You are currently viewing The Best Treatment for Sleep Problems in Elderly Adults – with Dr. Daniel Wachtel

The Best Treatment for Sleep Problems in Elderly Adults – with Dr. Daniel Wachtel

Episode #10May 26, 2020

You may be surprised to hear that the best sleep aid for older adults with insomnia is not a medication. It’s a type of psychotherapy, called CBT-I for Insomnia, or Cognitive Behavioral Therapy for Insomnia (CBT-I).


Insomnia is one of the most common sleep disorders experienced by older adults. Insomnia essentially means that a person has trouble falling or staying asleep, or experiences non-restorative sleep. This, of course, can lead to issues during the day like cognitive problems and mood and emotional issues.


Did you know that as many as 50% of older adults complain about difficulty falling asleep or staying asleep? And in fact, older adults (people 65 and older) are more likely to experience insomnia than younger or middle aged adults.


But here’s the thing… Sleep problems in elderly adults are treatable. In as little as one to ten (1-10 sessions) of CBT-I, older adults sleep better!


Today’s guest, Dr. Daniel Wachtel is a Clinical Psychologist and Geropsychologist. He works in private practice and is currently a clinical psychologist for the Home Based Primary Care Program at the Atlanta VA Health Care System, where he provides psychotherapy to chronically and terminally ill veterans and support to their families and caregivers. Dr. Wachtel has advanced training in sleep disorders and provides treatment for insomnia and related difficulties with sleep. Learn more on his website


In this episode of the Psychology of Aging Podcast, Dr. Wachtel tells us about the number one treatment for insomnia in elderly adults – Cognitive Behavioral Therapy for Insomnia (CBT-I)

Here’s a look inside my interview with Dr. Daniel Wachtel:

  • [05:24] Dr. Wachtel reveals the surprising statistics that explain exactly why sleep such an important topic when it comes to older adults
  • [07:59] Insomnia is one of those terms that people commonly use. Get the real definition of insomnia here.
  • [08:45] Dr. Wachtel reveals why insomnia is more prevalent in older adults than adults of any other age group
  • [15:43] Sleep is essential to health and well-being. Discover what happens when older adults don’t get enough sleep.
  • [17:54] Learn some of the biggest obstacles to helping older adults sleep well
  • [24:21] The best sleep aid for older adults with insomnia is not a medication, it’s Cognitive Behavioral Therapy for Insomnia, also known as CBT-I. Dr. Wachtel breaks it down.
  • [33:46] Want to improve your sleep today? Check out these sleep hygiene tips (a fancy term for healthy sleep behaviors)
  • [45:02] Not getting enough sleep can cause memory and concentration problems, leading older adults to worry that they may have dementia. Learn more here.
  • [47:13] Discover where can older adults and their families learn more about sleep issues and how to find treatment.

By the end of this episode, you’ll really get why sleep is so important in older adults, have tools for helping older adults sleep better, and have a keen understanding of the best treatment for insomnia in older adults.



Dr. Daniel Wachtel 0:00
The statistics are they range depending on which study you look at, but in in the average adult, say anywhere from 18 to 64. The rate of clinical insomnia, right, the sleep disorder of insomnia ranges anywhere from 31 to 38% of the population, a pretty high number. But when we look at older adults, those who are over 64 years of age, it rises to 45%.

Dr. Regina Koepp 0:32

Dr. Daniel Wachtel 0:33
Absolutely. So this is very much an issue for older adults.

Dr. Regina Koepp 0:41
I'm Dr. Regina Koepp. I'm a board certified clinical psychologist and I specialize with older adults and families. I created the psychology of aging podcast to answer some of the most common questions I get about aging questions about mental health and wellness changes in the brain. Like with dementia, relationships and sex, caregiving, and even end of life.Like I say in my therapy groups, no topicis off topic, we just have to have a healthy way of talking about it. So if you're an older adult or caring for one, you're in the right place. Let's get started.

Insomnia is one of the most common sleep disorders experienced by older adults. So insomnia essentially means that a person has trouble falling or staying asleep, or experiences non-restorative sleep. This, as you can imagine, can lead to issues during the day like cognitive problems and emotional distress. But did you know that as many as 50% of older adults complain about difficulty falling or staying asleep? In fact, older adults are more likely to experience insomnia than younger or middle aged adults.

