CGPR: Why is it important for clinicians to take sleep problems seriously and not accept them as a normal part of aging?
Dr. Lee: Sleep disorders are incredibly common among older adults: As many as 40%–70% of older adults have chronic sleep problems (Miner B and Kryger MH, Sleep Med Clin 2017;12(1):31–38). Many older adults have trouble falling asleep or staying asleep, wake up too early, or are unable to return to sleep—leaving them exhausted in the morning. Despite this, there’s a lack of awareness about the critical importance of sleep. Too often, these issues are dismissed as just a normal part of aging. However, I firmly believe that while sleep disorders may be common among older adults, they are not normal and should not be ignored. I want people to know that sleep disorders can and should be treated. I encourage patients to speak with their clinicians about their sleep concerns. Better sleep is possible, and addressing these issues can significantly improve overall quality of life. For many, the discomfort of sleeplessness is a strong motivator to seek help and find solutions. We need to prioritize sleep health for everyone, regardless of age.

CGPR: What are the key factors that impact sleep in older adults today?
Dr. Lee: Lately, we’re seeing a lot of changes in sleep driven by changes in technology. Older adults are spending more time on screens (Grigg-Damberger MM and Yeager KK, J Clin Sleep Med 2020;16(S1):25–26). It’s important to think about how light exposure and changes in our patients’ habits affect their sleep. There’s also a renewed interest in social media and how it affects sleep and mental health in older adults (Fu L and Xie Y, Healthcare (Basel) 2021;9(9):1143). 

CGPR: Tell us about sleep quality. Is this just subjective reporting?
Dr. Lee: Sleep quality is what’s experienced by the patient. In someone who is not sleeping enough, increasing their time asleep should improve sleep quality, assuming they don’t have sleep apnea or fragmented sleep from another cause. Often, improving sleep continuity or reducing overnight awakenings can improve sleep quality as well. Importantly, a patient’s subjective experience seems to be what most significantly impacts mood and cognitive functioning. 

CGPR: What about objective measures?
Dr. Lee: Objective measures are helpful, especially in older adults and people with psychotic disorders, because these patients don’t have to rely on their own memory of how well they slept. As sleep changes from night to night, objective measures can assess the variability of the experience. Still, while objective measures can be linked to the subjective sleep quality experience, the correlation isn’t always perfect. 

CGPR: Could you discuss the latest research on the relationship between sleep disturbances and cognitive decline in older adults? 
Dr. Lee: Over the last decade, we’ve seen compelling evidence that slow-wave sleep deficits and decreased lymphatic clearance of the brain may be causally associated with the development of neurodegenerative disease and particularly Alzheimer’s disease (Yee YF et al, Front Neurosci 2020;14:705). Amyloid and tau proteins are essentially cleared out of the brain during slow-wave sleep. When patients experience less slow-wave sleep, these proteins accumulate—slow-wave sleep might therefore be a modifiable risk factor (Himali JJ et al, JAMA Neurol 2023;80(2):1326–1333). Researchers are trying to artificially enhance and increase slow-wave sleep. A noninvasive acoustic stimulation device that sits beside your bedside clock now exists. It increases slow-wave activity in the brain during sleep, which could even improve cognitive outcomes, such as sleep-dependent memory consolidation (Lustenberger C et al, Commun Med (Lond) 2022;2:30). 

CGPR: Interesting. Can you tell us more about these acoustic stimulation devices?
Dr. Lee: Studies are still small and often lack long-term outcomes. We need more information, especially in broader populations, about how to use these devices in a way that makes sense. Even if they could increase slow-wave activity, they may also change brain synchronicity (the coordinated firing of neurons that supports cognitive function). While some such devices are commercially available, they’re not quite ready for prime time. Even if they improve one aspect of sleep, do they really lead to downstream benefits? Still, multiple studies suggest this kind of auditory stimulation improves at least short-term verbal declarative memory in healthy adults (Zhang Y and Gruber R, Yale J Biol Med 2019;92(1):63–80). One of the most well-validated sleep measures that improves with the use of acoustic stimulation is memory consolidation. If you learn something the night before, then you should be able to remember it better the next day if you have a good night’s sleep. Still, it’s unknown whether these short-term improvements translate to long-term improvement in Alzheimer’s-type memory issues. 

CGPR: Could these devices cause harm? 
Dr. Lee: We don’t know. They are likely less harmful than pharmacologic agents for insomnia, which have known side effects.

CGPR: What are your thoughts on digital sleep trackers? 
Dr. Lee: There can be a huge benefit when people talk about their sleep and track their personal data. It’s a great conversation starter with their clinicians. Many sleep trackers offer patients their sleep score, which is tied to sleep efficiency—how much time spent in bed versus time spent asleep. I like encouraging these preventative routines or good “sleep hygiene” like going to bed at the same time every night, waking up at the same time every day, and trying to make sure to sleep at least seven to nine hours. Many wearables remind people to wind down, to have less screen time, to avoid exercise before bed, and to avoid caffeine or alcoholic beverages right before bed. Just keep in mind that, although being aware of your sleep through these devices can be helpful, they are not usually able to diagnose specific sleep problems, and patients often need a confirmatory sleep evaluation to formally diagnose certain sleep disorders (Editor’s note: The Apple Watch Series 9 and later models can help detect sleep apnea).

