Treatment of insomnia in older adults

A comparison of sleep restriction and sleep compression on objective measures of sleep: A sub-sample from a large randomised controlled trial

Sleep restriction therapy is a central component of cognitive behavioural therapy for insomnia, but can lead to excessive sleepiness, which may impede treatment adherence. Sleep compression therapy has been suggested as a possibly gentler alternative. The aim of this study was to compare the effects of sleep restriction therapy and sleep compression therapy on objective measures of sleep, with a focus on magnitude and timing of effects. From a larger study of participants with insomnia, a sub-sample of 36 underwent polysomnographic recordings, before being randomised to either sleep restriction (n = 19) or sleep compression (n = 17) and receiving online treatment for 10 weeks. Assessments with polysomnography were also carried out after 2, 5, and 10 weeks of treatment. Data were analysed with multilevel linear mixed effect modelling. As per treatment instructions, participants in sleep restriction initially spent shorter time in bed compared with sleep compression. Participants in sleep restriction also showed an initial decrease of total sleep time, which was not seen in the sleep compression group. Both treatments led to improvements in sleep continuity variables, with a tendency for the improvements to come earlier during treatment in sleep restriction. No substantial differences were found between the two treatments 10 weeks after the treatment start. The results indicate that homeostatic sleep pressure may not be as important as a mechanism in sleep compression therapy as in sleep restriction therapy, and an investigation of other mechanisms is needed. In conclusion, the treatments led to similar changes in objective sleep at a somewhat different pace, and possibly through different mechanisms.

A comprehensive study on the relieving effect of Lilium brownii on the intestinal flora and metabolic disorder in p-chlorphenylalanine induced insomnia rats

CONTEXT

The bulb of Lilium brownii F. E. Brown (Liliaceae) (LB) is a common Chinese medicine to relieve insomnia.

OBJECTIVE

To investigate the molecular mechanism of LB relieving insomnia.

MATERIALS AND METHODS

Insomnia model was induced by intraperitoneally injection p-chlorophenylalanine (PCPA) in Wistar rats. Rats were divided into three groups: Control, PCPA (400 mg/kg, i.p. 2 days), LB (598.64 mg/kg, oral 7 days). The levels of 5-hydroxytryptamine (5-HT), norepinephrine (NE), melatonin (MT), and the expression of GABA_A, 5-HT1A and MT receptors, as well as pathological changes in hypothalamus, were evaluated. 16S rDNA sequencing and UPLC-MS/MS were used to reveal the change of the intestinal flora and metabolic profile.

RESULTS

The adverse changes in the abundance and diversity of intestinal flora and faecal metabolic phenotype altered by PCPA in rats were reversed after LB treatment, accompanied by the up-regulated levels of 5-HT as 8.14 ng/mL, MT as 16.16 pg/mL, 5-HT1A R and GABA_A R, down-regulated level of NE as 0.47 ng/mL, and the improvement of pathological phenomena of cells in the hypothalamus. And the arachidonic acid metabolism and tryptophan metabolism pathway most significantly altered by PCPA were markedly regulated by LB. Besides, it was also found that LB reduced the levels of kynurenic acid related to psychiatric disorders and trimethylamine-N-oxide associated with cardiovascular disease.

CONCLUSION

The mechanism of LB relieving insomnia involves regulating flora and metabolites to resemble the control group. As a medicinal and edible herb, LB could be considered for development as a health-care food to relieve increasing insomniacs in the future.

Sleep pattern and predictors of daily versus as-needed hypnotics use in middle-aged and older adults with insomnia

Introduction

This study aims to examine the sleep pattern and predictors of daily vs. as-needed use of hypnotics in middle-aged and older adults with insomnia.

Methods

Patients aged 50–75 who use hypnotics for insomnia were identified via electronic medical records and were recruited. Data about sociodemographics, mood and cognitive screening measures, and questions related to sleep patterns were collected through an interview conducted over the phone.

Results

A sample of 66 participants was recruited, of which 69.7% were females. Three quarters (49/66, 74.2%) used hypnotics daily, with 43% (21/49) of daily hypnotics users sleeping more than 8 h per night. Two-fifths (26/66, 39.4%) of participants still had clinically significant insomnia even after taking hypnotics. After adjusting for age, years of hypnotics use, sleeping hours per night, PHQ-2 score, and frequency of pain at night, the logistic regression model showed that younger age (p = 0.023) and longer sleeping hours per night (p = 0.025) were significantly associated with daily hypnotics use when compared to as needed hypnotics use.

Conclusion

Many hypnotic users still have clinically significant insomnia and poor quality of sleep as reflected by perceived longer sleep duration and more daytime napping which could be related to drug-related residual sedation. Hypnotic use may not be the best solution for insomnia treatment in an older population, and physicians should regularly reassess the use of hypnotics.

