Ultimately, late-insomnia (co-morbid or in isolation) should be viewed as a disorder that can be effectively treated 14. Additional research is needed to validate and/or modify CBTi for specific co-morbid conditions. Second, cognitive-behavioral treatment for insomnia was effective for late-life-insomnia in a study sample of older adults with representative rates of mental and physical co-morbidities, suggesting that CBTi need not be postponed until after co-morbid conditions have been treated 21. In fact, at a recent National Institute of Health (NIH) State-of-the Science Conference, it was recommended that the term co-morbid insomnia be used in place of secondary insomnia 20. Late-life insomnia presents so commonly with other health complaints that it may more appropriately be thought of as a co-morbid condition rather than a secondary complaint (i.e., secondary insomnia). Even when insomnia is preceded by another health condition, cognitive and behavioral factors often emerge to precipitate and perpetuate insomnia. However, two erroneous assumptions stemming from this perspective must be avoided: (1) that insomnia will generally subside once the co-morbidities have been treated and (2) that the behavioral treatment of insomnia cannot be successful in the presence of serious co-morbidities.įirst, insomnia generally persists long after co-morbidities have subsided. The recommendation that any co-morbid mental and physical health complaint should be the primary aim of treatment in late-life insomnia has been long maintained. In the primary care setting, however, sleep complaints are often poorly assessed, trivialized, and/or attributed to other mental and/or physical co-morbidities 19. Indeed, the likelihood of a complaint of insomnia increases when the sleep disturbance is more chronic and severe 10. This may be due in large part to the increased co-morbidity, chronicity, and severity of late-life insomnia 9. Older adults are more likely to present in a primary care setting (i.e., general practice) with sleep complaints than are younger adults 17, 18. Insomnia leads to and is precipitated by several health complaints 16, and because insomnia is often co-morbid with age related health problems, determining if aging has a direct or indirect role in the increased prevalence of insomnia has been difficult. Indeed, when mental and physical co-morbidities are controlled, the prevalence of late-life insomnia may be as low as 1%–7.5% 4, 15. While aging is associated with increased rates of insomnia, normal aging does not necessitate the onset of insomnia 12, 14. Research suggests that the increased rates of insomnia from mid-life to late-life are seen most prominently among older women, as elderly women present in a medical setting with insomnia complaints more frequently than men 6, 9, 12, 13. Importantly, the increased prevalence of late-life insomnia may be at least partially attributable to the finding that remission of insomnia is less common in older individuals than it is in younger individuals 11. The one year incidence rate of insomnia in the 65+ population has been reported to range between 3.1%–7.3% 9, 10. Regardless of the criteria, prevalence and incidence rates of insomnia significantly increase with age 4, 8. Likewise, these studies tend to yield larger prevalence rates (i.e., 30%–60%) 4, 5 than rates derived from studies that include these more stringent criteria (i.e., 12–25%) 6, 7. Epidemiological surveys in the United States generally do not reference the chronicity of the sleep complaint, do not require daytime impairment in the criteria of insomnia, or fail to screen out insomnia participants with comorbid somatic complaints. The prevalence and incidence rates of late-life insomnia depend largely on the criteria used in the specific study in question.
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