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date: 13 November 2019

Insomnia and Clinical Sleep Disturbance in Later Life

Summary and Keywords

Sleep health is understood as a key factor in lifelong health and for social participation, function, and satisfaction. In later life, insomnia and other sleep disturbances are common. Insomnia is experienced as poor, disrupted, or insufficient sleep associated with significant daytime impairments including increased fatigue or reduced energy, impaired cognitive function, and increased mood disturbance. Poor sleep is associated with negative outcomes across a range of dimensions that impair quality of life, increases risk for other diseases, and may interact negatively with the progression and treatment of other disorders. Evidence for effective psychological interventions to improve sleep in later life, specifically cognitive behavioral therapy for insomnia, is robust and well described. Good sleep should be understood as a substrate for psychological health and a reasonable expectation in later life.

Keywords: insomnia, sleep, sleep disturbance, later life, older adult

Introduction

By the age of 80, any of us might have spent almost 10,000 “days” asleep, from 10 to 13 hours per day as a newborn to 7 to 8 hours per night when over 65 years of age. Some aspects of sleep, defined along dimensions of duration, quality, timing, and regularity, are susceptible to change in later life. Some of these changes reflect lifespan or developmental trajectories, others reflect increased exposure to intrinsic or extrinsic factors that promote sleep disturbance and sleep disorders. In either case, sleep can be viewed as potentially more vulnerable in later life, with implications for sleep and circadian health, as well as for the many interactions between sleep and other mental health, physical health, well-being, social, and community dimensions to life. Changes in the sleep characteristics attributed to aging include a decrease in overall quality and quantity, changes in napping frequency, changes in the timing and distribution of sleep across the day, changes in the proportion and distribution of physiologically defined sleep stages within the night, and sleep that is more easily disrupted (Gooneratne & Vitiello, 2014; Crowley, 2011). These changes are not universal, with many older adults reporting satisfaction with their sleep (BaHammam & Pandi-Perumal, 2010), and age per se is not a strong predictor of future sleep disturbance (Smagula, Stone, Fabio, & Cauley, 2016).

Medical, psychiatric, and psychological diagnostic criteria identify up to 60 discrete sleep disorders. A number of these disorders, including obstructive sleep apnea (OSA), restless legs syndrome (RLS), a number of circadian rhythm (body clock) related disorders, and rarer sleep disorders can amplify otherwise normal age-related changes in sleep, increase sleep fragmentation, and reduce the quality of sleep. However, where sleep disturbance is frequent and impactful—but not due only to another sleep disorder—insomnia is a likely clinical diagnosis. Insomnia, experienced as particular difficulty getting to sleep or staying asleep, remains the most common sleep disorder seen in older adults and is the focus of this article.

Functions of Sleep

Sleep serves multiple functions: It is a restorative and recuperative process, vital for brain function and development (including plasticity and connectivity); a substrate for social and emotional self-regulation, integration, and function; essential for memory consolidation and new learning; and essential for cardiac and metabolic health. It has clear social and psychological dimensions, associated with change in consciousness and sense of self, with the construction of daily habits and routines, and with its positive and negative roles as a retreat from the world. The key physiological drivers of sleep are homeostatic (i.e., a need for sleep that accumulates throughout the day and with transient or chronic sleep loss) and circadian (i.e., a timing drive that acts to promote regular sleep in synchrony with nighttime hours). Because of this, sleep is reactive and responsive to a wide range of physiological, psychological, social, and environmental inputs and in turn is important across those same broad dimensions of life.

Insomnia and Clinical Sleep Disturbance in Later LifeClick to view larger

Figure 1. The human circadian rhythm is typically modeled as a transformed cosinar curve that approximates the 24-hour variation in core body temperature (dark line, with core temperature nadir indicated by Tmin). Environmental light acts as the primary time setter for this rhythm, acting to synchronize the internal body clock with the external night and day. Melatonin release provides a timing signal to peripheral “clocks” throughout the body, and this release is promoted by darkness and suppressed by light. Unmasked (e.g., dim light) melatonin onset (Mon) can occur several hours before sleep onset, and an indicative melatonin curve is depicted in the gray line.