Well, today I have a very special guest to talk with us about the number one treatment for older adults who are experiencing insomnia. Dr. Daniel Wachtel is a licensed clinical psychologist and Gero-psychologist, he received a master's degree in social work with a specialty in geriatrics. He then attained his doctoral degree in clinical psychology and gained exposure and training to a wide variety of populations and clinical environments. Dr. Wachtel is currently the clinical psychologist for the Home Based Primary Care Program at the Atlanta VA Medical Center. Dr. Wachtel's clinical work through the home-based program is spent making home visits and providing psychotherapy to chronically and terminally ill veterans and providing support and assistance to their caregivers and families. In an effort to provide similar services to non veterans. Dr. Wachtel has established Pioneer Psychological Associates located in Sandy Springs, Georgia. His practice serves adults 18 and up with a specialty in working with older adults. His areas of interest include chronic illness, dementia, grief and working with caregivers. Dr. Wachtel has advanced training in sleep disorders and provides treatment for insomnia and related difficulties with sleep.

Dr. Daniel Wachtel thank you so so much for making the time for our listeners today to talk about sleep and aging and some of the best practices that you have found that work with older adults related to sleep. As we get started, can you share a little bit about how you became interested in sleep and older adults?

Dr. Daniel Wachtel 4:01
Yeah, I'd be happy to and thank you for having me. Pleasure to be here. I've been looking forward to this. Yeah, my journey to working in the area of sleep was a, I think a very organic one. Like you, I have a passion for working with older adults, as you know. Some of my work is with a very medically complicated patients, patients who have a lot of physical ailments, a lot of physical disabilities, and I always am striving to see how can I assist them from a mental health perspective with their physical ailments, right. And the one common denominator that just seemed to be so clear, was sleep complaints, my problems with sleep and when I finally learned that, there was is a psychological treatment to psychotherapy designed for sleep disorders. It was sort of a no brainer. It just fit it fit with my population. And I found that I had a genuine interest. And I don't get tired, no pun intended of talking about sleep.

Dr. Regina Koepp 5:24
So why is sleep such an important topic when it comes to older adults? So you were talking about it being a common denominator with some of the more medically compromised individuals you're working with? So can you tell us a little bit about sleep and aging?

Dr. Daniel Wachtel 5:38
Sure. Yeah. Again, as I said, it was really an observation, right, a clinical observation of working with my patients that it just seemed to be that most if not all of my patients, at times were complaining of sleep problems. And I realized that that was, you know, a small subset. A small population. And I didn't know how indicative that was of the larger population. But as I really immersed myself in the sleep medicine world, I found that my observations were pretty accurate in the sense that to answer your question, older adults struggle with sleep- no two ways about it. Nearly half of all older adults complain of at least one sleep related symptom. Now that's not speaking of sleep disorders. But if we do for a moment, right, talk about sleep disorders. These statistics are they range depending on which study you look at, but in adults, say anywhere from 18 to 64. The rate of clinical insomnia right the sleep disorder of insomnia ranges anywhere from 31 to 38% of the population a pretty high number. But when we look at older adults, those who are over 64 years of age, it rises to 45%.

Dr. Regina Koepp 7:12

Dr. Daniel Wachtel 7:13
Absolutely. So this is very much an issue for older adults, much, much more even than average age adults. And, again, something that drove my interest and is why I do a lot of this type of work.

Dr. Regina Koepp 7:34
And so it makes sense that you are seeing it in your clinical practice if 45% (I mis-spoke and said 48%) are experiencing and that was just insomnia, that's sleep disorders in general.

Dr. Daniel Wachtel 7:44
That's specifically insomnia. Yeah, that's not even talking. You're right about other sleep disorders, sleep apnea, restless leg syndrome. There's so many other sleep disorders that other patients may suffer from as well. Absolutely.

Dr. Regina Koepp 7:59
Can you define insomnia?

Dr. Daniel Wachtel 8:01
Oh, sure. Yeah, the, you know, the term does have a few different types of definitions, depending on who you ask. But, you know, clinical insomnia is a persistent disruption in sleep. And it it, it's really what defines clinical insomnia is the frequency and the length of time. So it in order to be considered clinical insomnia, it occurs at least three nights a week for at least three months, despite adequate opportunity for sleep. So, you know, the sleep opportunity's there. It's not talking about if you have a job or something that's forced you to, to not sleep, but if the sleep is there, the opportunity for sleep, and you have this persistent disruption.

Dr. Regina Koepp 8:54
And what's the thought about what causes insomnia... what's creating this change for older adults?

