Behavioral and drug treatments are effective for the short-term management of late-life insomnia; however, sleep improvements are better maintained over time with behavioral treatment, according to an article published in The Journal of the American Medical Association (JAMA).
Charles M. Morin, Ph.D., of the University of Laval, Sainte-Foy, in Quebec, Canada, and colleagues studied 78 adults (50 women and 28 men with a mean age of 65 years) with chronic and primary insomnia to evaluate the effectiveness of drug therapies for late-life insomnia. The participants were randomized to 1) cognitive-behavior therapy (CBT); 2) drug therapy (using a sleep medication called temazepam); 3) both behavior and drug therapies; or 4) placebo. They received eight weeks of treatment, with follow-ups conducted at three, 12 and 24 months.
The researchers report that the three treatment groups were able to maintain sleep more efficiently than the placebo group. For example, the percentage of reductions of time awake after sleep onset was highest for the combined condition (63.5 percent), followed by CBT (55 percent), drug therapy (46.5 percent) and placebo (16.9 percent).
According to information cited in the study, sleep disturbance is a prevalent problem in late life. Between 12 percent to 25 percent of healthy seniors report chronic insomnia, and the estimates are even higher among older adults who have other medical or psychiatric illness.
The study participants receiving CBT attended eight weekly 90-minute therapy sessions conducted in small groups of four to six individuals. Treatment consisted of a structured program that involved behavioral, cognitive and educational components that targeted different facets of late-life insomnia.
The behavioral component incorporated sleep restriction therapy (curtailing time in bed to actual sleep time) and stimulus control procedures (restricting the use of the bed and bedroom only for sleep or sex). The cognitive therapy component was designed to alter faulty beliefs and attitudes that often serve to exacerbate insomnia, and the educational component aimed to distinguish normal from pathologic sleep changes occurring in late life.
The researchers report that although all three treatments were effective during the initial study period, sleep improvements were not equally well maintained across all conditions over time. Initial improvements gained by both the behavioral and drug therapies were well maintained short term (three-month follow-up), but only behavioral treatment produced durable changes in the long term (12- and 24-month) follow-up.
“Our results indicate that chronic insomnia can be effectively treated in late life with structured and sleep-focused interventions aimed at changing poor sleep habits and faulty beliefs and attitudes about sleep,” the authors write. “Although such behavioral intervention is more time consuming than drug therapy, it is worth the investment because therapeutic gains are well maintained. The results also indicate that PCT [pharmacotherapy, or drug therapy] alone, although effective in the short term, may not be sufficient for long-term management of chronic insomnia.” The researchers call for additional research to further evaluate other ways to optimally integrate biobehavioral approaches in the management of insomnia.
Insomnia is the most common sleep disorder and involves trouble falling asleep, frequent or prolonged nocturnal awakenings, or early morning awakenings with an inability to return to sleep. Older adults report primarily difficulty in maintaining sleep. Severe sleep disturbances are associated with fatigue during the day, impaired functioning, reduced quality of life and increased health care costs. When left untreated, chronic insomnia may increase vulnerability to major depression, and among older adults with cognitive impairments, it may even hasten nursing home placement. Fewer than 15 percent of individuals with chronic insomnia receive any treatment.
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