Insomnia and Nocturia: Causes and Connections

Shachi Tyagi, MD, is a geriatrician-scientist whose research centers on nocturia (nighttime wakening to void) and insomnia. She's interested in understanding the overlap in pathophysiology of these two prevalent and comorbid conditions among the elderly, as well as their role in increasing the risk of falls and fractures. In addition, she is investigating whether treatment for one may be beneficial to both.

Searching for the Causes of Nocturia-A New Study

In March 2017, Dr. Tyagi and colleagues from the Division embarked upon a new study.¹ It is designed to investigate the causes of nocturia and nocturnal polyuria. Each is a common and costly condition in older adults, with significant impacts on quality of life and risk for serious complications such as falls and fractures, depression, and increased rates of mortality. In fact, nocturia is one of the most common reasons for falls and fractures in older adults. "At night, individuals are not fully awake, their blood pressure is lower, and rushing to the bathroom to urinate provides the perfect scenario for a fall and possibly a fracture," says Dr. Tyagi.

Treatment of nocturia, especially in the elderly, is challenging because the underlying causes are not well understood. Building upon her past research^2-6 into how insomnia and nocturia are intertwined, Dr. Tyagi's new NIH grant is funding a first-of-its-kind study to examine the roles that sleep and circadian rhythm - and their dysfunction and disruption - play in nocturnal urine production in older adults.

Urine production follows a circadian pattern that is typically established by age 3 to 5 years and results in less volume (and higher concentrations of waste products) being produced at night. However, in most older adults this pattern can become disrupted, causing urine production to increase at night. Thus, Dr. Tyagi's study will examine the role of key hormones in urine production and how sleep dysfunction and consequent disruption of circadian patterns alter their regulation.

"We know that the rhythm of these hormones is somewhat blunted among older adults as a consequence of the natural aging process. So, if they already have some compromise of these rhythms, how do sleep and sleep disruption further impact their nocturnal urine production? This is the basis of the study," says Dr. Tyagi.

Dr. Tyagi's study will recruit healthy older adults who are 60 years of age or older and who do not suffer from insomnia or lower urinary tract dysfunction. Participants will take part in a battery of two 24-hour measurements designed to assess the diurnal variation in secretion of the hormones responsible for regulating salt and water excretion. Circadian rhythms will be assessed for phase and amplitude, allowing for an examination of diurnal variation in the secretion of the renal regulatory hormones and how sleep influences this process. "We may be able to uncover the existence of different phenotypes of nocturnal polyuria that would then point us to other lines of research and possibly to more targeted approaches to treatment," says Dr. Tyagi.

Insomnia and Nocturia - Treatments and Causes

Past research by Dr. Tyagi and colleagues has focused on a number of contributing causal factors to nocturia, as well as the efficacy of certain behavioral treatment approaches to insomnia and their effectiveness for nocturia. Dr. Tyagi has also examined the role of sleep quality and the amount of time spent in bed on the presence and severity of nocturnal polyuria in older women with urge urinary incontinence.⁴

She has also examined, for instance, the applicability of behavioral treatments for insomnia to treatments of nocturia. For example, she found that an offshoot of Cognitive Behavioral Therapy for Insomnia (CBTI) known as Brief Behavior Treatment of Insomnia (BBTI) was efficacious not only for insomnia but also in reducing the number of episodes of nocturia over a two-week period.²

  Another study,³ conducted with Daniel J. Buysse, MD, from the Sleep and Chronobiology Center at Western Psychiatric Hospital and Clinic of UPMC, suggests that treatment of individuals with insomnia may be negatively impacted by concurrent nocturia - suggesting that nocturia impairs the effectiveness of behavioral treatment for insomnia.

References and Further Reading

1. Impact of Sleep on Chronobiology of Micturition. Funding Entity: National Institute on Aging. Project Number: 5R21AG050892-02. Primary Investigator: Shachi Tyagi.

2. Tyagi S, Resnick NM, Perera S, Monk TH, Hall MH, Buysse DJ. Behavioral Treatment of Insomnia: Also Effective for Nocturia. J Am Geriatr Soc. 2014; 362(1): 54-60.

3. Tyagi S, Resnick NM, Perera S, Monk TH, Hall MH, Buysse DJ. Behavioral Treatment of Chronic Insomnia in Older Adults: Does Nocturia Matter? Sleep. 2014; 37(4): 681-687.

4. Tyagi S, Perera S, Clarkson BD, Tadic SD, Resnick NM. Nocturnal Polyuria in Older Women With Urge Urinary Incontinence: Role of Sleep Quality, Time in Bed, and Medications Used. J Urol. 2017; 197(3pt1): 753-758.

5. Clarkson BD, Tyagi S, Griffiths DJ, Resnick NM. Test-Retest Repeatability of Patterns of Brain Activation Provoked by Bladder Filling. Neurourol Urodyn. 2017; 36(6): 1472-1478.

6. Tyagi S, Perera S, Brach JS. Balance and Mobility in Community-Dwelling Older Adults: Effect of Daytime Sleepiness. J Am Geriatr Soc. 2017; 65(5): 1019-1025.