#129 - Sleep Problems & Dementia Risk: What Every Provider Must Know

Last week, a therapist told me about her client, an 82-year-old woman who hadn’t had more than 6 hours of sleep in years. “It’s just part of getting older,” the woman sighed. But here’s the truth—fatigue isn’t a normal part of aging, and chronic sleep problems may be quietly raising her risk for dementia. As professionals, we can no longer shrug off insomnia in older adults. The stakes are simply too high.

In this episode, I reveal the powerful connection between chronic sleep problems and dementia risk—and why ignoring insomnia symptoms can have lasting consequences for brain health.

Here's What You'll Learn In This Episode:

• Why half of older adults report insomnia symptoms (even if they don’t meet full diagnostic criteria)
• How sleep architecture changes with age—and why that’s not the same as insomnia
• The role of deep sleep in clearing beta amyloid, consolidating memory, and regulating emotions
• Three major research studies linking short sleep duration to higher dementia risk
• Five practical steps you can take to assess and improve sleep in older adults
• Why Cognitive Behavioral Therapy for Insomnia (CBT-I) is the gold standard, especially for people 65+
• The dangers of common over-the-counter sleep aids for older adults
• How collaborating with primary care and sleep medicine providers can change outcomes

As professionals, we hold the keys to better brain health in aging—often starting with something as simple, yet essential, as quality sleep.

Click here to go to show notes and get resources on sleep and aging. 

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Transcript

Dr. Regina Koepp: Chronic sleep problems among older adults, Don't just leave older adults tired, they also may be increasing the risk for dementia.

I'm Dr. Regina Koepp, and this is your weekly mental health and aging tip.

And here's the part most professionals miss or just don't know. Older adults have the highest rates of insomnia more than any other age group, and about 50%, about half of older adults report insomnia symptoms. So even if they don't meet criteria for the full insomnia disorder, half of older adults are reporting symptoms consistent with insomnia.

And yet. Sleep issues are dismissed often as just a normal part of aging, when in fact they may not be. Fatigue is not a normal part of aging and sleep issues. While sleep does change as we age and we need to be paying attention to that and modifying our environment and behavior for that, it doesn't mean it's a normal part of aging.

There are architectural changes in our sleep and changes in our circadian rhythm to be mindful of. But older adults still need seven to nine hours of sleep a night.

So if you're working with older adults, it's time to take sleep seriously, not just for quality of life, although that's really important, but for brain health and mental health too.

So let's talk about why sleep matters for brain health. Sleeping is not passive. In fact, it is incredibly powerful, especially in deep sleep. Our brain clears metabolic waste, including beta amyloid, which is implicated in Alzheimer's disease.

 It also helps us to consolidate memory and new learning and to help us regulate our emotional system as well. So when sleep is disrupted night after night, so too are these processes which can have detrimental effects down the road, including an increased risk for dementia disorders.

So let me start by defining insomnia and why this matters so much. So insomnia is classified by. One of three features, difficulty falling asleep, tossing and turning, not able to fall asleep for a significant period of time, or difficulty maintaining sleep, meaning that you fall asleep, okay, but then wake up and have difficulty going back to sleep.

Or early morning wakening, which means, or early awakening, which means waking around three or four and then having difficulty going back to sleep after a certain period of time. I am 49 at round menopause and I'm experiencing this early morning wakening.

But that's not all the person. In order to meet diagnostic criteria for an insomnia disorder. This sleep disturbance has to cause distress or significant impairment in functioning. It also needs to occur at least three times a week over the course of three months to meet diagnostic criteria. These symptoms cannot be attributed to medication or medical problem, or another sleep disturbance and some other nuances as well.

That is the diagnostic criteria for an insomnia disorder. 50% of older adults don't have an insomnia disorder. However, 50% of older adults do report symptoms related to insomnia disorder, and so there's a lot of sleep disturbance that occurs in older adulthood.

Studies show low sleep duration increases the risk for dementia. Let me share some research with you. I'm gonna share three research studies. The first research study was published in 2021

and was a 25 year longitudinal study that identified that adults who slept less than six hours of sleep a night in midlife had a 30% higher risk of developing dementia down the road.

In another study published in 2023, researchers found that short sleep duration and insomnia symptoms increase the risk for dementia disorders.

And finally, US data has revealed that sleep disturbances and depression together increase the risk for cognitive impairment.

So let's talk about why older adults are particularly vulnerable to sleep disturbance. 

Sleep naturally changes with age. We still need seven to nine hours of sleep. But as I mentioned, the architecture and our circadian rhythms change. And so as we age, we get less deep sleep. We wake more frequently throughout the night.

And we fall asleep earlier and wake earlier due to circadian rhythm shifts.

These changes are expected. But now that you know what insomnia is, you can see that they are not the same as insomnia. Older adults also have compounding risk factors that make them more likely to wake up more frequently throughout the night, like chronic pain, caregiving concerns, other medical concerns, medication side effects, or even medication dosing where you have to wake in the night to take a medication.

Increased frequency of urination, so waking throughout the night to go to the bathroom, then having difficulty falling back asleep after that. Social isolation, grief, and early stage cognitive decline or mild cognitive impairment.

Even though older people may have higher risk, doesn't mean that it's a foregone conclusion. There's a lot that we can do to help.

So if you're a medical provider, a mental health provider, aging services provider, caregiver, there is a lot that you can do to improve sleep and brain health.

So here are five critical steps that you can take if you're a medical provider, mental health provider, aging services provider to improve quality of sleep. And brain health. The first is to assess for insomnia. Simply ask questions like,

do you have trouble falling or staying asleep?

Are you worried about your sleep? Is your sleep frustrating you? How many hours of sleep are you getting? Tell me about your sleep. How do you feel during the day full of energy or really tired and lethargic?

