Abstract
Purpose of Review
To evaluate and summarize recent research articles pertaining to insomnia in older adults that can guide healthcare providers on factors to consider when assessing and managing insomnia.
Recent Findings
Up to 75% of older adults experience symptoms of insomnia. Insomnia is associated with socioeconomic status, racial and ethnic classification, family relationships, medical and mental health disorders, cognitive function, and dementia. Although one-fifth of older adults are still prescribed sleep medications, cognitive behavioral therapy for insomnia is the first-line treatment for insomnia and has resulted in short-term and long-term benefits for older adults.
Summary
To manage insomnia safely and effectively, healthcare providers need to consistently assess for insomnia during baseline and annual assessments, evaluate medical and social factors associated with insomnia, minimize the use of sleep medications, and provide referrals to and/or collaborate with providers who perform cognitive behavioral therapy for insomnia. Insomnia screening is important as it facilitates early intervention, reduces the potential for pharmacological management, and enables further assessment and early identification of associated outcomes, such as cognitive impairment.
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Introduction
Insomnia is one of the most common sleep disorders in older adults. It is defined as complaints of difficulty initiating sleep, difficulty maintaining sleep, or early morning awakenings with the inability to return to sleep in the presence of adequate sleep opportunity or ideal environmental factors; and is accompanied by daytime clinical distress or functional impairment [1, 2]. Based on the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders, the symptoms occur at least three nights a week for at least 3 months [1]. Insomnia may also be episodic if the symptoms recur and persist for several weeks at a time, over several years.
Up to 75% of older adults report insomnia symptoms [3,4,5,6,7,8]. The homeostatic and circadian mechanisms that drive the sleep and wake cycles diminish with age, thus, reducing the drive to sleep and increasing the risk for insomnia [9]. For example, older adults report an increase in wake time after initially falling asleep and early morning awakenings [9, 10]. Due to poor sleep efficiency, older adults experience daytime sleepiness and fatigue and tend to nap during the day [9, 10]. After retirement, many older adults no longer have fixed work schedules, which may also increase the risk of insomnia. Many other factors, such as reduced mobility, reduced participation in social activities, decreased social interaction, and increased caregiving responsibilities, are prevalent in the older adult population and increase the risk for insomnia [9].
Older adults with severe insomnia report a higher number of comorbid illnesses than those without insomnia [11]. Insomnia is associated with multiple medical and mental health problems, including an increased risk for psychiatric disorders, suicide, and chronic health conditions, such as obesity, diabetes, cardiovascular disease, and chronic pain [12••], which leads to increased medication consumption [7]. Treating insomnia is vital because it has the potential to reduce public health burden [11]. The aim of this paper is to evaluate and summarize recent research articles pertaining to insomnia in older adults to guide healthcare providers on factors to consider during assessment and management of insomnia.
Method
Search terms used in PubMed were “insomnia” (title/abstract) AND “older adult”. The filters were “humans” and “aged 65+ years.” We found 76 studies from 1/1/16 through 4/4/2019. We excluded literature reviews, clinical guideline reviews, and studies with participants who had human immunodeficiency virus, hepatitis, cancer, sickle cell disease, internet addiction disorders, and schizophrenia. After reviewing the abstracts, we included 48 studies (see Table 1). Twelve studies included middle-aged participants and one study each included older adults with osteoarthritis, chronic pain, general anxiety disorder, and major depressive disorder. Two co-authors evaluated the methodological quality of the studies using a validated scoring system for rating empirical studies with different methodologies [13]. A total of nine study components were rated a quality score ranging from 1 (very poor) to 4 (good), with a maximum potential score of 36 for each study. The studies in this review varied in overall quality, with scores ranging from 25 to 36 and an average score of 30.6, meaning that the majority of the studies were of fair to good quality (Table 1).
