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Psychological factors that most commonly affect sleep in elderly persons are reactions to loss, such as loss of health or functional capacity, and reactions to the death of a friend or loved one. Although bereavement is normal, it is often associated with substantial sleep disturbance (American Psychiatric Association 2000). When bereavement is associated with more frequent intrusive thoughts and avoidance behaviors, there appears to be more sleep disturbance, predominantly in the form of difficulty in falling asleep (Hall et al. 1997). Bereavement and depression are closely linked, however. Depression is usually diagnosed only when symptoms have persisted for more than 2 months after a loss or when symptoms are severe, such as suicidal ideation, psychotic symptoms, malnutrition, or dehydration (American Psychiatric Association 2000). Antidepressant medication may be helpful. A short course of sedative-hypnotic therapy may provide substantial symptomatic relief. If this approach is taken, the medication should be tapered off when the other symptoms of bereavement diminish. Because the clinician will not know at the outset how long treatment will be needed, considerations related to longer-term treatment pertain (see "Pharmacological Treatment" later in this chapter). Although unlikely, it is possible for rebound insomnia to occur after a relatively short course (3–4 weeks) of treatment. As a result, clinicians should warn patients of this possibility and wait at least several days after discontinuing the medication to determine whether there is persistent insomnia. If all symptoms of bereavement have resolved except insomnia, cognitive-behavioral therapy for insomnia should be considered (see "Cognitive-Behavioral Treatment" later in this chapter). Grief counseling should also be considered.

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