MINNEAPOLIS – Cognitive behavioral therapy tailored for insomnia management and delivered by health educators eased sleep impairment in older adults in a randomized trial of 159 community-dwelling veterans aged 60 years or older with chronic insomnia.
Researchers assigned the veterans to individual cognitive behavioral therapy for insomnia (CBT-I), group CBT-I, or general sleep education and hygiene as a control. The CBT-I combined sleep restriction, stimulus control, and cognitive therapy and was provided by health educators – primarily masters-level professionals – who had weekly telephone access to behavioral sleep medicine specialists. All study groups had five sessions of their assigned treatment over 6 weeks.
Dr. Cathy A. Alessi
CBT-I was associated with better self-reported sleep quality and reduced insomnia symptoms compared with controls 6 months after therapy, according to data presented at the annual meeting of the Associated Professional Sleep Societies. And it worked similarly well whether provided one-on-one or in groups.
"We believe future work is needed to disseminate and implement this and other innovative models of CBT-I ... So it’s very important that there is continued, ongoing work to fine-tune the CBT-I interventions," but particularly in older adults, in whom the risks of episodic or chronic use of sleeping pills may be particularly problematic, said Dr. Cathy A. Alessi, a geriatrician with the VA Greater Los Angeles Healthcare System in North Hills, Calif., and professor of medicine at the David Geffen School of Medicine at UCLA. "We feel strongly that it’s time to get these out into routine practice."
Some parts of the country have few or no sleep medicine specialists, she noted. Thus, the ability to use allied health professionals to deliver this safe and effective treatment should make it available to more patients.
Session cochair Brandy Roane, Ph.D., of the University of North Texas Health Science Center at Fort Worth, noted that the study is helpful in that it provides insight on the feasibility and efficacy of CBT-I in this patient population.
"As our population is aging and we are trying to use more behavioral-based interventions, it is important for us to look at the efficacy. Are they even going to engage in the intervention? Are they going to get lost in it?" asked Dr. Roane.
Do they have age-related inability to understand some of the concepts and do the required cognitive work? And if they are cognitively impaired, will CBT-I be effective? she asked. "Also, are they going to be able to change their behavior in general?"
Importantly, Dr. Roane noted, in addition to its sleep benefits, CBT-I could have a general health and cognitive benefit during the daytime.
The mean age of the veterans in the study was 72 years. They were cognitively healthy, and had no or only mild sleep apnea. But on average, they had six other health conditions in addition to insomnia.
At 6 months, the trial’s primary endpoint, the Pittsburgh Sleep Quality Index score was 7.7 for the control condition, but lower at 5.8 for individual CBT-I (P = .005) and 5.6 for group CBT-I (P = .002). Relative to the control condition, both CBT-I strategies yielded significantly better sleep-onset latency, total wake time, and sleep efficiency as assessed from sleep diaries. Differences in these measures were still significant at 12 months.
The groups were statistically indistinguishable, however, with respect to changes in sleep efficiency as assessed from wrist actigraphy, depressive symptoms, and health-related quality of life.
In related qualitative research, also presented at the meeting (Josephson et al., abstract 0544), the investigators conducted focus groups among the study veterans to get their impressions of the CBT-I model of care, Dr. Alessi noted in an interview.
"Many participants we spoke with preferred behavioral treatment for insomnia over sleeping medications, and were also very receptive to the idea of behavioral treatment being provided by health educators [and others] outside of the mental health setting [as was the case in our study]," she reported. "We also heard compelling anecdotes from participants who described dramatic improvements in their sleep problems, which, for many, had been present for years."
Dr. Alessi disclosed no relevant conflicts of interest.