Original ArticleEfficacy of brief behavioral treatment for insomnia in older adults: examination of sleep, mood, and cognitive outcomes
Introduction
Insomnia is defined as difficulty initiating, maintaining, or experiencing nonrestorative sleep concurrent with distress or impairment in critical areas of everyday functioning, such as increased daytime fatigue, negative mood, and poor concentration [1]. Given that the amount of deep sleep (ie, slow wave and REM) declines with age [2], older adults are at a greater risk of midnight and early morning awakenings than younger individuals [3]. Moreover, insomnia is the most common sleep disorder in later life and impacts approximately 20–50% of older adults [≥65 years; [4], [5]]. While pharmacological treatment of insomnia in old age continues to be much more common, there is a robust body of evidence that psychological treatments for insomnia: generally called cognitive behavioral therapy for insomnia (CBT-I). These are highly efficacious [6] and can result in fewer adverse side effects [7] and are preferred [8] relative to pharmacological treatments. Furthermore, the American College of Physicians now recommends CBT-I as the first line of treatment for older adults with insomnia [9]. The majority of the studies on CBT-I to date have utilized relatively lengthy treatment protocols (weekly one-hour individual sessions for 6–8 weeks). The current study investigates the impact of brief behavioral treatment for insomnia (BBTi) on sleep, mood, and cognitive outcomes in older adults.
Despite the fact that approximately 80–90% of patients with insomnia also have a concurrent medical or psychological diagnosis [10], previous research on older adults has focused on insomnia in isolation. This was mainly due to the belief that insomnia symptoms that occurred in the context of another medical or psychological condition were “secondary” to that condition. Thus, the treatment focus was on the “primary” nonsleep condition, and the sleep problem was not typically treated independently [11]. However, there has been a significant shift in the clinical and research conceptualization of insomnia based on evidence that was outlined in a 2005 State-of-the-Science Conference regarding chronic insomnia [12]. Based on the recommendations from that conference, insomnia is now conceptualized as comorbid, rather than secondary in nature when there are concurrent medical or psychological diagnoses. There is a growing body of empirical research that indicates that insomnia can be independently treated without the need to first resolve the comorbid condition [13], [14], [15], [16], [17]. However, many studies to date among older adults have specifically excluded individuals on the basis of the presence of comorbid medical or psychological conditions [18], [19], [20]. Given that conditions such as chronic pain, depression, and anxiety are particularly common among older individuals with chronic insomnia [21], a strength of the current study is its inclusion of older individuals with a wide variety of comorbid medical and psychological symptoms. Notably, results obtained for these individuals are more likely to be representative of the average older adult population with insomnia.
The efficacy of CBT-I is well established [22], [23], and research has shown that it is superior to benzodiazepine and nonbenzodiazepine sleeping medications for the long-term treatment of insomnia [24]. However, determining the critical elements of the intervention is not possible when delivering a multicomponent treatment such as CBT-I. A full decomposition study on CBT-I has not been performed to determine the most impactful elements of the treatment, but there is evidence to suggest that more succinct models of psychological treatment for insomnia may be as efficacious as longer treatment schedules among older adults [22], [25]. Several techniques including stimulus control, progressive muscle relaxation, and the cognitive technique of paradoxical intention have been judged to meet criteria as well-established standalone treatments [23]. In addition, there is some evidence to suggest that cognitive therapy can be efficacious as a standalone treatment [26]. Sleep hygiene has not been previously found to be an efficacious standalone treatment [27], whereas relaxation and stimulus control have been found to be efficacious [6], [28]. Of CBT-I studies to date in older adults, three have utilized either a more brief in-person behavioral intervention of four sessions [25], [29] or a brief mixed in-person and telephone intervention of four sessions [30]. In the Palleson and colleagues study, a comparison of sleep hygiene and relaxation, sleep hygiene and stimulus control, and wait-list control found no difference in efficacy between the two treatment approaches, and both groups showed significant improvement compared to a waitlist group [25]. In Buysse and colleagues’ study, BBTi resulted in significant improvements in subjective and objective sleep measures relative to a control group that read brochures on sleep, aging, and sleep hygiene; however, the two groups were not matched on time spent with a therapist [30]. Similarly, in Lovato and colleagues study evaluating small group-session BBTi, improvements in subjective wake after sleep onset [WASO], sleep efficiency [SE], and daytime functioning were observed relative to a waitlist control group at post-treatment relative to baseline [29]. The present study adds to this sparse literature by testing the impact of in-person delivery of a four-session BBTi protocol on primary subjective and objective sleep outcomes compared to a self-monitoring control (SMC) that provided equivalent contact with study personnel.
