Recognizing and Addressing Psychiatric Implications of Sleep Disorders

SPECIAL : GERIATRIC PSYCHIATRY

Sleep complaints are common among older adults.1 Such complaints may reflect their concerns about normative age-related changes in sleep, such as reduced total sleep time, lighter sleep, and increased wakefulness at night,2 as well as the prevalence of common sleep disorders in late life, including sleep-disordered breathing and chronic insomnia. Table 1 displays common sleep disorders in older adults and associated risk factors and correlates.1,3-5

Sleep-disordered breathing describes respiratory events that occur during sleep, ranging from simple snoring to pathological hypopneas (decreased air flow) and/or apneas (temporary breathing cessation). Obstructive sleep apnea (OSA) is defined as the apnea-hypopnea index (average hypopnea and apnea events rate per hour) being above 5. The general prevalence rate of OSA is approximately 22% in men and 17% in women, and it increases with age.6 Chronic insomnia, characterized by difficulties initiating and maintaining sleep, is also prevalent in the older population, with estimates of insomnia symptoms close to 50%, although estimates of insomnia diagnosis are variable.7

Both OSA and chronic insomnia are linked with various psychiatric concerns. OSA is associated with increased risks of vascular dementia, Alzheimer disease,8 and major depressive disorder.9 Insomnia is also associated with the onset of depression, anxiety, alcohol abuse, and psychosis.10 Sleep disturbances may potentiate symptoms of mental illness via several mechanisms: disruptions of memory consolidation processes that normally occur during sleep; increases in irritability and fatigue; and negative impacts on cognitive function.11

It is important to note the bidirectional relationship between sleep disorders and psychiatric disorders in older adults. That is, psychiatric disorders can be both the cause and consequence of sleep disturbances. Therefore, the challenge is to determine whether sleep disruption should be the primary target for intervention or whether there are also comorbid psychiatric symptoms that need to be addressed for treatment to be successful.

Assessment of Sleep Disorders

It is helpful to start with a detailed history regarding the nature of the patient’s sleep complaints, other areas of functioning, and any other comorbid conditions that might be impacting their sleep. It can be helpful to walk through a typical 24-hour period to review sleep problems in greater detail, including onset, duration, frequency of disturbances, and possible contributions of sleep environment (eg, temperature, noise, etc). A sleep diary can also provide a sampling of a typical week of sleep. Reported sleep difficulties often have daytime consequences, so it is important to ask about their daytime behaviors (eg, napping, canceling plans) used to counteract or cope with perceived and real sleep loss. This information sheds light on the patient’s relationship with their sleep, including whether sleep impacts their ability to function and their level of concern surrounding the possible downstream effects of sleep loss. The Figure summarizes the assessment flow.

Medical conditions, medications, pain level, and alcohol or drug use should be discussed, as these factors can adversely affect sleep. Table 2 shares screening measures that are useful for gathering information about other contributing factors to poor sleep, including possible comorbid sleep disorders.12-16 For example, the Pittsburgh Sleep Quality Index, a global measure of sleep quality, may help identify the presence of potential sleep disturbance due to medical comorbidities (eg, pain, waking to use bathroom), psychiatric comorbidities (eg, nightmares), and use of sleep medications, including over-the-counter sleep medications. Furthermore, assessment of daytime sleepiness and screening for sleep apnea may be helpful to determine whether a sleep study is needed.

To make a diagnosis of OSA, home study (level 3 study) or in-lab polysomnography (PSG; level 1 sleep study) are required. In-lab polysomnography is considered a gold-standard sleep study; home study is less accurate because fewer sensors are involved.17 Home study is usually indicated for the confirmation of OSA diagnosis in patients with a high pretest probability of OSA. In-lab PSG is recommended for patients with comorbidities such as congestive heart failure, chronic lung disease, or neurologic conditions.

Finally, it is crucial to ask the patient what they are currently doing to manage their symptoms and their level of optimism around efforts to help. This information will be helpful in designing a treatment plan that not only improves the quality and quantity of their sleep, but also addresses the psychological impact through psychoeducation, support, and problem solving.

Treatment for Sleep Disorders

Obstructive sleep apnea. Positive airway pressure (PAP), a device that helps keep the airway open during sleep through a stream of compressed air, is the first-line medical treatment for moderate or severe sleep apnea. Several types of PAP devices exist; the most commonly used is continuous PAP, and other advanced options include bilevel PAP. For individuals with difficulty adhering to PAP use, other treatment options can be considered, including oral appliances (eg, mandibular advancement devices) and surgical options (either soft or hard tissue surgery or implantation of a nerve stimulation device). Improvements in sleep quality, daytime symptoms, and cognitive functions are often observed when OSA is adequately addressed.

