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Assessment and Treatment of Sleep Disturbances in Senior Adults

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1 Assessment and Treatment of Sleep Disturbances in Senior Adults
Generational Resilience Conference October 29, 2014 Susan M. McCurry, PhD Northwest Research Group on Aging University of Washington School of Nursing Susan M. McCurry, Ph.D

2 Agenda for Today’s Talk
What is sleep? What causes sleep disturbances as we age? How do you measure sleep disruption and quality? What are your treatment options? Why are non-pharmacological treatments not more widely used?

3 Sleeping is no mean art: for its sake one must stay awake all day. 
~Friedrich Nietzsche

4 What is Sleep Anyway???? SM McCurry - Madison 11/4/11

5 Heart rate, eye movements slow down
STAGE 1 Transition to Sleep Easily awakened Muscle twitching STAGE 2 Light Sleep Heart rate, eye movements slow down STAGE 3 Deep Sleep Slow brainwaves Hard to wake Restorative STAGE 4 Deepest Sleep BP, body temp decrease Rhythmic breathing REM Sleep Dreaming Body paralysis Increased HR, BP, temp Delta wave sleep There are 5 stages of sleep. We cycle through all of them several times/night

6 Typical young adult. 25% rapid eye movement (REM) sleep, 75% Non-REM sleep (5% Stage 1, 45% Stage 2, 25% Stages 3-4) GHRI T-32 Journal Club_McCurry 3/11/14

7 Hypnogram: Young vs. Old
Awake REM 1 Sleep Stages 2 3 Young Adult 4 Awake REM 1 Sleep Stages 2 3 4 Older Adult Hours of Sleep Courtesy of Carol Landis, PhD

8 What Regulates Sleep? Homeostatic Process Sleep need (“drive”) increases the longer you are awake. sleepy Awake Sleep 2. The Circadian Process (Biological Clock) The propensity to sleep varies as a function of the time of day/night over 24 hours. sleepy Awake Sleep Germain A, Buysse DJ. Brief behavioral treatment of insomnia. In: Perlis M, et al. (eds.). Behavioral treatments for sleep disorders, pp Elsevier, 2011. SM McCurry - Madison 11/4/11

9 Homeostatic and Circadian Sleep Processes Work Together
“Drive” Edgar DM, Dement WC, Fuller CA, et al. Effect of SCN lesions on sleep in squirrel monkeys: evidence for opponent process in sleep-wake regulation. J Neurosci. 1993;13: 9

10

11 Circadian Rhythm Changes: Advanced Sleep Phase
Sleepy, Go to bed Wake Up Normal Phase Advanced Phase Sleepy Go to bed Wake up Ancoli-Israel, S All I want is a good night’s sleep. Mosby.

12 Points to Remember #1 Older adults do not need less sleep than younger adults BUT Aging reduces ability to achieve desired quantity and quality of sleep SM McCurry - Madison 11/4/11

13 Sleep Disturbance Risk Factors
Age-related change in sleep mechanisms Dementia Primary sleep disorders Other co-morbid conditions and treatments Environmental and behavioral factors Any combination of the above Least Modifiable Most Modifiable Bloom et al. J Am Geriatr Soc. 2009; 57(5): ; McCurry et al. Sleep Med Rev ; 4: SM McCurry - Madison 11/4/11

14 Sleep and Dementia Alzheimer’s disease
Loss of neurons that regulate circadian sleep-wake cycles (SCN: the body’s internal “clock”) and thermoregulatory processes Sleep architecture changes resemble an acceleration of normal age-related changes Parkinson’s disease and related disorders Sleep problems nearly universal in advanced PD Tremors, muscle contractions and cramps, limb jerks, nocturia, nightmares, daytime “sleep attacks” SM McCurry - Madison 11/4/11

