Insomnia in later life

Content provided by the Faculty of the Harvard Medical School

Insomnia in later life

Overcoming obstacles to a good night's rest.

The older you are, the more likely you are to have a sleep disorder. According to a National Institute on Aging study, more than 50% of people over age 65 report regular sleep problems that trouble them at night or interfere with daytime activities. They can't fall asleep when they want to, they wake up repeatedly, they wake up too early, their sleep is not refreshing, or they feel drowsy or groggy all day. Fortunately, our understanding of sleep itself and the sleep disorders of late life have improved greatly, and help is more easily available than ever.

Sleep becomes shallower and briefer with age. Its deepest stages practically disappear by age 50 in many people. As we grow older, we not only sleep more lightly but wake up more often, have more brief periods of wakefulness, and spend more time lying awake (experts use the term "poor sleep efficiency"). We may fall asleep and wake up earlier than is desirable, and make up for sleepless nights, if we can, by daytime napping.

One result is falling asleep at the wheel, in the metaphorical sense (loss of alertness, concentration, and memory) and the literal sense (drowsiness may account for 100,000 automobile accidents each year, many of them involving older drivers). Insomnia may be a mortal danger in other ways as well. According to a study, people who sleep less than five hours a night have twice the average rate of heart attacks. Another study found that older adults who lay awake in bed for a half-hour or more on most nights had a high death rate even if their overall health was good.

Risk factors

Insomnia has many causes. Medical conditions that can lead to sleep loss include overactive thyroid, diabetes, congestive heart failure, high blood pressure, asthma, emphysema, arthritis pain, chronic heartburn, and urinary difficulties. Some potentially insomnia-provoking medications and drugs are alcohol, caffeine, stimulants, steroids, diuretics, cold and allergy medications, antidepressants and anti-arrhythmia drugs.

Insomnia and daytime drowsiness are also features of many sleep disorders that occur in middle age and later. The most common is sleep apnea, which occurs when a person's breathing stops many times during the night, often for a minute or more at a time, because the airway is blocked by sagging tissue or the brain does not reliably cue breathing muscles in the diaphragm. People with sleep apnea wake up momentarily every time their breathing stops. Their sleep is not refreshing, and they may suffer morning headaches as well as daytime drowsiness. Their hearts bear the strain of working to supply oxygenated blood to the body during long periods when they are not breathing. The risk is greatest for overweight men, especially if they drink alcohol in the evening.

Circadian rhythm changes are another common feature of later life. The internal clock that controls the 24-hour cycle of sleep and waking drifts forward (i.e., earlier) in older people, so they are more likely to fall asleep early in the evening and wake up in the middle of the night. If they try to stay up later, they may be sleepy all day. The condition is called advanced sleep phase syndrome.

Insomnia and psychiatric disorders

Psychiatric conditions are a major cause of insomnia in later life. The Epidemiologic Catchment Area (ECA) survey of nearly a thousand Americans found that about half of those with insomnia had a psychiatric disorder, most commonly an anxiety disorder, depression, or alcohol abuse or dependence.

About two-thirds of depressed patients sleep too little. Their most common sleep symptom is waking up too early, but they also have less deep sleep, and often their rapid eye movement (vivid dreaming) sleep begins abnormally early in the night — a phenomenon called short REM latency. Studies also show that depressed people often think they get even less sleep than they do. Meanwhile, a minority who suffer from winter depression (seasonal affective disorder) or the depressed phase of bipolar disorder sleep too much rather than too little.

This connection runs both ways. A person may be anxious or depressed because he is lying awake in bed as well as wakeful because he is anxious or depressed. In the ECA survey, 17% of people who had insomnia for a year developed a psychiatric disorder in the following year. In another study, young people who said they had been sleepless at some time for at least two weeks were four times more likely than average to develop major depression in the following three years. Sleep loss also interferes with recovery from medical and psychiatric conditions. A person who is no longer depressed but still insomniac has five times the average risk of relapsing.

Depression, anxiety, and insomnia may have common causes in overactivity of brain arousal mechanisms and malfunctioning of the stress hormone system governed by the hypothalamic pituitary adrenal (HPA) axis. So insomnia might be an early indicator of depression and anxiety disorders, a symptom of those disorders, or an independent effect of similar underlying mechanisms.

Primary insomnia

Illness, emotional stress, or a change in the environment often cause temporary sleeplessness. In about 5% of these cases, the problem becomes chronic. This kind of insomnia, not linked to any other medical or psychiatric disorder and therefore labeled "primary," may be the most common sleep disturbance of later life. It's also called learned or conditioned insomnia because it results from an association the mind makes between wakefulness and being in bed — an association strengthened and prolonged by anxiety about sleeplessness itself.