Results
Prevalence of Insomnia
In studies that utilized the diagnostic criteria for insomnia disorder, the prevalence of insomnia ranged from 17 to 60% [14,15,16]. Gehrman and colleagues [17] reported that approximately 14% of the older adults in their sample (n = 291) had moderate insomnia and 2.7% had severe insomnia. In studies that asked about insomnia symptoms, the prevalence of insomnia ranged from 8.2 to 74.8% [3,4,5, 8, 18,19,20, 21•, 22,23,24]. The most common sleep complaints included difficulty maintaining sleep (range, 13.1 to 40.7%), difficulty initiating sleep (range, 10.3 to 55.6%), and early morning awakenings (range, 10.7 to 37.2%) [3, 5, 7, 8].
Eight studies assessed the prevalence of insomnia within specific populations, such as veterans, nursing home residents, older adults with pain, and males and females. The prevalence of insomnia among veterans ranged from 23.3 to 56.8% [25, 26••], and among nursing home residents ranged from 44.4 to 67.9% [22, 27]. The prevalence of clinical insomnia in older adults with chronic pain was 24.6% [11]. The prevalence of insomnia was much higher in females, ranging from 41.5 to 74.8%, compared with males, ranging from 32.3 to 52.8% [3, 8, 28]. In addition, females were more likely to experience insomnia for more than 6 months [29•, 30].
Demographic and Sociocultural Correlates of Insomnia
Employment, living environment, and social support were all associated with insomnia outcomes. Ma and colleagues [23•] found that older adults with insomnia were more likely to have no education (42%), no fixed income (48%), less social contact with children (81%) and friends (48%), less spiritual (61%) and financial (56%) support, and lack of trustworthy family (166%???) and friends (67%). Other researchers reported similar results. Specifically, older adults who were not married [29•, 30], widowed [3], living alone [3, 23•, 30], living in less desirable neighborhoods [12••], unemployed [3, 6], of lower wealth status [30], working in a low-rank position [18], and having economic difficulties [3] were more likely to report insomnia.
Insomnia symptoms were more prevalent among Black and Hispanic older adults compared to White older adults [12••]. However, the relationship between race and insomnia symptoms was not significant in the regression analyses that included socioeconomic, health, and functional status as covariates, suggesting that the association could be explained by social-economic and health status factors [12••]. Nevertheless, Kaufmann and colleagues [31] noted that the severity of insomnia over time was disproportionately greater in Hispanics compared with non-Hispanic Whites, even after controlling for health conditions and body mass index.
Medical and Mental Health Correlates of Insomnia
The presence of one or more medical illnesses may increase the risk for insomnia. Insomnia may also worsen chronic illnesses. Older adults with insomnia were more likely to report at least two chronic illnesses compared to older adults without insomnia (83.5% vs. 56.5%) [5]. Some diseases noted were cardiovascular disease [5, 6, 29•], hypertension [5, 32•], coronary artery disease [3, 32•], atrial fibrillation [7], and hyperlipidemia [3, 6, 32•]. Furthermore, older adults with chronic pain who had clinical insomnia were more likely to experience pain more often and at a greater intensity compared those without insomnia [11].
Older adults tend to lose muscle mass and become weaker with age, thus, increasing their risk for frailty and falls. The presence of insomnia compounds this phenomenon. Insomnia was significantly associated with frailty [28] and fall risk in older adults [17, 24, 29•]. Chen and colleagues [33••] found that older adults with greater insomnia symptoms had a higher risk of falling, and older adults who reported one additional insomnia symptom at baseline were 5% more likely to fall at follow-up.
Chronic insomnia symptoms in older adults were associated with poor mental health [18]. Insomnia symptoms, specifically difficulty initiating sleep compared with difficulty maintaining sleep or early morning awakenings, were significantly associated with depression [3, 7, 16, 20, 29•]. Surprisingly, the association of insomnia with depression was greater in men than in women [19]. Older adults with insomnia had a 1.59-fold risk for suicide attempts [34] and severe insomnia moderated the relationship between older adults with depression and suicidality [35].
