Presented by: Donn Posner, PhD
Adjunct Clinical Associate Professor, Psychiatry and Behavioral Sciences
January 28, 2016
Two of the widespread myths about insomnia are that babies get the best sleep—and aging people get the worst. But Donn Posner, PhD, says sleep doesn’t have to be lousy in older people.
“Insomnia is absolutely, positively not a normal part of aging,” said Dr. Posner, who spoke at a presentation sponsored by the Stanford Health Library. “If you’ve heard that sleep changes as we get older, that’s true. But insomnia doesn’t have to be there.”
Not getting enough sleep isn’t necessarily insomnia, Dr. Posner said. Many people in society today may “burn the candle at both ends” with work, projects and other things that get them to bed late at night and up early the next day. They’re not getting enough time to get enough sleep, which can leave them tired.
True insomnia is different, Dr. Posner said. It’s defined as difficulty getting to sleep at night, or waking up in the middle of the night without being able to fall back asleep. Or it can be waking up in the morning too early. When any of these problems last longer than 30 minutes, that’s a sign of insomnia.
Dr. Posner said that the fatigue that comes from true insomnia is not the same thing as daytime sleepiness. “Most people with insomnia don’t get very sleepy,” he said. “They feel tired but wired.”
The daytime consequences can be serious. People lack energy and feel so tired they have trouble concentrating. They may suffer poor job performance and be prone to errors while driving. They become irritable or develop mood disturbances.
About one-third of U.S. adults, or 30 percent experience insomnia at any given time. For most, it doesn’t last. Short-term or “acute” insomnia means having trouble sleeping for more than three nights per week for three months or less. That’s usually linked to some kind of temporary stress from a job, financial pressures, or illness. Once the stress eases, the sleep problems resolve.
But for 10 percent to 15 percent, the sleep problems don’t go away, leading to chronic insomnia. That’s defined as having trouble sleeping more than three nights a week for more than three months. Many people wait much longer before they seek help from a doctor. “Most of the patients I see have their insomnia five years, 10 years, 20 years” or more before they seek help, Dr. Posner said. “Most of us suffer in silence and try to fix it on our own.”
It’s common for people to take over-the-counter sleeping pills or to drink alcohol in an effort to improve sleep. Surveys find about 60 percent to 70 percent of people with insomnia never discuss it with their doctors. Some bring it up when they see a doctor for something else; only about 6 percent see a doctor specifically to get help for insomnia.
Eventually chronic insomnia impairs daily function and quality of life. It can increase absenteeism at work, or cause “presenteeism”—showing up for work but not functioning well, Dr. Posner said. Chronic insomnia is also linked to a higher risk for mental health problems or medical conditions like diabetes, heart disease and weight gain.
“We have this incredibly prevalent destructive disorder and none of us are talking about it,” Dr. Posner said. That has led to misunderstanding, and what he calls the myths of insomnia.
Myth No. 1: Insomnia is just a symptom of something else.
When other medical problems are present in a patient, doctors have often assumed it’s those problems that cause insomnia—not the reverse. This is especially true for people with psychiatric conditions and anxiety, Dr. Posner said. Many psychiatrists have assumed insomnia was a result of depression or anxiety. But research has now shown that insomnia sometimes comes first, before depression.
“It’s a two-way street,” Dr. Posner said. “This is what we now know: If I have bad sleep, that is going to make me more predisposed to things like depression and anxiety,” Dr. Posner said. Studies have found that people with chronic insomnia are two to four times more likely to develop depression. Treating the insomnia, while also treating the depression, can double the remission rate for depression, he said.
Myth No. 2: Babies sleep great, and it’s all downhill after that.
While babies sleep a lot, their slumber is fragmented. While sleep patterns do change as they grow up and then grow old, that’s not necessarily a bad thing.
“Deep sleep tends gets less as we get older,” Dr. Posner said. “But sleep doesn’t have to be lousy.” Individuals vary in how much sleep they need and what time of day they sleep best. Elderly people are more likely to become early birds, going to bed earlier at night and rising earlier. “Some people are going to get seven hours better from 10 to 5, but others will get seven hours better from 12 to 7,” he said.