Treatment

Drugs: The easy way? By this time, almost everyone has seen advertisements for prescription sleeping pills, and more people are using them than ever. Prescriptions for sedative-hypnotic drugs (the medical term) doubled between 2000 and 2004, mainly because of new medications that are supposed to be safer and more effective than the old. But there is still much evidence that sleeping pills are often unreliable and can be risky, especially in the long run and for older people.

Benzodiazepines. These drugs, also used to treat anxiety and seizures, once accounted for most sleep medicine prescribed by physicians. They boost the activity of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA), and include triazolam (Halcion), temazepam (Restoril), lorazepam (Ativan), and clonazepam (Klonopin). Today, they are used less in the treatment of insomnia, replaced by benzodiazepine receptor agonists (BRAs).

BRAs. Although they act on the brain in a similar way, these drugs — zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta) — are believed by some to be more selective than the benzodiazepines, with fewer side effects. Compared to benzodiazepines, they may create less risk of rebound insomnia, withdrawal reactions, and addiction. Eszopiclone is the only sleeping pill approved by the FDA to be used for as long as six months. Because it has a longer period of action than the others, it may be better for staying asleep (as opposed to falling asleep), which can be particularly difficult for older people and those with depression.

The risks of benzodiazepines and BRAs, especially daytime carryover effects, are greater in older people because they have less resilient bodies, and break down and eliminate drugs more slowly.

Ramelteon (Rozerem). This drug is a new kind of sleeping pill. It differs from benzodiazepines and BRAs in its mechanism of action, working at receptors for the hormone melatonin. So far ramelteon has shown little evidence of causing rebound insomnia or a withdrawal reaction. But we won't know much about its long-term effects until it has been used for a longer time by more patients.

Antidepressants. Antidepressant drugs with sedative properties, such as amitriptyline (Elavil) and trazodone (Desyrel), are often used in place of BRAs because they are less addictive. But they take several weeks to work, and there are few controlled studies showing that they are actually effective in the treatment of insomnia. For people with both depression and insomnia, adding a sedative may help while they wait for the antidepressant to take effect. One study found that a combination of eszopiclone with fluoxetine (Prozac) relieved symptoms of both depression and insomnia faster and more effectively than either drug taken alone.

Over-the-counter medicines. An antihistamine (usually diphenhydramine) is the main active ingredient in sleep remedies sold under names like Benadryl, Sominex, Nytol, and Tylenol PM; sometimes a pain medicine is added. The effectiveness of these drugs doesn't match their popularity. They don't work well or for long as a treatment for insomnia, and older people are especially susceptible to their undesirable side effects, including daytime grogginess and blurred vision. Most experts do not recommend them.

Alternative remedies. Various herbal medicines are sold as "natural" sleep aids; the most common are valerian, kava, and chamomile. There is little solid evidence about these herbs, and what there is suggests that they are not particularly effective. They contain a variety of chemicals with uncertain combined effects, and most of them have not been carefully tested on older people.

The hormone melatonin is marketed as a dietary supplement for the treatment of insomnia, but studies suggest that it is not effective. It may have some promise specifically for older people with low levels of melatonin or advanced sleep-phase syndrome.

The FDA does not regulate herbal medicines and dietary supplements, so quality and purity may be questionable, and side effects have not been carefully recorded or described.

Sleeping pills: Illusions?

Even at best, sleeping pills are only modestly effective. A 2005 review based on 24 controlled trials including more than 2,000 patients found that benzodiazepines and BRAs sometimes did more harm than good. Compared with placebos, the drugs lengthened sleeping time by an average of a half-hour and reduced the number of times a person woke up at night by an average of 0.63. But the researchers estimate that 13 people had to be treated for one to show significantly improved sleep quality, and one in six would have some harmful effect.

So this apparently easy way to help yourself through the night is sometimes an illusion. And despite the advertising, most people remain skeptical. In a 2005 Gallup poll, more than 75% of people over 60 said they were concerned about the long-term effects of sedative drugs, and fewer than one in 10 regarded the drugs as "very safe."

That doesn't mean they are ineffective for everyone and in all circumstances. For some chronically sleepless older people, a sedative antidepressant or BRA may be almost a necessity. But most people should use sleeping pills chiefly when they need uninterrupted sleep on a special occasion or, at most, for a few weeks to prevent acute insomnia from turning into chronic primary insomnia. Until we know more about the long-term effects of eszopiclone and ramelteon, it cannot be said that their advent changes the situation.