Insomnia increased the risk for short-term or long-term cognitive impairment. Older adults with insomnia were significantly more likely to have impaired attention compared with those without insomnia [4]. Furthermore, older adults with insomnia performed worse on a cognitive task (executive function) compared with those without insomnia [36]. In a case-control study with a follow-up after 3 years, insomnia was independently associated with a 2.17-fold higher risk of subsequent development of dementia, and younger patients with primary insomnia had a higher risk of developing dementia [32•]. However, Castello-Domenech and colleagues [27] found that global cognitive performance, measured by the Mini-Mental State Exam, did not correlate with insomnia symptoms in older adults in nursing homes.
Non-pharmacologic Management of Insomnia
Behavioral Therapies
Dysfunctional attitudes and beliefs surrounding sleep were strong predictors of insomnia [37••]. Cognitive behavioral therapy insomnia (CBTi) is a multisession, multicomponent intervention which includes the following: stimulus control techniques (helping the patient associate the bed with sleep instead of being awake), sleep compression or restriction strategies (reducing the amount of time spent in bed to consolidate sleep), cognitive restructuring (techniques that challenge thoughts that interfere with sleep), and sleep hygiene [9, 38, 39]. Sixty, older veterans had significant improvements in sleep onset latency, sleep efficiency, total wake time, and insomnia symptoms immediately, at 6 months, and at 12 months post-treatment, after receiving five sessions of CBTi when compared with a sleep education program [40••]. While the sleep variables increased between the post-intervention and the 12-month assessment, the participants’ symptoms remained significantly improved at 12 months when compared with baseline measures [40••]. Results from a secondary data analysis showed that 160 veteran participants who received the same CBTi protocol experienced a significant decrease in insomnia (5 points over a 12-month period) regardless of levels of physical activity [41]. In 141 older adults living in a rural setting and having generalized anxiety disorder, telephone-delivered CBT significantly improved insomnia symptoms over a 15-month period compared to a control intervention (7.39, CBT vs. 2.59, control) [42••].
Brief Behavioral Therapy for Insomnia (BBTi) is the shortened version of CBTi. Four weeks of BBTi resulted in improved sleep onset latency for 27 older adults with chronic insomnia compared to a self-monitoring attention control group (n = 23) with chronic insomnia [43••]. Specifically, subjective sleep onset latency decreased by about 48% in the BBTi recipients compared to a 22% decrease in the self-monitoring attention control group [43••]. Wilckens and colleagues [44] also found that 4 weeks of BBTi (2 in-person sessions and 2 phone calls) resulted in a significant decrease of 23 min in wake after sleep onset compared with the control group, which only had an increase of 3 min of wake after sleep onset.
Exercise
Laredo-Aguilera and colleagues [45] found that older adult participants (n = 38) had a 6-point, non-significant decrease in their insomnia scores after participating in a 10-week functional training program which included aerobic exercise, strength training, and balance training. Morning exercise compared with evening exercise did not result in any change in insomnia symptoms for 43 participants, but those who were in the morning exercise group had less shifts in sleep stages during the night, as measured by polysomnography [46]. Older adults with regular physical activity, such as walking, were less likely to report insomnia symptoms [3, 12••, 21•, 30, 47]. Furthermore, older adults who participated in organized social activities, such as clubs and classes, were less likely to report insomnia symptoms [12••].
Mixed Interventions
A 16-week intervention study comparing the efficacy of sleep hygiene and aerobic exercise versus non-physical activities, such as social or educational activities, resulted in decreased wake after sleep onset by more than 30 min for both groups (n = 17) [48•]. Thirty-eight older adults participated in a crossover-controlled trial comparing the effects of listening to soothing music before bed and listening to music while walking on a treadmill, on insomnia symptoms [49•]. They reported that listening to music reduced sleep onset latency by 11 min and wake after sleep onset by 16 min, and exercising while listening to music reduced sleep onset latency by 12 min [49•]. Ninety-two percent of these participants preferred listening to music before bed.
