Elsevier

Sleep Medicine

Volume 9, Issue 2, January 2008, Pages 165-171
Sleep Medicine

Original article
Psychological treatment of insomnia in hypnotic-dependant older adults

https://doi.org/10.1016/j.sleep.2007.02.009Get rights and content

Abstract

Background

The existing literature does not address the question of whether cognitive-behavioral therapy would have an impact on insomnia in older adults who are chronic users of sleep medication and have current insomnia, but are also stable in their quantity of medication usage during treatment. The present report seeks to answer this question.

Methods

Hypnotic-dependant older adults, who were stable in their amount of medication usage and still met the criteria for chronic insomnia put forth by American Academy of Sleep Medicine, were treated using a cognitive-behavioral intervention for insomnia. The three-component treatment included relaxation training, stimulus control, and sleep hygiene instructions. Participants were randomly assigned to either the active treatment group or a comparably credible placebo control group, and were instructed not to alter their pattern of hypnotic consumption during treatment.

Results

The active treatment group had significantly better self-report measures of sleep at post-treatment. Statistically significant improvement was paralleled by clinically meaningful improvement for key sleep variables. As planned, there was no significant change in sleep medication usage from pre- to post-treatment.

Conclusions

The findings support the use of cognitive-behavioral therapy for insomnia in hypnotic-dependant older adults.

Introduction

Data from our recent epidemiological study support the hypothesis that older adults (OA) report higher rates of insomnia and more severe insomnia than younger adults [1]. Across age groups, insomnia has been associated with difficulties such as impaired functioning, daytime fatigue, increased health care costs, and reduced quality of life [2], [3]. These difficulties may be particularly salient for OA as they often experience other age-related decrements in general health. These findings highlight the importance of establishing optimum treatment strategies for insomnia in the OA population.

Hypnotic medication is typically the first line of defense for OA seeking treatment for insomnia, most likely because hypnotic medications are easily accessible through primary care physicians and promise rapid improvement for insomnia symptoms [4], [5]. The rate of hypnotic usage for OA is approximately 10–15%, a rate nearly five times that of younger adults [6], [7]. Although hypnotic medications have been shown to be effective in many cases, tolerance may lead to an attenuation of efficacy over time.

Psychological treatments such as cognitive-behavioral therapy (CBT) provide a second avenue of treatment for OA with insomnia. CBT for insomnia (CBTi) often consists of a combination of several techniques such as stimulus control, sleep restriction, sleep hygiene instruction, and relaxation practice. Individual studies have supported the use of CBTi with the OA population [6], [8], [9], and a recent Cochrane review of non-pharmacological therapies for sleep problems in later life concluded that CBTi was mildly effective in the short term but unproven in regards to long-term effects [10].

There is less published research regarding CBTi outcomes in OA who are chronic users of hypnotics. Recent results from a study using a mixed age population suggest that chronic users of sleep medication respond to CBTi [11]. The authors reported that in a hypnotic-dependant, mixed-age sample, participants significantly improved on global sleep quality as measured by the Pittsburg Sleep Quality Index (PSQI) and reduced medication usage relative to a ‘no additional treatment’ control group. Other CBTi treatment research with hypnotic-dependant OA focused on withdrawal from those medications. For instance, Baillargeon and colleagues [12] reported that gradual benzodiazepine tapering in combination with CBTi was more effective in reducing benzodiazepine usage relative to benzodiazepine tapering regimen alone. Morin and colleagues [13] reported that CBTi given to hypnotic-dependant OA led to reduced medication usage and improved sleep in the form of self-report measures, including decreased total wake time, increased sleep efficiency, increased total sleep time, and decreased sleep onset latency.

The existing literature does not address the question: what impact does CBTi have on OA who are chronic users of sleep medication and have current insomnia but are also stable in their quantity of medication usage during treatment? As some OA may be hesitant to withdraw from their sleep medications but also want more improvement in their sleep, an exploration of CBTi in conjunction with stable medication use is called for. The lack of a psychological placebo control group has been a weakness in previous CBTi research with hypnotic-dependant OA. Thus, the current study is a randomized, placebo-controlled trial of CBTi in hypnotic-dependant OA that are stable in their amount of hypnotic use. It is hypothesized that this population will benefit from CBTi.

Section snippets

Participants

The sample was a subset of participants recruited for a larger study of withdrawal from chronic hypnotic use. The relationship between the present study and the larger one will be described in more detail in Section 2.9. Older adults, defined as age 50 years or older, with chronic insomnia, and regularly using prescription sleep medication, were recruited by newspaper announcements.

Participant screening

A four-stage screening process established whether potential participants met the criteria for inclusion into the

Demographic variables

Groups were compared on the following demographic variables. Age in the treatment group ranged from 51 to 85 years (M = 63.5, SD = 8.7), and in the placebo group from 50 to 70 years (mean (M) = 64.82, standard deviation (SD) = 6.5); a between-subjects t-test revealed no significant difference between groups [t(45) = 0.96, ns]. Education level in the treatment group ranged from 12 to 22 years (M = 14.7, SD = 2.7), and in the placebo group from 12 to 20 years (M = 14.9, SD = 2.3) [t(42) = −0.10, ns]. In regards to

Discussion

We found that CBTi led to significant improvements in subjective SOL, WASO, and SE in hypnotic-dependant OA. Significant improvements in these variables were paralleled by medium effect sizes for SOL and WASO, and a large effect size for SE. The magnitude of these effect sizes suggests that the results were not only statistically significant but also clinically meaningful. These results suggest that CBTi can be a valuable treatment for hypnotic-dependant OA who do not wish to withdraw from

Acknowledgments

Support for this study was provided by National Institute on Aging grant AG14738.

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