15 Primary Sleep Disorders
Obstructive sleep apnea (OSA) Overlapping risk factors for stroke (HTN, diabetes, atrial fibrillation, cardiac and carotid disease) Widely underdiagnosed; compliance w/CPAP often poor Periodic leg movement syndrome (PLMS) Restless legs syndrome Linked to low iron levels In persons with dementia more strongly associated with nocturnal agitation than OSA and PLMS REM sleep behavior disorder (RBD) Most common in older men RBD – dream enactment leading to aggressive/complex behavior; treat with clonazepam. Sleep apnea: The temporary stoppage of breathing during sleep (apnea= Greek “want of breath.“) OSA most common, muscles of the soft palate around base of tongue relax, obstructing the airway The most common form of sleep apnea is obstructive sleep apnea. In obstructive sleep apnea, the muscles of the soft palate around the base of the tongue and the uvula relax, obstructing the airway. The airway obstruction causes the level of oxygen in the blood to fall (hypoxia), increases the stress on the heart, elevates blood pressure, and prevents the patient from entering REM sleep, the restful and restorative stage of sleep. In other words, sleep apnea causes deprivation of quality sleep. Increased in persons with Parkinson’s Philips B, et al Arch Intern Med, 160: Gehrman PR, et al J Am Geriatr Psychiatry, 11: Young T, et al JAMA, 291: Rose KM, et al Sleep, 34: SM McCurry - Madison 11/4/11

16 Laugh and the world laughs with you, snore and you sleep alone.
Anthony Burgess

17 Insomnia and Medical / Psychiatric Conditions (National Health Interview Survey)
45.9 30.3 29.4 20.9 16.6 10.8 9.3 5.6 3.0 0.7 Pearson NJ, Johnson LL Nahin RL.. Arch Intern Med :

18 Drugs that Can Worsen Sleep
Alcohol CNS stimulants (e.g., caffeine, theophylline, nicotine) Beta-blockers, calcium channel blockers Bronchodilators Corticosteroids Decongestants Diuretics Stimulating antidepressants, cognitive enhancers Thyroid hormones SM McCurry - Madison 11/4/11

19 Environmental & Behavioral Causes
Noise Light Temperature Season of year Bedding Television Dietary practices Exercise routines Pets Roommate or bed partner behaviors SM McCurry - Madison 11/4/11

20 There is no snooze button on a cat who wants breakfast.
~Author Unknown

21 Points to Remember #2 Many physical and environmental risk factors for sleep problems are common in older adults and should be considered as part of any sleep assessment and plan. SM McCurry - Madison 11/4/11

22 What is Insomnia? SM McCurry - Madison 11/4/11

23 Diagnostic Criteria (DSM-5)
Dissatisfaction with sleep quality or duration Subjective difficulties initiating/maintaining sleep (generally lasting 30+ minutes/night) Insomnia (or daytime fatigue) causes marked distress or significant impairment in social or occupational functioning Sleep difficulties are present 3 nights or more per week and for more than 3 months Despite adequate opportunity to sleep

24 Prevalence of insomnia
33% 10% Insomnia Symptoms with Daytime Impairments Sleep Dissatisfaction 15% Insomnia Diagnosis 6-12% Ohayon MM. Sleep Med Rev 2002; 6:97-111; Morin et al. Sleep Med 2006; 7:

25 Insomnia Assessment: History
The healthcare practitioner should screen patients for symptoms of insomnia during health examinations. An in-depth sleep history is essential in identifying the cause of insomnia. Polysomnography is not indicated for the routine evaluation of chronic insomnia. Standard. AASM Practice Parameters for the Evaluation of Chronic Insomnia Chesson A. et al. Sleep ; 23(2): 1-5.