Insomnia Definition

Insomnia can be broadly defined as any sustained difficulties initiating sleep, difficulty maintaining sleep throughout the night, waking up earlier than desired, or sleep that is in some way unsatisfying, non-restorative, poor in quality, and significantly impacts some aspect of daily life and well-being. This definition does not fully capture the degree of disruption and distress experienced by people with chronic insomnia. Qualitative or person-centered descriptions of insomnia are rare in the psychological literature but in general demonstrate clearly that the experience of insomnia can be pervasive and inclusive of many dimensions of everyday life. It can also be highly debilitating, unpleasant, and the cause of significant stress and worry. Araújo et al. (2017) reported psychosocial experiences of social stigma, personal and social deficits (including misunderstanding of insomnia as an illness), resignation and hopelessness, and help avoidance. Deemphasis among health practitioners of the importance of insomnia as a disorder and as part of lived experience is a common frustration and one that has implications for the recognition, prioritization, and management of insomnia.

Three major diagnostic classification systems provide specific criteria for the diagnosis of insomnia. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) the upcoming revision to the International Classification of Diseases (ICD-11, World Health Organization, 2018) provided broad definition of insomnia (termed “insomnia disorder” in the DSM-5), while the International Classification of Sleep Disorders (ICSD-3; American Academy of Sleep Medicine, 2014) previously provided a fuller definition of insomnia subtypes but has now simplified and consolidated the schema into short-term, chronic, or “other” insomnia disorders. Earlier evidence to support differences in treatment choice or outcome after subtyping had been modest, although evidence for meaningful differences based upon new conceptualizations of presentation, biomarkers, and potential mechanisms is increasing (Benjamins et al., 2017). The three schema are consistent in requiring only self-report of symptoms to determine the presence of insomnia and do not require specific additional clinical testing. Each classification requires a report of significant distress or impairment occurring during the waking hours that can be attributed to difficulties in nighttime sleep and each includes a criteria for frequency (three nights per week for ICSD-3 and DSM-5) and duration (one month for ICD and ICSD, three months for DSM-5), although other aspects of chronicity and temporal patterning are not defined.

Table 1. Insomnia is Characterized by Both Nighttime and Daytime Symptoms. The Indicators of an Insomnia Disorder, Common Across Schemas, Include the Following (Morin et al., 2019):

1.

Predominant complaint of poor sleep quality or insufficient duration.

2.

Difficulties with falling asleep at bedtime, and/or frequent or prolonged wake periods during the night, and/or early morning wake with an inability to fall back to sleep.

3.

Sleep difficulties occur despite adequate opportunity and environment for sleep.

4.

Sleep difficulties are associated with clinically significant distress or impairment of daytime function.

5.

Sleep difficulties are present on at least 3 nights per week, over at least a three-month period.

While these classification schemes include some quantification of sleep disturbance (e.g., ratings of severity, frequency, or duration), they do not provide thresholds or other guidance around sleep duration. Despite that, duration and change in duration over time are often particular concerns of patients. In older adults (those aged 65 years or older), the recommended sleep duration is seven to eight hours (Badr, Belenky, et al. 2015). However, these recommendations acknowledge that as little as five to six hours, or as much as nine hours of sleep, may be appropriate, given that some individuals are naturally longer or shorter sleepers. There is now support for a broad range of genetic contributions to sleep duration and to features of circadian timing (Jagannath et al., 2017). The recommended sleep duration in older adults differs only slightly from that for middle-aged adults, for whom seven to nine hours per night (and potentially six to ten for some) is recommended (Hirshkowitz et al., 2015). These guidelines suggest that in healthy aging any decrease in sleep duration from middle age to old age may be gradual. Other data suggests that the presentation or presence of illness, disease, or poor health eclipses any changes directly attributable to age itself (Ohayon, 2004). These data frame expectations around both inter-individual sleep needs and for changes in an individual’s sleep over time, that might contrast with the desire for a “regular eight hours.”

