Chronic Insomnia in the Elderly: Current Approaches to Diagnosis and Treatment

The article shows that in the treatment of chronic insomnia in geriatric patients, it is recommended to use a step-by-step treatment and start with steps aimed at the elimination of somatic, environmental and psychological barriers which affect the quality of sleep. An algorithm for the evaluation of sleep disorders at a later age firstly desctibed. The specifics of the clinical and psychological evaluation of the quality of sleep in geriatric patients presented. Evidence on the effectiveness of pharmacological and non-pharmacological approaches for the treatment of chronic insomnia at a later age presented on the basis of a number of foreign studies. It is recommended to use multicomponent cognitive-behavioral psychotherapy as a first-line treatment of chronic insomnia at a later age Types, forms and structural components of cognitive-behavioral therapy of chronic insomnia in the elderly are detailed. Practical difficulties and reccomentations for the use of medical approach in the treatment of sleep disorders in the elderly are also presented.

1. Melehin A.I. Effektivnost' kognitivno-povedencheskoj psihoterapii v pozdnih vozrastah [The effectiveness of cognitive-behavioral psychotherapy in later ages]. XVI S’ezd psihiatrov Rossii. Vserossijskaya nauchno-prakticheskaya konferenciya «Psihiatriya na etapah reform: problemy i perspektivy». pod red. N.G. Neznanova [XVI Congress of Russian psychiatrists. All-Russian scientific-practical conference "Psychiatry at the stages of reforms: problems and prospects"]. Saint-Petersburg: Al'ta Astra, 2015. pp. 709–710.
2. Melehin A.I. Kognitivno-povedencheskaya psihoterapiya rasstrojstva sna v pozhilom i starcheskom vozraste [Cognitive-behavioral psychotherapy sleep disorders in elderly]. Konsul'tativnaya psihologiya i psihoterapiya [Consultative psychology and psychotherapy], 2015, vol. 23, no. 1, pp. 84–103.
3. Melehin A.I. Effektivnost' kognitivno-povedencheskoj psihoterapii pri lechenii rasstrojstva sna (CBT-I) u geriatricheskih pacientov [The effectiveness of cognitive-behavioral psychotherapy in the treatment of sleep disorders (CBT-I) in geriatric patients]. In M.G. Poluektova, K.N. Strygina (Eds.) Sbornik tezisov X Vserossijskoj nauchno-prakticheskoj konferencii Aktual'nye problemy somnologii. [Proceedings of the X All-Russian Scientific and Practical Conference Actual problems of somnology]. Moscow, 2016, pp. 74–75.
4. Poluektov M.G. Diagnostika i lechenie rasstrojstv sna. [Diagnosis and treatment of sleep disorders]. Moscow: MEDpress-inform, 2016, 256 p.
5. Poluektov M.G., Strygin K.N. Rasstrojstva sna v pozhilom vozraste [Sleep disorders in old age]. Medicinskij sovet [Medical advice], 2014, no. 5. URL: http://www.med-sovet.pro/jour/article/view/572. doi: 10.21518/2079-701X-2014-5-74-81
6. Aurora R.N., Zak R.S., Auerbach S.H. Best practice guide for the treatment of nightmare disorder in adults. J Clin Sleep Med, 2010, vol. 6, no. 4, рр. 389–401. URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2919672/
7. Belanger L., et al. Cognitive Behavioral Therapy for Insomnia in Older Adults. Cognitive and Behavioral Practice, 2012, vol. 19, no. 1, рр. 101–115. doi: 10.1016/j. cbpra.2010.10.003
8. Boullin P., Ellwood C., Ellis J.G. Group vs. Individual Treatment for Acute Insomnia: A Pilot Study Evaluating a “One-Shot” Treatment Strategy. Brain Sciences, 2017, vol. 7. no 1. URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5297290/. doi: 10.3390/brainsci 7010001
9. Brewster G.S., Riegel B., Gehrman P.R. Insomnia in the Older Adult.  Sleep Med Clin, 2018, vol. 13, no. 1, pp. 13-19. doi: 10.1016/j.jsmc.2017.09.002.
10. Buysse D.J., Germain A., Moul D.E. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med., 2011, vol. 171, no. 10, pp. 887–895. doi: 10.1001/archinternmed.2010.535.