26 Edinger JD et al. Sleep 2004; 27(8):1567-96 (Research Diagnostic Criteria for Insomnia)

27 Insomnia History Daytime activities and impairments: Napping, fatigue, cognitive function, mood Sleep related practices and environment (“sleep hygiene”) Longitudinal course General medical history (including diagnoses of primary sleep disorders) Psychiatric history Medication and substance use Life situation and circumstances (stressors)

28 Self-Administered Questionnaires
Assessment Domain Instrument Global sleep Pittsburgh Sleep Quality Index (PSQI) Insomnia symptoms Insomnia Severity Index (ISI) Fatigue Flinders Fatigue Scale (FFS) Sleepiness Epworth Sleepiness Scale (ESS) Attitudes about sleep Dysfunctional Beliefs About Sleep (DBAS) scale Sleep-related behaviors Sleep Hygiene Index (SHI) Quality of life SF-36 (includes pain subscale) Psychological symptoms Patient Health Questionnaire (PHQ-9) Generalized Anxiety Disorder scale (GAD-8) Pre-Sleep Arousal Scale (PSAS) Undiagnosed primary sleep disorders Berlin Apnea Questionnaire Restless legs single question* *When you try to relax in the evening or sleep at night, do you ever have unpleasant, restless feelings in your legs that can be relieved by walking or movement? (Ferri R. et al. 2007)

29 Purpose of Questionnaires
Capture subjective aspects of sleep experience that may not be reflected in objective measures Generally quick to administer Many have good validity/reliability data and shown to be sensitive to change in RTCs Many validated with senior populations Can use multiple measures to assess the heterogeneous context of insomnia symptoms

30 Limitations to Questionnaires
No consistency in referent time frame (generally 1 week to 1 month) Subjects often fill out incorrectly (e.g., leave items blank, circle 2 options, write explanatory notes in the margins) Poor readers, non-native English speakers may have difficulty with them Few are validated for use with other cultures Can be expensive to use proprietary instruments

31 Purpose of Daily Sleep Diaries
Teach people to observe their own sleep habits and patterns Gather daily sleep quality/satisfaction data over time Can collect other real-time data related to sleep (e.g., daily pain or depression ratings) Provide validation check for actigraphy data editing

32

33

34 Graphic sleep diary in insomnia patient
DJ Buysse. Advanced Practice in Primary and Acute Care Conference, November 10, 2007, Seattle, WA

35 Limitations to Daily Diaries
Wide variability in diaries across users (c.f., Carney et al. Sleep 2012; 35(2): ) Some people don’t like to keep them, especially for weeks at a time They are often filled out incorrectly If not completed every day poor recall can invalidate data Computing daily sleep stats for clinical review can be cumbersome

36 Tricks for Getting Good Diary Data
Provide clear written instructions and repeated practice in how to complete Review diaries every week when they are returned and follow up immediately when there are problems Particularly look for patterns suggestive of backfilling Keep diary as brief and as simple as possible If using paper diaries, put all weeks into a single booklet

37 Purpose of Actigraphy/Acclerometers
Provide objective measure of sleep/wake (activity) across the 24 hour period Data can be collected for longer period of time and at less cost/personnel training than PSG Some provide additional sensory measures (e.g., light or sound readings) Some insurance companies are covering

38

39 Actigraphic Sleep Assessment
Normal Sleeper Person with dementia Wake/activity Sleep/inactivity Time of day

40 Problems with Actigraphy
Although cheaper than PSG, actigraphs plus software are not inexpensive Wide variability in types of equipment, scoring algorithms, and editing procedures across studies Some people don’t like to wear them Data failure is not rare Analysis can be complicated and time-consuming (Note: Although easy to use, devices like Fitbit are not comparable to actigraphic scoring)

41 Tricks for Getting Good Actigraphy Data
Careful training and QA monitoring of persons who do initialization, downloading, and editing Hospital bands for at-risk patients can facilitate compliance keeping the device on Don’t count on devices being fully waterproof Make friends with your company tech support staff

42 All have been validated with older adults.
Points to Remember #3 Assessment of insomnia should include a combination of sleep history and standardized self-report questionnaires. Sleep diaries and actigraphy provide additional information on day-to-day variability and sleep patterns. All have been validated with older adults. SM McCurry - Madison 11/4/11

