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Insomnia Is Not To Be Ignored

An estimated 15 to 35 percent of older Americans have insomnia— difficulty falling asleep or staying asleep or getting non-restorative sleep with resulting symptoms during waking hours that include fatigue, trouble concentrating and mood disturbances. Also troubling, insomnia is associated with falls and hip fractures among older adults. These side effects all make it all the more important to address insomnia and not regard it as an inevitable part of aging.

Another assumption to avoid making is that sleeping pills are the only answer. In actuality, drugs and behavioral treatments are about equally effective, yet older adults are prescribed hypnotic agents at disproportionate rates and are also more likely than younger patients to experience adverse drug effects.

A recent study, posted online and to be published in the May 23 print issue of Archives of Internal Medicine, one of the JAMA/Archives journals, showed that a behavior-centered, short-term type of counseling may both help correct insomnia and, because of its limited duration, not carry the typical social stigma often associated with seeking mental therapies.

Daniel J. Buysse, MD, of University of Pittsburgh School of Medicine, and colleagues conducted a randomized clinical trial of a brief behavioral treatment involving 79 older adults (with an average age of 71.7) with insomnia. Thirty-nine participants received the treatment, which consisted of individualized behavioral instruction delivered by a nurse clinician over four sessions, two in person and two by phone. The other 40 were assigned to an information control group and received only general printed educational material about insomnia and sleep habits.

All participants provided demographic information, completed self-report and interviewer-administered questionnaires about sleep habits, kept two-week sleep diaries and underwent sleep assessment by actigraphy (using a wrist or ankle monitor) and polysomnography (a more in-depth monitoring procedure) before treatment and four weeks after beginning therapy. Participants who showed a response to the brief treatment were contacted again after six months and asked to complete questionnaires and sleep diaries.

After four weeks, a larger percentage of those receiving the brief behavioral treatment showed a favorable response to the treatment (67 percent vs. 25 percent) or were classified as no longer having insomnia (55 percent vs. 13 percent). Based on the results, the authors estimate that for every 2.4 patients treated, one would respond favorably and one would no longer meet criteria for insomnia.

The brief intervention produced significantly better outcomes at four weeks as measured by patients' reports of sleep and health, sleep diaries and actigraphy, but not polysomnography. Improvements were maintained at the six-month follow-up.

"Although brief behavioral treatment for insomnia shares many features with other behavioral insomnia treatments, some particular features make it an especially attractive option," the authors write. The program's strong behavioral focus may avoid some of the stigma associated with "psychological" treatments, it provides patients with a workbook and specific written instructions and it is simple enough to be taught to nurses in a short period of time.

"Brief behavioral treatment for insomnia possesses efficacy, efficiency and acceptability—three characteristics of a successful 'entry level' treatment in a stepped care approach to behavioral management of insomnia," the authors concluded. Though future studies are needed to examine the feasibility of educating nurses and other health professionals in brief behavioral treatment for insomnia and its effectiveness in a variety of settings, it’s important to know that not all remedies come in the form of a pill.

Tried and true lifestyle changes for insomnia include getting exercise early in the day, creating a no-stress bedroom environment with a cool temperature and even drinking the classic glass of warm milk. When these remedies don’t help, talk to the doctor about behavior therapy and whether it might be the answer to getting more restful sleep.