Chronic insomnia: pharmacological approaches. There are several US Food and Drug Administration-approved prescription hypnotics for insomnia, including benzodiazepines (eg, estazolam, temazepam), nonbenzodiazepines (eg, eszopiclone, zolpidem), melatonin receptor agonists (eg, ramelteon), orexin/hypocretin receptor antagonists (eg, suvorexant), and an antihistamine (doxepin). Other pharmacological drugs with sedating effects that are commonly prescribed for sleep include trazodone, mirtazapine, gabapentin; other sedative antipsychotics include quetiapine. However, many sedative hypnotics have negative side effects. Benzodiazepines, in particular, are not recommended for late-life insomnia due to their increased risks of cognitive impairment and falls.18 Nonpharmacological approaches are therefore regarded as the first line of treatment for insomnia, as they have been found to be more effective, with minimal side effects.19

Nonpharmacological approaches. Cognitive behavioral therapy for insomnia (CBTI) is an evidence-based, multicomponent therapy that is recommended as the first line of treatment for insomnia, with strong empirical support for the general population20 and older populations.21 In the context of medical and psychiatric comorbidities, CBTI was found to improve sleep and comorbid psychiatric symptoms.22 To optimize CBTI for older adults with comorbid psychiatric symptoms, Table 3 illustrates CBTI intervention components as well as adaptation considerations for older adults23 and modifications in the context of comorbid depression and anxiety.

For older adults with psychiatric comorbidities, additional modifications may be warranted. Depressive symptoms, such as low motivation and energy, may be associated with lower adherence in the behavioral recommendations of CBTI, highlighting the need for motivational enhancement strategies. Incorporating positive mood strategies into CBTI, such as behavioral activation (eg, daily pleasant activity scheduling), cognitive reframing (eg, thought records focusing on depression-related thoughts), and positive affirmation (eg, positive data logs and cue cards), could all help address comorbid insomnia and depression.24

For older adults who have anxiety, considerations include assessing sleep anxiety, as certain CBTI strategies may become less effective among those who are significantly anxious about sleep. For example, sleep restriction, intended to promote sleep drive, may be less effective in consolidating sleep due to heightened arousal levels masking sleep drive.25 To address heightened arousal at night, there may be benefits in introducing relaxation exercises (eg, diaphragmatic breathing or progressive muscle relaxation) and other cognitive-behavioral strategies for managing anxiety (eg, constructive worry).

More research is needed to better understand whether to treat these comorbid conditions sequentially or concurrently in order to optimize treatment outcomes for both sleep and psychiatric symptoms. Recent data support further development of transdiagnostic treatments that concurrently target common cognitive, behavioral, and biological underpinnings across psychiatric disorders, such as sleep disturbances. One example is the Transdiagnostic Sleep and Circadian Intervention, a transdiagnostic treatment targeting sleep and circadian problems for individuals with comorbid psychiatric disorders.26 This approach is informed by CBTI and other circadian optimization strategies. Although more studies on transdiagnostic treatments are underway, CBTI is appropriate for older adults with comorbid insomnia and psychiatric disorders.

Concluding Thoughts

Sleep disturbance often co-occurs among older adults with psychiatric symptoms and disorders. A thorough assessment, looking at difficulty initiating and maintaining sleep, daytime sleepiness/dysfunction, and other physical markers (eg, snoring), will help providers identify the presence of sleep disorders, such as OSA or chronic insomnia, that co-occur with psychiatric conditions. Modifications can optimize the treatment of sleep disturbance in the presence of such psychiatric conditions as depression and anxiety.

Appropriate treatment is essential, as the long-term consequences of not addressing sleep disturbances may be severe. Interactions between sleep disruption and mental health symptoms even may set into motion a cascade of neurodegeneration that can ultimately lead to dementia.27 Mood disorders also increase risk of dementia, potentially through accelerated brain aging from stress exposure that leads to pathological changes in the brain, termed the brain-age gap. Sleep disturbances may constitute a type of stressor that increases the brain-age gap. Treatment of these common, yet complex, patients with evidenced-based methods is essential to improving their symptoms, quality of life, and brain health.

Dr Juang is a clinical assistant professor in the Division of Sleep Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine. Dr Mills-Finnerty is an instructor (affiliated) in the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine. She is a research health science specialist in the Veterans Administration (VA) Palo Alto Health Care System. Dr Cassidy-Eagle is a clinical professor in the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine. Dr Kawai is a clinical associate professor in the Division of Sleep Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine. Dr Gould is associate director for education and evaluation at the VA Palo Alto Health Care System’s Geriatric Research, Education, and Clinical Center. She is also a clinical assistant professor in the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine.

Dr Juang is a member of the advisory board for Koko. Dr Gould receives research funding from Meru Health, Inc. None of the other authors have any disclosures to .

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