Pharmacologic Treatments
Among older adults with insomnia in China, 21.9% used sleep medications, and 11.1% used sleep medications at least three times a week [3]. Among a sample of 879 veterans who were diagnosed with insomnia during the previous 12 months, 41.7% used sedative-hypnotics, 14.7% used selective benzodiazepine agonists (z-drugs), 14.7% used Trazadone, 11.8% used on-label benzodiazepines, 3.9% used off-label benzodiazepines, 2.5% used diphenhydramine, and 1% used hydroxyzine [26••]. However, sleep medications were less acceptable with increased age among 402 female veterans [25]. Specifically, 16.9% of the veterans over 70 years old reported insomnia medications as very acceptable compared with 28.6% of those between 60 and 69 years of age [25]. Sleep medications increase the risk for many side effects including falls. Older adults who used physician-recommended sleep medications experienced a consistently higher fall risk, regardless of the severity of their insomnia symptoms [33••].
Discussion
Although insomnia is not a normal part of aging, it is common among older adults and is often undertreated. In our review of 48 publications on insomnia in older adults published over the last 3 years, up to 75% of older adults experience symptoms of insomnia. Given that insomnia is associated with multiple chronic conditions and negative consequences such as falls, cognitive decline, and suicide, it is important to identify older adults who experience insomnia, for prevention or treatment, and to reduce the risk for the development, occurrence, or severity of these negative outcomes [5, 50, 51].
Measures of Insomnia
Healthcare providers in primary care offices should integrate an insomnia-screening questionnaire into their baseline and ongoing annual assessment forms. Some forms to consider include the following: Insomnia Severity Index [52], Epworth Sleepiness Scale [53], Athens Insomnia Scale [54], Pittsburgh Sleep Quality Index [55], Women’s Health Initiative Insomnia Rating Scale [56], or Minimal Insomnia Symptoms Scale [57]. In addition, it is important to ask about risk factors for insomnia, such as medical comorbidities, substance use, recent falls, psychiatric conditions, and social factors, like employment status, living environment, and social relationships [38]. Living alone and not being able to trust someone, or not having contact with family and friends, can be stressful for older adults and further increase the risk for insomnia [23•]. Therefore, probing about the quality and type of living environment and social relationships can help to further identify potential factors associated with insomnia and guide the development of shared provider-patient treatment goals.
Objective sleep measures are not necessary to diagnose insomnia. However, actigraphy, which measures movement, uses algorithms to determine sleep and wake, and it can be used during treatment, in conjunction with a sleep diaries, to evaluate treatment effectiveness of interventions [38].
Management of Insomnia
After diagnosing insomnia, behavioral interventions like CBTi and BBTi are the first-line recommendations for treating insomnia. As recent studies have shown, both CBTi and BBTi have resulted in short- and long-term improvement in insomnia symptoms [40••, 44, 58••]. Since many primary care providers are often unfamiliar with implementing behavioral interventions for insomnia, these healthcare providers can collaborate with behavioral and sleep medicine providers, or refer their patients to healthcare providers specializing in sleep medicine. The Society of Behavioral Sleep Medicine also has resources for providers and a listing of members who conduct CBTi in each state [59]. Primary care providers can also complete specialized training courses for which they will receive continuing education credits. Insurance companies may not always cover CBTi sessions; therefore, some older adults, who usually have fixed incomes, may not be able to afford the sessions. However, healthcare providers can provide in office education about the basics of cognitive behavioral therapy for insomnia. Healthcare providers can also educate their patients about participating in organized social activities, listening to soothing music before bed, and exercising consistently, since all these activities appear to be protective from insomnia [49•]. Other therapies, such as acupuncture [60, 61] and bright-light therapies have also been shown to reduce symptoms of insomnia [38, 62••].
