Insomnia affects approximately half of all older adults. Research suggests that insomnia may be underdetected and undertreated in clinical settings. While many older adults report difficulty sleeping, only about 10% are actually treated for a sleep disorder. In addition, older adults are high consumers of health services, with a substantial proportion of spending coming from hospitalizations, home healthcare services, and nursing home use.
Focusing on Older Patients
Previous studies have explored the relationship between insomnia and healthcare services use, but most have used clinical samples or focused on younger individuals. My colleagues and I, led by doctoral student Christopher Kaufmann, MHS, published a study in the Journal of Gerontology: Medical Sciences that examined the association between insomnia and the subsequent use of three different health services in a representative sample of middle-aged and older people. The study involved 14,355 participants in the Health and Retirement Study who were asked about their insomnia symptoms in 2006 and responded to questions about health service use 2 years later, including whether or not they had been hospitalized, used home healthcare, or used nursing home services. Specific insomnia symptoms included trouble falling asleep, waking during the night, waking early and not falling asleep again, and not feeling rested when wakening.
We found that insomnia symptoms were associated with greater odds of subsequently using costly health services. Those with two or more insomnia symptoms were more likely to be hospitalized and to use home healthcare services. Even after accounting for common medical conditions and depressive symptoms, we observed an association between insomnia symptoms and use of any of the three health services assessed in the study.
More than 40% of participants in our study reported having at least one insomnia symptom, which further supports that insomnia is common in the general population of middle-aged and older adults. If the associations we observed are causal, our results would indicate that preventing insomnia could decrease health service use and that treating insomnia might reduce patient loads in various healthcare settings. This might, in turn, substantially reduce healthcare costs.
Although insomnia appears to be an important indicator of future hospitalization among middle-aged and older adults, more research is needed to determine whether safe and effective treatment of insomnia and careful monitoring of symptoms might actually reduce health service use and costs. Older individuals with insomnia commonly have other health conditions that might lead to health service use, but insomnia might also exacerbate the severity of other underlying health problems, thereby increasing service utilization. Clinicians should be vigilant to safely treat insomnia and monitor symptoms when older patients present with this sleep disorder. Cognitive behavioral therapy for insomnia (CBT-I) can be an excellent choice in this patient population. CBT-I has been shown to be effective and may be safer than sedative-hypnotic medications, which are associated with potentially dangerous side effects.
Readings & Resources (click to view)
Kaufmann CN, Canham SL, Mojtabai R, et al. Insomnia and health services utilization in middle-aged and older adults: results from the Health and Retirement Study. J Gerontol A Biol Sci Med Sci. 2013 May 9 [Epub ahead of print]. Available at: http://biomedgerontology.oxfordjournals.org/content/early/2013/05/09/gerona.glt050.full.
Kaufmann CN, Spira AP, Rae DS, West JC, Mojtabai R. Sleep problems, psychiatric hospitalization, and emergency department use among psychiatric patients with Medicaid. Psychiatr Serv. 2011;62:1101-1105.
Jaussent I, Dauvilliers Y, Ancelin ML, et al. Insomnia symptoms in older adults: associated factors and gender differences. Am J Geriatr Psychiatry. 2011;19:88-97.
Spira AP, Covinsky K, Rebok GW, Stone KL, Redline S, Yaffe K. Objectively measured sleep quality and nursing home placement in older women. J Am Geriatr Soc. 2012;60:1237-1243.
Ozminkowski RJ, Wang S, Walsh JK. The direct and indirect costs of untreated insomnia in adults in the United States. Sleep. 2007;30:263-273.