Insomnia often goes hand in hand with depression in older adults


As people get older, the symptoms of insomnia often creep up. They may toss and turn for hours, struggling to fall or stay asleep. Frequent nighttime and early morning awakenings are very common in older adults. This in turn contributes to higher rates of depression, social isolation and physical health problems. The combination of insomnia and depression can be quite disruptive to an older adult’s quality of life.

“Poor sleep can lead to poor daytime functioning, including memory difficulties, irritability and daytime sleepiness,” said Douglas Kirsch, MD, medical director of sleep medicine at Atrium Health in Charlotte, North Carolina, and a past president of the American Academy of Sleep Medicine.

Over time, sleep deprivation has been linked to an increased risk of not only depression, but also anxiety, hypertension, type 2 diabetes, heart attacks, falls and accidents, substance abuse disorders, and premature death. It may also be a risk factor for Alzheimer’s disease.

“Chronic insomnia takes a toll on overall health,” said Josepha A. Cheong, MD, professor of psychiatry at the University of Florida College of Medicine and a staff physician and psychiatrist at the Malcom Randall Veterans Affairs Medical Center in Gainesville.

Research shows that sleep plays a role in storing memories and has a restorative function.

“Lack of sleep impairs reasoning, problem solving and attention to detail, among other things,” Cheong said, adding that during sleep, the brain’s cerebrospinal fluid works to “flush” metabolic waste accumulated during the day.

Behavior therapy: A proven first-line intervention

The good news is that treating insomnia can help alleviate depression and related problems.

“Insomnia is a risk factor for depression,” said Natalia S. David, PsyD, DBSM, a health psychologist specializing in behavioral sleep medicine at the University of Texas Southwestern Medical Center’s O’Donnell Brain Institute in Dallas. “Therefore, reducing insomnia in older adults should be a focus of clinical attention.”

Cognitive behavioral therapy for insomnia (CBT-I) is the first-line and gold standard treatment for insomnia, as recommended by the American Academy of Sleep Medicine.

“Insomnia is very difficult to treat with medication, so behavioral and cognitive interventions with durable results are preferred over medication alone,” said David.

Sleep hypnotic medication should only be used to treat acute insomnia – lasting less than 3 months. Relying on this medication long-term can cause more sleep problems, potentially resulting in addiction and cognitive impairment. David said research suggests those who used sleeping pills were twice as likely to develop dementia.

To break the vicious cycle of insomnia

Kathleen Primm, 68, who lives in Keller, Texas just outside of Fort Worth, took David’s 7-week CBT-I course earlier this year, which was recommended by Primm’s sleep medicine doctor.

Primm said she suffers from anxiety and her doctor noted that she also has mood swings. Her sleep problems intensified during the COVID-19 pandemic. Although she did not sleep during the day, she could only sleep 2-3 hours at night.

“It was just a vicious cycle,” the substitute elementary school teacher said of her insomnia. “But I took the course and found it very beneficial.”

After implementing behavioral changes, Primm gradually weaned himself off sleep medication and is now able to get up to 8 hours of rest each night.

She also learned not to stay in bed longer than 20 minutes if she couldn’t fall asleep. Instead, she went into her living room, cleared her mind and did breathing exercises, breathing in and out until she felt relaxed enough to go back to bed and fall asleep. She also listened to a cell phone app playing soothing rain.

A recent randomized clinical trial from UCLA’s David Geffen School of Medicine found that CBT-I prevented depression in community-dwelling adults age 60 and older with insomnia. In 291 older adults without depression but with insomnia disorder, 2 months of CBT-I “resulted in a reduced likelihood of incident and recurrent depression over 36 months of follow-up compared with an active comparator control, sleep education therapy.”

CBT-I teaches people practical methods to sleep better. One commonly used technique is called sleep compression, Kirsch said. By choosing a limited and personal window of time to sleep – often less than the patient has previously allocated – the clinician guides the individual’s sleep to become more efficient. Gradually, that window expands to a more typical amount of sleep time, he said.

The process often follows a 6- to 8-week course for most patients, but it can take longer in some difficult cases. Sometimes medication and CBT-I are used together for patients who need both types of therapy to sleep well. Recently, there has been interest in evaluating the use of telemedicine to conduct CBT-I, especially given the limited number of trained therapists, Kirsch said.

A free mobile phone app, CBT-i Coach, provides various tools to establish improved sleep habits, as well as to identify potential factors that can cause insomnia.

CBT-I does not involve the use of medication and is considered effective, said Cheong, who is board certified in geriatric psychiatry and serves as a psychiatry director for the American Board of Psychiatry and Neurology. She adds that about 70%-80% of patients with primary insomnia experience improvement with CBT-I, falling asleep more quickly after going to bed and waking less during the night.

“If practiced consistently, CBT-I produces sustained results over time,” she said.

Identifying signs of these overlapping disorders

Geriatricians often see patients with sleep disorders, which affect women more commonly than men.

“Sleep disorders are complex, especially in older adults, because many factors can affect sleep, such as medications, sleep apnea, and even changes that accompany normal aging,” said Yoon Hie Kim, MD, MPH, a geriatric medicine specialist at Duke Health in Durham. , North Carolina. “Numerous medical conditions can also disrupt sleep, including neurocognitive disorders, pain, nocturia, and restless legs syndrome.”

Despite the prevalence of sleep disorders and depression in older adults, they are likely underdiagnosed in this age group. Sleep disorders affect as many as half of the elderly population, whereas depression varies across settings and occurs more in nursing homes, Kim said.

“These conditions may not be very obvious to the patient, but they can be the cause of many problems that affect daily functioning,” she said.

Depression in older adults can be difficult to recognize because they may have different symptoms than younger people. For some older adults with depression, the main symptom isn’t sadness or low mood — it’s a feeling of numbness or lack of interest in activities, hobbies or socializing, said Michelle Drerup, PsyD, director of behavioral sleep medicine at the Cleveland Clinic in Ohio.

Other common symptoms include unexplained or worsening aches and pains, weight loss or loss of appetite, feelings of hopelessness or helplessness, lack of motivation, sleep problems and loss of self-esteem (worries about being a burden, a sense of worthlessness or self-worth). disgust), fixation on death or thoughts of suicide and neglect of personal care (skipping meals, forgetting medications or neglecting personal hygiene), Drerup said.

The symptoms of sleep disorders and major depressive disorder may overlap and may include fatigue, mood swings, daytime sleepiness and impaired concentration.

“It is critical for sleep and mood to be assessed when someone is undergoing an evaluation for cognitive impairment, as improvement in sleep and mood symptoms can result in improvement in functioning,” Kim said. “A wellness visit that is focused on preventive care can be a good place to systematically screen for sleep or mood disorders.”

Susan Kreimer is a New York-based freelance health journalist.

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