, like hypertension, cardiovascular disease, rheumatoid arthritis, chronic pain, and diabetes,” says Townsend, a clinical psychologist who is board certified in sleep medicine and behavioral sleep medicine. “In any number of these conditions, the medication used to treat has an impact on sleep.”
In the retirement mecca of Scottsdale, Townsend sees many insomnia problems related to the loss of regular working hours. He says, “A lot of them retire abruptly, and that changes everything in life. They went from working 60 hours a week and now have 60 hours of free time. One thing I have to do with older adults is structuring their day so they are just as busy and productive as they once were.”
Over- and Under-Diagnosing
William V. McCall, MD, believes that over-diagnosing insomnia in older adults may be as big of a problem as under-diagnosing. “The people who over-diagnose may be the patients themselves,” says McCall, who serves as the Case Distinguished University Chair of the department of psychiatry and health behavior and executive vice dean for the Medical College of Georgia at Augusta University.
Failing to recognize the unfavorable aspects of normal aging is the usual culprit. “There are more middle-of-the-night awakenings among older adults, sleep is perceived as lighter, and older folks may fall asleep earlier and get up earlier,” McCall says, “so they may complain of waking up too early.”
To make the diagnosis of insomnia disorder, McCall says sleeping problems “must cause either significant psychological distress, some sort of functional impairment, or other type of daytime problems such as irritability, loss of concentration, and fatigue.”
Under-diagnosis can also happen because talk of cholesterol, high blood pressure, pre-diabetes, arthritis, and other disorders perceived as more urgent tend to “move the insomnia complaint down to the bottom,” McCall says.
“Certainly there are people who have insomnia pure and simple, unrelated to physical conditions or psychological problems,” McCall says. “However, by the time someone votes with his feet and sees a doctor for help, you now have a more rarified group, and the presence of comorbidities is quite high. Comorbidity is the rule rather than the exception when it comes to insomnia. Of the comorbidities that are most interesting over the last few years, the first is sleep apnea.”
Thirty years ago, clinicians assumed that obstructive sleep apnea (OSA) was a feature of hypersomnia—that is, too much sleep. “There is accumulating evidence over the last decade that OSA can, in some instances, present with insomnia as opposed to hypersomnia,” McCall says.
Another neglected facet of insomnia is its relation to suicide. McCall completed a study two years ago with a cohort of patients who had insomnia complicated by major depressive disorder, and all were suicidal. The study looked at whether targeted treatment of insomnia did something beneficial for their suicidal thinking.4
“I intensely followed the literature until there were about 60 studies showing that insomnia was a risk factor for suicide,” McCall says. “This was true in older people, middle-aged people, young adults, adolescents, men, women. It is absolutely a universal phenomenon.”
McCall ultimately got together a group of “depressed suicidal insomniacs” and treated their depression by putting them on Prozac, or something similar, eventually giving half of the cohorts a sleeping pill while the other half received a placebo. “The hypothesis was that targeted treatment of insomnia does a better job, in conjunction with antidepressants, of reducing suicidal ideation as compared to an antidepressant combined with a placebo,” he says. “That turned out to be the case.”4
Jennifer Martin, PhD, professor of medicine at the David Geffen School of Medicine, University of California, Los Angeles, agrees that the psychological side of the insomnia equation should continue to warrant attention. “We have known for a long time that more medical comorbidities are associated with higher risk for insomnia in older adults,” says Martin, who also serves on the board of directors for the American Academy of Sleep Medicine. “What has been clearer in the recent past is that there is a strong connection between poor sleep and poor mental health. We also know that treating insomnia can be very beneficial for older adults and that we can use the same treatments regardless of age.”
One of the reasons insomnia is difficult to diagnose in older adults is that many people accept poor sleep as part of normal aging. In Martin’s experience, it means they are unlikely to discuss sleep concerns with healthcare providers. “Furthermore, older adults are likely to have more than one sleep disorder, especially sleep apnea and insomnia together,” she says. “We know from recent studies that it is usually necessary to treat both conditions for older adults to feel well.”