Behavioral treatment

The most rigorously confirmed and widely recommended treatment for long-term insomnia, especially in older people and those with psychiatric disorders, includes several common features:

Stimulus control (reconditioning). A person who spends too much time lying awake in bed (poor sleep efficiency) comes to associate the bedroom with wakefulness. The problem is especially common in people with a chronic physical or mental illness, and the solution is to break the chain of association by reforming sleep habits. Patients are asked to keep a diary recording those habits for a month or so to see which thoughts and actions promote and interfere with a restful night. They are encouraged to go to bed only when sleepy, avoid reading and watching television in bed, and get up at the same time no matter how little they have slept. They are also instructed to leave the bedroom after lying awake for 20 minutes and return only when they feel sleepy again.

Most patients receiving stimulus- control therapy should avoid naps, but that is not always advisable for older people because of their relatively shallow and interrupted nighttime sleep. A regular nap of a half-hour to two hours in the early afternoon may be helpful for them, as long as the purpose is understood — not sleeping longer at night, but being more active and clear-minded during the day.

Sleep restriction. This is an extension of stimulus control. The patient goes to bed later than usual (so that she is more likely to fall asleep immediately) but gets up at the usual time. Then bedtime is gradually moved back.

Sleep hygiene education. What you do in the daytime affects how you sleep at night. The standard advice is to exercise regularly, but not in the evening; get out into the sun if possible (most older people spend more time indoors); don't smoke; don't eat a heavy meal shortly before bedtime; avoid alcohol and caffeine; keep the bedroom dark and quiet, using heavy curtains and earplugs or a white noise machine if necessary; try a warm bath before going to bed.

Relaxation training. The body and mind can be prepared for sleep with meditation, self-hypnosis, slow rhythmic breathing, or the repetition of neutral words or visualization of soothing scenes. Another technique is progressive muscle relaxation, which involves alternately tensing and fully relaxing the muscles, starting with the feet. Older people can skip the tensing if it is too difficult or uncomfortable.

Cognitive therapy. The aim is to correct unrealistic expectations of perfect (or youthful) sleep and the catastrophic thinking about the consequences of imperfect sleep that sometimes prevents relaxation and keeps people awake. Cognitive therapy is usually part of a package that includes behavioral treatments as well.

Treating insomnia in psychiatric disorders

Insomnia in a person with depression or anxiety disorder is usually called secondary insomnia, with the implication that it results from or is a symptom of the anxiety or depression. Many used to think that especially in older people, there was little point in treating insomnia separately. Either it was considered a normal or inevitable effect of age, or experts thought only treatment for the underlying psychiatric disorder would help.

Opinion has changed. Many studies now show that behavioral treatment specifically for sleep disturbances can be effective even in people suffering from depression, anxiety, and posttraumatic stress disorder (PTSD). For purposes of treatment, it may not be necessary to distinguish between primary and secondary insomnia. A review found that behavioral treatments for insomnia could be effectively combined with psychotherapy for depression, anxiety, PTSD, obsessive-compulsive disorder, and other psychiatric conditions. Good controlled studies are in short supply, but in general, the results seem similar for primary and secondary insomnia.

There is one caution: Sleep restriction can be risky for some people with psychiatric disorders. It may heighten anxiety, trigger manic episodes in patients with bipolar disorder, or raise the risk of daytime panic attacks in people with panic disorder and agoraphobia.

Many experts are convinced that behavioral sleep therapy, although it seems slower and more difficult, works better than drugs in the long run for most patients. A controlled trial published in 2006, confirming earlier research, found that a package of cognitive and behavioral treatments was more effective than eszopiclone, the latest popular sedative-hypnotic drug, in both the short term and the long term (six months) for the treatment of primary insomnia in people with an average age of 61. The drug had barely more effect than a placebo (sugar pill). Patients given behavioral treatment spent less time lying awake in bed; they had more deep sleep and their daytime functioning improved a little more. Unfortunately, improvements are still modest compared to the relief patients get from similar treatment for anxiety and depressions.

It's not clear whether all parts of the cognitive behavioral therapy package are actually needed. In 2006 a meta-analysis of 23 controlled studies found that both stimulus control alone and relaxation training alone were sufficient.

The future of sleep medicine

Sleep medicine researchers still have much to learn. They're looking for more selective drugs with fewer side effects, and ways to target specific sleep problems — drugs that affect the sleep-wake cycle, brain arousal circuits, the stress hormone system, and various neurotransmitters and hormones involved in sleep regulation. It turns out that one of these hormones may be orexin, now known chiefly as a regulator of appetite.

Just as important, clinicians are increasingly treating insomnia as a disorder as well as a symptom — a disorder that is often chronic, especially in older people. The American Academy of Sleep Medicine has started training programs in behavioral sleep medicine and is trying to provide more access to behavioral treatments by encouraging group therapy and the use of nurses as therapists. The hope is that as we gain a better understanding and control of sleep, we will not have to resign ourselves to accepting insomnia and its consequences as normal or inevitable at any age.

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Last updated:	November 20, 2006