Sleep, Quality of Life, and Intervention

Maria T. Caserta, M.D., Ph.D.

Youre not healthy, unless your sleep is healthy.
Dr. William Dement

Sleep complaints are extremely common in

community-dwelling older adults and have been estimated to be as high as 50%.1 Sleep disturbances affect
health outcomes and many studies have shown that
sleep disturbances affect functional disability in patients with various chronic diseases.2,3 A recent study
of 213 community-dwelling Chinese adults demonstrated that 50% of that population reported sleep
complaints and most significantly that poor sleep
quality, by itself, was significantly associated with functional disability after controlling for the effects of other
established risk factors such as depression and chronic
illnesses.4 There are many studies, both large and small,
that have shown that sleep disturbances contribute to
functional disability across the globe. In one very large
study of more than 40,000 community-dwelling older
adults in eight countries in Asia and Africa, the authors
found that 16.6% of the participants reported severe
sleep problems, with a wide variation across different countries.5 Given the population studied (900
million people), 150 million would be experiencing
sleep problems now; and this number is more likely
going to grow as these countries experience ongoing
epidemiologic and demographic transitions as the population ages. There seems to be an emerging global
epidemic of sleep problems in older adults that remains
unrecognized and not simple to address.
The study in this months issue by authors Brenes,
Danhauer, Lyles, Anderson, and Miller6 focuses on
addressing the treatment of sleep disturbances in rural,
community-dwelling older adults diagnosed with generalized anxiety disorder (GAD) and assessing the

effects of treatment on quality of life and physical

disability. They compared telephone-delivered cognitive behavior therapy (CBT-T) with telephonedelivered nondirective supportive therapy (NST-T)
for the treatment of GAD and focused on the non
mood-related outcomes of sleep, health-related quality
of life (HRQL), and disability. The results indicate
that CBT-T was more effective in improving sleep
and also in improving HRQL than NST-T, although
both treatments did result in improvements in both
domains. These improvements were maintained at 1
year follow-up.
Are these findings generalizable to other older adult
populations (i.e., of lower educational and socioeconomic status)? How can we reach broader audiences
in addressing sleep problems so we can prevent the
inexorable declines in ability and quality of life in older
adults? Many of us in the medical community are not
accustomed to using any other interventions besides
face-to-face sessions in our office, in a clinic, or in a
home visit. The delivery of care is changing rapidly,
with more technological interventions being used such
as telemedicine and telepsychiatry. Telephoneadministered therapy is not a new technology and is
easily available to most elderly patients of varying economic means. Mobile apps for smart phones are being
developed and are already on the market for monitoring and even treating depressive symptoms, but
have not yet been validated. Nevertheless, CBT-T has
been studied and compared with face-to-face CBT and
found to be equally effective for the treatment of
depressionwith the added benefit of having less discontinuation, that is, greater adherence.7
If we are going to address the growing epidemic of
poor sleep in the burgeoning elderly population as one
way to improve quality of life and prevent future

Received June 13, 2016; accepted July 8, 2016. From the Department of Psychiatry, University of Illinois College of Medicine, Neuropsychiatric
Institute, Chicago, IL. Send correspondence and reprint requests to Dr. Maria Caserta, Department of Psychiatry, University of Illinois College
of Medicine, Neuropsychiatric Institute, 912 S Wood Street # 430, Chicago IL 60612. e-mail: mcaserta@psych.uic.edu
2016 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jagp.2016.07.004

Am J Geriatr Psychiatry 24:10, October 2016

855

Invited Perspective
disability, we will need to develop and implement interventions such as telephone- delivered CBT, or other
targeted therapy delivered by phone, that can reach

rural and house-bound elderly in poorer and underserved communities and nations where face-to-face
intervention is not possible.

References
1. OHayon MM: Epidemiology of insomnia: what we know
and what we still need to learn. Sleep Med Rev 2002; 6:97
111
2. Klink M, Quan SF: Prevalence of reported sleep disturbances in the
general population and their relationship to obstructive airway diseases. Chest 1987; 91:540546
3. Luyster FS, Chassens ER, Wasko MC, et al: Sleep quality and functional disability in patients with rheumatoid arthritis. J Clin Sleep
Med 2011; 7:4955
4. Chien M-Y, Chen H-C: Poor sleep quality is independently associated with physical disability in older adults. J Clin Sleep Med 2015;
11:225232

856

5. Stranges S, Tigbe W, Gomez-Olive F, et al: Sleep problems : an Emerging Global Epidemic? Findings from the INDEPTH WHO-SAGE study
among more than 40,000 older adults from 8 countries across Africa
and Asia. Sleep 2012; 35:11731181
6. Brenes GH, Danhauer SC, Lyles M, et al: The effects of telephonedelivered cognitive-behavioral therapy and nondirective supportive
therapy on sleep, health-related quality of life, and disability. Am J
Geriatr Psychiatry 2016; doi:10.1016/j.jagp.2016.04.002
7. Mohr D, Ho J, Duffecy J, et al: Effect of telephone-administered vs
face-to face cognitive behavioral therapy on adherence to therapy
and depression outcomes among primary care patients. JAMA 2012;
307:22782285

Am J Geriatr Psychiatry 24:10, October 2016