expert roundtables

Insomnia in Adults and the Effects of Aging: Special Considerations

by Ravi Allada, MD; Stephen M. Stahl, MD, PhD, DSc (Hon); and John W. Winkelman, MD, PhD

Overview

Healthy aging is associated with some reduction in total sleep duration and an increase in sleep fragmentation. Insomnia in older adults differs from the normal age-associated changes in sleep and is worthy of further investigation, as it could lead to functional deficits or worsen the trajectory of comorbid conditions.

Q:

How does sleep change with age, and what are the crucial considerations in the approach to older individuals with insomnia?

Stephen M. Stahl, MD, PhD, DSc (Hon)

Professor of Psychiatry
University of California, Riverside
University of California, San Diego
Honorary Fellow, University of Cambridge
Senior Academic Advisor, California Department of State Hospitals
Sacramento, CA

“Discussing the importance of good sleep hygiene, particularly the need to avoid napping during the day, is an important component of addressing sleep difficulties in older adults.”

Stephen M. Stahl, MD, PhD, DSc (Hon)

I would emphasize the importance of taking a good history. People with age-related changes in sleep tend to ease into it, whereas sleep issues with depression may emerge more suddenly by comparison. My focus is psychiatry, and poor sleep hygiene is very common among older patients, particularly those with mood and cognitive disorders. These individuals tend to awaken very early in the morning, which leads to a continuous cycle of early awakening, afternoon napping, and nighttime sleeplessness. So, discussing the importance of good sleep hygiene, particularly the need to avoid napping during the day, is an important component of addressing sleep difficulties in older adults.

A regimen of melatonin and/or light therapy may be worth trying in this population, although data showing efficacy are limited. A hypnotic that allows a patient to sleep slightly longer and adjust their circadian rhythm may also help to improve sleep quality. It is difficult to overemphasize the value of good sleep in the management of psychiatric disorders. If the patient is not sleeping, they are not going to function in the daytime. Exercise is a great tool to use, as well as cognitive behavioral therapy. However, if none of those options work, you use medications to aid sleep (ie, addressing pain disorders, mood disorders, psychotic disorders, and the like first).

There is the risk of being too puritanical in avoiding hypnotic agents. Of course, care must be taken, as benzodiazepine receptor agonists can lead to dependence, motor incoordination, and an increased risk of falls. Some of these agents put you to sleep and then wear off over the night, which works for a number of people, but those who have middle insomnia or late insomnia do not do as well. Orexin inhibitors work quite differently. They actually block the ability of orexin, an endogenous neuropeptide, to stabilize wakefulness. Orexin levels naturally fall at night and rise in the morning. So, as orexin levels rise in the morning, they are reversing the blocking effects of the orexin inhibitor. In contrast, a gamma-aminobutyric acid–based agent works until it is out of your system.

John W. Winkelman, MD, PhD

Professor of Psychiatry
Chief, Sleep Disorders Clinical Research Program
Department of Psychiatry
Massachusetts General Hospital
Harvard Medical School
Boston, MA

Older adults with insomnia may have an advanced delayed sleep phase and more fragmented sleep. Underlying causes of sleep disruption should be evaluated, as poor or inadequate sleep has been implicated as a risk factor in a variety of disorders.”

John W. Winkelman, MD, PhD

The circadian phase is known to advance with age, and healthy older people tend to fall asleep earlier and wake up earlier than younger patients. Sleep duration is generally reduced and becomes more fragmented with age. Awakening early may result in daytime naps, which may exacerbate the problem of insomnia during the night. There are challenges associated with measuring the impact of insomnia in older individuals, however. In the analysis by Roth et al, while reports of difficulty falling and staying asleep increased with age, diagnoses of insomnia were paradoxically lower among older and elderly adults than among younger adults. The older adults in this study did not fulfill all of the criteria necessary for a diagnosis of insomnia disorder, which includes distress or daytime dysfunction related to poor sleep. This may be due, in part, to changes in role expectations of older adults. For instance, in an older person with insomnia, the need to extend morning wake time or napping during the day may not lead to as much dysfunction as in a younger person who is working on a full-time basis and/or who cares for young children.