Insomnia Prevalence in Later Life

An occasional night of poor sleep is a common experience, and a wide range in prevalence estimates has been reported for complaints of chronic or persistent insomnia. This variation reflects historical differences and changes in the criteria used to define insomnia, differences in discrimination and interpretation of levels of insomnia severity, differences in sampling, and certainly differences in culture and geography. The most robust international estimates of prevalence (Ohayon, 2002) suggest that at least 30% of the general population report at least one symptom of insomnia, but perhaps 6% to 9% would meet conservative criteria for a clinical diagnosis. A comparison of the sleep complaints of older adults in low- and middle-income countries found prevalence rates varying from 9% to 38% (Mazzotti et al., 2012).

The frequency of insomnia is likely to be higher within selected populations or in groups with particular disorders, including those that also increase in likelihood with age. These include people experiencing chronic pain, depression and anxiety, heart disease, and diabetes. Prevalence of insomnia in the range of 40% has been reported in primary care (Léger et al., 2010) and for older adult in-patient populations (Isaia et al., 2011). The prevalence of insomnia is often reported to increase with age, with up to 50% of older adults complaining of some kind of sleep problem (Vitiello, 2006); however, most estimates of insomnia prevalence in community-dwelling older adults (Ohayon, 2002) are within the same range as for the general population. The annual incidence rate may be about 5% for adults over the age of 65 (Foley et al., 1999), although other epidemiological parameters are not well described but may be important (Parthasarathy et al., 2015). Concomitant factors including increased inactivity and sedentary time, increased isolation and loneliness, and the presence of other disorders have been found to be stronger predictors for the presence of insomnia than age per se (Nau et al., 2005).

Insomnia Measurement

The conventional and current standard for assessment of insomnia remains a clinical interview, which may be structured (e.g., Taylor et al., 2018), or supported with psychometric measurement including the use of a sleep diary and symptom rating scales. Formal parameters for sleep quantity have been operationalized for the definition of insomnia in research settings (Lichstein et al., 2003), and the use of standardized diaries has been encouraged (Carney et al., 2012). A large number of sleep-related scales and measures exist (Shahid et al., 2011) and remain in use because of the complex and multidimensional nature of sleep and the experience of sleep. A smaller number of scales more clearly orientate to diagnostic criteria for insomnia, including the Insomnia Severity Index (Bastien, Vallieres, & Morin, 2001) and the more recent Sleep Condition Indicator (Espie et al., 2014) directly addresses DSM-5 criteria for insomnia disorder by including items eliciting level of nighttime sleep disturbance, frequency of disturbance, impact on daytime functioning, and duration of the disturbance. Most such measures are brief and may not be explicitly developed for use in older adults. and they typically lack specific age-stratified norms. Further, most do not attempt to differentiate insomnia from other sleep disorders. There is potential for the use of parallel screening measures for other disorders (such as brief scales rating obstructive sleep apnea symptoms), or more omnibus measures that address a broader range of disturbances in clinical decision making, but the utility of such decision pathways has not been robustly demonstrated. Current evidence is that use of such measures has not translated well into practice outside of specialist settings (Miller & Berger, 2016). While some specific measures have demonstrated validity against an interview, they are still best described as adjunctive measures for identification of insomnia in psychological practice.

Actigraphy (typically wrist-worn activity recorders) has a conditional recommendation for use in estimating sleep parameters in insomnia (insomnia disorder; see Smith et al., 2018). The benefits of actigraphy over other assessment methods include relatively low patient burden and health service costs, the capacity for prospective longitudinal assessment including assessment of treatment progress and response, and utility in differentiating insomnia from circadian rhythm disorders. Many different actigraphy devices are available, with important variations in accelerometer technologies and sleep-wake detection algorithms. These differences have implications for measurement accuracy in specific populations, especially those without strong normative data. In particular, an increased frequency of habitual daytime napping can be seen in older adults, and detection of naps outside of the primary sleep episode may require adjustment of detection algorithms or other considerations in the interpretation of actigraphy. Attempts at establishing a consensus for actigraphy use in clinical settings (Ancoli-Israel et al., 2015) face a challenge in keeping pace with technological advances, and reliable clinical algorithms for discrimination of insomnia from circadian rhythm disorder are not in widespread use. Effective use of actigraphy to guide clinical decision making will require integration into clinical education and health services, as well as reimbursement frameworks. While personal devices including varieties of “smart watches,” commercial sleep trackers, and mobile phone-based applications show promise for engaging, low cost, and ecologically valid assessment of sleep-wake behaviors, current evidence of benefit is variable, and there are specific concerns about the use of consumer devices in diagnosis (Khosla et al., 2018). These concerns include a lack of standardization, use of inaccessible or proprietary algorithms, and lack of validation against clinical criteria. Further issues around governance and safety approvals, and the treatment of patient data and data ownership, are similar to those faced by other medical and media technologies.

