Insomnia is a sleep disorder characterized by difficulty falling and/or staying asleep,together with daytime symptoms, such as fatigue, irritability, and poor concentration. The condition is highly prevalent among older adults, with almost a third reporting some symptoms of insomnia. While symptom severity may vary, 10% of older adults suffering from insomnia experience persistent and significant health and functional consequences that approach and sometimes exceed quality of life problems that are seen with other chronic conditions, such as congestive heart failure and depression.
Several treatments for insomnia are available, but a common barrier to diagnosis and treatment in the elderly is physician reluctance to assess this patient group for insomnia. “Pharmacotherapy, a standard treatment for insomnia, is effective but has been associated with significant side effects and safety concerns,” explains Daniel J. Buysse, MD. “Insomnia itself may lead to fatigue, cognitive impairment, and increased risk for falls and hip fractures in older adults. Hypnotic medications may further increase those risks.” Cognitive behavioral therapy for insomnia (CBTI) is another effective strategy for treating older adults. It is often preferred by patients and has few apparent adverse effects, but CBTI typically involves several treatment sessions with clinical psychologists. This approach is often not readily available to older adults, especially to those with fixed incomes.
Assessing a New Insomnia Intervention
In the May 23, 2011 Archives of Internal Medicine, Dr. Buysse and colleagues published a study that examined the efficacy and feasibility of a potential new treatment option for physicians caring for older patients with insomnia. The study sought to evaluate the short-term efficacy and 6-month durability of a brief behavioral treatment for insomnia (BBTI) versus an information control intervention among patients with insomnia, according to Dr. Buysse. A sample of 79 older adults with chronic insomnia was evaluated for 6 months. The BBTI included a 1-hour, in-person session, a 30-minute follow-up “booster” session at 2 weeks, and follow-up phone calls after 1 week and 3 weeks (Table). Outcomes were assessed at 1 month. “Previous psychological-behavioral treatments for insomnia have established efficacy but have also been costly and timely to implement,” says Dr. Buysse, who was the lead investigator in the analysis. “Our study team aimed to develop a similarly effective treatment, but in a brief format that could facilitate dissemination and utilization among a larger population.”
An Effective, Practical Alternative to Treat Insomnia
Dr. Buysse’s Archives of Internal Medicine study demonstrated that BBTI may be an effective and practical alternative to previous treatment options (Figure). Two-thirds of the sample treated with BBTI showed a clinical response, versus 25% in the control group. In addition, over half (55%) of those in the active treatment group no longer met criteria for insomnia at study completion, compared to a 13% rate in the control group. “On average, physicians would need to treat 2.4 patients with the BBTI to see improved outcomes relative to the control condition,” Dr. Buysse says. “BBTI appeared to have comparable efficacy to established treatments. These data suggest that the available psychological behavioral treatments for insomnia can be delivered in a brief format by a nurse practitioner with results that can be documented quickly and sustained at 6 months follow-up.”
“There’s a realistic possibility that other allied health professionals can deliver BBTI in a
Previous research has shown that medication use spontaneously decreases among older insomnia patients, even when they adhere to an effective form of CBTI. Dr. Buysse says that while his study team did not have the sample size to evaluate this phenomenon in the investigation, some participants were taking medications for insomnia, and BBTI appeared to be no less effective among these patients. Furthermore, time, cost, staffing availability, and widespread application have been identified as barriers to delivering effective treatments for insomnia. “The BBTI studied in our analysis eliminates many, if not all, of these barriers,” Dr. Buysse says. “In addition, there’s a realistic possibility that other allied health professionals can deliver BBTI in a cost-effective manner.”
The Future in Insomnia Research
Despite improvements in the management of insomnia in older adults, research gaps remain. Data are needed on how to deliver insomnia treatments safely and effectively. Dr. Buysse and colleagues are currently evaluating novel forms of behavioral treatment delivery, such as internet programs. “If proven effective, we could have an even broader potential for disseminating enhanced services for older adults,” says Dr. Buysse. “We look forward to learning more about the association between treatment and improved functional and quality of life, as well as health outcomes. Additionally, future studies should examine the feasibility of educating nurses and other health professionals in the BBTI.”
Readings & Resources (click to view)
Buysse DJ, Germain A, Moul DE, et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med. 2011 Jan 24 [Epub ahead of print]. Available at http://archinte.ama-assn.org/cgi/content/short/171/10/887.
Buysse DJ, Germain A, Moul DE. Diagnosis, epidemiology and consequences of insomnia. Prim Psychiatry.2005;12:37-44.
Bloom HG, Ahmed I, Alessi CA; et al. Evidence-based recommendations for the assessment and management of sleep disorders in older persons. J Am Geriatr Soc. 2009;57:761-789.
Morin CM, Bélanger L, LeBlanc M; et al. The natural history of insomnia: a population-based 3-year longitudinal study. Arch Intern Med. 2009;169:447-453.