Restful Relief Without Medication: Explore Cognitive Behavioral Therapy for Insomnia in Older Adults

Since his retirement ten years ago, Jim’s had trouble adjusting to the lack of structure and routine that decades as a San Francisco bus driver offered. The occasional nap turned into regularly drifting in and out of sleep throughout the day, and dinnertime became later and later as he began watching TV for hours every evening. What started as a mild case of restless sleep developed into chronic insomnia as a result of habits that altered his sleep cycles and made sleeping less comfortable.
A few years went by before Jim visited a doctor about the problem, who prescribed a medication to induce sleep. For a while, it helped Jim fall asleep more easily and sleep more soundly, but he always felt groggy during the day—a lingering effect of the medication. It left him feeling discouraged, but his doctor responded to this complication with an alternative treatment: cognitive behavioral therapy for insomnia, or CBT-I for short. Jim didn’t know what to expect, but his doctor told him that a therapist would help him get to the root of what was causing his insomnia, so they could begin to heal it from the inside out.

Feeling Empowered to Take on Chronic Insomnia

Suffering from chronic insomnia can often feel like a losing battle. Medication is one way to urge your body toward sleep, but it can often turn into a crutch with its own set of complications. And medications can come with a range of side effects, including daytime drowsiness, addiction, depression, stroke, and impaired memory, cognition, coordination, balance, and vision, all putting older adults at a higher risk of falls.
CBT-I, on the other hand, can help older adults face their insomnia head on, including the behavioral, emotional, and thought patterns that stand as barriers against falling and staying asleep at night. The American College of Physicians now recommends CBT-I as the primary course of treatment for adults with insomnia before considering whether medication might be necessary. By practicing CBT-I with a compassionate therapist, older adults can gain the awareness and confidence needed to develop better habits around waking and sleeping. They can reduce anxious or helpless thoughts, making way for a healthier life supported by deep rest and relaxation.
At its core, CBT-I is a process of empowering the individual to be conscious and to steer their own life in the direction of well-defined goals of self-care. The therapist is a guide through the process—they help to shine a light on the thoughts and the habits that aren’t serving their patient well—but it’s the individual who really brings about this change. And by feeling such a connection to these positive life changes, they maintain this self-awareness and new habits. For aging adults, CBT-I offers the structure and sense of purpose that often feel lacking after the transition through retirement and into an unfamiliar stage of life.

CBT-I Shines a Light on Habits and Patterns

Some older adults will need medication to treat their insomnia—perhaps when co-occurring disorders such as depression, anxiety, or other psychiatric conditions are also involved. But, medication is often just a short-term solution to restless nights. CBT-I can work hand-in-hand with medication to offer longer-term solutions for adapting behaviors and even preventing relapse after the medication is stopped.
CBT-I is not, however, a quick and easy fix. It involves careful monitoring and journaling of behaviors, thoughts, and feelings. CBT-I therapy is carefully tailored to each individual and supported by some of the following methods:

• Sleep restriction therapy: Napping throughout the day, or sleeping late into the morning, can have a significant impact on regular sleep cycles, so restricting and limiting the amount of time for sleep can help train the body to sleep more soundly during that designated window. When starting out with CBT-I, this can look like avoiding naps and forcing oneself to stay up later, so the body is tired and ready for nighttime sleep. Medication can make this important process more difficult if drowsiness is continuing into the day.
• Stimulus control: Keeping a journal or record of behaviors and thought patterns can help identify active barriers to sleep. Therapists can then help guide older adults to develop clearer associations between sleeping and waking. For example, Jim was advised to reserve the bedroom for sleep only, so as not to associate it with wakefulness. Even if he was having trouble falling asleep during the night, he would leave the bedroom until he felt ready to go back to bed. Another common suggestion is to cover the clock because compulsive clock watching can stimulate anxiety and thoughts that keep one awake. Sedative medications can leave older adults in a foggy state, making it more difficult to recognize their triggers and better control the environment for healthy sleep.
• Sleep hygiene education: There are common dos and don’ts that support or prevent healthy sleep: do follow a regular sleeping and waking schedule, do get regular exercise and outdoor time with sun exposure, don’t drink caffeine in the afternoon or evening. Other observances will be particular to the individual. For someone who often has to get up to visit the bathroom at night, it’s important to limit liquid intake later in the day. Good sleep hygiene depends on empowered thinking, decision making, and acting—unlike relying on a medication for more than a short time, which could eventually lead to dependency.
• Relaxation training: Another very helpful technique that can work without the help of medication is self-relaxation. An older adult can explore various methods with their therapist to see which one works best for them: progressive muscle relaxation, soothing visualizations, conscious breathing, or perhaps even counting backward. The therapist will have different suggestions, and this is something an individual can do in bed to relax their body and mind for restful sleep—and to take the place of persistent or anxious thoughts that get in the way of sleep.
• Relapse prevention: One important component of long-term relief from insomnia is the ability to recognize when one is slipping back into old habits that contribute to irregular sleep patterns. When an older adult is able to understand their own triggers, they can nip those triggers in the bud before they alter progress. This awareness itself is a powerful habit.

How Caregivers Can Help Support an Older Adult’s Progress

Older adults can find guidance through these CBT-I processes with individual or group therapy sessions, over the phone, through online learning, or even with the help of books. CBT-I has been shown to help older adults fall asleep in less time, spend less time awake during the night, and report better quality sleep.
A home caregiver can be exceptionally helpful in this process of becoming aware of, and recording, behaviors and patterns, understanding what it means to restrict and change unhealthy habits, and recognizing when these unhealthy habits begin to slip back in even after healthier habits have taken hold. Because of the challenges to memory and cognition in older age, patients may benefit from frequent repetitions of the insights and suggested practices from their therapy sessions.
If the older adult agrees, and it appears to assist in their progress, as a caregiver you may want to attend therapy sessions with them. It may even be possible to record a therapy session so that you can listen to it together and be reminded of the triggers to be aware of and the positive habits to move toward.
Oftentimes, insomnia is dismissed as an inevitable result of aging. Instead, changes in sleep patterns that happen with age should be seen as a new challenge to adapt to, not one to suffer through. With the help of an attentive and compassionate caregiver, an older adult can not only leave behind the harmful symptoms of insomnia, but also discover a new energy and mindful presence in their new stage of life.
If you’re interested in finding out more about CBT-I, or finding an experienced therapist for your aging loved one, get in touch today. Institute on Aging offers diverse resources, programs, and services to help you and your aging loved one feel empowered to live a life of balance.