By Mary Carpenter
CONNECTICUT organic farmer L.P. struggled for decades to get a good night’s sleep until, in her early 70s, she engaged a “sleep consultant”—and started cognitive behavior therapy for insomnia (CBT-i). So far, determining the best timing for nighttime sleep, called “sleep consolidation,” has been the most helpful—along with a variety of familiar “sleep hygiene” measures, such as avoiding electronic screens in the hours before bedtime.
The goal of improved sleep—along with reducing pain and anxiety—is currently driving soaring levels of cannabis use among seniors, according to the New York Times. For people age 65 and older—“one of the fastest-growing populations of cannabis users in the United States”—the numbers rose from about .4% in 2007 to about 8% in 2022. Said Denver geriatric psychiatrist Aaron Greenstein, “People are just desperate.”
Numbers of “wisdom customers,” which refers to those 55 and older, have increased each year for grower and seller Trulieve, which has “the largest retail footprint for cannabis products in the United States,” according to the Times. A major drawback to cannabis use, however, is insufficient research and ongoing obstacles: cannabis remains federally illegal; and the wide variability that exists among different cannabis products as well as its effects on different individuals.
And what gives pause to many sleep sufferers about cannabis is the risk of potentially serious side effects, such as dizziness and panic attacks—as well as cannabinoid hyperemesis syndrome, which causes recurrent vomiting. According to the Times, California ER visits associated with cannabis use among older adults rose more than 1,800 percent from 360 visits in 2005 to 12,167 in 2019. Also, as with many medications, any beneficial effects can diminish over time.
For insomnia, CBT is “generally…the first treatment recommended,” according to the Mayo Clinic. “The cognitive part of CBT teaches you to look for and change beliefs that affect your ability to sleep…help you control or get rid of negative thoughts and worries that keep you awake.” One recommendation, for example, is to “remain passively awake”—by suppressing thoughts about falling asleep.
Sleep consolidation, also known as sleep restriction, begins with limiting the time spent in bed—with an initial goal based on hours of actual sleep previously recorded: for example, five hours of sleep out of seven or eight spent in bed. For the first few nights of consolidation, the allowed amount of sleep is insufficient, causing fatigue that slowly helps make it easier to fall asleep, to sleep better during the time allotted and eventually to sleep well for a longer time period.
Improvements in total sleep time and sleep efficiency by eight to ten percent were the findings of a 2015 meta-analysis of CBT-i involving 1162 patients, reported in the Annals of Internal Medicine—with the note: “psychological approaches are likely to produce sustained benefits without the risk for tolerance or adverse effects associated with pharmacologic approaches.”
“The long-term improvements seem to result from the patient learning how to support and promote the body’s natural sleep mechanism,” writes Jeffrey Rossman, “Life Management Director” at Canyon Ranch in Lenox, Mass., in the American Journal of Lifestyle Medicine. “Changing sleep patterns requires changing the negative thoughts and beliefs…like “I dread getting into bed because I won’t be able to get to sleep… and I’ll be a wreck tomorrow!”
“CBT-i produces results that are equivalent to sleep medication, with no side effects, fewer episodes of relapse, and a tendency for sleep to continue to improve long past the end of treatment,” Rossman observes. While sleep medication can be effective short-term, side effects can include episodes of amnesia, cognitive impairment and morning hangover—and in some patients, these can require increasingly higher doses and lead to dependence and tolerance.
Sleep hygiene, in addition to avoiding electronic screens and other bright lights before bed, includes refraining from eating and from drinking alcohol two to three hours before bedtime, and avoiding caffeine in the afternoon and evening. Other recommendations include exposure to bright outdoor light in the morning or early afternoon, and developing a relaxing evening routine.
In addition, CBT-i advocates relaxation training and biofeedback, which involves practicing “how to relax both your mind and your body,” according to Sleep Education. Various devices can help teach relaxation by signaling levels of muscle tension or brain wave frequency, which the user can learn to alter in ways that improve sleep.
Cognitive control and psychotherapy make up another component of CBT-i, to help “identify attitudes and beliefs that hinder your sleep,” according to the sleep education site. One suggestion is to set a “’worry time” in the afternoon or early evening [to] review the day and plan for tomorrow…You focus on getting all your worries out of your system.”
Another suggestion is to use guided imagery: “You imagine you are in a story…try to picture what things look, feel and sound like…try to make it as real as possible,” according to Sleep Education. Keeping your mind away from worries can also help prevent active efforts to sleep and allows the body to relax and eventually to sleep.
CBT-i also includes “stimulus control:” going to bed only when you feel very sleepy; and if you are not asleep after 20 minutes, get out of bed and do something relaxing. But maybe most important, according to Sleep Education, is using the bed “only for sleep and for sex,” and not doing anything else in bed, including watching TV and reading.
But reading before bed, for some people, “actually allows our brain to move from ‘doing’ mode to ‘just being’ mode,” according to Orlando sleep psychologist Sarah Silverman. If you associate reading with sleep, Silver advises to keep it up, with whatever books you are accustomed to choosing before bed. Other sleep experts advise against reading crime, thrillers and books that might be “emotionally distressing.”
To find behavioral sleep medicine specialists, available to meet in person or online, the Mayo clinic recommends checking sleepeducation.org/sleep-center, and behavioralsleep.org. And the site suggests most people need six to eight sessions—which can be covered by insurance.
Although doing much better, L.P. still struggles enough on some nights that she takes Seroquel, the sedative she relied on for years to help with sleep. While I don’t often have trouble sleeping, if I can predict a bad night—such as before early-morning travel plans—I take the antihistamine doxylamine, recommended for sleep. On weekends, I sometimes eat a low-dose cannabis candy because these seem to provide deeper sleep. And on the few nights when I slowly become aware that I’m struggling to get to sleep, I try to figure out what could be bothering me, and then work on sorting it out—or else I start going through lists, such as European countries or U.S. states.
—Mary Carpenter regularly reports on topical subjects in health and medicine.