Link Between Anxiety and Insomnia in the Older Person
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Sleep disturbances are very common in the context of psychological distress.1,2 Studies of individuals with insomnia have found rates of comorbid psychiatric disorders as high as 62%.3 A substantial amount of research has been conducted investigating insomnia in the context of depression in later life, but relatively little research has been conducted investigating sleep disturbances in the context of anxiety symptoms experienced by the elderly. This is surprising, given that complaints about anxiety and sleep disturbances are among the most common that the elderly express to their physicians.4 This article describes current knowledge concerning the link between anxiety and insomnia in older adults. It begins by discussing separately the research findings on sleep and anxiety, and then briefly reviews current knowledge concerning the relation between insomnia- and anxiety-related variables. It concludes with a section on the impact of the pharmacological treatment of anxiety on sleep-related variables in older patients.
SLEEP AND INSOMNIA IN THE ELDERLY
Older adults tend to go to sleep and wake up earlier than their younger counterparts.5,6 This phenomenon is commonly referred to as an advanced sleep phase. There is some evidence that, in spite of their increased likelihood of going to bed relatively early, older individuals have greater difficulty initiating sleep than their younger counterparts.7 In addition, older individuals awaken more frequently during the night than do younger persons8 and take more naps than younger adults,9 especially in the evening.10
The alternation of sleep and wake is one of the many functions governed by the suprachiasmatic nucleus of the anterior hypothalamus. There are age-related changes, such as volume and cell loss, in this structure that likely contribute to changes in sleep observed in the elderly.11 It is also likely, however, that schedule changes that accompany retirement (ie, a less structured day, fewer demands requiring wakefulness) contribute to these commonly observed changes. In addition, medical problems that can interfere with a restful night’s sleep are common in the elderly. These include but are not limited to: obstructive sleep apnea, arthritic or neuropathic pain, nocturia, and cramping related to peripheral vascular disease.
ANXIETY-RELATED DISTRESS
Anxiety disorder diagnoses are less common among older adults than among their younger counterparts.12 A number of explanations have been offered for this observation. Researchers have pointed out that the diagnostic criteria for anxiety disorders were established on the basis of symptom reports by younger adults and might not be appropriate for the elderly,13,14 and that anxiety problems that present subclinically according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)15 criteria might have a substantial impact on functioning in the elderly.16 It has also been suggested that existing measures of anxiety might omit items that are important to the elderly, and might therefore be invalid when applied to this population.17
In spite of the evidence for a decreased prevalence of anxiety disorders in the elderly, compared to younger adults, findings indicate that anxiety-related distress may be more common in the elderly than are other forms of pathology that have received substantially more attention, including both depression and dementia.12 Himmelfarb and Murrell,18 in a study of 2860 individuals age 55 and older, found that 20% of participants reported a clinically significant level of anxious symptomatology. Female gender, lower income and education, and poorer quality housing were associated with elevated levels of anxiety.
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