Sleeping Your Way to Health and Happiness

Melissa Sandler, MSW, ACSWPromising Practices: Mental Health and Aging

January 14, 2015

A Few Sleep MythsPoor sleep is an inevitable part of aging.

The older we get, the less sleep we need.

Staying in bed and counting sheep are the best way to solve insomnia.

My PCP knows the best treatments.

What is Insomnia?(1) difficulty falling asleep, staying asleep or

nonrestorative sleep; (2) this difficulty is present despite adequate

opportunity and circumstance to sleep; (3) this impairment in sleep is associated

with daytime impairment or distress; and (4) this sleep difficulty occurs at least 3 times

per week and has been a problem for at least 1 month.

Insomnia: Definition, Prevalence, Etiology, and Consequences. Thomas Roth, PhD J Clin Sleep Med. Aug 15, 2007; 3(5 Suppl): S7–S10.

How Much is Enough?Countless research studies have shown that

7-8 hours of sleep is ideal for most people. (sleep duration)The average time spent in bed is 6 hours and

55 minutes - with 6 hours and 40 minutes spent actually sleeping.

The percentage of time in bed spent actually sleeping(sleep efficiency) is also important.86% and up is considered normal. 85% and below is considered poor sleep

efficiency.>90% may signal that the individual needs

more sleep.

As we age, our sleep patterns change

Image from the National Sleep Foundation

How Many of Us are Losing Sleep?Approximately 70 million people in the United States are affected by a sleep problem.

About 40 million Americans suffer from a chronic sleep disorders, and

an additional 20-30 million are affected by intermittent sleep-related problems.

One in 10 U.S. adults routinely has trouble getting to sleep or staying asleep, 3 in 10 experience occasional sleeplessness, federal statistics show.

However, an overwhelming majority of sleep disorders remain undiagnosed and untreated (National Commission on Sleep Disorders Research, 1992).

Under-diagnosis and under-treatment in older adults is further exacerbated by aging stereotypes held by healthcare providers – and internalized by seniors themselves.

Sleep Disturbances Increase With AgeLate-life insomnia is less studied and less

understood.Nearly 60% of community-dwelling seniors

report sleep problems.For those 65 and older, the one year

incidence rate for the development of insomnia has been reported to be between 3.1% and 7.3%

Sleep disturbances are often seen as part of “normal aging” and is therefore ignored during clinical evaluations.

Unlike insomnia in younger adults, late-life insomnia is commonly associated with comorbid mental or physical health conditions. It also tends to be more severe and chronic.

Sleep Does Change with Age• Physiological Changes

• Decrease in REM sleep• Decrease in delta “deep sleep” or slow wave sleep• Increase in less restorative sleep• Changes in circadian rhythms lead to earlier shift in

sleep/wake preferences

• Behavioral and Environmental Changes• Irregular schedules• Decreased exposure to light• Decreased exercise and social interactions• Increased daytime napping

So What’s the Big Deal?• Sleep disturbance is associated with

• Declines in physical health• Declines in mental health• Increases in all-cause mortality in older

adults• Sleep disturbances connection to depressive

disorders is especially troubling, as depression carries additional risks for morbidity and mortality.

Insomnia Causes Both Individual and Societal

Burdens

Insidious Effects of Sleep LossPatients with chronic insomnia have daytime

impairment of cognition, mood, or performance that impacts on the patient and potentially on family, friends, coworkers and caretakers.

Chronic insomnia patients are more likely to use health care resources, visit physicians, be absent or late for work, make errors or have accidents at work, and have more serious road accidents.

Increased risk for depression, suicide, substance use relapse, and possible immune dysfunction have been reported.

Effects Can Occur Without the Sleep-Deprived Person’s Awareness• Fatigue, daytime sleepiness or malaise• Attention and memory impairments,

cognitive speed and accuracy, reaction time, and social/vocational dysfunction

• Mood disturbance and/or irritability• Reduced motivation, energy and/or

initiative• Tension headaches, gastrointestinal

symptoms, and other aches and pains

Our Bodies Turn on OurselvesLosing sleep for even part of one night can

trigger the key cellular pathway that produces tissue-damaging inflammation, prompting one’s immune system to turn against healthy tissue and organs.

This research out of UCLA helps to explain the association between sleep disturbance and risk of a wide spectrum of medical conditions includingcardiovascular diseaseArthritis diabetes certain cancersobesity

Chronic Sleep LossChronic sleep loss can lead to more physical problems than just chronic exhaustion.