To diagnose insomnia, Martin maintains that clinicians should be looking for symptoms that occur at least three times per week for at least three months and are significant enough to impact how a person feels or functions during the day. “A few bad nights in response to a stressful situation is actually normal,” she says, “and getting back to good sleep habits usually does the trick.”
The ability to know the difference between “a few bad nights” and actual insomnia has only sharpened over the years. Seema Khosla, MD, FCCP, FAASM, medical director at the North Dakota Center for Sleep in Fargo, ND, has seen the progress firsthand. “For example, paradoxical insomnia used to be called ‘sleep-state misperception,’” she says. “This is when someone feels like they aren’t sleeping well, or at all, but when we study them, they are getting adequate sleep hours and are actually asleep by EEG criteria.”
Khosla appreciates that clinicians are more willing these days to explore the short-term and long-term effects of insomnia. Far from the old days of dismissing the importance of diagnosing insomnia in the elderly, the medical community has continued to link negative outcomes to insomnia. “For example, there has been more data linking coronary artery disease with insufficient sleep,” Khosla says. “We have learned how important sleep is for memory and how sleep allows for the brain to be ‘cleared’ of debris. When this debris has been analyzed, some is beta-amyloid, one of the proposed culprits for Alzheimer’s. The list of comorbid medical disorders [with insomnia] is growing as both clinicians and researchers explore these links. What was once felt to be a nuisance has proven to be a significant disorder that merits evaluation and treatment.”
With so many physical and psychological concerns underpinning the presentation of insomnia in older adults, Eric Nofzinger, MD, founder and chief medical officer of Ebb Therapeutics, is not surprised that insomnia often gets overshadowed. One solution is to recognize insomnia as an independent medical disorder that is worthy of treatment, while also putting some additional thought into marketing.
“Sleep physicians should begin with educational marketing campaigns, elaborating on the causes and cures for insomnia in the elderly,” Nofzinger says. “Distribute this information to referring healthcare providers. The sleep physician needs to be seen as an authority in this area, ready to take the time and energy to evaluate and treat these individuals. Over time, practice referrals will begin to broaden as sleep physicians are seen as trusted allies.”
W. Joseph Herring, MD, PhD, associate vice president, global clinical research, neuroscience at Merck Research Laboratories, echoes the sentiment that education is key. “Education to enhance insomnia awareness would help physicians and patients be better prepared to recognize insomnia as a clinical entity unto itself which warrants treatment and to appreciate that bad sleep doesn’t have to just be accepted as a part of the aging process,” he says. “A better understanding of the importance of good sleep hygiene behaviors would also be important, both to confirm that sufficient opportunity is being given for quality sleep and to evaluate the potential for other therapeutic options to provide relief if sleep hygiene measures alone fail to alleviate the problem.”
Use the channels that a patient population is already accustomed to receiving information to get the word out. “Examples sleep physicians could consider for outreach include through primary care physicians, hospitals where care is administered, local nursing homes, via advocacy organizations, or even through family and caregivers,” Herring says. “The elderly often rely on and need the help of their loved ones and health advocates to speak up and proactively discuss their sleep issues with their treating clinician; targeted community outreach could help facilitate these conversations and ensure patients get the insomnia treatment plan that’s right for them.”
Greg Thompson is a Loveland, Colo-based freelance writer.
- Trauer JM, Qian MY, Doyle JS , et al. Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis. Ann Intern Med. 2015 Aug 4;163(3):191-204.
- Geiger-Brown JM, Rogers VE, Liu W, et al. Cognitive behavioral therapy in persons with comorbid insomnia: A meta-analysis. Sleep Med Rev. 2015 Oct;23:54-67.
- Wu JQ, Appleman ER, Salazar RD, Ong JC. Cognitive behavioral therapy for insomnia comorbid with psychiatric and medical conditions: a meta-analysis. JAMA Intern Med. 2015 Sep;175(9):1461-72.
- McCall WV, Benca RM, Rosenquist PB, et al. Reducing suicidal ideation through insomnia treatment (REST-IT): a randomized clinical trial. Am J Psychiatry. 2019 Nov 1;176(11):957-65.