Cognitive Behavioral Therapy for Insomnia in Older Veterans Using Nonclinician Sleep Coaches: Randomized Controlled Trial

Abstract

OBJECTIVES To test a new cognitive behavioral therapy for insomnia (CBT-I) program designed for use by nonclinicians. DESIGN Randomized controlled trial. SETTING Department of Veterans Affairs healthcare system. PARTICIPANTS Community-dwelling veterans aged 60 and older who met diagnostic criteria for insomnia of 3 months duration or longer (N = 159). INTERVENTION Nonclinician “sleep coaches” delivered a five-session manual-based CBT-I program including stimulus control, sleep restriction, sleep hygiene, and cognitive therapy (individually or in small groups), with weekly telephone behavioral sleep medicine supervision. Controls received five sessions of general sleep education. MEASUREMENTS Primary outcomes, including self-reported (7-day sleep diary) sleep onset latency (SOL-D), wake after sleep onset (WASO-D), total wake time (TWT-D), and sleep efficiency (SE-D); Pittsburgh Sleep Quality Index (PSQI); and objective sleep efficiency (7-day wrist actigraphy, SE-A) were measured at baseline, at the posttreatment assessment, and at 6- and 12-month follow-up. Additional measures included the Insomnia Severity Index (ISI), depressive symptoms (Patient Health Questionnaire-9 (PHQ-9)), and quality of life (Medical Outcomes Study 12-item Short-form Survey version 2 (SF-12v2)). RESULTS Intervention subjects had greater improvement than controls between the baseline and posttreatment assessments, the baseline and 6-month assessments, and the baseline and 12-month assessments in SOL-D (−23.4, −15.8, and −17.3 minutes, respectively), TWT-D (−68.4, −37.0, and −30.9 minutes, respectively), SE-D (10.5%, 6.7%, and 5.4%, respectively), PSQI (−3.4, −2.4, and −2.1 in total score, respectively), and ISI (−4.5, −3.9, and −2.8 in total score, respectively) (all P < .05). There were no significant differences in SE-A, PHQ-9, or SF-12v2. CONCLUSION Manual-based CBT-I delivered by nonclinician sleep coaches improves sleep in older adults with chronic insomnia.

A Four-Session Sleep Intervention Program Improves Sleep for Older Adult Day Health Care Participants: Results of a Randomized Controlled Trial

“…Some participants, for example, reporting taking longer than 1 hour to fall asleep, but then reported that their sleep quality was "very good." Furthermore, in our recent insomnia treatment study of older veterans in the same health care system who were not participating in the ADHC program, 23 the mean baseline PSQI score was 9.1 and the mean baseline ISI score was 11.1, while their baseline sleep efficiency based on actigraphy was 83%. ADHC Patients in the current study had similar actigraphically assessed sleep efficiency (85%); however, their questionnaires reflected substantially less "complaint."…”

“…In addition, this program was similar to CBT-I in terms of the number of sessions, but each session was shorter than many CBT-I intervention programs, which are typically 4-8 sessions lasting 60 minutes per session. 20,22,23 Some studies of brief interventions are also effective with older patients. 21,34 Consistent with traditional CBT-I interventions, all recommendations were tailored to the individual patient, addressing their specific circumstances, sleep patterns, and level of motivation to engage in the intervention.…”

“…A five-point Likert-like scale is used to rate each item, ranging from 0 (no problem) to 4 (very severe problem). Total scores range from 0 to 28 and are interpreted as follows: no insomnia (0-7), subthreshold insomnia (8)(9)(10)(11)(12)(13)(14), moderate insomnia (15)(16)(17)(18)(19)(20)(21), and severe insomnia (22)(23)(24)(25)(26)(27)(28).…”

“…CBT-I has been shown to be as effective for older as for younger adults; 17 however, studies of older adults have typically been conducted in outpatient settings with participants who do not have significant functional impairments. [20][21][22][23] It also is not clear whether adapting CBT-I for patients with limited physical abilities will reduce potency. ADHC participants may not be able to adhere to all of the traditional recommendations of CBT-I, such as getting out of bed at night (because of high fall risk) or completing complex sleep diaries (due to visual or cognitive difficulties).…”

Sleep and mild cognitive impairment

“…Sleep disturbances in older adults are commonly addressed by sleep specialists. Given the shortage of clinicians specializing in assessing and treating sleep difficulties, it is imperative that sleep be evaluated routinely in other clinical settings and that alternative implementation models, such as using sleep coaches (Alessi et al 2016), be considered to reach more patients in need of effective treatments. Given the high prevalence of sleep disturbances, assessments need to be incorporated in regular health checks and referrals made for a thorough diagnostic workup when disturbances are reported, particularly given the evidence that it may represent a prodromal state of dementia.…”