Sleeping Your Way to Health and Happiness

1. Sleeping Your Way to Health and Happiness Melissa Sandler, MSW, ACSW Promising Practices: Mental Health and Aging January 14, 2015

2. A Few Sleep Myths • Poor 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.

3. 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.

4. 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.

5. As we age, our sleep patterns change Image from the National Sleep Foundation

6. 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.

7. 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.

8. Sleep Disturbances Increase With Age • Late-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.

9. 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

10. 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.

11. Insomnia Causes Both Individual and Societal Burdens

12. Insidious Effects of Sleep Loss • Patients 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.

13. 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 disturbanceand/or irritability Reduced motivation, energy and/or initiative Tension headaches, gastrointestinal symptoms, and other aches and pains

14. Our Bodies Turn on Ourselves • Losing 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 including • cardiovascular disease • Arthritis • diabetes • certain cancers • obesity

15. Chronic Sleep Loss Chronic 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

16. Medical Disorders Can Disrupt Sleep • Arthritis • Osteoporosis • Cancer • Parkinson's Disease • Incontinence • Alzheimer's Disease & Other Dementias • Gastroesophageal Reflux (GER) and/or Heartburn • Chronic Obstructive Pulmonary Disease • Nocturnal Cardiac Ischemia • Congestive Heart Failure • Peripheral Vascular Disease

17. Cardiovascular Health • Results 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

18. Diabetes and Sleep • People 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.

19. 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

20. Weight Gain • In 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.

21. 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

22. Medications Affect Sleep Beta Blockers Calcium Channel Blockers CNS Stimulants Corticosteroids Antidepressants Bronchodialators Decongestants Stimulating Antihistamines Thyroid Hormones

23. Psychological Impact

24. Comorbidities with Late-Life Insomnia • Comorbid 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.

25. 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

26. 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.

27. 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.

28. 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 disorders • Chronic medical conditions such as stroke, heart disease, COPD, and cancer • Researchers accounted for sociodemographic factors such as age, gender, marital and financial status.

29. Paranoia • A 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.

31. 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.

32. 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/

33. 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.

34. 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/)

35. Main Interventions of BBTI BBTI 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: Reduce time in bed Get up at the same time each day, regardless of sleep duration Do not go to bed unless sleepy Do not stay in bed awake

36. 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

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

38. 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

39. 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.

40. 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%.

41. Other Do’s and Don’ts • Engage 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.

42. More Do’s and Don’ts • Don’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.

43. 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.