The standard overnight clinical sleep study, known as polysomnography (PSG), whether conducted in a sleep laboratory or as a home-based study, is still the mainstay for investigations in sleep medicine. However, PSG has not been recommended in current guidelines for evaluation of insomnia (Schutte-Rodin et al., 2008), reflecting and reinforcing an early dichotomy between psychological and biomedical approaches to understanding sleep disorders. PSG may sometimes be necessary to rule out the presence of other sleep disorders. Other primary sleep disorders may initially present with similar subjective features as insomnia. For example, Rapid Eye Movement (REM) sleep behavior disorder has a demonstrated prodromal association with neurodegenerative disorders, including Parkinson’s disease (Mantovani et al., 2018) but requires PSG confirmation. While current testing standards and recording montages have largely been determined on their utility for the detection of obstructive sleep apnea (OSA) and a limited set of other sleep disorders, increased use of PSG may shed greater light on the physiology and neurophysiology of insomnia.

Insomnia Comorbidity

Insomnia and subclinical sleep disruption often co-occurs with other medical conditions. These relationships may not always be certain but can be understood as a comorbidity where insomnia may increase the overall burden of disease and decreased quality of life; however, it may also act to promote or exacerbate other conditions via direct or indirect pathways. Because of this, insomnia when present warrants treatment in its own right. Clinically important comorbidities have been identified in increased prevalence of insomnia in patients with heart disease, hypertension, and neurological complaints, diabetes, stroke, depression, and anxiety (Benca, 2005, Budhiraja et al., 2011). Insomnia may also occur comorbidly with other sleep disorders, including OSA. The risk for OSA increases with age (and with any gains in body mass). A high frequency of comorbid insomnia and OSA has been identified in patients presenting initially with either provisional diagnosis (Sweetman et al., 2017). Detection and management of OSA in older adults is low overall (Namen et al., 2017). This may be in part due to misatributions of symptoms to insomnia alone, or to expectations or beliefs about the ineveitability of poor sleep in later life.

There appears to be complex and reciprocal links between insomnia and dementia (including Alzheimer’s disease, vascular dementia, and other forms; see de Almondes et al., 2016) where insomnia may be a risk factor for dementia and commonly co-occurs, often increases stress and health burden on the individual (including increased risk of falls). It also often increases the burden of care and is a predictor of insitutionalization (e.g., Beaudreau et al., 2008; Cipriani et al., 2015).

The prevalence and significance of comorbid insomnia suggests that questions about sleep quality and quantity should be included in initial consultation for almost any presentation and that insomnia should be treated when identified. Further specialist investigations are warranted following suspicion of comorbid sleep disorders, in particular if symptoms consistent with OSA (snoring, witnessed apneas, excessive daytime sleepiness) are reported. Assertive management of insomnia in the context of dementia has the potential to improve quality life for individuals and families and may increase capacity for home-based and community care.

Critically, treatment of insomnia appears robustly effective in the presence of such comorbidities (Stepanski & Rybarczyk, 2006, Geiger-Brown et al., 2015, Okajima & Inoue, 2018) and in fact appears robust even when sleep disturbance is more classically defined as secondary to another condition. Further, insomnia may present a barrier or moderator of response to treatment for some other disorders (Wallace et al., 2018), and management of insomnia may improve symptoms or amplify the response to other treatments (Vitiello et al., 2014). As such, the consensus view is now that clinically significant insomnia warrants treatment in its own right, and is likely to improve overall health in patients with comorbid conditions (Smith et al., 2005). These findings provide a good rationale for early and effortful intervention to improve sleep quality in older adults.

