August, 2006

What is Insomnia?

Insomnia is defined as taking more than 30 minutes to get to sleep, waking for a period of more than 30 minutes, or waking earlier than desired, with feelings of fatigue and drowsiness during the day, recurring over at least a 30 day period (Lacks, 1987).

Dimensions of the Problem

Insomnia is a very common problem in the elderly. People over age 65 experience sleeping problems more and are more sensitive to sleeping aids than other groups (Aging and Drugs, undated). The National Commission on Sleep Disorders Research reported $15.9 billion as direct cost of sleep disorders and sleep deprivation, with an estimated $50 to $100 billion in indirect costs, mostly from accidents (Overview of the Findings, 1998). In European studies, drowsiness has been found to be a greater traffic hazard than alcohol consumption (Haraldsson and Akerstedt, 2001).

The cost to Americans for products and services to treat insomnia is $14 billion annually, with $10 billion of that being spent on nursing home patients; Americans spend $2 billion annually on sleep products (Walsh and Engelhardt, 1999), with seniors or their insurance carriers paying a substantial percentage of that amount, since older people are prescribed sleep medicines twice as much as younger people (Folks and Burke, 1998).

Causes of Chronic Insomnia

Although a number of medical conditions can cause insomnia, chronic insomnia is most commonly a behavioral or mind-body problem (Lacks, 1987). In the geriatric population, other conditions must also be considered, since their symptoms (e.g., chronic pain) can contribute to insomnia.

Temporary sleeplessness during stressful times can lead people to form a link between bed and worrying. Insomniacs tend to have higher than normal levels of anxiety and depression, low self-efficacy, and expect too much of themselves -- all of which can either cause or effect sleeplessness. Hormonal changes and drug use, including prescription drugs, cigarettes, and alcohol, can also cause insomnia (Lacks).

Medical Treatment

Until recently, sleeping pills have had as many risks as benefits. With older pills, people can build up a tolerance to them in about two weeks With the newer ones, it can take about four weeks. In elderly patients, sleep medications can cause falls or breathing complications, and are associated with a high incidence of hip fracture (Ray, Griffin, et al, 1987; Ray, Griffin, et al, 1989; Ray, Griffin, and Malcom, 1991).

Sleep aids can interact with other medications or alcohol, and can disrupt natural sleep/awake cycles circadian rhythms. There is a rebound effect after people stop taking them. The next day, the after-effects of sleep medications can make people feel as bad as not sleeping does (Lacks, 1987).

Nonpharmacologic Treatment Including Guided Imagery

"CBT [cognitive behavioral therapy] has emerged as 'the treatment of choice'" for managing the sleep/wake aspects of primary insomnia, according to one research team (Edinger & Means, 2005.) Behavioral therapy has been repeatedly demonstrated the most effective long-term approach to chronic insomnia, in both general and specific populations (Backhaus, Hohagen, et al, 2001; Dashevsky & Kramer, 1998; Jansson & Linton, 2005; McClusky, Milby, et al, 1991; Morin, Colecchi, et al, 1999; Morin, Mimeault, 1999; Pallesen, Nordhus, et al, 2003). The main categories of behavior therapy for insomnia are stimulus control – using bed only for sleep – a sleep hygiene program, keeping a sleep log, cognitive control, and progressive relaxation. These methods are often combined.

Cognitive distraction – a major component of guided imagery, hypnosis, and similar techniques, can be instrumental in avoiding worry and anxiety that often contributes to insomnia (Harvey & Payne, 2002; Ree, Harvey, et al, 2005).

Relaxation is effective, with or without stimulus control measures, in reducing sleep-onset insomnia (Cannici, Malcolm & Peek, 1983). Effects are better when the two techniques are combined (Jacobs, Rosenberg, et al, 1993). In one well-designed clinical trial, seniors using Cognitive Behavioral Therapy (CBT) and relaxation therapy were able to fall asleep 54% faster and 16% faster respectively (Edinger, Wohlgemuth, et al, 2001). Similar results were reported in a 2002 study of older patients: 54% of patients who received classroom CBT, and 35% of patients who used home-based audio relaxation treatment achieved significant changes (Rybarczyk, Lopez, et al, 2002).

Authors of a 2006 review of the literature reported that seniors (age 55+) using CBT had “robust improvements in sleep quality, sleep latency, and wakening after sleep onset” (Irwin, Cole & Nicassio, 2006).

Since CBT and relaxation (including audio tapes) are both effective, evidence suggests that combining the two would yield greater benefits. This seems to be borne out by the Engle-Friedman study of older adults. It demonstrated that progressive relaxation and learning new sleep habits helped patients become less depressed, and achieve a better sense of control, fell asleep faster, and slept better, even two years later (Engle-Friedman, Bootzin, et al, 1992).

Authors of three reviews of the literature of mind-body techniques (including techniques such as relaxation, meditation, biofeedback) concluded that there is, respectively, either “considerable,” “sufficient,” or “moderate” evidence of their effectiveness in insomnia (Astin, Shapiro, et al, 2003; Barrows & Jacobs, 2002; Mamtani & Cimino, 2002). A 2003 study found that at-home use of relaxation tapes was just as effective as massage in improving subjects’ sleep (Hanley, Stirling & Brown, 2003).