Dr. Daniel Wachtel 9:00
Oh, yeah, see, that's a that's an important piece, the older adults piece. So, look, insomnia, you know, can be triggered in so many different ways. And we'll talk, I'm guessing we'll talk a little bit more about that when we talk about the therapy, the treatment that I use for insomnia. But it can be triggered in so many different ways. Sometimes it can be just a change in lifestyle, right or a change in jobs. It could be you know, the addition to having a child obviously, it could be the onset of some mental health issue, depression, anxiety, PTSD, you name it, right. A lot of different things can potentially trigger insomnia. If we're talking specifically about older adults, and of course we, you and I, know we can't stereotype and put everyone in a box everyone is even older adults, especially older adults are unique and different, but there are some common denominators and things that sometimes lead to insomnia in older adults to get back to your question. And the things that are most often... number one is certainly physiological changes, we do see that the brain ages and that there are physiological changes as we age. And in terms of sleep, we do often see that the need for sleep does decrease the amount of hours, sometimes even the timing the time of when someone maybe prefers or is ideal for them to sleep changes over time. Now, that doesn't mean there's a problem, right? Just because we're sleeping a little bit less or sleeping a little different time. It doesn't mean there's a disorder, we still might be getting the amount of sleep that we need. But as those changes occur, sometimes people start making adjustments based on that sometimes people find that they don't like those changes and they start making adjustments to when they go to sleep or they start getting anxious because they're no longer sleeping, what they used to sleep like right now, those changes sometimes can create the insomnia or lead to the insomnia. But not only the physiological changes, we can't forget about and not overlook the lifestyle changes that commonly occur with older adults. So if we think about things like retirement, right, major lifestyle change, someone goes from working all day to maybe not working, staying home, sitting in their recliner, maybe. Obviously, some people are very active, but others may not be right. And now you have all these behavioral lifestyle changes where someone may be sleeping during the day nodding off. Now that starts to disrupt their sleep at night, right? There may be less active, less physically active. And that may impact their sleep cycle. So there's so many things that can really impact one's sleep pattern and sleep cyclein old age.

Dr. Regina Koepp 12:23
Yeah, I was thinking, the common interruptions to sleep I hear that might create an insomnia kind of pattern are pain. The pain wakes people up at night. And then polyuria, which is going to the bathroom frequently throughout the night. And so people have trouble going back to sleep after going to the bathroom throughout the night. And then that creates this sleep pattern that it's hard to break.

Dr. Daniel Wachtel 12:44
You got it? Absolutely. Yeah, I mean, we could sit here all day, and list all the reasons that that may contribute. And you know, this is what's, in my opinion, fascinating about sleep work, is you do have to be a little bit of a detective as you do this work. And it is my job to find out all the things that may be contributing to a person's problems with sleep, it may not and is unlikely to be just one of those things that we just mentioned, it could be multiple things. And until we sit down and really dissect it and look with a microscope at all the things that they're doing differently and all the things related to sleep, we're not going to get to the bottom of it. So I get to sit there with my patients, I, you know, get to spend enough time with them, where we're really able to put sleep under the microscope and figure it out.

Dr. Regina Koepp 13:39
Wonderful, and when you do figure it out, what happens?

Dr. Daniel Wachtel 13:43
Great question. Yeah. I'm happy to say and one of the reasons why even maybe I think you can hear the passion in my voice about this work is that it is effective. I can confidently say that it is it is effective. You know, there's So many things in mental health, that we obviously work very hard with our patients with the hopes that we're planting seeds that we have some impact on mental illness. And that we make a difference. And oftentimes we do, of course, and there's so many mental illnesses that have very effective treatments. But there's nothing like sleep work in the sense that we get to see it so clearly, a person's change in sleep. I have people and we'll get into this, have people document and log, they write a sleep diary. We'll talk about that in a little bit. But they log their sleep. Now one of the reasons to log their sleep is so that we can see together the changes that are happening and that the treatment is effective. And I'm I'm happy to say that so many patients that I work with, do see change. I never make promises about what changes we're going to make. But I feel confident enough to say that we can get your sleep better, we can improve, we can make improvements to your sleep. Could it be sleeping like you were when you were 21? That I don't promise?

Dr. Regina Koepp 15:18
Well, who's sleeping at 21, anyway? I mean, I wasn't.

Dr. Daniel Wachtel 15:23
But I do say with confidence that I think with with hard work with effort and sticking to it, we could make improvements to your sleep.

Dr. Regina Koepp 15:34
And when people are sleeping better, they have more energy during the day. How does it improve the quality of their life?

Dr. Daniel Wachtel 15:43
Oh, boy. Yeah, we can have a whole podcast on on just that question alone because I don't know where to start. Sleep is obviously critical. That's why we're talking about it. People know the importance of sleep. You know? There's this a little bit of a morbid analogy when it comes in the sleep medicine world where we kind of try to emphasize the importance of sleep. And what do we say sometimes we say that there is a reason why sleep deprivation is the torture of choice for something, right? That it breaks down everything without sleep. Physically, we cannot function. It affects every part of our brain, our mind and our body. And that's not even getting into lifestyle issues or functioning right. So sleep is critical, sleep is critical to the, to the body, to the heart. You know, you had a great post recently on Instagram that talked about depression and what happens if depression goes untreated. Right? I saw that (and i think that i think i'm quoting that correctly). And, I agree with it completely the importance of detecting depression. Of course, I agree with all that. The same could be said for sleep without identifying a sleep problem and treating it effectively. It could be set as the even the precursor for depression. I was listening to a lecture just today on the relationship between sleep disorders and suicide. And there are studies that have identified that by treating sleep disorders, specifically insomnia, we reduce the likelihood of suicide. So we're not even talking about just level of functioning, we're talking about something that could save lives.