11. Clinical Handbook of Insomnia Third Edition. P. Hrayr (ed.). Chicago: Springer. 2017. 292 p.
12. Creti L., Libman E. Effectiveness of Cognitive-Behavioral Insomnia Treatment in a Community Sample of Older Individuals: More Questions than Conclusions. Journal of Clinical Psychology in Medical Settings, 2005, vol. 12, no. 2, pp. 153–164 doi: 10.1007/s10880-005-3275-8
13. Cunninghama J.E., et al. Cognitive Behavioural Therapy for Insomnia (CBT-I) to treat depression: A systematic review. Journal of Psychosomatic Research, 2018, vol. 106, pp. 1–12. doi: 10.1016/j.jpsychores.2017.12.012
14. Fiorentino L., Martin J.L. Awake at 4 AM: treatment of insomnia with early morning awakenings among older adults. J Clin Psychol, 2010, vol. 66, no. 11, pp. 1161–1174. doi: 10.1002/jclp.20734. 
15. Gong H., Ni C.X., Liu Y.Z. Mindfulness meditation for insomnia: A meta-analysis of randomized controlled trials. J Psychosom Res, 2016, vol. 89, no. 1–6. doi: 10.1016/ j.jpsychores.2016.07.016
16. Guided Internet-Based Treatments in Psychiatry. N. Lindefors, G. Andersson (eds.). Stockholm: Springer, 2016, 244 p.
17. Harsora P., Kessmann J. Nonpharmacologic management of chronic insomnia. Am Fam Physician, 2009, vol. 79, no. 2, pp. 125–130.
18. Insomnia. A Clinical Guide to Assessment and Treatment. C.M. Morin, C.A. Espie (eds.). New York: Springer, 2004. 190 p.
19. Irwin M.R., Olmstead R., Carrillo C. Cognitive behavioral therapy vs. Tai Chi for late life insomnia and inflammatory risk: a randomized controlled comparative efficacy trial. Sleep, 2014, vol. 37, no. 9, pp. 1543–1552. doi: 10.5665/sleep.4008
20. Krishnan P., Hawranik P. Diagnosis and management of geriatric insomnia: a guide for nurse practitioners. J Am Acad Nurse Pract, 2008, vol. 12, no. 20, pp. 590-599. doi: 10.1111/j.1745-7599.2008.00366.x
21. Kuhn E., Weiss B.J., Taylor K.L. CBT-I Coach: A Description and Clinician Perceptions of a Mobile App for Cognitive Behavioral Therapy for Insomnia. J Clin Sleep Med, 2016, vol. 12, no. 4, pp. 597–606. doi: 10.5664/jcsm.5700
22. Kyle S.D., Hurry M.E. Effects of digital Cognitive Behavioural Therapy for Insomnia on cognitive function: study protocol for a randomised controlled trial. Trials, 2017, Vol. 18. no 1, pp. 281–290 doi: 10.1186/s13063-017-2012-6
23. Luik A.I., Kyle S.D., Espie C.A. Digital Cognitive Behavioral Therapy (dCBT) for Insomnia: a State-of-the-Science Review. Current Sleep Medicine Reports, 2017, vol. 3, no. 2, pp. 48–56. doi:10.1007/s40675-017-0065-4
24. Management of Chronic Insomnia. Ontario, Toronto: Centre for Effective Practice. 2017. URL: https://thewellhealth.ca/wp-content/uploads/2017/01/20170116 _Insomnia _FINAL.pdf
25. Martin J., Shochat T., Ancoli-Israel S. Assessment and treatment of sleep disturbances in older adults. Clin Psychol Rev, 2000, vol. 20, no. 6, pp. 783–805. doi: 10.1016/S0272-7358(99)00063-X
26. Mathur S., Sharma M.P., Bharath S. Mindfulness-based cognitive therapy in patients with late-life depression: A case series. International Journal of Yoga, 2016, vol. 9, no. 2,