Insomnia Conceptualizations

Humans have a demonstrated capacity to willfully vary, manipulate, and interrupt their sleep to respond to work, social, leisure, and other purposes. While strong biological factors create a drive toward some degree of nightly consistency and regularity in sleep, this drive is not absolute. Sleep can be reactive to factors such as danger and threats, including stress and pain, and responsive to recuperative needs, including illness and fever. In the context of that flexibility, it is not clear why so many individuals do not find their sleep satisfactorily within their control.

Current mainstream conceptualizations of insomnia take two broad but non-exclusive perspectives. The first is that insomnia can be understood within a broadly psychological or behavioral learning and negative reinforcement framework. Speilman’s influential 3P model (Spielman et al., 1987) proposed predisposing, precipitating, and perpetuating factors that provide an explanatory framework for the initiation and persistence of insomnia and of the cognitive and behavioral interactions that can act to promote continuation. Other hybrids, cognitive and neurocognitive models, have elaborated upon these processes and incorporate more recent evidence for the roles of arousal, attention, and perception in the maintenance of insomnia (Harvey & Talbot, 2016). The second perspective is that insomnia can be understood within a more biological framework, specifically as a state of chronic physiological arousal (hyperarousal) that impacts sleep but can also be observed right through the day. Such hyperarousal has been described for metabolic, hormonal, electroencephalogram, and sympathetic nervous system functions. This framework provides conceptual and mechanistic links to many of the negative health outcomes associated with insomnia and also identifies a range of potential endogenous risk factors for predisposition to insomnia (Bonnet & Arand, 2010). Neither conceptualization is explicitly addressed in current diagnostic schema.

There is current strong interest in the possibility of distinct phenotypes of chronic insomnia (Vgontzas et al., 2013) that broadly align with (and may help integrate) those previous conceptualizations. The first is characterized by short objective sleep duration and particular physiological hyperarousal, along with increased cardio-metabolic and mental health risks. The second is characterized by longer objective sleep duration, sleep misperception, anxiety, and emotional arousal. These phenotypes have empirical support and do suggest tailoring of interventions to prioritize strategies toward either presentation (Bathgate et al., 2016). A mismatch between phenotype and treatment has been proposed as one reason for dropout from CBTi in clinical environments and particular benefit from pharmacological intervention has been suggested for the first phenotype. However, CBTi has been found to be comparably beneficial for patients with insomnia who had short and longer objective sleep before treatment (Lovato, Lack, & Kennaway, 2016). While heritability for insomnia has been identified (e.g., Stein et al., 2018), the role that genetics plays in differential presentations of insomnia, or differential response to treatment, is not yet clear.

A third conceptual approach that may have particular relevance in aging is that of insomnia as part of a change or deterioration in circadian health and function. There is evidence that circadian function may change to some degree across the lifespan (Hood & Amir, 2017). This can be seen in daily routines, with a relative phase advance of the circadian rhythm with aging seen as earlier bedtimes and early wake times (i.e., becoming more of a “morning person,” even without clear change in chronotype), and the possibility of decreased circadian amplitude (see Figure 2; Roenneberg et al., 2004; Skeldon, Dirks, & Dijk, 2016). Some of these features may reflect mechanisms such as changes in clock gene expression, decreased melatonin expression, reduced light availability to retina due to changes in the cornea, or decreased pineal, cortical, or peripheral clock responsiveness to light stimuli, and behavioral changes in habitual light exposure and activity patterns. The potential disruptive roles of environmental light as the primary timing signal to the circadian system, including mistimed artificial light during the night (Obayashi, Saeki, & Kurumatani, 2014) and insufficient light exposure during the daytime (Shochat et al., 2000), may be increasing with increasing population densities, urbanization, and institutionalization. Consideration of circadian health in later life may be particularly important in light of strong circadian regulation of hormonal, endocrine, metabolic, and other functions and the relationship between disrupted circadian function and major neurodegenerative burdens associated with aging, such as Alzheimer’s disease and Parkinson’s disease (e.g., Mantovani et al., 2018).