Dr. Regina Koepp 17:54
So improve the quality of life and save lives. It's remarkable... and why it's so important and if insomnia is affecting 45% of older adults, not to mention other sleep disorders that affect many more. Now there are treatments that you're using that are effective to help older adults improve their sleep, improve their quality of life and potentially even save somebody from just the despair of suicide and suicidal thinking. Before we get there, can you share some of the biggest obstacles to helping older adults sleep well?

Dr. Daniel Wachtel 18:38
Well, this is where you'll hear my tone change a little bit. Why? Because this is, this is challenging work. This is not easy. I ask my patients to make changes to their sleep to their routine. This is very challenging to many people we'll talk about and we'll get into it, I'm guessing, again a little bit in a little bit. But we talk about behavioral changes in this type of work. Talk about setting a certain sleep time. Waking up early in the morning or a certain time in the morning. We talk about resisting the urge to take a long nap, right? All these things that are rewarding are enjoyable. And I'm the bearer of bad news. And I'm often the one who has to tell someone, if you want to make a change to your sleep, we're going to have to change that. So there is a buy-in factor to this type of work. I do become a salesman a little bit and I highlight with the passion you heard a little bit earlier, my voice, how just how effective this could be. We talked about the impact importance, not only for lifestyle and functioning, but in terms of their physical health and longevity. So I really upsell it right. And then I break the bad news, which is that someone is going to have to make changes that they may not like. The really bad news is it may get worse before it gets better. That's the really difficult pill to swallow. So the sleep problems in doing this type of work, I'll say that again, sometimes gets worse before it gets better, which means that they may sleep less for a period of time, short period of time, but a period of time before it starts to improve. And I'll explain what I mean by that a little later.

Dr. Regina Koepp 20:48
So yeah. So it's a big buy in that you're talking about. One, they have to have the motivation to do it, the commitment to do it because they have to weather the storm of sleep getting worse before it gets better.

Dr. Daniel Wachtel 21:00
That's right,

Dr. Regina Koepp 21:00
and a lot of trust in you to sort of guide them in this process.

Dr. Daniel Wachtel 21:06
It is such a collaborative process though this is where the therapy skills, the gaining rapport that we learned early in our career, hopefully, come into play, because it is....there's a lot of ways, there's a lot of ways to do this type of therapy. Yes, there are the most aggressive treatments that you and changes that someone could make that I could just recommend. But if I don't get the buy-in from the patient, they're going to leave they're going to end and so it takes a collaboration and it takes gaining rapport, it takes negotiation. Sometimes that means that the efficacy is not going to be as strong; the impact won't be as strong. And I tell patients that. I tell them what is the most recommended course of action. And if they're not able or willing or ready for that, we negotiate and we talk about, okay, what are you willing to do? And let's talk about that that can still have an impact on your sleep. It may not be as profound, right?

Dr. Regina Koepp 22:27
Yeah, I was thinking, how often do you see substance use as an obstacle to sleep change? I'm thinking of a lot of the folks I work with will talk about needing to drink before they go to sleep to help them fall asleep, and then that disrupts sleep once their body starts to metabolize the alcohol. Do you notice that very much?

Dr. Daniel Wachtel 22:52
Oh, absolutely. Yeah. You know, another fascinating part of this work is the different things that people do sometimes (with all the good intentions, of course), that sometimes are the very reason why they're having sleep problems, right. Maybe daytime fatigue, because they're not getting the good quality sleep that they could be getting. So, you know, cognitive behavioral therapy for insomnia, really is a treatment that has many different components. And one of them is the educational component. So yes, with substances, we do spend a lot of time if that's an issue, if that's present, we talk a lot about the impact of those substances. We educate, right, patients are often, not always, but are often doing it with good intentions. They say, well, alcohol puts me to sleep, what's the problem there? And we have to provide education about how alcohol reduces the quality of sleep even though it may put you to sleep, you are not getting the type of sleep that you need. And that sometimes takes a while to, to sink in and to again to buy in to make that kind of major life change. Yeah.

Dr. Regina Koepp 24:21
Okay, so now for the state of the art intervention.So you mentioned a minute ago about cognitive behavioral therapy for insomnia. So tell us so what is the best or the most effective treatment that you've been using for for sleep disorders with older adults?

