Insomnia is highly prevalent among elderly patients, but a new study suggests that a brief behavioral treatment can significantly improve insomnia in this population.
In a pilot study, Anne Germain, Ph.D., and her colleagues at the University of Pittsburgh demonstrated that a 45-minute training session followed 2 weeks later by a 30-minute booster session significantly improved scores on the Pittsburgh Sleep Quality Index (PSQI), decreased the time it took to fall asleep, and decreased the amount of wake time after sleep onset (J. Clin. Sleep Med. 2006;2:403–6).
The behavioral training was delivered by a master's-level adult psychiatric and primary-care nurse practitioner who had been trained in the technique. But in an interview, Dr. Germain said, “I think we can train any health care worker at this point to deliver the intervention.” She specifically mentioned clinical nurse assistants.
The 35 participants in the study lived in the community, but Dr. Germain said the technique would also be applicable in nursing homes, assisted living centers, and even hospices.
The participants, whose average age was 70 years, were randomized to receive either the brief behavioral treatment or an “information-only control:” brochures published by the American Academy of Sleep Medicine on insomnia, sleep and aging, and sleep hygiene. This was intended to emulate the type of behavioral instructions most primary-care patients might receive.
In the initial treatment session, study participants were given four individually tailored instructions. They were told to reduce the time spent in bed to closely match their number of hours of sleep, to get up at the same time every day of the week, not to go to bed unless they were sleepy, and not to stay in bed unless they were asleep.
Several of these instructions get at the notion of “sleep restriction,” which Dr. Germain explained this way: “A lot of people with insomnia tend to increase the amount of time they spend in bed, hoping to catch up on their sleep. They hope that if they stay in bed longer maybe they're going to sleep longer. This typically feeds back into the insomnia by conditioning the body and the brain that the bed is no longer a place only to sleep, but also to be awake.”
Allowing the patients to be in their beds only when they are actually asleep conditions them to associate the bed with sleep and not with reading, thinking, watching television, or other activities, she said.
At the booster session, the sleep schedules were modified if necessary. For example, if patients were falling asleep in less than 30 minutes and were waking up during the night for less than 30 minutes, they were told to increase their time in bed by 15 minutes, and to maintain that new time in bed for 1 week.
If after that week they were still falling asleep in less than 30 minutes and waking up during the night for less than 30 minutes, they were allowed to increase their time in bed by another 15 minutes.
In contrast, if it took them longer than 30 minutes to fall asleep or they awoke during the night for more than 30 minutes, they were instructed to decrease their time in bed by 15 minutes.
Twelve (71%) of the 17 participants who received the behavioral treatment met the study criteria for response, and 9 (53%) also met the criteria for remission. Among the patients in the control group, 6 of 18 (33%) met the criteria for response, and 3 (17%) met criteria for remission.
On average, patients receiving the behavioral treatment lost about four points on the Pittsburgh Sleep Quality Index, while scores among the control patients remained unchanged.
Average sleep latency (the time it takes to fall asleep) fell from 38 minutes to 17 minutes among the patients in the treatment group, and from 30 minutes to 27 minutes among the control patients. The number of minutes of wakefulness after sleep onset fell from 61 minutes to 28 minutes among the treated patients, and from 48 minutes to 36 minutes among the control patients.
All three of these differences between treated and control patients were statistically significant.
On the other hand, there were no statistically significant differences in total sleep time, but this may have been an artifact of the sleep-restriction aspect of the behavioral treatment as well as the relatively short length of follow-up in this pilot study–just 4 weeks after the initial treatment and 2 weeks after the booster session, she noted.
“We didn't have enough time to verify whether or not in the long run we do increase people's total sleep time,” Dr. Germain said.