from: The New York Times March 17, 1999
Treating Insomnia in Older Adults
By ERICA GOODE
If "the sleep of a labouring man is sweet," as the Old Testament insists,
the slumber of a retired man, or woman, should be even sweeter. But for 25
percent to 35 percent of older Americans, sleep is not something that comes
all that easily.
Anthony Telles Sr., for instance, 63 years old and retired from a glass
factory, happily loses consciousness at 10:30 P.M. but is wide awake again
two hours later, and again an hour after that. Margaret Baker, 70, a
retired librarian, has conquered the oeuvres of Tony Hillerman, Dorothy L.
Sayers and P. D. James -- all during the midnight hours when she cannot
fall asleep. "I am a devoted mystery fan," she said.
A study may change the way old people view an inability to sleep.
Both Telles and Mrs. Baker eventually sought help at a research clinic at
the University of Pittsburgh. But insomnia in older adults, sleep experts
say, is often neglected by family doctors, who may view fitful nights, like
wrinkles and farsightedness, as a normal accompaniment of aging. And
patients themselves rarely deem their troubled sleep important enough to
complain to a doctor.
A new study may change all that. In today's issue of The Journal of the
American Medical Association, Dr. Charles Morin, a professor of psychology
at Laval University in Quebec, and his colleagues report that insomnia in
older adults can be effectively treated with cognitive-behavior therapy,
with sleeping medication, or a combination of the two.
And the behavioral therapy, which was specially tailored to educate
patients about "sleep hygiene," to correct faulty beliefs and expectations
about sleep and to instill better sleep habits, proved longer lasting than
drug treatment, the researchers found.
"Chronic insomnia is a treatable condition even in late life," Dr. Morin
and his colleagues concluded.
In their study, the researchers compared the treatments in 78 men and
women, aged 55 and older, all of whom had suffered from insomnia. The
subjects either had difficulty falling asleep or staying asleep, at least
three nights a week for at least six months, and had complained of daytime
fatigue, impaired functioning or mood disturbances that they attributed to
loss of sleep.
People with major depression, medical conditions producing insomnia, or
sleep apnea, and those who were unable to stop taking previously prescribed
sleeping pills were excluded from the study.
Subjects who received weekly 90-minute sessions of cognitive-behavioral
therapy, a trial of the sleeping pill Restoril, or a combination of the
therapy and Restoril all showed significant improvement in their sleep
patterns at the end of the eight-week treatment period. These patterns were
measured by sleep diaries, brain-wave recordings during sleep and the
ratings of the subjects' bed-partners. These results were compared with
control subjects given dummy pills.
Twenty-four months later, subjects in the group receiving cognitive
behavior therapy alone were still sleeping much better, but the improvement
of subjects in the group receiving medication alone was lost after the
drugs were discontinued. Surprisingly, subjects who received both
medication and therapy did not hold onto their gains as effectively as
those who received therapy alone, perhaps because they attributed their
improvement to the sleeping pills and did not invest as much in the
behavioral learning program, the researchers speculated.
Other sleep researchers said the study was significant because it would
alert doctors to the importance and the practicality of treating insomnia
in older patients, and because it offered a treatment option other than
drugs.
"If you have a behavioral intervention that works and that is durable,
that's got to be important," said Dr. Daniel J. Buysse, an associate
professor of psychiatry at the Sleep and Chronobiology Center of the
University of Pittsburgh School of Medicine, who was co-author of an
accompanying editorial in the journal.
The direct costs of insomnia, according to a 1995 estimate, approach $14
billion a year, though some experts suspect this figure is high.
Fewer than 15 percent of people who suffer from chronic insomnia receive
treatment, according to surveys. But studies indicate that untreated
insomnia may put people at higher risk for major depression and may cause
elderly people to be placed in nursing homes sooner than if the condition
had been treated.
Insomnia increases with age, often linked to medical or psychiatric
problems or changes in life style. At any age, women, though they sleep
more deeply and longer than men, are also more likely to have insomnia,
particularly during menopause and pregnancy.
The appropriate role of sedative-hypnotic drugs, a class that includes most
sleeping pills, in treating chronic insomnia is controversial, particularly
in the elderly. Unlike antidepressants, sleep medications treat symptoms
but do not address the underlying causes of insomnia.
"The fire may be out, but the embers are still there," said Dr. David
Kupfer, chairman of psychiatry at the University of Pittsburgh, a co-author
of the journal editorial.
With long-term use, patients can develop tolerance for sedative-hypnotic
drugs, and the medications can produce side effects, including a morning
"hangover," disturbances in short-term memory and concentration, and
rebound insomnia when the medication is discontinued. In older people, who
metabolize drugs more slowly, side effects may be more pronounced. And
sedative-hypnotics have been linked in some studies to an increased risk in
the elderly to falls, hip fractures and automobile accidents.
Some researchers contend that the risks of drug treatment for insomnia have
been somewhat exaggerated. The vast majority of patients, they say, do not
abuse sleeping pills, and no good studies have been done of long-term
treatment.
Dr. James K. Walsh, executive director of the Sleep Medicine and Research
Center at St. Luke's Hospital in St. Louis, cited studies showing that of
people who reported taking sleeping pills within the past year, 60 percent
say they took them 30 times or fewer, and only 11 percent said they took
them every night or nearly every night.
"Behavioral treatments work, but there are only a few dozen experts in
treating insomnia with behavioral techniques," Dr. Walsh said. "To just say
you can't take sleeping pills or can only take them for a few weeks is not
practical."
Dr. Walsh says he carries out trials of new sleep medications for drug
companies and is a paid lecturer for some of the companies.
Many doctors, and many patients, however, remain wary of sleeping pills,
and welcome treatment strategies that do not involve medication. In Dr.
Morin's study, for example, 80 percent of the subjects, when asked which
method of treatment they would want if they had a choice, said they would
prefer to receive behavioral treatment.
One reason cognitive-behavior therapy may be longer-lasting in helping
patients with chronic insomnia, sleep experts say, is that it trains people
to serve as their own therapists and to take responsibility for their
sleeping habits.
The subjects in Dr. Morin's study, for example, were instructed in basic
principles of "sleep hygiene," including the effects of caffeine, alcohol
and diet, and taught ways to increase their chances of sleeping, like going
to bed only when they were sleepy, getting up and going to another room if
they could not fall asleep within 15 or 20 minutes, and arising at the same
time every morning, regardless of how much they slept the night before.
The therapists also worked to correct "faulty" beliefs, like the notion
that sleep should be as enveloping in later life as it is in young
adulthood. The percentage of time spent each night in the deepest stage of
sleep begins to decrease after the age of 40, and by 60 or 70, people spend
little time in deep sleep. "Even with the best sleeping pill in the world,
you cannot make a 65-year-old person sleep like a 25-year-old person," Dr.
Morin said.
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Copyright 1999 The New York Times Company