Dr. Daniel Wachtel 24:41
Absolutely. So CBT-I, cognitive behavioral therapy for insomnia. Very long title, but it does describe what it is. I'm happy to say that it is now considered be clinical recommended first line treatment for insomnia For a period of time it was, it was recommended. It was encouraged for a period of time it was recommended equally with medication for sleep. And now it is considered the first line treatments.

Dr. Regina Koepp 25:16
So will you describe to us what it is? You were kind of alluding to it a little bit about keeping a sleep log? And yeah, can you walk us through what you actually do?

Dr. Daniel Wachtel 25:28
Absolutely. So cognitive behavioral therapy for insomnia CBT-I is a it's a non-medication treatment for insomnia. It's a therapy, a psychotherapy. And really, the goals are to help people fall asleep, to stay asleep and improve daytime functioning, all right? Because that's really the big litmus test for sleep problems, right? Someone may say that they have sleep problems, but what we're really looking for is not Even how many hours they're getting, but we're looking for how are they functioning during the day, right? And CBT is really a multi component treatment. And it has many different parts. The two main parts are behavioral strategies, and cognitive restructuring. And I'll explain what that means, of course, but the behavioral strategies, this is really teaching people personal sleep habits that are really based on the latest sleep research. You know, there's a lot of myths out there right and, and commonly held beliefs about what what really does help sleep and what does not. So CBT is again the behavioral piece in cognitive behavioral, we focus on the behaviors that the research shows, most affect sleep, the cognitive piece, focus is on the thoughts, the feelings and the expectations about sleep and insomnia that may stand in the way of good sleep. And what I mean by that is, boy, people have all kinds of thoughts about sleep, they have thoughts about how many hours they should get, right? They have thoughts about how many times is okay to wake up or not, you know, or to sleep straight. They have thoughts about, you know, what one should do in the middle of the night, right? They have fears about what might happen if you don't get one good night of sleep that lead to more anxiety, right? So we focus on the thoughts, the cognitions we focus on the behaviors and teach people what they can do to increase the likelihood of them getting a more quality night of sleep.

Dr. Regina Koepp 27:57
Okay, so there are behavioral changes and cognitive restructuring as two pillars of sleep CBT-I, and will you walk us through? Well, actually, before I asked you to do that, how long does a sleep treatment usually last?

Dr. Daniel Wachtel 28:20
Yeah, absolutely CBT-I, it varies a little bit from how one practices it, but it's anywhere from six to 10 sessions. It's still considered a short term therapy. And it varies from person to person. You know, I go to the extreme sometimes I've had a patient come in, who was so concerned about their sleep. In putting it under the microscope, acknowledging that they're not tired during the day, but maybe they were fearful because like I said earlier, maybe they're the amount of hours changed, or some other maybe like you said, Maybe they're getting up in the middle of the night, they're urinating more and having a little difficulty falling asleep. But when examining it, they're functioning perfectly well. And all they needed was just a little reassurance to say, you're fine, you're fine. And once they heard that from a professional, it took one session, and they're, they're doing great. They're doing great. But of course, that's not the norm. And we are looking at anywhere from six to 10 sessions.

Dr. Regina Koepp 29:33
Okay, so what do you do in those sessions?

Dr. Daniel Wachtel 29:35
Yeah, let's talk about that. Well, we're going to talk a little bit about the model and then I'll talk a little like you said a little the nuts and bolts of it. So again, I mentioned the two pillars, like you said, very accurately, we're going to be correcting what we call cognitive distortions, right the different thoughts that people have about sleep and...You please stop me when I, I have so many stories to tell. But you know cognitive distortions when I say that an example of that is a patient I had once came in and felt very strongly that they, when they wake up in the middle of the night, two, three in the morning, they must eat a big meal. And that's the very thing that will put them to sleep. And they're confident of that, right? And so that would be an example of what we call a cognitive distortion, we may have to challenge that belief and say, You know what, here's what happens when you eat a big meal. And that may be the very reason why you're waking up in the middle of the night is that you have trained your brain to get ready to eat at three in the morning. And so we challenge against some of the cognitive distortions. We talk about sleep hygiene, like many you know, books, you'll find out about sleep. We do talk about sleep hygiene, but again, we focus on the reading research what the research shows about hygiene and what behaviors actually improve sleep. We also address any maladaptive behaviors again, that example of the eating not only the thought of the eating, but the actual behavior, right, so we address those. We also try to reduce any stimuli that might lead to somebody waking up. So in really putting sleep under the microscope, we may find out that they're sleeping with a lot of lights on and that it's not cool enough in their room and we find out that they have four dogs in their bed, right? So all the things that we try to change the environment as well. We also teach them some skills. We teach them relaxation exercises, different kind of exercises that may increase the likelihood that they'll fall back asleep or That they'll maybe reduce the anxiety the fears that they have. But if we talk about the nuts and bolts, so we do a thorough assessment right in the first one to two sessions, we really, again put sleep under a microscope and look at when they go to sleep. What an average night of sleep is for them. What I tell my patients is no detail is too small. You know, oftentimes they spend a little time with their sleep medicine doctor, which is great if they see a sleep medicine doctor before they see me. But you know, sleep medicine doctor just has so much time to find out all the details to go through an entire night of sleep, right hour by hour. But in my assessment, that's exactly what we do. And by doing that, we're again like I said earlier, we're able to identify all the things that contribute to the sleep problems. I introduced them to the sleep log, like I mentioned earlier, so I give them what's called a sleep diary or a sleep log. There's many different ways to do this. There are some electronic versions of this. I am old fashioned, I use a paper pencil version of it. But there are different ways and there's different things that we're looking to track. Things that maybe like a Fitbit doesn't necessarily do. And so we're going to be asking them to log certain aspects of their night and their daytime. And so, you know, this is where the collaboration comes in. I pitched it to my patients, that we're sort of like a team of scientists, right, looking at their sleep, examining their sleep, and documenting what happens in their sleep.