43 How Is Insomnia Treated???

44 Treatment for insomnia
Treatment Strategies Treatment for insomnia Pharmacologic Cognitive-Behavioral (CBT-I)

45 Pharmacological Approaches
Hypnotics – Benzodiazepines Hypnotics – Benzodiazepines Receptor Agonists (BZRAs) Zaleplon (Sonata) Zolpidem (Ambien, Ambien-CR*) Eszopiclone (Lunesta*) Melatonin agonists Ramelteon (Rozerem*) Antidepressants Doxepin (Silenor*) Others agents currently available or in development: OTC - Melatonin, valerian, anti-histamines, etc. Prescription - Anti-depressants (e.g.,trazodone), anti-psychotics, HTN meds (prazosin; PTSD nightmares) In development –5HT, GABA and Hypocretin/Orexin

46 Sedating Medications and Aging
Don’t always help or they stop working Can cause unwanted side effects (poor balance, confusion, paradoxical reactions) Primarily tested in younger adults with different pharmacokinetics Polypharmacy is always a concern Not preferred by many older adults Few randomized efficacy trials with specialty populations, e.g., persons with dementia SM McCurry - Madison 11/4/11 46 46

47 Advantages of CBT for Insomnia
Addresses perpetuating and, in some cases, precipitating causes of sleep disturbances No interactions with other medications or side effects Can improve symptoms of comorbid conditions Can reduce need for long-term hypnotic medications (or help taper off) Empowering for patients; provides tools they can use in future situations Susan M. McCurry, Ph.D

48 The 3-P Model of Insomnia
How did your insomnia start? Predisposing factors (genetics, biological traits, personality, “owls” and “larks”) Precipitating factors (“triggers,” e.g., illness, pain, bereavement, work stressors, shift changes) Why is it still here? Perpetuating factors that undermine underlying homeostatic (sleep drive) or circadian processes (e.g., staying in bed longer, going to bed early, napping, practicing counter-fatigue [e.g., caffeine] or self- medication [e.g., ETOH, OTC sleep aid] strategies)

49 Spielman’s Modified 3-P Model
Insomnia Insomnia Threshold No Insomnia Preclinical Acute Onset Early Insomnia Chronic Insomnia Predisposing Precipitating Perpetuating Kryger MH, et al. Principles and Practice of Sleep Medicine. 4th ed. New York, NY: Saunders; 2000; Perlis et al Cognitive Behavioral Treatment of Insomnia. New York, NY: Springer; 2005

50 CBT-I Multicomponent Approach
Domain Technique Aim Behavioral components Sleep hygiene Promote habits and environments that help sleep Stimulus control Strengthen bed and bedroom as sleep stimuli Sleep (bed) restriction Restrict time in bed to improve sleep depth and consolidation Cognitive components Cognitive therapy Address thoughts and beliefs that interfere with sleep Relaxation training Reduce arousal and decrease anxiety Acceptance based Decrease struggle to control sleep at cost of living your life Circadian components Circadian rhythm entrainment Reset or reinforce biological rhythm Susan M. McCurry, Ph.D

51 Cognitive-Behavioral Treatment for Insomnia Multicomponent Approach
Domain Technique Aim Behavioral components Sleep hygiene Promote habits and environments that help sleep Stimulus control Strengthen bed and bedroom as sleep stimuli Sleep (bed) restriction Restrict time in bed to improve sleep depth and consolidation Susan M. McCurry, Ph.D

52 Sleep Hygiene Recommendations
Regularize sleep / wake schedules (especially rise time) Establish a relaxing bedtime routine Increase daytime light exposure, keep sleep areas dark Reduce alcohol and caffeine use Keep bedroom a comfortable (cooler) temperature Eliminate environmental factors that interrupt sleep (pets!) Avoid stimulants and stimulating behavior at night (including screens and radio if you wake up during at night) Don’t watch the clock if you can’t sleep (turn it around!) Get regular exercise Ask your pharmacist about medication side effects Note many of these recommendations overlap with the other strategies we’ll be talking about next. Stepanski EJ, Whatt JK Sleep Med Rev, 7(3):: 52