You can use tools like the Insomnia Severity Index to track symptoms and the impact of sleep.

You can also change the narrative, validate sleep concerns. So instead of saying, oh, that's just what happens as we age, instead say.

Yes, the sleep architecture and the quality of our sleep does change with age, but it doesn't mean that's something you're just gonna have to bear. It isn't something that you just have to live with. Maybe we can improve it a little bit or a lot.

Cognitive behavioral therapy for insomnia is the gold standard treatment for insomnia for all age groups, including for older adults. And the great thing here is that it doesn't include medication. It's actually recommended before medication for older adults. And this is because often the medication used for insomnia among older adults is contraindicated or is on the beers list.

The beers list is a list of medications and over the counter supplements and medications that are contraindicated for older adults and in some cases can increase what looks like cognitive impairment among older adults. So on that list are things like Tylenol PM and Benadryl, and those are often what people are using to help with sleep, but they're not good for older adults.

And so cognitive behavioral therapy for insomnia is the recommended treatment, you don't have to be a mental health provider to recommend some of the strategies that are common with cognitive behavioral therapy for insomnia. And I'm gonna share some of those with you now.

So one is sleep restriction to spend the time in bed only when you are sleeping. To avoid naps throughout the day. So the sleep restriction being like to reserve your sleep time only for nighttime, so no naps during the day, and to really just have your sleep time, be your nighttime sleep. Another is called stimulus control, and that means that you only use the bed for sleeping and intimacy. Nothing else. No screens, no stress, like talking on the phone and having an argument. The bed needs to be associated with sleep and intimacy only.

No screens, no stress, no snacking. Another is cognitive restructuring or reframing. an example here would be to change catastrophic beliefs. Like I'm never gonna sleep again to something more accurate I'm awake now, but I can get back to sleep later.

Another is relaxation training, like progressive muscle relaxation or mindfulness or meditation before bed. Other things like keeping a dark room, a cool room free of distractions, free of noise, and another that people don't often talk enough about is having the same wake time every day. Those are just some quick principles from cognitive behavioral therapy for insomnia. This is just a couple of seconds of recommendations. This is not the full list of recommendations, but just gives you some ideas to get started.

Another thing you can do is assess for root causes for insomnia. So sometimes insomnia is a signal that something else is happening, like unresolved trauma or grief or caregiving stress, or not enough support with caregiving, unmanaged pain, untreated medical illness that's not properly treated over medication being prescribed too many medications, or not understanding the pacing of medications.

And so spending time understanding the root cause of the insomnia may help to guide you in how you might coach or provide support to the client. And so if it's poorly managed pain or medical condition that's poorly managed or difficulty pacing medications and the medical provider or the prescriber doesn't know that the person is having these symptoms.

You may be in a really important position to guide that person in having conversations with their medical providers or prescribers. So just getting clear about what the real concerns are and as it relates to caregiving concerns, making sure that the caregiver has scaffolding and support so that they could get a good night's sleep as well as they care for somebody.

And especially if they're caring for somebody with dementia. People with dementia often have sleep problems and have difficulty with their sleep wake cycles getting reversed, and this can be a challenge for many dementia caregivers, and so making sure that dementia caregivers have support is key and really caregivers of all conditions deserve support.

And the fifth thing that you can do is to collaborate with medical providers. And this is really important because obstructive sleep apnea also increases the risk for dementia disorders. And you as a mental health provider or aging services provider, you don't wanna be the only person on this individual's team providing care.

That person needs to see their primary care provider and may likely need to see a sleep medicine provider as well, and to get a sleep study done to understand their sleep architecture and what supports they need in place for their particular concern. So you want to be working with and referring to primary care and also sometimes to sleep medicine to understand what's really causing the sleep disturbance.

Primary care to help optimize like what we were just talking about. Medication, pacing, medical problems, chronic pain, et cetera. And then sleep medicine providers to potentially do a sleep study or understand if there's restless leg syndrome or sleep apnea. And like I said, you don't wanna be the only person on this client's team. You want your client to have all of the providers providing input and support to optimize that person's health and functioning.

And as we were talking about earlier, there are many medications and over the counter medications that are contraindicated for use among older adults like Benadryl and Tylenol PM or other sedatives that older adults, if they knew what the consequences were, may choose not to use them.

And so working with primary care providers to help provide that education and assess for some concerns related to that is really important as well.

So as with other conditions, the earlier we can identify sleep disturbance or insomnia, the better. And as I mentioned, cognitive behavioral therapy for insomnia is the gold standard treatment, and it tends to be time limited treatment as well. In my comprehensive mental health and aging certificate program, which is an 18 hour program that I offer a couple of times a year to train mental health providers in providing psychotherapy to older adults. We dive deeper into cognitive behavioral therapy for insomnia. So I hope that you check out my certificate course when enrollment opens.

Here's what's important to remember. Sleep problems are not a foregone conclusion among older adults. Older adults benefit from care, benefit from collaboration with their medical providers, benefit from sleep studies to understand how to optimize sleep, and you have a really important role and helping them to gain those resources and a better quality of life.

And better brain health down the road. So thank you for being here and doing your part, 'cause you really do have an important role in making sure that older adults get the mental health care that they need and deserve.

I'm Dr. Regina Koepp. I'm a board certified clinical psychologist and Geropsychologist, and I founded the Center for Mental Health and Aging. For more than 20 years, I've been working with older adults and some of the largest healthcare systems in the world, from Stanford to Emory to the Veterans Health Administration, and I'm providing all of my insight and learning to you.

So if you enjoyed this episode, please subscribe and leave a review and share with people that you think might find this helpful. It really does help other people to find this information and improve mental health for older adults. So thank you for being here and doing your part.