Dr. Regina Koepp 33:46
Thank you for that overview. That's so helpful. You mentioned sleep hygiene, and you mentioned healthy sleep behaviors. Will you share a little bit of those?

Dr. Daniel Wachtel 33:59
Oh, sure. Well, there's some some of the things that get a little repetitive I apologize to my patients in advance because I do a lot of repeating and it bears repeating. This type of work and the training that we received is not just my style, it's recommended that the sleep hygiene piece needs to be recommended and the education component is constant and it bears repeating, because again, some of these changes are really hard to make and can, we can easily resort back to the way we were doing things before. But the most important tenants of sleep hygiene, certainly first and foremost is a regular bedtime and wake time, a consistent bedtime and wake time is one of the most effective things you can do. You know, we do have this internal sleep clock and we have to set. Right? We have to set the sleep clock. And we have to send a very clear messages to our brain when we want it to go to sleep, and when we want it to wake up. And so that's sometimes the most significant change a person can do. You know, again, we're talking about older adults. And one of the benefits sometimes that I don't know about you, but my older adult patients tell me is that now they can wake up whenever they want to wake up, right? They don't have to wake up for work anymore. And it's wonderful. The challenge with that is now their wake time is inconsistent. And their brain potentially can start to get confused: "when is sleep time?" and "when is wake time?" So certainly first and foremost, bedtime and wake time. Absolutely. Other sleep hygiene that we, you and I, have alluded to already earlier is maybe eating certainly. We want to give a nice amount of time in between our last meal, the last thing we eat, and when we go to sleep. If the brain and body is actively involved in digestion and processing food, then we cannot divert all our attention to sleep. So we try to give a nice amount of time in between that, you know a lot of these are some commonly held beliefs too... won't be surprises to you. Certainly exercise is not something we want to do right before bedtime. We want to reduce the stimulation, right? We want to increase the likelihood of us being in a calm, relaxed state. One of the most effective things we could do is a bedtime routine, right? Getting into a nice routine and what is really the routine do it sends signals to the brain That is we are getting ready for bed. We're, the brain needs a little time to adjust. We can't just snap our fingers. At least most people can't. Of course, we all know that person who can sleep, you know, the moment their head hits the pillow, but not everyone, right? And most people they need a little time. They need a little time from going from from one activity into bedtime. So if you can establish and this is critical, a constant bedtime routine, it needs to be consistent. Every night we do the same thing. You know, it's no wonder this is a... I think a very commonly held recommendation for rearing children, right? Bedtime routine for kids as well. What do we do with children with little babies where at least I think it's recommended right that we do tubby time and then we read a story. And then but why do we do those, not just because maybe it's enjoyable, but because the baby's brain understands after a period of time, oh, okay, we're going to the tub, that means we're going to need to release melatonin pretty soon, right? So the more consistent we could be with a bedtime routine, the more likely it is that we'll go to sleep when we want to go to sleep. And that will increase the likelihood of a good night's sleep.

Dr. Regina Koepp 38:24
Having the routine signals to the brain that it needs to produce melatonin to help you sleep.

