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Sleep Your Way to Healthier Aging

New therapies can improve sleep in older adults

Key points

  • Many older adults have sleep problems, which can compromise health and accelerate aging.
  • Effective treatments for sleep problems exist, including Cognitive Behavioral Treatment for Insomnia (CBT-I).
  • CBT-I uses techniques like sleep restriction and stimulus control to get your sleep on track.

Co-authored by Laura Fenton and Darby Saxbe
"Sleep is for the weak.” “I’ll sleep when I’m dead.” The rapidly growing field of sleep science has begun to dispel the antiquated belief behind these statements. Findings from research studies suggest that sufficient sleep quality and quantity confer benefits including increased creativity, healthier diet choices, improved emotion regulation, and increased immune function (Besedovsky et al., 2012; Cai et al., 2009; Greer et al., 2013; Palmer & Alfano, 2017). In fact, you would be hard-pressed to find a medical condition or mental process that sleep does not benefit. While many of us appreciate the scientific support for hitting the snooze button, this research can induce anxiety in those who struggle to get the sleep they need – a common problem among adults over the age of 65.

Photo by Alvarez / Creative Commons license
Source: Photo by Alvarez / Creative Commons license

Up to 50 percent of older adults complain about difficulty initiating or maintaining sleep (Foley et al., 1995), and the prevalence of insomnia within this age group may be as high as 40 percent (Foley et al., 2004). These difficulties can result from a weakening in the strength of one’s circadian rhythm, often thought of as an internal clock that regulates sleep-related biological processes such as melatonin and body temperature to promote sleep during normal sleeping hours (e.g., at night). Insomnia can also be worsened by age-related medical conditions (such as arthritis and depression) and/or lifestyle changes (like retiring and getting less exercise) (Li et al., 2018). Whatever the causes, the consequences of diminished sleep in older adults can be profound. In the short term, inadequate sleep can result in difficulties with cognitive processes such as memory and attention (Crowley, 2011). Perhaps even more alarming, however, is that older adults with impaired sleep quality show increased mortality rates, even when controlling for age, gender, and other medical conditions (Dew, et al., 2003).

Assuming that everyone is now sufficiently convinced that sleep is not for the weak, the question becomes, what do we do to improve it? Fortunately, psychologists have developed an empirically validated treatment for insomnia which has been shown to be effective for older adults.

Cognitive Behavioral Therapy for Insomnia (CBT-I) is a talk therapy treatment that generally consists of six to eight weekly 50 minute sessions. Unlike pharmacological treatments such as benzodiazepines, CBT-I does not offer a “quick fix.” However, the improvements in sleep obtained from CBT-I have been shown to last longer than those from hypnotic medications (Morin et al., 2009). Additionally, unlike pharmacological treatments, CBT-I doesn’t raise concerns about adverse interactions with other medications or hangover effects that can lead to falls or accidents (Tannenbaum et al., 2015). Furthermore, the treatment has been shown to alleviate symptoms of insomnia even in individuals with other psychological disorders or medical illnesses, which are often present in older adult populations (Rybarczyk et al., 2005). What does CBT-I treatment look like?

As mentioned, CBT-I is not an instant cure but demands about six to eight weeks of active commitment and consistency on the part of the client. During the initial session, your therapist will emphasize this point, and provide an overview of treatment in addition to education about sleep and circadian rhythms. For older adults, this will include information about normal changes in sleep that occur during aging (e.g., experiencing lighter and more fragmented sleep). Because all individuals are unique, you and your therapist will also need to get a clear picture of the factors contributing to your sleep disturbances. To facilitate this, you may be asked to complete a sleep diary leading up to your first session. This is a core component of the treatment and allows you and your therapist to understand how your sleep varies from day to day, and to track improvements that occur throughout treatment.

During treatment, your therapist may work with you to identify unhelpful mental processes that contribute to sleep disturbance (e.g., worry, unhelpful beliefs about sleep, etc.). For example, many clients have what cognitive-behavioral therapists call negative automatic thoughts (NATs) related to sleep. Although these NATs may not always be easy to detect, they can induce powerful emotions. For example, a thought like, “I can’t sleep as well as I used to” or “I’m going to be so exhausted tomorrow” while lying in bed may induce anxiety and make it even harder to fall asleep. In CBT-I, you will gain practice not only identifying these NATs but also in questioning whether they are correct. Your therapist might ask you, “What is the evidence for this thought?” Or “Are there any other explanations that might apply?” The therapist will help you recognize that many NATs are not valid. This realization can reshape not just your emotions, but also your behaviors (e.g., sleeping). Even when NATs do contain truth (the thought, “I can’t sleep as well as I used to” in older adults) you and your therapist can work towards accepting the thoughts. In this example, simply accepting the fact that sleep patterns change with age can reduce anxiety and promote better sleep.

Photo by Congerdesign / Creative Commons license
Source: Photo by Congerdesign / Creative Commons license

Two core behavioral components of CBT-I are sleep restriction and stimulus control. The rationale behind sleep restriction is that the bed should be associated only with sleep. Following this logic, at the beginning of treatment, your therapist will reduce the time in bed to reflect only the estimated time you spend sleeping each night. For example, if you estimate that you spend eight hours in bed every night, but sleep for only five, your total time in bed will be limited to five hours (for example, between 12 am and 5 am). While this may sound scary, using this technique will gradually increase your sleep efficiency and help you get more consolidated sleep. As you and your therapist observe increased sleep efficiency via your sleep diary, you can extend your time in bed.

Stimulus control is a second technique that might sound intimidating but can be very effective. It is based on the idea that insomnia results from an association between the bed and an inability to sleep. To break this association, clients are advised to go to bed only when they feel sleepy, to get out of bed if they cannot fall asleep within 15-20 minutes, to use the bedroom only for sleep and sex, and to avoid napping. The recommendation to get out of bed, however, might be adapted when working with older adults. For example, an older adult with concerns about falls might be instructed to stay in bed, but to stop trying to fall asleep. The idea of getting out of bed or stopping to try to sleep can be especially challenging for clients. Therefore, you and your therapist can work together to think of relaxing activities to engage in when this situation arises. Some examples include reading a book, doing a crossword puzzle, or listening to calming music. Importantly, you will want to avoid any energizing activities or technology use. While this may sound daunting, the long-term benefit of a restful night of sleep can be well worth avoiding watching that rerun of your favorite show or checking your phone.

This post seeks to give you a preview of what CBT-I might look like, but your treatment will be personalized to address the factors most relevant to your sleep disturbances. While the treatment is demanding on the part of the client, the benefits can be profound. After all, if you knew that a few weeks of investment could improve your emotional regulation and memory, boost your creativity, and even reduce your likelihood of death, would you turn it down?

Co-author Laura Fenton is a graduate student within the University of Southern California's doctoral Clinical Science program.

Courtesy of the author
Laura Fenton
Source: Courtesy of the author


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