Dr. Posner acknowledged that the elderly have a higher risk for health problems that can trigger insomnia. Depression, reflux, thyroid dysfunction and diabetes are risk factors for insomnia. Prostate enlargement that can comes with age increases the urge to urinate and causes men to wake up at night. So can sleep apnea, alcohol, and some prescription medicines.
“There are a lot of things that happen as we age that assaults sleep,” Dr. Posner said. “There are ways to fix some of that. None of this says our sleep should be lousy.”
Myth No. 3: Insomnia cannot be treated without a pill.
The common belief that sleeping pills are the only treatment for insomnia may explain why some people don’t go to a doctor, because they may not want to take habit-forming drugs, Dr. Posner said.
There is an effective alternative to sleeping pills for treating insomnia: cognitive behavioral therapy for insomnia, known as CBT-I, Dr. Posner said. CBT-I is one of the two therapies recommended for insomnia by the National Institutes of Health. (The other recommended therapy is prescription medicine known as benzodiazepine receptor agonists such as Ambien or Lunesta.) Studies show both CBT-I and these medicines help insomnia, but CBT-I brings improvement that lasts longer. “Cognitive behavioral therapy is absolutely equal in effectiveness to medication in the short run,” Dr. Posner said. “CBT has the edge when it comes to maintaining the gains long-term.”
People who have heard of CBT-I often confuse it with “sleep hygiene,” the set of lifestyle changes people can make to improve sleep—like keeping a bedroom cool and quiet, wearing eyeshades and avoiding coffee and alcohol late in the day. CBT-I includes sleep hygiene, but it addresses a lot more factors that can go awry: circadian rhythm, conditioned arousal, restless racing thoughts, sleep drive, and general worries that disrupt sleep. CBT-I targets whatever is aggravating any of these factors and then tailors therapy to fit.
“Medications do help, but you don’t have to go down that road,” Dr. Posner said. CBT-I is as effective as the sedative hypnotic drugs (Ambien or Lunesta) for the first 4-8 weeks, and after that CBT-I is more effective in the long run. “There is overwhelming preponderance of evidence that cognitive behavior therapy works for insomnia,” he said.
Myth No. 4: Insomnia can’t be treated without treating another “primary” problem.
Treatment for insomnia sometimes improves symptoms of other conditions like depression. But even when the insomnia treatment doesn’t help other problems (like chronic pain), studies show it improves quality of life and gives people the “wherewithal” to cope with these other problems, Dr. Posner said.
The important thing to know is that insomnia can be effectively treated even when other problems like cancer, chronic pain or PTSD are present. Studies have shown that 70-80 percent of people benefit from CBT-I with a reduction of at least 50-60 percent in their symptoms (like waking up at night), Dr. Posner said. About 40 percent of them become normal sleepers.
Dr. Posner is conducting a study at the Palo Alto Veterans Administration Hospital to analyze which components of CBT-I have the biggest impact on insomnia. All participants get at least one component of treatment, and no one gets a placebo. To be eligible, people must be age 60 or older and have insomnia. For more information, contact Stephanie Thompson or Ryan Lee at (650) 849-0584 or Stephanie.firstname.lastname@example.org or email@example.com.
About the speaker:
Donn Posner received his PhD from S.U.N.Y. at Stony Brook. Over the past 25 years he has seen a wide variety of patients with sleep disorders including primary insomnia, comorbid insomnia, circadian rhythm disorders, sleep apnea, and parasomnias. He is a staff psychologist at the Palo Alto VA Hospital working on a grant to clarify the relative efficacy of each of the components of cognitive behavioral therapy for insomnia (CBT-I). He is also adjunct clinical associate professor at Stanford University School of Medicine and before that served as clinical associate professor in psychiatry and human behavior at the Warren Alpert School of Medicine at Brown University, where he also worked treating sleep and anxiety disorders at Rhode Island Hospital. He is one of the authors of Cognitive Behavioral Treatment of Insomnia: A Session-by-Session Guide, a book written for clinical trainees.
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