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Insomnia is defined by difficulty falling asleep, difficulty staying asleep, nonrestorative sleep, and waking symptoms such as fatigue, impaired concentration, and mood disturbance. The prevalence of insomnia is approximately 5% to 20% in the general adult population and 20% to 30% in primary care medical settings. Insomnia is commonly comorbid with physical and mental disorders and chronic, persisting for a year or longer in 74% of individuals. The health and functional consequences of insomnia include reduced quality of life, increased health care utilization and costs, disability, and risk for psychiatric disorders and cardiovascular disease. Insomnia is especially relevant for older adults, given its high prevalence (estimated at 15%-35%), persistence, and association with falls and hip fractures. Older adults are prescribed hypnotic agents disproportionately frequently and for disproportionately long-term use and are more likely than other populations to experience adverse drug effects.
Pharmacologic and behavioral treatments for chronic insomnia have approximately equivalent efficacy. Each has specific merits and drawbacks. Hypnotic agents approved by the US Food and Drug Administration, including benzodiazepine receptor agonist (BZRA) drugs, are widely available, easy to use, and have rapid and sustained efficacy. However, BZRA safety concerns include dependence and abuse, cognitive impairment, and increased risk of falls and hip fractures, particularly in older adults. Behavioral and psychological techniques include sleep education, restriction of time in bed, stimulus control (strengthening associations between bed and sleep), and addressing anxiety-provoking beliefs about sleep. These treatments, particularly multicomponent cognitive behavioral therapy for insomnia (CBTI), are often preferred by patients and have consistent short-term and long-term efficacy with few apparent adverse effects. However, widespread use of CBTI is limited by the number of specialty-trained clinicians and by the duration, intensity, and initial cost of 6 to 8 individual treatment sessions. Moreover, most efficacy trials of pharmacologic and behavioral treatments have studied patients with primary insomnia and excluded the larger group of patients with substantial medical and psychiatric comorbidities, which includes many older adults.
The present study was conducted to test a behavioral treatment of insomnia that offers potential for widespread use. For a behavioral treatment to be relevant in general medical settings, it must be brief, acceptable to patients, deliverable by nurses or other allied health professionals, and efficacious over a short time interval in patients with typical comorbidities. The specific aim of this study was to test the short-term efficacy and 6-month durability of brief behavioral treatment for insomnia (BBTI) vs an information control (IC) intervention among older adults with insomnia.
Buysse DJ, Germain A, Moul DE, et al. Efficacy of Brief Behavioral Treatment for Chronic Insomnia in Older Adults. Arch Intern Med:archinternmed.2010.535. http://archinte.ama-assn.org/cgi/content/abstract/archinternmed.2010.535v1
Background Chronic insomnia is a common health problem with substantial consequences in older adults. Cognitive behavioral treatments are efficacious but not widely available. The aim of this study was to test the efficacy of brief behavioral treatment for insomnia (BBTI) vs an information control (IC) condition.
Methods A total of 79 older adults (mean age, 71.7 years; 54 women [70%]) with chronic insomnia and common comorbidities were recruited from the community and 1 primary care clinic. Participants were randomly assigned to either BBTI, consisting of individualized behavioral instructions delivered in 2 intervention sessions and 2 telephone calls, or IC, consisting of printed educational material. Both interventions were delivered by a nurse clinician. The primary outcome was categorically defined treatment response at 4 weeks, based on sleep questionnaires and diaries. Secondary outcomes included self-report symptom and health measures, sleep diaries, actigraphy, and polysomnography.
Results Categorically defined response (67% [n = 26] vs 25% [n = 10]; {chi}2 = 13.8) (P < .001) and the proportion of participants without insomnia (55% [n = 21] vs 13% [n = 5]; {chi}2 = 15.5) (P < .001) were significantly higher for BBTI than for IC. The number needed to treat was 2.4 for each outcome. No differential effects were found for subgroups according to hypnotic or antidepressant use, sleep apnea, or recruitment source. The BBTI produced significantly better outcomes in self-reported sleep and health (group x time interaction, F5,73 = 5.99, P < .001), sleep diary (F8,70 = 4.32, P < .001), and actigraphy (F4,74 = 17.72, P < .001), but not polysomnography. Improvements were maintained at 6months.
Conclusion We found that BBTI is a simple, efficacious, and durable intervention for chronic insomnia in older adults that has potential for dissemination across medical settings.
Trial Registration clinicaltrials.gov Identifier: NCT00177203