Guided imagery can help senior patients cope with chronic insomnia, and may save resources spent on prescription sleep medications. Effects will be stronger if included behavioral recommendations are followed.


[no authors listed] Aging and Drugs. Merck Manual Home Edition. Undated.
Accessed August, 2006.

Astin JA, Shapiro SL, Eisenberg DM, Forys KL. Mind-body medicine: state of the science, implications for practice. J Am Board Fam Pract. 2003 Mar-Apr;16(2): 131-47.

Backhaus J, Hohagen F, Voderholzer U, Riemann D. Long-term effectiveness of a short-term cognitive-behavioral group treatment for primary insomnia. Eur Arch Psychiatry Clin Neurosci. 2001 251(1):35-41.

Barrows KA, Jacobs BP. Mind-body medicine. An introduction and review of the literature. Med Clin North Am. 2002 Jan;86(1): 11-31.

Cannici J, Malcolm R, Peek LA. Treatment of insomnia in cancer patients using muscle relaxation training. J Behav Ther Exp Psychiatry. 1983 Sep;14(3):251-6.

Dashevsky BA, Kramer MJ. Behavioral treatment of chronic insomnia in psychiatrically ill patients. Clin Psychiatry. 1998 Dec; 59(12):693-9.

Edinger JD, Means MK. Cognitive-behavioral therapy for primary insomnia. Clin Psychol Rev. 2005 Jul;25(5):539-58.

Edinger JD, Wohlgemuth WK, Radtke RA, Marsh GR, Quillian RE. Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled trial. JAMA. 2001 Apr 11;285(14):1856-64.

Engle-Friedman M, Bootzin RR, Hazlewood L, Tsao C. An evaluation of behavioral treatments for insomnia in the older adult. J Clin Psychol. 1992 Jan;48(1):77-90.

Folks DG, Burke WJ. Psychotherapeutic agents in older adults. Sedative hypnotics and sleep. Clin Geriatr Med. 1998 14:67-86.

Hanley J, Stirling P, Brown C. Randomised controlled trial of therapeutic massage in the management of stress. Br J Gen Pract. 2003 Jan;53(486):20-5.

Irwin MR, Cole JC, Nicassio PM.Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age. Health Psychol. 2006 Jan;25(1):3-14.

Haraldsson PO, Akerstedt T. Drowsiness--greater traffic hazard than alcohol. Causes, risks and treatment. Lakartidningen. 2001 Jun; 20;98(25):3018-23.

Jacobs GD, Rosenberg PA, Friedman R, Matheson J, Peavy GM, Domar AD, Benson H. Multifactor behavioral treatment of chronic sleep-onset insomnia using stimulus control and the relaxation response. A preliminary study. Behav Modif. 1993 Oct; 17(4) :498-509.

Jansson M, Linton SJ. Cognitive-behavioral group therapy as an early intervention for insomnia: a randomized controlled trial. J Occup Rehabil. 2005 Jun;15(2):177-90.

Lacks P. (1987). Behavioral Treatment for Persistent Insomnia. Oxford, England: Pergamon Books.

Mamtani R, Cimino A. A primer of complementary and alternative medicine and its relevance in the treatment of mental health problems. Psychiatr Q. 2002 Winter;73(4): 367-81.

McClusky HY, Milby JB, Switzer PK, Williams V, Wooten V. Efficacy of behavioral versus triazolam treatment in persistent sleep-onset insomnia. Am J Psychiatry. 1991 Jan; 148(1):121-6.

Morin CM, Colecchi C, Stone J, Sood R, Brink D. Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. JAMA. 1999 Mar 17;281(11):991-9.

Morin CM, Mimeault V, Gagne AJ. Nonpharmacological treatment of late-life insomnia. Psychosom Res. 1999 Feb;46(2):103-16.

[no authors listed] Overview of the Findings of the National Commission On Sleep Disorders Research. Stanford University. 1992. Updated July 22, 1998.
Accessed August, 2006

Pallesen S, Nordhus IH, Kvale G, Nielson GH, Havik OE, Johnsen BH, Skjotskift S. Behavioral treatment of insomnia in older adults: an open clinical trial comparing two interventions. Behav Res Ther. 2003 Jan;41(1):31-48.

Ray WA, Griffin MR, Schaffner W, Baugh DK, Melton LJ 3rd. Psychotropic drug use and the risk of hip fracture. N Engl J Med. 1987 316:363­9.

Ray WA, Griffin MR, Downey W. Benzodiazepines of long and short elimination half-life and the risk of hip fracture. JAMA. 1989 262:3303­7.

Ray WA, Griffin MR, Malcolm E. Cyclic antidepressants and the risk of hip fracture. Arch Intern Med. 1991151:754­6.

Ree MJ, Harvey AG, Blake R, Tang NK, Shawe-Taylor M. Attempts to control unwanted thoughts in the night: development of the thought control questionnaire-insomnia revised (TCQI-R). Behavioral Research and Therapy. 2005 Aug; 43 (8): 985-98.

Rybarczyk B, Lopez M, Benson R, Alsten C, Stepanski, E. Efficacy of two behavioral treatment programs for comorbid geriatric insomnia. Psychol Aging. 2002 Jun;17(2):288-98.

Walsh JK, Engelhardt CL. The direct economic costs of insomnia in the United States for 1995. Sleep. 1999 May 1;22 Suppl 2:S386-93.