Nevertheless, older adults with insomnia may have sleep deficits that are worthy of investigation. Older adults with insomnia may have an advanced delayed sleep phase and more fragmented sleep. Underlying causes of sleep disruption should be evaluated, as poor or inadequate sleep has been implicated as a risk factor in a variety of disorders, including Alzheimer’s disease and other dementias, as well as depression. And, for those already living with varying degrees of cognitive impairment or dementia, poor sleep or nighttime awakenings can create a risk for falls and can limit the ability to live independently. For those living with family, nighttime awakenings may strain the family’s caregiving capacity. Effective treatment of the insomnia can improve quality of life for patients and their caregivers, and it might even have the potential to change the trajectory of certain comorbid conditions, such as depression and anxiety.

Ravi Allada, MD

Edward C. Stuntz Distinguished Professor of Neuroscience
Chair, Department of Neurobiology
Northwestern University
Evanston, IL

“The jury is still out on whether fixing the sleep problem will have an impact on diseases such as Alzheimer’s disease. However, this is an exciting area of research because we currently lack disease-modifying therapies for these illnesses.”

Ravi Allada, MD

The focus of our research relates to circadian disorders, and there is considerable scientific interest in the potential link between sleep and circadian clock disruption and mild cognitive impairment, depression, Alzheimer’s disease, and other neurodegenerative diseases. People are looking at links between circadian clock disruption and consequences for sleep, and links to many of the disorders that we have been talking about. One area that is particularly interesting is a link to neurodegenerative diseases. There are a number of research groups examining sleep therapeutics as a way of potentially impacting those diseases, including their progression. The jury is still out on whether fixing the sleep problem will have an impact on diseases such as Alzheimer’s disease. However, this is an exciting area of research because we currently lack disease-modifying therapies for these illnesses.

Regarding sleep therapeutics in older patients, I would just add that the side effects can be much more prominent in this population (eg, memory and motor issues). In individuals who already start out with some of those impairments, there is more caution. Those comorbidities can certainly be limiting in terms of motor impairment and the risk of next-day function issues because those patients are going to be at risk for falls.

References

Brzecka A, Leszek J, Ashraf GM, et al. Sleep disorders associated with Alzheimer’s disease: a perspective. Front Neurosci. 2018;12:330. doi:10.3389/fnins.2018.00330

Maust DT, Solway E, Clark SJ, Kirch M, Singer DC, Malani P. Prescription and nonprescription sleep product use among older adults in the United States. Am J Geriatr Psychiatry. 2019;27(1):32-41. doi:10.1016/j.jagp.2018.09.004

Patel D, Steinberg J, Patel P. Insomnia in the elderly: a review. J Clin Sleep Med. 2018;14(6):1017-1024. doi:10.5664/jcsm.7172

Roth T, Coulouvrat C, Hajak G, et al. Prevalence and perceived health associated with insomnia based on DSM-IV-TR; International Statistical Classification of Diseases and Related Health Problems, Tenth Revision; and Research Diagnostic Criteria/International Classification of Sleep Disorders, Second Edition criteria: results from the America Insomnia Survey. Biol Psychiatry. 2011;69(6):592-600. doi:10.1016/j.biopsych.2010.10.023

Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(2):307-349. doi:10.5664/jcsm.6470

Shechter A, Kim EW, St-Onge M-P, Westwood AJ. Blocking nocturnal blue light for insomnia: a randomized controlled trial. J Psychiatr Res. 2018;96:196-202. doi:10.1016/j.jpsychires.2017.10.015

Smith RA, Lack LC, Lovato N, Wright H. The relationship between a night’s sleep and subsequent daytime functioning in older poor and good sleepers. J Sleep Res. 2015;24(1):40-46. doi:10.1111/jsr.12237

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