    pp. 168–172. doi: 10.4103/0973-6131.183711
27. McCrae C.S., et al. Treatment of Late-life Insomnia. Sleep Medicine Clinics, 2009,
    vol. 4, no. 4, pp. 593–604. doi: 10.1016/j.jsmc.2009.07.006
28. Newman C. Using REBT in the Treatment of Restless Leg Syndrome: A Case-Study.
    J Rat-Emo Cognitive-Behav Ther, 2014. vol. 32, pp. 139–149. doi: 10.1007/s10942-013-
    0174-z
29. Ogundele A., Ighoroje M. Insomnia and Dysfunctional Beliefs and Attitudes about Sleep among Elderly Persons in Abeokuta, Nigeria. International Journal of Clinical Psychiatry, 2017, vol. 5, no. 2, pp. 25–31 doi:10.5923/j.ijcp.20170502.01 
30. Ong J., Suh S. Utilizing Cognitive-Behavioral Therapy for Insomnia to Facilitate Discontinuation of Sleep Medication in Chronic Insomnia Patients. Sleep Med Res, 2012,
    vol. 3, no. 1, pp. 1–6 doi: doi.org/10.17241/smr.2012.3.1.1
31. Ong J., Ulmer C.S., Manber R. Improving sleep with mindfulness and acceptance: a metacognitive model of insomnia. Behav Res Ther, 2012, vol. 50, no. 11, pp. 651–660.
    doi: 10.1016/j.brat.2012.08.001
32. Pigeon W.R. Treatment of adult insomnia with cognitive-behavioral therapy. J Clin Psychol, 2010, vol. 66, no. 11, pp. 1148–1160. doi: 10.1002/jclp.20737
33. Qaseem A., Kansagara D., Forciea M.A. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med, 2016, vol. 165, pp. 125–133. doi: 10.7326/M15-2175
34. Riemann D. Sleep hygiene, insomnia and mental health. J Sleep Res, 2018, vol. 27, no. 1, pp. 3. doi:10.1111/jsr.12661
35. Riemann D., Baglioni C., Bassetti C. European guideline for the diagnosis and treatment of insomnia. J Sleep Res, 2017, vol. 26, no. 6, pp. 675–700. doi: 10.1111/jsr.12594
36. Riemann D., Spiegelhalder K., Feige B. The hyperarousal model of insomnia: a review of the concept and its evidence. Sleep Med Rev, 2010, vol. 14, no. 1, pp. 19–31.
    doi: 10.1016/j.smrv.2009.04.002
37. Rodriguez J.C., Dzierzewski J. M., Alessi C.A. Sleep Problems in the Elderly. The Medical Clinics of North America, 2015, vol. 99, no. 2, pp. 431–439.
    doi: 10.1016/j.mcna.2014.11.013
38. Rybarczyk B., Lund H.G. Cognitive Behavioral Therapy for Insomnia in Older Adults: Background, Evidence, and Overview of Treatment Protocol. Clinical Gerontologist, 2013, vol. 36, no. 1, pp. 70–93. doi.org/10.1080/07317115.2012.731478
39. Sateia M.J., Buysse D.J., Krystal A.D. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med, 2017, vol. 13, no. 2, pp. 307–349.
    doi: 10.5664/jcsm.6470
40. Suzuki, K., Miyamoto M., Hirata K. Sleep disorders in the elderly: Diagnosis and management. Journal of General and Family Medicine, 2017, vol. 18, no. 2, pp. 61–71.
    doi: 10.1002/jgf2.27
41. Taylor H.L., Hailes H.P., Ong J. Third-Wave Therapies for Insomnia. Curr Sleep Medicine Rep, 2015, vol. 1, no. 3, pp. 166–176 doi: 10.1007/s40675-015-0020-1
42. Trauer J.M., Qian M.Y., Doyle J.S. Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis. Ann Intern Med, 2015, vol. 163, no. 3, pp. 191–204. doi: 10.7326/M14-2841
43. Vitiello M.V., Rybarczyk B., Von Korff M. Cognitive Behavioral Therapy for Insomnia Improves Sleep and Decreases Pain in Older Adults with Co-Morbid Insomnia and Osteoarthritis. Journal of Clinical Sleep Medicine, 2009, vol. 5, no. 4, pp. 355–362.
44. Wennberg A.M., Canham S.L., Smith M.T. Optimizing Sleep in Older Adults: Treating Insomnia. Maturitas, 2013, vol.76, no. 3, pp. 247–252 doi: 10.1016/j.maturitas. 2013.05.007.