Dr. Daniel Wachtel 38:30
And the opposite side is true, too. You know, what do we say when people have energy problems? You know, people report daytime fatigue, we talk about the opposite as well. The opposite side of the spectrum is the importance of getting out of bed to actually getting maybe some sunlight during the day some exposure to sunlight. Why? Because it's the same thing. The sunlight sends messages to the brain that it's time to wake up. Right. You know where we are. I think we're a little inefficient in communicating with our own brain, right? We do not have the ability to just sit there and tell our brain "Okay, time to wake up time to go to sleep." The brain doesn't work that way. So we have to send messages to the brain maybe in, I don't know if you consider it more subtle ways, but certainly consistent messages. And and really we have to train the brain.

Dr. Regina Koepp 39:27
Yeah, we're coaching the brain to do what we want it to do to help us sleep better and live a better quality life.

Dr. Daniel Wachtel 39:33
You got it?

Dr. Regina Koepp 39:34
And what about caffeine?

Unknown Speaker 39:36
Oh, yeah. Well, look, you know, it can potentially go under the heading of substances, right. And...

Dr. Regina Koepp 39:46
Well, then it's my substance of choice.

Dr. Daniel Wachtel 39:48
Well, most people's right? But yes, substances in general. Of course, like we talked about a little bit earlier. We talked about the impact on sleep and what it does that even if some of the substances help us go fall asleep, or we think it helps us fall asleep, it disrupts the natural sleep cycle. Caffeine of course, is a stimulant that's even more obvious of what it might do. Right? And so I really drive home the point I really highlight that it is you know, it is a stimulant. What we are trying to do, is trying to do the opposite, right? If someone comes into my office and says they have a problem going to sleep, their problem is not the need to stimulate themselves more. It's the opposite. We want them tired when, of course, they want to be tired, right? So this is where we have to deliver some of the bad news. What is maybe the most effective thing to do? The most effective thing to do is reduce all stimulants, all stimulants. Some people are certainly unwilling are not ready to give up their morning cup of coffee. And so, you know, there is certainly some negotiation here. It is reasonable and I think commonly practice where many therapists would say that as long as it's before noon, sometimes people go even further before early afternoon, that it should be out of the system. But I always start with the most aggressive approach. I provide the education saying, "Hey, this is what if you really want it to be as aggressive as possible? This is make sense to try." If I see how much joy they're a cup of coffee gives them of course we talk about, okay, "how do we set limits? And how do we reduce the impact that it might be having by reducing the quantity of caffeine and also the timing of caffeine." Right.

Dr. Regina Koepp 42:02
That's something... so those are strategies anybody can do, even if they're not doing CBT-I, they can make any of those behavioral changes now.

Dr. Daniel Wachtel 42:13
This is where we get into those vicious cycles, you know, and sometimes again, it's only this is where therapy is only a couple of sessions when a patient comes to me, and I've had these patients who are drinking 13 cups of coffee a day. And just by having that conversation, and then making that change, that can make all the difference in the world. Now, again, that person of course, they're fatigued during the day, they're doing what they can to function. But by sitting them down and really acknowledging the impact it's having on their sleep, and the impact that the positive impact they could have by reducing, that can make all the difference.

Dr. Regina Koepp 42:58
Great. These are such actionable strategies that anybody can use. You're actually demystifying what therapy looks like to just to improve sleep and it. And it has such an incredible impact on quality of life. Sleep is an essential part of our body's strategy for repairing and replenishing. And so if people don't get enough sleep, I don't know the research on this, maybe you do, but the risk for illnesses and diseases I think my hunch is that those increases as well. And so not only is it improving quality of life, it's also improving physical health in the long run.

Dr. Daniel Wachtel 43:36
Absolutely. Yeah. I mean, you know, sleep disorders there, again, more and more on different radars. And, you know, one of the sleep disorders that we in CBT-I that we rule out for, from the very beginning, is we look for sleep apnea, right sleep apnea, a Breathing dysfunction when it comes to sleep. Often the common symptom is daytime fatigue. And we rule that out from very early on why and this is where CBT doesn't necessarily treat sleep apnea, but we rule it out so that we can sometimes refer to a sleep medicine specialist. Why? Because getting back to your point is, it is commonly becoming widely known that untreated sleep apnea can increase the likelihood of a cardiovascular event. Lead to heart attack, stroke, you name it. So we we as therapists, again, the power of this work, we have the opportunity to actually save lives by being the first person to identify a sleep problem and getting a person the treatment and the care that they need. To prevent further illness.

Dr. Regina Koepp 45:02
Great. The other thing I noticed when older adults are not sleeping well, that some of their daytime symptoms can include cognitive dysfunction. And when we improve sleep, it improves their cognitive dysfunction so families will say, or even the older adult will say "I'm worried my memory and my concentration are not good, I'm worried I'm getting dementia, what is going on with me?" And then we evaluate their sleep and and start to make changes with sleep, and then those cognitive symptoms improve. And this is where it gets really scary for older adults and families because dementia is a scary condition and something that needs assessment and evaluation and if we can identify sleep problems that are causing cognitive symptoms during the day, it can alleviate some of those stressors as well. Imagine if you're worried you're have dementia, you're not going to sleep well because you're anxious.