Insomnia and Clinical Sleep Disturbance in Later LifeClick to view larger

Figure 2. The relationship between circadian phase position in younger adults (thinner line) and older adults (thicker line) depicts here a relative phase advance with corresponding earlier evening sleep onset and earlier morning sleep offset, and a possible reduction in rhythm amplitude. Broad insomnia subtypes of difficulties with sleep onset, sleep maintenance, or undesired early morning wake are illustrated.

Rationale for Treatment

The magnitude and pervasive nature of distress associated with chronic insomnia is significant. This has been consistently demonstrated by evidence for impairment in health-related quality of life (Léger et al., 2012; Lichstein et al., 2001). Untreated insomnia in later life has also been linked to an increased risk for impaired cognitive functioning and dementias, increased risk for mood disorders and anxiety, increased risk for falls, decreased quality of life, functional decline (Spira et al., 2012), and increased all-cause mortality (Ford et al., 2015). While some of these associations have not been confirmed in prospective studies with older adults, others have (e.g., that insomnia precedes and predicts depression; see Baglioni et al., 2011; Bao et al., 2017), and plausible mechanistic pathways have been described for the role of insomnia in precipitating or promoting other disorders (Mantovani et al., 2018). Meta-analyses show that primary insomnia can be a predictor or precursor of later-life depression (Riemann & Voderholzer, 2003), raising the potential for insomnia management as an early intervention for mood disorders in older adults. In addition to these direct individual and health-systems costs, insomnia is also associated with decreased social functioning and community participation (Baglioni et al., 2010). For those still in the workforce, insomnia contributes to decreased productivity and increased absenteeism (Daley et al., 2009). The economic costs of insomnia are difficult to estimate from available socioeconomic data. These costs may be direct or indirect but have been estimated at around US$100 billion (Wickwire, Saya, & Scharf, 2016), and around US$2 billion in France (Léger & Bayon, 2010).

Treatment of insomnia (with either or both non-pharmacological or pharmacological interventions) robustly improves sleep quality, improves at least some comorbid medical outcomes, improves quality of life, and has been shown to be cost effective. Cost effectiveness of treatment of older adults specifically has been demonstrated (Wickwire et al., 2016). As such, there are clear individual distress, health, and safety benefits to treatment for insomnia, and these benefits flow to industrial, societal, and other community benefits.

Insomnia Treatment Approaches

Cognitive behavioural therapy for insomnia (CBTi) is as a robust, effective, and durable treatment for older adults with insomnia (Irwin et al., 2006). CBTi generally refers to a package of complementary behavioral, cognitive, and psychoeducational strategies that are delivered together, typically oriented around weekly progression tracked with a sleep diary. This approach conventionally includes components of stimulus control (Bootzin et al., 1991), sleep restriction (Spielman et al., 1987), and cognitive therapy (Morin et al., 1993) and may also include additional adjunctive components common in psychological practice such as relaxation therapy (Means et al., 2000), or other strategies to address barriers to implementation or to encourage motivation. Recommendations about positive sleep practices, previously termed “sleep hygiene” (which include instructions around reduction in exogenous disruptors of sleep such as excessive caffeine or alcohol use, bedroom lighting, and similar (Irish et al., 2015) now have an increased evidence base and form part of lifelong “sleep health” strategies (Buysse, 2014). The individual components of CBTi arose from different conceptual approaches to insomnia and have evolved over time. However, the core elements are compatible with each other and are consistent with concepts of habit forming, reinforcement, social and circadian rhythm regularity, and sleep homeostasis. Because improved sleep can be directly experienced, CBTi is reinforced by positive feedback from perceptions of improved sleep and daytime functioning. Inherent in the approach is individualized titration of sleep scheduling and other aspects that allow for flexible and incremental intervention. A specific intention of the approach is to develop the sleep skills of a patient so that they can build resilience to poor sleep and respond knowledgeably and effectively to future recurrence of insomnia. This benefit is seen in durable long-term outcomes after CBTi (e.g., Vitiello et al., 2014) and the equivalence or benefit of CBTi over long-term use of hypnotics as an alternative treatment. While the exact components, duration (number of sessions), and the specification and delivery of those components also vary across studies, there is currently no clear benefit to single-component therapies (Harvey, Inglis, & Espie, 2002), and meta-analysis of randomized controlled trial studies (Wang, Wang, & Tsai, 2005) has demonstrated that a CBTi package is superior to single-component treatments.

