Treatments for sleep problems in elderly peopleBMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7372.1049 (Published 09 November 2002) Cite this as: BMJ 2002;325:1049
Cognitive behavioural therapy is useful, but its benefits seem to be short lived
- Paul Montgomery, researcher ()
Sleep problems are common among older people—12-25% of healthy elderly people report chronic insomnia, with higher rates among those with coexisting medical or psychiatric illness.1 Despite these high rates little has been published that specifically concerns sleep in people over 60 years. This article provides a brief summary of some of the main evidence available on treatments for what is one of the main sleep related problems in otherwise healthy elderly people, based on a recent series of Cochrane systematic reviews.2–4
There are three main sleep problems: too much (excessive sleepiness); too little (sleeplessness); and “things that go bump in the night” (parasomnias). Nearly 90 sleep disorders are, however, listed in the International Classification of Sleep Disorders.5 When considering a patient's sleep it can be helpful to think about the quality (was it refreshing?), duration (in hours and minutes, taking account of onset, offset, and wakes), and timing (did the sleep occur at socially acceptable times?). A careful sleep history is fundamental to the diagnosis, and yet a recent study indicates that this is taken in less than 10% of patients attending general medical services.6 According to one report the median amount of time spent on sleep related issues in medical training in the United Kingdom is five minutes, and that in clinical psychology it is no better. 7 8
Sleep requirements and patterns change throughout life, although whether older people need less sleep or cannot get the sleep they need has not yet been answered. Despite the high prevalence of sleep disorders, fewer than 15% of adults with chronic insomnia receive treatment.9 Those who receive treatment typically receive benzodiazepines, which have known side effects including tolerance, addiction, daytime sedation, associated falls, hip fractures, and car accidents—especially from preparations with a long half life—and impaired sleep due to long term use. As an alternative, non-pharmacological interventions may be considered. These include cognitive behavioural interventions typically used for psychophysiological insomnia, bright light treatments for problems related to timing of sleep, and physiological interventions such as exercise for insomnia. Currently the evidence is that cognitive behavioural therapy seems worthy of consideration, but its benefit seems to be short lived.2 Perhaps top up sessions or booklets providing further information and reminders might help, as booklets have been found to be effective in other populations.10
No good quality randomised controlled trials exist of bright light treatment in elderly people. Limited evidence indicates that it has some use in treating sleep phase problems.4 A small but encouraging study (n=16, mean age 70 years) reported that exposure to bright light in the early evening successfully delayed the time of sleep onset.
As for physical interventions such as exercise, again, evidence is limited,3 and generalisability of the results is also limited because they have tended to focus on good sleepers or young sleepers, leaving little scope for the measurement of improvement (a ceiling effect). The results of the one small trial of exercise in elderly people are, however, encouraging, particularly for women, for whom outcomes were analysed separately. While sleep latency (time between bedtime and sleep onset) improved only slightly for both sexes, duration of sleep, and scores on a sleep quality questionnaire improved significantly for all participants, and duration of sleep for women increased by an hour. Exercise such as brisk walking and moderate weight training may, however, be unsuitable for many older people.
Some research implies that passive body heating may increase slow wave sleep (a deeper form of sleep, which older people often complain they lack). Such heating could achieve similar results with chronically ill, disabled, or unfit people and that this would be of benefit, particularly for people for whom exercise is difficult or impossible. Exercise programmes designed for older people may help prevent and treat sleep disorders (D F Kripke, personal communication, 2001).
In the future it would be helpful to have good, pragmatic, randomised controlled trials of cognitive behavioural therapy versus (and in combination with) pharmacological interventions, taking into account comorbidities, such as dementia, that occur in this population. A similar need exists for well designed studies of bright light and physiological treatments. A systematic review of the efficacy of acupuncture and acupressure is currently under way, and another on the efficacy of melatonin will begin soon.
I thank Jane Dennis for her collaboration in the Cochrane Reviews and Gregory Stores for his support.
Competing interests None declared.