Evaluating the Feasibility and Efficacy of A Novel CBTi/SMT Treatment Protocol for Cardiac Rehab Patients: A Non-Randomized Pilot Trial

INTRODUCTION

Cardiac patients and those with chronic medical conditions often suffer from comorbidities such as insomnia and mood disorders. Previous treatment protocols have focused on resolving symptoms of anxiety and depression in this population using Stress Management Training (SMT). However, these treatments have neglected the importance of sleep problems in these patients. This pilot trial sought to address this by examining the feasibility of a novel CBTi/SMT treatment protocol.

METHODS

42 participants attending a Cardiac Rehab (CR) exercise program registered in this 7-week non-randomized pilot trial. The primary objective of the pilot trial was to determine the feasibility of the protocol for retention and adherence rates. Secondarily, the authors sought to examine the potential efficacy of the program in terms of treating insomnia, depression, anxiety, emotion dysregulation, and arousal.

RESULTS

29 participants attended at least 1 class, with 21 participants completing the program. The average attendance for the program completers was 6 out of 7 classes (SD = 0.8) with four days of practice each week (SD = 1.6) for 33 minutes daily (SD = 16.8). Moreover, the number of participants meeting clinical threshold for insomnia, anxiety, and/or depression was significantly reduced at post-treatment and follow-up. Similarly, raw scores on the relevant scales were significantly reduced at both timepoints.

CONCLUSION

This pilot trial provided preliminary evidence for the feasibility and efficacy of targeting sleep improvement with a combined CBTi/SMT protocol. This provides the groundwork for future RCTs to establish the effectiveness of targeting insomnia in a range of medical populations.

Psychotherapie im höheren Lebensalter in der Psychotherapieausbildung

Zusammenfassung. Theoretischer Hintergrund: Psychotherapie im höheren Lebensalter (PihL) gewinnt in Deutschland in den letzten Jahrzehnten zunehmend an Bedeutung. Dennoch ist dieses Feld trotz des großen Bedarfs weiterhin unterrepräsentiert. Fragestellung: Wie werden angehende Psychotherapeut_innen aktuell in Bezug auf die psychotherapeutische Behandlung älterer Menschen ausgebildet? Methode: Sämtliche Ausbildungsinstitute in Deutschland mit dem Schwerpunkt Verhaltenstherapie sowie Dozierende mit Seminaren zu PihL wurden im Jahr 2018 zu einer Befragung eingeladen. Ergebnisse: Von 48 Instituten boten zum Zeitpunkt der Befragung 64.6 % gerontopsychlogische Unterrichtsstunden (M = 13.03 h) an (2.2 % des Theorieunterrichts). In den ausfindig gemachten Seminaren zeigen sich zu einem großen Teil die von Knight et al. (2009 ) vorgeschlagenen Themenschwerpunkte von allgemeinen und pathologischen Alterungsprozessen über diagnostische Besonderheiten bis hin zu konkreten Interventionsmethoden. Diskussion: Sowohl die Weiterbildungsstudiengänge als auch die neuen psychotherapeutischen Bachelor- und Masterstudiengänge sollten mehr Inhalte zum Thema PihL ähnlich wie die hier ausfindig gemachten Seminare berücksichtigen. Eine Orientierung für eine Basiswissensvermittlung bieten die vorgeschlagenen Themenschwerpunkte.

Brief Behavioral Treatment of Insomnia

Cognitive behavioral treatment for insomnia (CBTI) is an effective treatment of insomnia; however, there are insufficient CBTI providers for the 10% to 25% of the population who have insomnia. Brief behavioral treatment for insomnia (BBTI) is a 4-session manualized treatment paradigm administrable in medical settings by nonpsychologist health professionals. BBTI is effective in reducing symptoms of insomnia, such as sleep onset latency, wake after sleep onset, and sleep efficiency. In some cases, BBTI resulted in full remission from insomnia. Ongoing clinical trials are further testing the efficacy of BBTI using alternative treatment deliveries and in primary medical care settings.

A pilot randomized controlled trial of the effects of cognitive-behavioral therapy for insomnia on sleep and daytime functioning in college students

The purpose of this study was to pilot test if cognitive behavioral therapy for insomnia (CBT-I) is an effective intervention for insomnia and daytime functioning in college students. College students' developmental stage and lifestyle are significantly different than the general adult population, yet there have been no studies of CBT-I in this age group. Thirty-four college students (ages 18-27; M=19.71, SD=2.10) were randomly assigned to and completed either six sessions of CBT-I or a 6-week wait list control (WLC). All participants completed 1-week sleep diaries and actigraphy, as well as sleep and daytime functioning questionnaires at baseline and posttreatment. The treatment group repeated all measures at 3-month follow-up. Students who received CBT-I showed greater baseline to posttreatment improvements in sleep efficiency, sleep onset latency, number of awakenings, time awake after sleep onset, sleep quality, insomnia severity, dysfunctional beliefs about sleep, general fatigue, and global sleep quality than the WLC group. These improvements were durable at 3-month follow-up. Ninety-four percent of participants in the CBT-I condition completed at least 4 sessions of treatment. Significantly more participants in the CBT-I group than the WLC group responded (68.8% vs 7.7%, respectively) and remitted (68.8% vs 15.4%, respectively). CBT-I is an effective treatment for insomnia in college students. This study found that treatment responses were similar to results from studies in the general population. The treatment appeared to be well tolerated based on very low attrition rates.