Chronic insomnia has been linked to worse mood across the lifespan [31], [32], [33], with nearly 90% of participants with insomnia symptoms in one epidemiological study reporting symptoms of depression or anxiety [33]. While sleep disturbance is included in the diagnostic criteria for numerous mood and anxiety disorders, insomnia often develops an independent course during time as patients adopt compensatory behaviors and thought patterns intended to help improve their sleep, but which often have the opposite effect. With time, the insomnia is maintained by these factors rather than those that contributed to its onset [34]. Additionally, there is considerable evidence that insomnia is a risk factor for the subsequent development of depressive symptoms [32], [35]. Daily patterns of covariation have been noted between disturbed sleep and daytime functioning. For instance, greater subjective sleep disturbance has shown to predict worse mood [36] and global daytime functioning the next day [37]. While the underlying mechanisms for this relationship remain to be determined, it is clear that sleep and mood factors are highly related. There is some evidence to suggest that the use of CBT-I in the treatment of insomnia can result in improvements in depression and anxiety symptoms [38], [39]. However, these findings have not been consistent across the existing research and deserve further investigation to determine whether brief interventions for insomnia can result in improvements in other mental health symptoms.
Changes in cognition concurrent with aging have been documented across a number of domains including memory, attention, processing speed, and executive functioning. In addition, there is evidence that self-reported sleep disturbance among older adults is related to cognitive performance impairments in the domains of memory, attention, and executive function [40], [41], [42], [43]. While there is evidence to suggest a relationship between subjective sleep disruption and cognitive functioning [44], results across numerous studies have not been consistent among cross-sectional and longitudinal designs, with many studies finding no meaningful differences between those with and without insomnia [45], [46], [47]. These inconsistent findings may be partially explained by small sample sizes, methodological differences in the assessment of insomnia symptoms, and the different populations under study [45], [47]. The relationship between sleep disruption and cognitive impairment may be moderated by the relative amount of cognitive reserve/resilience, measured by proxy using educational attainment, such that individuals with greater premorbid education display less cognitive impairment in the presence of sleep onset or maintenance difficulties [48]. In addition, independent of the effects of health problems or the use of sleeping medication, chronic insomnia has been found to be associated with an increased risk of cognitive decline among older men compared to those without insomnia but not among older women [49]. Results from a secondary analysis in Buysse and colleagues BBTi study supported these suggestions and showed that the intervention did not improve executive function or episodic memory with time or relative to an informational control group [50]. However, the authors note that the length of treatment (two in-person and two telephone sessions) and/or the follow-up period may not have been long enough to detect cognitive changes [50]. At this time, there is no sufficient evidence to conclude that treatment of insomnia symptoms will result in improvements in cognitive functioning [51]. However, there is a clear need for additional research into the potential effects of sleep disruption on cognitive functioning among older adults.
In sum, the present study investigated the effect of a BBTi in older adults with insomnia on sleep, cognition, and mood outcomes immediately following treatment and at a three month follow-up. We hypothesized that compared to SMCs, older adults with insomnia who undergo BBTi would exhibit significant improvements in self-reported sleep quality and self-reported and actigraphy-measured outcomes related to insomnia [sleep onset latency (SOL), WASO, total sleep time (TST), and SE], and those gains would either be maintained or further improved at three month follow-up. We further hypothesized that compared to SMC, older adults with insomnia who undergo BBTi would exhibit significant improvements in anxiety and depression immediately following treatment, and those gains would either be maintained or further improved at three month follow-up. Finally, given lack of prior conclusive findings regarding the relationship between insomnia and cognition, it is unclear whether, compared to SMC, older adults with insomnia who undergo BBTi would exhibit significant improvements in cognitive performance across various domains (ie, global cognition, attention/processing speed, memory, language and executive functioning). Given the large range of sleep (both self-reported and objective), cognition, and mood evaluations, results of the present study will provide insight into the mechanisms underlying the efficacy of BBTi and/or help determine whether sleep disruption is an important pathway associated with mood and cognition in older adults.
Section snippets
Overview
The present trial compared changes in sleep, mood, and cognitive performance in older adults with insomnia immediately and three months following four weeks of BBTi or SMC. The University of Florida's Institutional Review Board (IRB-02) approved the trial protocol. All participants gave written informed consent to participate. This trial is registered at www.clinicaltrials.gov (NCT02967185).
Participants
Participants (N = 62) were recruited from Gainesville and surrounding areas through newspaper and other
Treatment adherence
Of the 62 participants who were randomized, eight declined and did not participate in a single weekly session. Chi-square analyses to assess for systematic group differences in this baseline dropout rate were not significant [χ2 (1, N = 62) = 2.61, p = 0.11]. Of the remaining 54 participants, all completed the first two weeks, three dropped out after the second session, and one dropped out after the third session. The remaining participants completed all sessions (n = 50) and the majority of
Discussion
The present randomized clinical trial examined the effectiveness of a four week BBTi relative to the SMC group in improving (at post-treatment) and maintaining (at three month follow-up) sleep diary, actigraphy, mood, and neuropsychological outcomes in older adults with chronic insomnia.
Financial support
The project described was supported by Award Number AG024459 (Christina S. McCrae, PhD., PI) from the National Institute on Aging (NIA). Additional support was provided by an institutional training grant award number AG020499 (Michael Marsiske, PhD, Director) and Award Number K23AG049955 (Joseph Dzierzewski, PhD, PI). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIA.
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