Cognitive Behavioral Therapy for Insomnia in Older Adults: Background, Evidence, and Overview of Treatment Protocol

Sleep and Aging: Challenges and Recommendations for Middle-Aged and Older Adults

“…Because of the prevalence and consequences of sleep problems in midlife and older adulthood, counselors should assess sleep quality routinely during the intake process by asking about the following areas: satisfaction with quality of sleep; amount of sleep each night; any sleep changes within the past year; time to fall asleep and any associated difficulties; problems with daytime sleepiness; daytime naps; awakenings during the night or early morning and ability to return to sleep; and, if applicable, the impact of sharing the sleeping environment with another person or pet (Puterbaugh, ). If the hallmark signs of insomnia—sleep complaints, worry about sleep, or significant daytime consequences (Rybarczyk, Lund, Garroway, & Mack, )—surface from the intake, additional assessment and intervention are indicated.…”

“…A thorough assessment of insomnia, including consultation between mental health and medical practitioners, best ensures what Hidalgo et al () emphasized as crucial for aging adults: recognizing insomnia and identifying its true origins to effectively target treatments. It is hoped that this process will lead to alternative treatments, rather than the typical first‐line approach to insomnia, which is sleep‐inducing medication (e.g., Buysse et al, ; Rybarczyk et al, ). In addition to side effects and dependency possibilities, these medications carry particular risks for older adults, including psychomotor and cognitive slowing, daytime fatigue, increased fall risk, and rebound insomnia (e.g., Masters, ; Rybarczyk et al, ).…”

“…It is hoped that this process will lead to alternative treatments, rather than the typical first‐line approach to insomnia, which is sleep‐inducing medication (e.g., Buysse et al, ; Rybarczyk et al, ). In addition to side effects and dependency possibilities, these medications carry particular risks for older adults, including psychomotor and cognitive slowing, daytime fatigue, increased fall risk, and rebound insomnia (e.g., Masters, ; Rybarczyk et al, ). Given these risks and the equal, if not superior, efficacy of other treatments for insomnia, such as cognitive behavior therapy (CBT), numerous authors have argued strongly that medications should not be the first‐line approach (e.g., Irwin, Cole, & Nicassio, ; Masters, ; Rybarczyk et al, ; Trauer, Qian, Doyle, Rajaratnam, & Cunnington, ).…”

“…Moreover, among a sample of adults ages 50 and older who were still experiencing insomnia despite using sleep medication, Lichstein et al () found that CBT in conjunction with medication tapering was an effective treatment. On the basis of these findings and recommendations from others (i.e., Milner & Belicki, ; Puterbaugh, ; Rybarczyk et al, ), the following strategies and techniques are recommended:…”

“…Thus, rather than simply informing clients of these recommendations, counselors need to engage clients in discussions about challenges and potential solutions, including negotiating with others in the household if needed. Cognitive restructuring, which consists of identifying, challenging, and modifying unrealistic beliefs about sleep and fears related to not sleeping. Rybarczyk et al () listed erroneous beliefs about sleep that are commonly experienced by older adults, such as

If I don’t get eight hours of sleep (or a good night's sleep), I will get sick, my medical conditions will get worse, or I will not be able to do anything tomorrow.Because of my age, my sleep is broken and cannot be fixed.I should be able to sleep like I did when I was younger.Fatigue and problems concentrating are due solely to my sleep problems.If I sleep in, take naps, or spend enough time in bed, I will get the rest I need. (p. 84)

Presenting clients with a checklist of these thoughts is an efficient tool for identifying thoughts that are connected to the difficulty of falling asleep or returning to sleep upon awakening.…”