53 Sleep Hygiene: Contraindications
Non-compliance “There is nothing more uncommon than common sense.” ~Frank Lloyd Wright People so rarely follow suggestions on lists like this that sleep hygiene recommendations are often used as a control condition in randomized trials When they do try to make changes, they often don’t stick with them

54 Stimulus Control To prevent your bedroom from becoming associated with poor night sleep, do the following: Get up at the same time every day, no matter how much you slept the night before Don’t go to bed if you are not sleepy Get out of bed if you wake up and can’t fall back to sleep right away (~15 mins) rather than stay in bed fretting about being awake Do not nap during the day (except brief “power naps”) Use bed only for sleep and sex

55 If you can't sleep, then get up and do something instead of lying there worrying. It's the worry that gets you, not the lack of sleep. ~Dale Carnegie

56 Stimulus Control: Contraindications
Stimulus control is contraindicated in those: Persons who are disabled and cannot easily get out of bed unassisted People at risk for slips and falls Persons without cognitive capacity to follow stimulus control instructions People who develop a habit of getting up in the middle of night to “do things” Bootzin RR & Perlis ML. Stimulus control therapy. In: Perlis M, et al. (eds.). Behavioral treatments for sleep disorders, pp Elsevier, 2011.

57 Bed Restriction If you reduce your time in bed, you increase your time awake Being awake longer will help you fall asleep faster and stay asleep for more of the night How long should I stay in bed? Keep a sleep diary for 5 – 7 days Write down time you went to bed, time you got up, and estimate how much of that time you were asleep Bed restriction time = estimated week sleep time average plus 30 minutes

58 Bed Restriction Example
7 day sleep log How long should I stay in bed? Write down time you went to bed, time you got up, and estimate how much of that time you were asleep Bed restriction time = estimated weekly sleep time average So in this example, you would restrict yourself to 7 hours in bed per night for one week (reduced from 9 hours) Pick your target rising time and work backwards to set bed time Monitor with daily log Went to Bed Got up I was awake about this much So I got about this much sleep 11:15 pm 8:45 am 3 hr 6.5 hr 10:20 pm 8:20 am 7 hr 10:30 pm 8:00 am 8:15 am 45 mins 9 hr 11:00 pm 7:30 am 1 hr 7.5 hr 11:30 pm 8:30 am 2.5 hr 6/5 hr 12:15 am 7:45 am 2 hr 5.5 hr Averages: 11:03 pm 8:09 am 2.2 hrs 6.9 hrs

59 Modifying Bed Restriction Plans
If after one week you are Falling asleep at night in less than 30 minutes AND Spending less than 30 minutes awake during the night OR Sleep percent (TST/TIB) > 85% (=“sleep efficiency”) THEN increase your time in bed “sleep window” 15 minutes If you are still having trouble sleeping Stick with the plan another week Cut back your time in bed by going to bed 15 minutes later

60

61 Bed Restriction: Contraindications
Bed restriction is contraindicated in those: Conditions that are exacerbated by sleepiness (epilepsy, mania, parasomnias [e.g., sleep walking], sleep disordered breathing) People who need to maintain vigilance, e.g., long- haul truck drivers, air traffic controllers, etc. Short sleep latencies and regular compact sleep times Some people will refuse to follow restricted schedule Spielman AJ, et al. Sleep restriction therapy. In: Perlis M, et al. (eds.). Behavioral treatments for sleep disorders, pp Elsevier, 2011.

