New Directions in Sleep Research for Older Adults and Their Caregivers

Fellow Clinical Gerontologists

Sleep is essential to overall physical health, mental health, and quality of life. This has been consistently proven through research and clinical work; however, what has steadily gained traction is the concept that, even though sleep may change as we age, worse sleep is not guaranteed. Additionally, and importantly, sleep in older adults can be improved through appropriate assessment and treatment. Issue three of 2024 focuses on sleep and insomnia in healthy and medically complex older adults and their caregivers.

Reviews

Despite natural age-related changes in sleep architecture, poor sleep is not a marker of aging. However, there is growing evidence to suggest that poor sleep may serve as a marker of poor health during the aging process while good sleep quality may be a marker of healthy aging, as summarized in the first paper in this issue. Our opening review considers 14 cross-sectional or longitudinal studies that evaluate sleep and healthy aging where healthy aging was explicitly defined (Ravyts & Dzierzewski, 2022). This review highlights that good sleep can exist and be maintained well into older adulthood and that older adults who have aged healthily tend to report better sleep quality, moderate sleep duration, and an absence of sleep disorder history. As such, the review suggests the prioritization, assessment, and monitoring of sleep as an important aspect of overall health in older adulthood.

Caregivers are essential to the care of some of our older adult populations. Our second review considers sleep in caregivers from 32 studies, specifically of persons living with dementia, and examines the predisposing and precipitating factors of sleep disturbances (Brewster et al., 2022). For predisposing factors, the authors found that sex differences played a role in reported sleep concerns with female caregivers more likely to report insomnia symptoms and male caregivers more likely to endorse shorter sleep duration while demonstrating lower sleep efficiency, less slow wave sleep, and longer durations of middle insomnia. As for precipitating factors, cohabitation with the care recipient was associated with more frequent nightly disruptions. Caregiver sleep quality was also impacted by severity and type of cognitive and functional impairment, presentation of the impairment (e.g., wandering), care needs of the care recipient (e.g., having to use the bathroom at night), risk of the care recipient (e.g., recent falls), poor perceived social support, and depression, among other factors. This review strongly encourages the consideration of caregiver sleep disturbance, especially for informal caregivers of older adults living with dementia.

Original articles

Three studies examine relationships of sleep with mental and physical health factors in older adults. The first study evaluates the relationship between sleep problems and suicide risk in a sample of younger adults ages 18–40 (n = 296) and a sample of older adults over age 60 (n = 432) (Bolstad et al., 2022). Findings demonstrated that while sleep problems were related to suicide risk in the younger adult group, sleep-related daytime dysfunction was related to suicide risk in the older adult group. Further, the use of sleep medication was related to suicide risk for both age groups, even when accounting for depression symptoms. As such, the authors reinforce the recommendation that Cognitive Behavioral Therapy for Insomnia (CBT-I) should be encouraged before medication in older adult populations. The second study examines 168 older adults with heart failure (Seo & Son, 2022) finding that those with longer sleep duration were 2.6 times more likely to have cognitive frailty. Depression was also predictive of cognitive frailty, suggesting that implementing a healthy sleep pattern and managing depression in older adults with heart failure may assist in lowering the risk for cognitive frailty (Seo & Son, 2022). Finally, the third study examines 421 older adults with Parkinson’s disease (Du et al., 2022). Results showed that excessive daytime sleepiness was significantly related to greater depression and worse performance on completing activities of daily living (ADLs) in older adults with Parkinson’s disease (Du et al., 2022). Similar to the first article described in this paragraph, this article suggests that daytime dysfunction is an important aspect of sleep during older adulthood and that addressing excessive daytime sleepiness may assist in improving daytime function.

The next two studies focus on the treatment of insomnia in older adults. In 10,911 older adults in India who reported one or more insomnia symptoms, only 5.7% received treatment (i.e., taken medication or used other doctor-recommended treatments for sleep) with lower access to treatment in those who were rural, poor, and had less education (Muhammad et al., 2023). Treatment for sleep was associated with lower depression. This study with data from India also provides another example of the global importance of sleep during older adulthood. However, medication is not a recommended first line treatment for insomnia in older adults, especially benzodiazepine receptor agonist (BZRA) drugs which populate the BEERs list of potentially inappropriate medications for older adults (Fick et al., 2019). In the next study, 2,009 older Veterans who had received at least one BZRA prescription in the past 18 months (74% for sleep management) were selected to participate in a randomized trial aiming to reduce BZRA prescriptions (Mak et al., 2022), using “low touch” educational mailing. Participants received an informational brochure about insomnia and a free online CBT-I program, or the same information with a telephone reinforcement call, or more general informational brochure about sleep. There were no significant differences in BZRA use at 6 and 12 months between the groups. The highly-readable discussion outlines important next steps for enhancing uptake of CBT-I as opposed to pharmacological interventions with their associated safety risks (Mak et al., 2022). Taken together these two studies underscore the importance of education about insomnia treatment – and its limits – and the need to increase ready access to BZRA alternatives such as CBT-I.

Finally, we cannot forget about caregivers and their sleep. The concluding three studies in this section further explore the positive and negative impacts of the level of caregiver burden on sleep. In our first caregiver focused study, researchers evaluated 403 spouse caregivers in heterosexual marriages and found that, when performing light caregiving duties, insomnia severity was similar to that of non-caregivers (Kong et al., 2023). Relatedly in 3,237 grandparents living in South Africa, more caregiving to grandchildren was not associated with worse sleep; in fact, for women, more caregiving to grandchildren was associated with a lower incidence of insomnia (Pengpid & Peltzer, 2023). The authors point to the potential benefits of meaningful social roles, particularly in cultures where active grandparenting is consistent with cultural norms and values. Despite these findings, there is other research suggesting that caregiving can have a significant and negative impact on sleep. In 530 family caregivers, mediation analyses examining relationships of sleep disturbance, mental health, and quality of life found that those who provided 20 or more hours of caregiving per week to an individual with physical, psychological, cognitive or other impairments had lower quality of life (Ravyts & Dzierzewski, 2020). Taken together, these studies point to the complexity of relationships between sleep and caregiving – where the impact of caregiving on sleep must be examined through the lens of culture, roles, mental health impacts, and overall demands.

Clinical studies

These last two articles are clinical studies that consider the prevalence and treatment of insomnia for older adults across care settings. From an inpatient setting perspective, this first clinical study examines insomnia symptoms and environmental disruptors in a sample of Veterans aged 50 years and older receiving care in a subacute rehabilitation setting. Findings illustrated that ~50% of the Veterans within the sample reported at least subthreshold insomnia symptoms (Boyle et al., 2024). Further, ~90% reported at least one environmental disruptor (e.g., awakenings by staff for care, noise, light). These disruptors were not successfully addressed with sleep resources (e.g., sleep masks, ear plugs), suggesting a need for more widespread environmental change to promote sleep within this care setting. From an outpatient perspective, this final article in the issue describes a program evaluation study within a primary care clinic in which 29 of 34 older adult patients who began CBT-I successfully completed the treatment (Hinrichsen & Leipzig, 2022). Further, sleep medications were deprescribed as part of CBT-I and 69% of those whose medications were deprescribed were not taking them one year later.

These articles illustrate the importance of evaluating and treating sleep difficulties and insomnia symptoms in our older adult patients across settings and their caregivers. We thank all the authors for their important contributions.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This material is the result of work supported with resources and the use of facilities at the VA Boston Healthcare System. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government. Dr. Boyle was supported by funding from VA Rehabilitation Research and Development (CDA1; IK1RX004762-01).