• Cardiovascular Health• Diabetes• Increased Fall Risk• Weight Gain• Susceptibility to the Common Cold

Medical Disorders Can Disrupt SleepArthritisOsteoporosisCancerParkinson's DiseaseIncontinenceAlzheimer's Disease & Other DementiasGastroesophageal Reflux (GER) and/or

HeartburnChronic Obstructive Pulmonary DiseaseNocturnal Cardiac IschemiaCongestive Heart FailurePeripheral Vascular Disease

Cardiovascular HealthResults indicate that participants with insomnia

and who sleep less than five hours had a risk for hypertension that was 500% higher than participants without insomnia who slept more than six hours.

People with insomnia and a moderately short sleep duration of five to six hours had a risk for hypertension that was 350% higher than normal sleepers.

In contrast, neither insomnia with a normal sleep duration of more than six hours nor a short sleep duration without a sleep complaint was associated with a significant risk for hypertension.

Arch. Internal Medicine vol 168 (no. 20) 11/10/08

Diabetes and SleepPeople who sleep less than 6 hours a night

appear to have a higher risk of developing impaired fasting glucose — a condition that can precede type 2 diabetes.

People who sleep too much or not enough are at greater risk of developing type 2 diabetes or impaired glucose tolerance. The risk is 2½ times higher for people who sleep less than 7 hours or more than 8 hours a night.

Increased Fall Risk in Older Adults• After adjustment for age and race, there was a U-

shaped pattern of association observed between total sleep and risk of falls.

• Increased risk of falls for those with <5 hours and those with >8 hours of sleep.

• Increases in sleep fragmentation (including difficulty falling asleep or early waking) also associated with increased fall risk.

• Conflicting research on effects of benzodiazepines and Z-drugs (e.g. Zolpidem)

Archives of Internal Medicine, vol. 168, 9/8/08

Weight GainIn a study published in the May 2009 issue of Psychoneuroendocrinology, UCLA researchers, looked at two hormones that are primarily responsible for regulating the body's energy balance, telling the body when it is hungry and when it is full.

The study found that chronic insomnia disrupts one of these two hormones.

This finding helps to explain the biochemical basis of the dozens of recent medical studies linking sleep and obesity.

The Common Cold• In January 2009, researchers found that

people with fewer than 7 hours of sleep were 294% more likely to develop a cold than those with or more hours.

• Even a minimal habitual sleep disturbance is associated with almost a 4-fold increase in catching the common cold.

• 2%-8% sleep loss• 10 -38 minutes for an 8-hour sleeper

Medications Affect Sleep• Beta Blockers• Calcium Channel

Blockers• CNS Stimulants• Corticosteroids• Antidepressants

• Bronchodialators• Decongestants• Stimulating

Antihistamines• Thyroid Hormones

Psychological Impact

Comorbidities with Late-Life InsomniaComorbid conditions, particularly

depression, anxiety, and substance use, are common.

Approximately 40% of adults with insomnia have a comorbid diagnosable psychiatric disorder, most notably depression.There is a bidirectional increased risk between

insomnia and depression. Other medical conditions, unhealthy

lifestyles, smoking, alcoholism, and caffeine dependence are also risks for insomnia.

Insomnia Can Predict Relapse For seniors with a history of a past

depression, insomnia is a very strong predictor of having a new bout of depression.

Seniors suffering from insomnia but with no prior history of depression are not at higher risk.

This connections was independent of other depressive symptoms, socio-demographics, and other characteristics.

Am J Psychiatry 2008; 165:1543-1550

Effect on Depression Treatment• Taking longer than 30 minutes to fall

asleep is associated with significantly increased risk of non-remission following pharmacologic and/or psychotherapeutic treatment for depression.

• Results were independent of • baseline clinical characteristics (depression

or anxiety symptoms),• length of follow-up, • treatment modality (psychotherapy alone

versus pharmacotherapy with or without psychotherapy)

• and demographic characteristics (age, sex) which are known to influence treatment outcomes.

Anxiety• Anxiety increases with poor sleep, and

anxiety over sleep worsens insomnia• Older adults with insomnia have

elevated rates of anxiety symptoms that do not meet criteria for official diagnosis.

• However, these symptoms are associated with daytime impairments in social functioning, as well as increased sleep fragmentation at night.

Suicide Risk"People with two or more sleep symptoms

were 2.6 times more likely to report a suicide attempt than those without any insomnia complaints,“

The results were adjusted for several factor known to influence suicide:Substance abuse, depression, anxiety and

other mood disordersChronic medical conditions such as stroke,

heart disease, COPD, and cancerResearchers accounted for sociodemographic

factors such as age, gender, marital and financial status.