62 Sleep Compression: A Kinder, Gentler Way….
7 day sleep log How long should I stay in bed? TIB this week = ~9 hours/night Target TIB = ~7 hours/night Subtract target from current TIB (9 – 7 = 2 hours) Divide difference by 4 (2 hours / 4 = 30 minutes) Set rise time then reduce TIB 30 minutes each week Week 1: 10:30-7:00 Week 2: 11:00-7:00 Week 3: 11:30-7:00 Week 4: 11:30-6:30 Went to Bed Got up I was awake about this much So I got about this much sleep 11:15 pm 8:45 am 3 hr 6.5 hr 10:20 pm 8:20 am 7 hr 10:30 pm 8:00 am 8:15 am 45 mins 9 hr 11:00 pm 7:30 am 1 hr 7.5 hr 11:30 pm 8:30 am 2.5 hr 6/5 hr 12:15 am 7:45 am 2 hr 5.5 hr Averages: 11:03 pm 8:09 am 2.2 hrs 6.9 hrs

63 General Disadvantages to Behavioral Strategies
Meds are widely available and work rapidly (when effective) Non-compliance and attrition are common due to effort and discomfort Things may get worse before they get better (improvements may not be seen until weeks) Require closer diary monitoring than meds

64 Cognitive-Behavioral Treatment for Insomnia Multicomponent Approach
Domain Technique Aim Cognitive components Cognitive therapy Address thoughts and beliefs that interfere with sleep Relaxation training Reduce arousal and decrease anxiety Acceptance based Decrease struggle to control sleep at cost of living your life Susan M. McCurry, Ph.D

65 In other words, worrying about sleep makes it harder to sleep
Attention-Intention Effort (AIE) Pathway Normal and automatic sleep processes become disrupted when individuals selectively focus on: Attention to sleep Intention to sleep Effort to sleep In other words, worrying about sleep makes it harder to sleep Espie, C.A., et al. Sleep Medicine Reviews, 10: , 2006.

66 Insomnia and Cognitive Effort
People with insomnia … Tend to use more thought control strategies (suppression, reappraisal, worry) Are more involved in excessive and counter- productive thinking about sleep and daytime function Have more hyper-arousal and anxiety

67 Cognitive Therapy Address misconceptions about sleep
I must get 8 hours/sleep at night to function I can control how much I sleep All daytime problems are due to my lack of sleep Cognitive arousal (“Insomnia Brain”) “Constructive worry” scheduling to reduce in-bed rumination Cognitive errors Catastrophizing (“If I don’t get a good sleep tonight, xx will happen”) Overgeneralization (“There’s nothing that will help my sleep.”) Magnification (“Insomnia is destroying my life.”)

68 Relaxation and Stress Management
Progressive muscle relaxation Deep breathing Mindfulness meditation or prayer Pleasant visual imagery Engaging the mind in something other than worry or planning (mental math, repeated words) Creating a “buffer zone” between ending day activities and going to bed Practice during the day to enhance nighttime effectiveness 68

69 Acceptance-Based Strategies
We cannot control sleep Sleep is an automatic, physiological process “Trying to sleep” increases arousal and risk for insomnia Thoughts and feelings are not your enemy Mindfulness: Notice – don’t resist – judgments, evaluations, criticisms, negative or positive thinking about sleep and self, feelings and sensations, memories, beliefs Life is about more than a good night’s sleep Normal sleepers have bad nights too Value-based action: What is important to you that you’ve been missing out on because of your insomnia? Story – Woman uses medical marijuana plus ½ tab of ambien every night, plus white noise machine, plus blackout curtains, plus evening routine….. She is no longer a normal sleeper. GHRI T-32 Journal Club_McCurry 3/11/14

70 CBT-I Multicomponent Approach
Domain Technique Aim Circadian components Circadian rhythm entrainment Reset or reinforce biological rhythm Susan M. McCurry, Ph.D

71 Strengthening Circadian Rhythms
Set consistent first exposure to light Increase daytime light Get outside whenever you can Open household curtains during the day Use full spectrum lighting if possible Regular morning light will help you fall asleep earlier at night, evening light will help you fall asleep later Use of a bright light box may help (http://www.sltbr.org/; see Corporate members list) Decreasing nighttime light Use bathroom night lights not overhead lights Close curtains to outside traffic and street light No screens (computer, TV, smart phone) at night