CGPR: What is the role of personalized medicine in treating insomnia among older adults, especially those with coexisting psychiatric conditions like depression or anxiety? 
Dr. Lee: As we age, we see heterogeneity increase. A 60-year-old who’s very healthy will look very different than a 60-year-old who has many chronic medical issues. It’s not only the physical comorbidities; we also have to think about medications, whether depression, anxiety, or other mental health factors are contributing to sleep, or whether they also have a primary sleep disorder. As a psychiatrist, I try to encourage people to get formally evaluated for sleep issues. We know that sleep apnea—which can affect mood, anxiety, and functioning—is more common as people get older. We don’t want to miss treating a primary sleep disorder just because sleep problems are common in depression and anxiety. It can take an investigation from the clinician; trying to figure out the history; what’s worked, what hasn’t worked, and why; and then finding the right treatments to improve sleep. There’s a lot of opportunity for approaches like using artificial intelligence (AI) to consolidate this data and help us make better decisions. 

CGPR: In your view, what are the most effective nonpharmacologic interventions for managing insomnia in the geriatric population?
Dr. Lee: Cognitive behavioral therapy for insomnia (CBT-I) is the most effective and the safest treatment. Unlike sleep medication, whose side effects can be devastating in older adults, CBT-I has no side effects. CBT-I helps patients manage the amount of time they spend in bed asleep. It helps to control the cues that are associated with the bed that are clearly associated with sleep, not with other things like staying awake or feeling anxious or planning the day. Successfully managing insomnia with CBT-I can prevent recurrence, or even development, of depression in older adults (Irwin MR et al, JAMA Psychiatry 2022;79(1):33–41). Brief Behavioral Treatment for Insomnia (BBTI) is another great treatment that simplifies and shortens the process, focusing on the core tenets of CBT-I (Editor’s note: For more on BBTI, see our interview with Dr. Buysse in this issue). It can be helpful for people with mild cognitive impairment or those struggling to adhere to CBT-I. Adults with psychotic disorders often have cognitive deficits that begin around the time of the illness, so BBTI is great for them. 

CGPR: Can you walk us through your algorithmic approach? Many people aren’t able to connect with a CBT therapist for CBT-I.
Dr. Lee: My algorithm always starts with sleep hygiene measures and getting a really thorough sleep history. I also think about what’s waking the patient up at night, which can be anything from pain to a prostate issue. I consider REM sleep behaviors that can be a prodrome for Parkinson’s disease. I ask about prior sleep studies and the patient’s experience with sleep medications. I ask about use of melatonin, cannabis, and Tylenol PM or other over-the-counter medicines. Understanding how mood and anxiety symptoms may be related to sleep problems can help too. For treatment options, although CBT-I and BBTI are not always available locally with an in-person therapist, there are app-based or even telephonic options that can be helpful. 

CGPR: Can you speak more about how CBT-I can be delivered telephonically? 
Dr. Lee: There’s good evidence that you can deliver CBT-I over the telephone; you don’t need a video call (McCurry SM et al, JAMA Intern Med 2021;181(4):530–538). Although finding a CBT-I therapist can be tricky, clinicians can incorporate CBT-I principles into their patient appointments. The major limitation can be filling out the sleep diary (www.tinyurl.com/h94s3b84). This is such an important part of the treatment because it helps people understand their sleep better. What often improves is their perception of sleep, but it can also change objective measures. For people with cognitive issues, though, it can be hard to remember to complete the sleep diary. It can even be beneficial for patients to do CBT-I on an app, using a chatbot or generative AI format. This way, people can interact with a therapist who is available all the time and can encourage patients to keep up good sleep habits.

CGPR: Which medications do you consider for treating sleep disorders in older adults?
Dr. Lee: I tend to prefer melatonin in many situations because it’s so safe and efficacious. I would next consider the newer orexin medications or low-dose doxepin. Trazodone doesn’t have strong evidence for improving insomnia, but anecdotally it can help individuals (Sateia MJ et al, J Clin Sleep Med 2017;13(2):307–349). If sleep problems are related to nightmares or PTSD, I consider prazosin. The evidence is mixed, but it can be effective for some. Depending on comorbidities, I might consider a sedating antidepressant like mirtazapine. For older adults with comorbid anxiety at nighttime, I’ll consider gabapentin as well. In younger adults, I would consider Z-drugs earlier, but this is probably third or fourth line for an older adult. I try to avoid anticholinergic medications or medications that increase the fall risk, like benzodiazepines in older adults.

CGPR: How do antipsychotic medications influence sleep patterns in older adults? 
Dr. Lee: Although we try to avoid antipsychotics for insomnia alone, in patients with psychotic symptoms, certain antipsychotics can also help with sleep difficulties. We see a lot of quetiapine prescriptions for sleep complaints, ­especially in people with psychotic disorders or neuropsychiatric symptoms of dementia. Quetiapine may improve sleep quality or self-reported experiences of sleep, but it’s not clear if it also affects breathing control and arousal threshold that may influence sleep apnea (Lin CY et al, Eur Neuropsychopharmacol 2023;67:22–36). Because quetiapine is associated with weight gain and metabolic problems more generally, it’s likely that it increases the risk for sleep apnea. Other antipsychotic medications have histaminergic effects, or alpha-1 adrenergic effects, or even serotonergic over dopaminergic effects. Many antipsychotics are sedating for individuals with psychotic disorders and are prescribed to help them fall asleep. Still, it’s not clear if increasing the amount of sleep or increasing total sleep time or sleep efficiency results in downstream improvements related to sleep benefits. Antipsychotics do a great job of managing positive symptoms. If those symptoms are driving a sleep problem, then addressing them could also be a reason that sleep is improving.

CGPR: Thank you for your time, Dr. Lee.