ParanoiaA 2008 study - the first to examine insomnia

and persecutory thoughts - found that in the general population individuals with insomnia were five times more likely to have high levels of paranoid thinking than people who were sleeping well.

In an extension of the research, over half the individuals attending psychiatric services for severe paranoia were found to have clinical insomnia.

Psychological Treatment of Late-Life Insomnia• Common assumption is that health problems with

physiological mechanisms, such as late-life insomnia, require medical and/or pharmacological interventions.

• This view overlooks the importance of the mind-body connection and increasing amount of research that demonstrates the ability of non-medical interventions to affect the physiological mechanisms underlying health problems.

Sleep Journals• Keep a bedside notebook to record changes in

sleep• Each night record night time routine and any

related changes• In the morning, note (to best estimates)

• How long it took to fall asleep• Number, time, and duration of any awakenings• Time awake and time to leave bed• How rested you feel

• The Consensus Sleep Diary, Sleep, Feb 1, 2012; 35(2):287-302 can be found online: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3250369/

Cognitive Behavioral Therapy for Insomnia (CBTi)• Numerous studies have confirmed the effectiveness

of CBTi to treat older adults with insomnia.• The success may be part to the multiple techniques

that target one or all of the three factors thought to contribute to late life insomnia.

• Physiological arousal during the desired sleep period• Disruption of homeostatic sleep drive• Disregulation of the circadian sleep cycle

• However, many medical doctors are not aware of CBTi and its efficacy, and it can be hard to find certified practitioners.

Brief Behavioral Treatment for Late-Life Insomnia (BBTI)• Researchers at the University of Pittsburgh Sleep

Medicine Institute have been developing an easily taught intervention that can be implemented by nurses in primary medical settings.

• BBTI includes many of the same interventions as CBTi, but is conducted in only two in-person sessions and two phone sessions.

• Unlike CBTi, it has been shown effective in patients with the medical & psychiatric comorbidities common in patients with late-life insomnia.

(see http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3101289/ and http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3622949/)

Main Interventions of BBTIBBTI educates about general behaviors that promote or interfere with sleep, as well as homeostatic and circadian mechanisms of human sleep regulation. This education provides the rational for the main interventions:1. Reduce time in bed 2. Get up at the same time each day,

regardless of sleep duration3. Do not go to bed unless sleepy4. Do not stay in bed awake

Common Sleep Hygiene Components

• Avoid caffeine after noon• Don’t go to sleep too hungry or too

full• Avoid within 2 hours of bedtime:

• Exercise• Nicotine• Alcohol• Heavy Meals

Common Relaxation Practices• Progressive muscle relaxation• Passive muscle relaxation• Diaphragmatic/deep breathing• Autogenic phrases• Mental imagery• Meditation

Stimulus Control• Go to bed only when tired• Do not use the bed/bedroom for

anything but sleep and intimacy• Keep the bedroom dark enough to

facilitate sleep• Keep the temperature in your bedroom

comfortable• Keep the bedroom quiet, or use white

noise• Do not read or watch television in bed

Stimulus Control• Avoid daytime napping• Wake at the same time every

morning• If sleep is not obtained in 15-20

minutes, leave the bedroom.• Only return to bed upon tiredness,

repeating as necessary.

Sleep Restrictions• Retire at the same time every night.• Wake at the same time every morning.• Avoid daytime napping• Using sleep diary, calculate the

individual’s sleep efficacy and adjust time spent in bed to be within 85% and 90%.

Other Do’s and Don’tsEngage in stimulating activity just before

bed, such as playing a competitive game, watching an exciting program on television or movie, or having an important discussion with a loved one.

Don’t read or watch television in bed. Do not use electronic devices during the hour

or two before sleep.Try chamomile, mint or sleepytime teas.Combine tryptophan and complex

carbohydrates for a healthy evening snack.

More Do’s and Don’tsDon’t take another person's sleeping pills. Consult a doctor before using over-the-

counter sleeping pills. Tolerance can develop rapidly with these medications. Diphenhydramine (an ingredient commonly found in over-the-counter sleep meds) can have serious side effects for elderly patients.

Resist commanding yourself to go to sleep. This only makes your mind and body more alert and anxious.

And a few more…• Get regular exercise each day, preferably in

the morning. There is good evidence that regular exercise improves restful sleep. This includes stretching and aerobic exercise.

• Get regular exposure to outdoor or bright lights, especially in the late afternoon.

• Take medications as directed. It is helpful to take prescribed sleeping pills 1 hour before bedtime, so they are causing drowsiness when you lie down, or 10 hours before getting up, to avoid daytime drowsiness.