72

73 Light Therapy: Contraindications
Bright light therapy is contraindicated in those: Persons with eye abnormalities, systemic illnesses that affect the retina, or those using photosensitizing medications Persons who are unable to sit still and stay awake the correct angle and distance from the light for the prescribed treatment period Bright light can induce migraines (in ~1/3 of migraine sufferers), mania in bipolar individuals, agitation in cognitively impaired individuals

74 All have been validated in older adult populations.
Points to Remember #4 Multiple non-pharmacological strategies for improving sleep in persons with insomnia exist and have relatively few contraindications for their use. All have been validated in older adult populations. SM McCurry - Madison 11/4/11

75 Common Stated Barriers to CBT-I
Doesn’t work Not as effective as pharmacotherapy Takes too long Requires too much specialized training Costs too much Not suitable for individuals with contributing medical conditions Patient unwillingness to participate Susan M. McCurry, Ph.D

76 Does CBT-I Work? 1.19 1.2 C B T P C T 1.0 0.94 0.91 0.89 0.84 0.81 LARGE 0.78 0.8 0.66 Effect Size 0.6 0.51 0.46 MEDIUM 0.4 0.2 SMALL 0.0 SOL WASO FMA TST QUAL Morin CM, et al. Am J Psychiatry. 1994;151: Murtagh DR, et al. J Consult Clin Psychol. 1995;63:79-89. Nowell PD, et al. JAMA. 1997;278: Smith MT, et al. Am J Psychiatry. 2002;159:5-11. Courtesy of Charles Morin, PhD Susan M. McCurry, Ph.D

77 It is Frustrating When Treatment Doesn’t Seem to Be Effective
Expectations HUGE GAP Reality

78 What Do Improvements Look Like?
“Practice makes perfect” Changes in sleep are gradual and not necessarily steady Sleep Improvement Time Buysse D. Personal communication. BBTI Workbook. v

79 Does CBT-I Take Too Long?
Abbreviated Cognitive-Behavioral Insomnia Therapy1 Two 25- minute sessions, 2 weeks apart Eliminate sleep-incompatible activities in bed/bedroom Avoid all daytime napping Follow a consistent sleep-wake schedule Brief Behavioral Treatment for Insomnia2 One session with booster phone call 2 weeks later Reduce your time in bed Don’t go to bed unless you are sleepy Don’t stay in bed unless you are asleep Get up at the same time every day of the week, no matter how much you slept the night before Edinger JD, et al. Sleep. 2003;26: Buysse DJ et al. Arch Intern Med. 2011; 171(10); Susan M. McCurry, Ph.D

80 Does CBT-I Cost Too Much?
Shorter interventions help contain costs More cost-effective delivery models are being developed and tested in RTCs Group administered sessions Telephone Video recordings Internet Stepped care approaches Vitiello MV et al. J Am Geriatr Soc. 2013; 61(6): ; McCurry SM et al. Sleep. 2014; 37(2): ; Lovato N et al. Sleep. 2014; 37(1): ; Bastien CH et al. J Consult Clin Psychol. 2004; 72(4): ; Arnedt JT et al. Sleep. 2013; 36(3): ; Savard J et al. Sleep. 2014; 37(8): ; Espie CA et al. Sleep. 2012; 35(6): ; Cheng SK, Dizon J. Psychother Psychosom. 2012; 81: ; Espie CA. Sleep. 2009; 32(12): Susan M. McCurry, Ph.D

81 Does CBT-I Require A Sleep Specialist?
Newer brief interventions developed for primary care typically use non-sleep specialist delivery (e.g., RNs, MS-level sleep educators) Not all patients are appropriate for CBT-I, however, so practitioners need to be qualified to assess and refer as needed. Susan M. McCurry, Ph.D