Many older adults prefer non-pharmacological management compared with pharmacological treatment for insomnia [25]; however, benzodiazepines and other sedative-hypnotics are still regularly prescribed to older adults, often at higher doses than recommended [25, 26••, 63]. The first-line treatment for insomnia is not pharmacological management since many sleep medications cause side effects like ataxia, falls, or residual sedation [33••, 64]. Additionally, recommendations for the use of prescription and over-the-counter sleep medications for treating insomnia are weak [65••]. Consequently, healthcare providers should intentionally identify and review medications of patients who are at a high risk for insomnia, such as veterans and persons with chronic pain [25, 26••]. Furthermore, if patients have been using sleep medications for more than 12 months, it is important to discuss the goal of working toward de-prescribing, while developing healthy sleep habits [66, 67]. If medications must be prescribed, they should be used for a limited period, usually less than 6 months [68].
Sociodemographic Factors
African American and Hispanic older adults experience greater rates of insomnia compared to White older adults. However, African American older adults are under-diagnosed with insomnia. In one study, only 6.7% of African American participants were actually diagnosed with insomnia, although close to 20% of them had insomnia [69]. Non-Hispanic Black older adults had greater difficulty falling and staying asleep compared to non-Hispanic White older adults [70]. Potential explanations for these differences could stem from racism, discriminatory policies, and historical and structural oppression, which have contributed to African Americans in the USA having less access to economic, educational, and healthcare resources, thus increasing their risk for insomnia and poor sleep [71, 72]. Perceived racial discrimination is a significant predictor of sleep disturbance with individuals who experience perceived discrimination, as they are 60% more likely to experience sleep difficulties, even after adjusting for social, demographic, and mental health covariates [73].
Cognitive Function
Insomnia increases the risk for cognitive decline and dementia [74]. One potential mechanism is its association with amyloid β–related neurodegenerative processes. A recent study found that persons with insomnia have higher levels of cerebrospinal fluid amyloid-beta (Aβ) 42 levels when compared with those without insomnia [75]. The glymphatic system, which is a perivascular network throughout the brain, allows for the clearance of amyloid β and other interstitial solutes from the brain through the interaction of cerebrospinal fluid and intracellular fluid [76]. The glymphatic system exchange significantly increases during sleep, enabling the elimination of the various metabolites from the extracellular space that accumulate during wakefulness [77, 78]. Therefore, insomnia can potentially lead to an accumulation of amyloid β deposits, potentially initiating earlier cognitive decline. Healthcare providers can educate older adults about the mechanisms by which insomnia increases their risk for cognitive decline, the importance of developing good sleep habits, and seeking help when they have insomnia. Primary care providers can also conduct brief memory screens using instruments such as the Mini-Cog [79] of older adults with insomnia.
Conclusion
With the projected growth of the aging population to 98 million by 2060 [80], the number of persons at risk for, and experiencing insomnia, will increase. Insomnia is associated with poor quality of life and poor outcomes on the physical and psychological domains of quality of life [6, 11, 22]. Insomnia is also associated with increased healthcare costs for older adults [11]. Therefore, healthcare providers should be cognizant about assessing insomnia in all older adults, especially those who may be at greater risk, including veterans, women, and non-Whites, and specifically evaluate sociodemographic and life experience factors that can contribute to insomnia. These assessments should be performed at baseline visits and annual preventive visits, so older adults can receive early interventions and minimize the risk for insomnia to trigger or worsen comorbid conditions.
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This research was supported by the National Institute on Aging (grant number R01AG054079).
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Nguyen, V., George, T. & Brewster, G.S. Insomnia in Older Adults. Curr Geri Rep 8, 271–290 (2019). https://doi.org/10.1007/s13670-019-00300-x
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DOI: https://doi.org/10.1007/s13670-019-00300-x