Standardized treatment programs, including assessment materials and patient resources, are available to clinicians in the form of books, manuals, and online resources. In some cases, brief CBT-based interventions can be effective, and such approaches may support efforts to move the therapy from specialized clinics into the public and preventative health arenas, for delivery by other health professionals or non-professionals, or as a stepped-care approach to triage pathways.

Current evidence suggests that both individual and group (Koffel, Koffel, & Gerhman, 2015) approaches to CBTi can be effective in older adults (McCurry, Logsdon, Teri, & Vitiello, 2007). Use of online or application-based CBTi delivery is increasing, and there is evidence for effectiveness similar to that for face-to-face interventions (Zachariae, Lyby, Ritterband, O’Toole, 2016). The efficiency of this approach might depend on access and familiarity with technology, the degree of individual care that can be incorporated into the program, and the health service models supporting dissemination (Manber & Simpson, 2016).

CBTi is recommended as the first-line therapy in most peak clinical guidelines (e.g., Qaseem et al., 2016 and Riemann et al., 2017), supported by many randomized control trials across different patient groups, and a number of systematic and meta-analytic reviews (Irwin, Cole, & Nicassio, 2006). Specifically, CBTi is recommended as a beneficial for treatment of insomnia in older adults (Alessi & Vitiello, 2011). In many cases CBTi has equivalence or advantage over pharmacological treatment (Omvik et al., 2006), can be more cost effective, and may be preferred for use with older patients because of its favorable safety profile relative to sedative/hypnotic medications. This is a particular consideration for older adults due to an increased risk for falls associated with sedative/hypnotic medications (Treves et al., 2017), including an increased risk for falls in care environments (Berry, Lee, Cai, & Dore, 2013). While combination therapies providing CBTi together with medication have been suggested (Beaulieu-Bonneau, Ivers, Guay, & Morin, 2017), most guidelines recommend use of sedative/hypnotics only in the case of non-responsiveness to CBTi (Qaseem et al., 2016). The overall weak evidence for use of pharmacotherapy for insomnia reflects the low quality of evidence provided by published trials (Wilt et al., 2016, Sateia et al., 2017). Complementary and alternative medicines (CAM; including herbal remedies) are accessible, and their use to improve sleep is common. However, evidence for benefit from CAM’s is currently poor and the safety profile of specific CAM’s is uncertain. As such, their use is not supported (Leach & Page, 2015).

Evidence to support the use of alternative psychological approaches to insomnia, such as mindfulness therapies, suggests modest benefits demonstrated by meta-analysis of extant trials and no consistent benefit over CBTi currently (Gong et al., 2016), despite more positive outcomes for older adults in specific trials (Black et al., 2015).

Strategies to optimize circadian timing are not an overt component of most CBTi interventions, although aspects of sleep scheduling (i.e., the setting of consistent wake times) is congruent with stabilization of circadian phase, through promotion of a social rhythm and possibly via regulation of light exposure. Conversely, explicit consideration of circadian timing—as well as manipulation of light via light boxes, light tables, or wearable light devices to reinforce circadian regularity—may be of particular benefit for older adults (Montgomery & Dennis, 2002). There is limited evidence for specific improvement in overall sleep and insomnia symptoms when used alone, especially at higher light intensities (Van Maanen, Meijer, van der Heijden, & Oort, 2016).