82 Does CBT-I Work In Comorbid Disease?
Common age-related comorbidities/general primary care (Buysse et al. Arch Intern Med. 2011; 171: ; Espie et al. Sleep. 2007; 30: ) Osteoarthritis pain (Vitiello et al. J Am Geriatr Soc. 2013; 61: ; McCurry et al. Sleep 2014; 37: ) Mixed psychiatric conditions (Edinger et al. Sleep. 2009; 32: ) Cancer (Espie et al. J Clin Oncol. 2008; 26: ) Major depression (Manber et al. Sleep, 2008; 31: ) Mixed medical (OA, CAD, COPD) (Rybarczyk et al. J Consult Clin Psychol. 2005; 73: ) Dementia (McCurry et al. J Am Geriatr Soc. 2005; 53: ; McCurry et al. J Am Geriatr Soc. 2011; 59: ; McCurry et al. Am J Geriatr Psychiatry 2012; 20: )

83 Are People Willing to Do It?
Unrealistic patient expectations Daytime side-effects (fatigue, poor concentration, mood swings) Real/perceived obstacles to sleep plan (bed partner, physical mobility, “it’s cold and dark out there!”) Boredom during increased out-of-bed time Paradoxical reactions (e.g., anxiety during relaxation)

84 I’m for anything that gets you through the night, be it prayer, tranquilizers or a bottle of Jack Daniel’s. ~Frank Sinatra

85 Preparing the Patient Takes Time
Introduce self-management approach Gauge patient expectations Assess acceptability of non-pharmacological approach Importance of a sleep diary Setting short-term goals Negotiate a time-limited contract Secure support from significant others Morin CM. Insomnia: Psychological assessment and management. Guilford; 1993.

86 CBT-I Contraindications
A Few General Guidelines CBT-I Contraindications Try Instead Patient takes < 30 mins to fall asleep, and is awake for < 30 mins/night, but still has sleep or daytime complaints Educate patient; refer for evaluation for primary sleep disorder causing nonrestorative or fragmented sleep Untreated medical and/or psychiatric illness causing sleep disruptions Wait and see if insomnia resolves with appropriate diagnosis & treatment; reassess for CBT-I at later time Medical condition that may prevent patient from doing sleep restriction or stimulus control Consider alternative CBT-I components (e.g., relaxation training); pharmacological treatment may be indicated Perlis ML et al. Cognitive behavioral treatment of insomnia. Springer; 2008. SM McCurry - Madison 11/4/11

87 Ethical Issues to Consider
What are the implications of increased daytime sleepiness for the functioning and well-being of the client? Insomnia is a suicide risk factor: Is this risk being monitored? Non-prescribing clinicians cannot taper meds, alter CPAP protocols without physician oversight

88 Many commonly cited arguments against the use of CBT-I are untrue
Points to Remember #5 Many commonly cited arguments against the use of CBT-I are untrue BUT Non-pharmacological interventions do require time and commitment – on the part of both patient and provider – to be successful SM McCurry - Madison 11/4/11

89 Want to Know More? Books for Clients Books for Clinicians
Edinger JD, Carney CE. Overcoming Insomnia: A Cognitive-Behavioral Therapy Workbook. Oxford University Press, 2008. Hauri P, et al. No More Sleepless Nights. John Wiley & Sons, Book and Workbook. Meadows, G. The Sleep Book. London: Orion House, 2014. Books for Clinicians Edinger JD, Carney CE. Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach Therapist Guide. Oxford University Press, 2008. Perlis ML et al. Cognitive Behavioral Treatment of Insomnia: A Session- by-Session Guide. Springer, 2005. Perlis ML et al. (Eds). Behavioral Treatments for Sleep Disorders: A Comprehensive Primer of Behavioral Sleep Medicine Interventions (Practical Resources for the Mental Health Professional). Elsevier, 2011.

90 Websites http://www.cbtforinsomnia.com http://www.sleepeducation.com/
px?topicID=68&cnt=1&areaID=0

91 A good laugh and a long sleep are the best cures in the doctor's book. 
~Irish Proverb


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