Dr. Daniel Wachtel 45:56
What you're talking about right now is one of the reasons why I was so excited to be on this podcast because what you are doing is you're sending out the message, right the importance of sleep. Now some people who may be listening to this are already pursuing sleep treatments or sleep medicine or working... But some people and I see them all the time and maybe like, like you just said to some people are normalizing sleep problems right there. I can't tell you how many times I've seen a patient. And you know, they casually mentioned that they've had sleep difficulties for the last 20 years, right. This is something that is commonly overlooked. Again, some people do report it as their primary issue of concern, but other people and again, if we could reach one person today with this podcast, right, again, back to that Instagram post that you had, this is what happens if insomnia sleep problems go untreated. So please go if you have problems with sleep, go and get assessed go get seen, do not normalize this, this is something that can be treated and your sleep can improve.

Dr. Regina Koepp 47:13
Right and with excellent clinicians like you saving one night's sleep at a time. That was very corny. So where can older adults and their families learn more about sleep issues and how to find treatment?

Dr. Daniel Wachtel 47:29
Absolutely. There's there's so many ways to begin the journey. Certainly, sleep hygiene for some people making some changes to sleep hygiene, maybe all you need to do making a few changes here and there, especially people who are quite disciplined, who are motivated to make some changes. We might you might see some dramatic results based on one or two of the things we talked about today. And so again, it's through education. There's so many ways to get education on sleep. There's a few great tools that I certainly can recommend. There is a wonderful app called CBTI-coach, CBTI-Coach. You can find that both on Apple and Android. It's a wonderful app that is free and provides education about CBT-I... provides education about sleep hygiene. There's a tool on the app that and I have no association with this, by the way either, but it can log your sleep. It has relaxation exercises. So I think it's a wonderful tool. I was just recently informed about a wonderful website and platform called Path To better Sleep. This is another self guided format for doing CBT-I for learning about it; for making some changes to sleep. But if you want to go a step further, there's again a couple different avenues you could obviously someone may want to see a sleep medicine specialist, you would many centers in most cities, they're very common and you would go, they would rule out some of the sleep disorders. They may or may not recommend a sleep study depending on some of your symptoms. Sometimes they do a home monitor, sometimes just based on a you know, identified symptoms, they'll have a treatment of choice. And of course, one can see someone like myself a trained therapist and cognitive behavioral therapy for insomnia happy to give you my information where people can check in with me.

Dr. Regina Koepp 50:06
Yeah, where can people learn more about you?

Dr. Daniel Wachtel 50:09
Oh, yeah. Well, thank you and yeah, people can of course contact me. Through my website, you can learn more about me and more about cognitive behavioral therapy for insomnia. at my website, which is That's

Dr. Regina Koepp 50:33
I'll link to that in my show notes as well and on my website, into the CBTI-Coach and Path to Better Sleep I'll link to as well. Dr. Daniel Wachtel, thank you so much for sharing with us your expertise and really breaking it down for us so people can use it today and the resources that you're providing that are just free and actionable. The list of sleep hygiene tips that you gave and just kind of dispelling and demystifying what therapy for sleep actually looks like.

Dr. Daniel Wachtel 51:08
Well, you're welcome. And thank you for having me. And if I can just spend a moment thanking you too. Well, yes. Today we talked all about sleep disorders and certainly one of my specialties and, and a passion of mine. Like I said at the beginning, most of my work is with older adults, not necessarily sleep disorders. I share that passion with you. And I wanted to thank you for having this type of format this type of medium to obviously spread the word you know, this is a underserved population. As you were talking about in your podcast, this is something an area that people know so little of, right? We are not trained. We are not educated about this stage in life. We don't go through schooling, although we should In my opinion, we don't go through schooling, they don't teach a class on how you're going to live your life as an older adult, right. And so I, again, I want to thank you on behalf of everyone in the geriatric world, right? For having this type of platform to both educate and to spread the word, so thank you.

Dr. Regina Koepp 52:19
Wow, thank you so much. That's so that means a lot to me. Thank you very much.

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I hope you leave this episode with the takeaway that insomnia is treatable in older adults, and with tips that you can use today for getting a good night's sleep. If you like this episode, be sure to subscribe and leave a review. subscriptions and reviews actually help people to find this show. And here's why this is so important. Older Adults are often left out of the conversation when it comes to mental health and wellness. So do your part to include them by subscribing and leaving a good review I'll see you next week, same time, same place. Lots of love to you and your family. Bye for now.

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