Sleep in Care Context

While many societies seek to support older adults to remain in their communities for as long as possible, for many older adults some exposure to longer-term or permanent institutional care (e.g., hospital or rehabilitation admission, move to aged care facility, dementia care, or to a palliative care environment) is a reality. Many choices around preferred sleeping habits, routines, and environment, including crucial factors such as timing of bedtime and daily exposure to light are restricted, constrained, or altered in these environments (Neikrug & Ancoli-Israel, 2010). Further, this change in environment may be precipitated by poor health, acute disease, and medical and pharmacological interventions. This presents a difficult environment in which to achieve good sleep and to address insomnia. Architectural (e.g., Sinoo, van Hoof, & Cort, 2011), cultural, and health systems solutions are required to improve the structural elements supporting good sleep and to dismantle barriers to good sleep. More work needs to be done test current therapies for insomnia in these environments (Herrmann & Flick, 2011), where uptake of standardized CBTi programs may be less common. Particular cases are those of palliative care environments, a point at which a person’s comfort might become a paramount consideration and where interventions to improve sleep might be a great individual benefit (Mercadante et al., 2015), and dementia care environments where circadian function may be particularly impaired yet opportunity exists for reinforcement (Van Hoof, Aarts, Rense, & Shoutens, 2009).

Toward Sleep Health in Later Life

Sleep is a fluid and multidimensional state that matures, responds, and reacts to changes across the lifespan and supports general health. This role places sleep as a process quite central to the life-course experience, and this centrality has been articulated in 21st-century definitions of “sleep health.” Sleep health has been defined as “a multidimensional pattern of sleep-wakefulness, adapted to individual, interpersonal, and environmental demands, that promotes physical and mental well-being. Good sleep health is characterized by subjective satisfaction, appropriate timing, adequate duration, high efficiency, and sustained alertness during waking hours.” (Buysse, 2014). This general orientation has been reflected in increased interest in sleep, the promotion of sleep health in the community, and consideration of sleep as a population health priority. This newer approach to understanding sleep in later life is also consistent with contemporary positive aging frameworks (Anton et al., 2015). One advantage of this definition is that it characterizes sleep health positively as something that can be desirable, comforting, and restorative. Placing sleep health on a continuum contrasts with traditional deficit or dichotomous models of sleep disorders. Instead, it recognizes that sleep quality may ebb and flow in a way that only sometimes meets criteria for insomnia. This approach moves some responsibility for sleep to agencies and institutions outside of health. For example, emerging work recognizes of the role of environmental factors, suggests a role sleep in social and economic disparity at a community or population level, and raises the possibility of an individual right to sleep security.

Insomnia in later life is common and impactful but can be improved. Sleep health underpins many physical health, mental health, social, emotional, and community functions and should be seen as an achievable goal if not a right in later life.

Further Reading

Alessi, C., & Vitiello, M. V. (2011). Insomnia (primary) in older people. BMJ Clinical Evidence, 2011(10), 2302.Find this resource:

Buysse, D. J. (2014). Sleep health: Can we define it? Does it matter? Sleep, 37(1), 9–17.Find this resource:

Crowley, K. (2011). Sleep and sleep disorders in older adults. Neuropsychology Review, 21(1), 41–53.Find this resource:

Chokroverty, S. (2017). Overview of normal sleep. In S. Chokroverty (Eds.), Sleep Disorders Medicine. New York, NY: Springer.Find this resource:

Scullin, M. K., & Bliwise, D. L. (2015). Sleep, cognition, and normal aging: Integrating a half century of multidisciplinary research. Perspectives on Psychological Science, 10(1), 97–137.Find this resource:

Roenneberg, T., & Merrow, M. (2016). The circadian clock and human health. Current Biology, 26(10), R432–443.Find this resource:

Riemann, D., & Espie, C. (2018). Evidence-based psychological therapies for insomnia. The Lancet, 392(10149), 735.Find this resource:

Kim, J. H., & Duffy, J. F. (2018). Circadian rhythm sleep-wake disorders in older adults. Sleep Medicine Clinics, 13(1), 39–50.Find this resource:

Brewster G. S., Riegel, B., & Gehrman, P. R. (2018). Insomnia in the older adult. Sleep Medicine Clinics, 13(1), 13–9.Find this resource:

Mattis, J., & Sehgal, A. (2016). Circadian rhythms, sleep, and disorders of aging. Trends in Endocrinology & Metabolism, 27(4), 192–203.Find this resource:

References

Alessi, C., & Vitiello, M. V. (2011). Insomnia (primary) in older people. BMJ Clinical Evidence, 2011(10), 2302.Find this resource:

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