The High Costs of Insomnia

By Jamie Santa Cruz

Although insomnia is pervasive among older adults, it continues to be underrecognized and undertreated, often with significant emotional and financial detriment.

Individuals who suffer from insomnia no doubt perceive the condition to be a significant inconvenience. But patients and physicians alike may be unaware that insomnia—defined as difficulty falling asleep or staying asleep, with an associated impact on daytime hours—is quite costly in financial terms as well. The total economic burden of insomnia is approximately $100 billion per year, according to a new review from researchers at the University of Maryland.1 The report indicates that increasing the availability of treatment would not only impact patient health and well-being but would also lead to a reduction in health care costs.

The Costs of Insomnia
Some of the costs identified in the report are direct costs, namely those associated with treating insomnia. The majority, however, are indirect. They include, for example, increased use of health care services. Overall medical expenditures are higher among patients with insomnia, with one study cited in the review concluding that six-month expenditures for older adults with insomnia were $1,143 higher ($1,314 in 2016 USD) than for matched older adults without insomnia.2

Other indirect costs are related to lost productivity at work. According to the review, insomnia sufferers have been found to miss more days of work and to be at higher risk of disability than employees without insomnia, and they are also known to be less productive when they do show up to their jobs. One study cited in the report put the annual costs of poor performance associated with insomnia at $2,280 per employee (translating to $2,416 in 2016 USD).3 A third source of indirect costs stems from the increased likelihood of accidents and injuries both in and out of the workplace.4

In addition to these economic costs, insomnia also takes a psychological toll; sufferers of insomnia consistently report lower quality of life, as described in the report. "Once thought merely a symptom, insomnia is now well known to worsen outcomes in a number of chronic conditions, including both medical and psychiatric disorders," says Emerson Wickwire, PhD, an assistant professor at the University of Maryland School of Medicine and director of the insomnia program at the University of Maryland Medical Center. "In fact, insomnia has a profoundly negative impact on quality of life, regardless of disease state."

An Underrecognized Problem
Despite the significant negative consequences of insomnia, the disorder often goes untreated.5-7 Poor reimbursement for insomnia services is partly to blame, according to the report. But a lack of awareness among physicians regarding sleep and sleep disorders is also a substantial contributing factor. "It's not all the doctors' fault," Wickwire says. "They literally don't know any better because sleep frequently isn't included in medical school curricula. When it is included, the average instruction lasts about an hour."

Patients, for their part, are often hesitant to bring up sleep problems to their physicians. According to Jennifer Martin, PhD, an associate professor at the David Geffen School of Medicine at UCLA and spokesperson for the American Academy of Sleep Medicine, focus group research suggests one reason for the silence is because patients don't want to take sleeping pills, and they assume medications are the lone option doctors would provide. "There is a disconnect between what patients are looking for and what they think their provider is going to offer," she says.

Older patients, Martin adds, are particularly unlikely to mention sleep difficulties to their doctors. "When we look at rates of complaining about sleep, we're now finding that the oldest age groups don't complain much at all. It looks like people in their 70s and 80s almost never have insomnia, because they don't say much about it."

Prevalence of Insomnia Among Older Adults
Despite patient reticence to discuss them, sleep difficulties are common in the older adult population. Over one-half of older adults say they experience significant sleep disruption, about one in five complain of early morning awakenings, and approximately 29% suffer from insomnia.8 And there is consistent evidence that older adults are more likely than younger individuals to report sleep problems in general and insomnia in particular.9

As for why sleep problems increase with age, Martin cites changes in lifestyle as a major contributor. Older adults often spend more time in bed than their younger counterparts and may start to nap more frequently than they used to. Meanwhile, physical limitations often also lead to a reduction in activity level, and all of these changes can lead to difficulty sleeping.

In addition to lifestyle factors, changes in sleep architecture also impact older adults' sleep. For instance, Martin says, older adults experience less deep sleep, meaning they may not be able to sleep through sounds, such as the movements of a pet or the snoring of a spouse, that they could have slept through earlier in life.

But the prevalence of sleep difficulties in older age does not mean they should be ignored, according to Martin. "There are a lot of healthy older adults who sleep really well," she says. "When older people are not sleeping well, it's not part of normal aging. It's usually a sleep disorder."

Unfortunately, Martin says, physicians are often unaware that their patients are having difficulty. Physicians don't routinely screen patients for insomnia, and since older adult patients don't mention it, the disorder is often missed. It's a problem she says physicians can solve by taking the initiative with older adult patients and questioning them about sleep patterns at primary care visits. Her recommendation is that older adults who are not getting at least seven hours of sleep per night—regardless of the cause—should be evaluated and referred for treatment if a sleep disorder is the suspected cause.

"If a physician is screening other health behaviors like diet and physical activity, sleep really should be considered the third pillar of a healthy lifestyle," Martin says.

Treating Insomnia in Older Adults
Fortunately there are effective treatments suitable for older adult patients, including nonpharmacologic options. Cognitive-behavioral therapy for insomnia (CBTI) has been shown to be highly effective for all age groups and is recommended as the first line treatment for older adults.10 Although patients may experience differing forms of insomnia—trouble falling asleep vs trouble staying asleep—cognitive-behavioral therapy is the preferred treatment in both cases, Martin says. Patients who are unable to fall asleep, for example, might be going to bed too early or may be dealing with chronic pain. Those who have a difficult time staying asleep, by contrast, may need to minimize factors in the environment that wake them up (by finding a new home for the dog, for example).

"The benefits from CBTI are equal to sleeping pills, and the gains are far more durable, lasting at least two years after treatment ends," Wickwire says. "Plus, CBTI has none of the risks or unwanted side effects of medications."

The one case in which cognitive-behavioral therapy is not the preferred treatment, according to Martin, occurs when patients complain of waking too early in the morning. This sleep difficulty results from a shift in circadian rhythms and is generally treated through light therapy—specifically, timed exposure to light in the evening to adjust the patient's biological rhythms.

As for sedating medications, the American Geriatrics Society recommends using them sparingly in older adults and only after patients have first received behavioral interventions.11 The major concern related to their use is an increased risk of falls, but there is also risk of cognitive problems and confusion.12,13

In general, Martin says, physicians have become significantly more attuned to sleep issues in the last decade, but there remains a lack of awareness with respect to insomnia and how to treat it. Martin's main message, therefore, is that insomnia in older adults should be taken seriously.

"Insomnia disorder is a clinical condition worthy of attention," she says. "If it can't be managed with simple strategies in primary care, then a referral to a sleep specialist is indicated, even for older patients. Insomnia is not part of normal aging; it is a sleep disease that requires clinical attention."

— Jamie Santa Cruz is a freelance writer based in Englewood, Colorado.

References
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10. Bloom HG, Ahmed I, Alessi CA, et al. Evidence-based recommendations for the assessment and management of sleep disorders in older persons. J Am Geriatr Soc. 2009;57(5):761-789.

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12. Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ. 2005;331(7526):1169.

13. Sivertsen B, Omvik S, Pallesen S, et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA. 2006;295(24):2851-2858.