Sleep discrepancy, sleep complaint, and poor sleep among older adults

OBJECTIVES

Discrepancy between self-report- and actigraphy-measured sleep, often considered an artifact of measurement error, has been well documented among insomnia patients. Sleep problems are common among older adults, and this discrepancy may represent meaningful sleep-related phenomenon, which could have clinical and research significance.

METHOD

Sleep discrepancy was examined in 4 groups of older adults (N = 152, mean age = 71.93 years) based on sleep complaint versus no complaint and presence versus absence of insomnia symptoms. Participants completed the Beck Depression Inventory-second edition (BDI-II) and 14 nights of sleep diaries and actigraphy.

RESULTS

Controlling for covariates, group differences were found in the duration and frequency of discrepancy in sleep onset latency (SOLd) and wake after sleep onset (WASOd). Those with insomnia symptoms and complaints reported greater duration and frequency of WASOd than the other 3 groups. Quantities of SOLd and WASOd were related to BDI-II score and group status, indicating that sleep discrepancy has meaningful clinical correlates.

DISCUSSION

Discrepancy occurred across all groups but was pronounced among the group with both insomnia symptoms and complaints. This discrepancy may provide a means of quantifying and conceptualizing the transition from wake to sleep among older adults, particularly those with sleeping problems.

Cognitive training improves sleep quality and cognitive function among older adults with insomnia

Study Objectives

To investigate the effect of an eight-week, home-based, personalized, computerized cognitive training program on sleep quality and cognitive performance among older adults with insomnia.

Design

Participants (n = 51) were randomly allocated to a cognitive training group (n = 34) or to an active control group (n = 17). The participants in the cognitive training group completed an eight-week, home-based, personalized, computerized cognitive training program, while the participants in the active control group completed an eight-week, home-based program involving computerized tasks that do not engage high-level cognitive functioning. Before and after training, all participants' sleep was monitored for one week by an actigraph and their cognitive performance was evaluated.

Setting

Community setting: residential sleep/performance testing facility.

Participants

Fifty-one older adults with insomnia (aged 65–85).

Interventions

Eight weeks of computerized cognitive training for older adults with insomnia.

Results

Mixed models for repeated measures analysis showed between-group improvements for the cognitive training group on both sleep quality (sleep onset latency and sleep efficiency) and cognitive performance (avoiding distractions, working memory, visual memory, general memory and naming). Hierarchical linear regressions analysis in the cognitive training group indicated that improved visual scanning is associated with earlier advent of sleep, while improved naming is associated with the reduction in wake after sleep onset and with the reduction in number of awakenings. Likewise the results indicate that improved “avoiding distractions” is associated with an increase in the duration of sleep. Moreover, the results indicate that in the active control group cognitive decline observed in working memory is associated with an increase in the time required to fall asleep.

Conclusions

New learning is instrumental in promoting initiation and maintenance of sleep in older adults with insomnia. Lasting and personalized cognitive training is particularly indicated to generate the type of learning necessary for combined cognitive and sleep enhancements in this population.

Trial Registration

ClinicalTrials.gov NCT00901641

Age and Gender Effects on the Pharmacokinetics and Pharmacodynamics of Ramelteon, a Hypnotic Agent Acting via Melatonin Receptors MT1and MT2

Effects of age and gender on the pharmacokinetics and pharmacodynamics of ramelteon, a hypnotic acting via binding to melatonin MT(1) and MT(2) receptors, were evaluated in healthy young (18-34 years) and elderly (63-79 years) volunteers. Part 1 evaluated the pharmacokinetics of open-label oral ramelteon, 16 mg. Part 2 was a double-blind, randomized, 2-trial crossover pharmacodynamic study of 16-mg ramelteon and matching placebo. Ramelteon clearance was significantly reduced in elderly vs young volunteers (384 vs 883 mL/min/kg, P<.01) and half-life significantly increased (1.9 vs 1.3 h, P<.001). Gender did not significantly influence clearance or half-life. Ramelteon was extensively transformed to its hydroxylated M-II metabolite, with serum AUC values averaging about 30 times those of the parent drug. Compared to placebo, ramelteon increased self- and observer-rated sedation, but age and gender did not influence the magnitude of the ramelteon-placebo difference. Ramelteon did not significantly impair digit-symbol substitution test performance or impair information acquisition and recall. Thus, the reduced clearance and higher serum levels of ramelteon in elderly subjects were not associated with enhanced pharmacodynamic effects. The usually recommended clinical dose of ramelteon (8 mg) does not require modification based on age or gender.

Neurophysiopathogenesis of fibromyalgia syndrome: a unified hypothesis

The characteristic presenting complaint of patients with fibromyalgia syndrome (FMS) is chronic widespread allodynia. Research findings support the view that FMS is an understandable and treatable neuropathophysiologic disorder. The pain of FMS is often accompanied by one or more other manifestations, such as affective moods, cognitive insecurity, autonomic dysfunction, or irritable bowel or bladder. Growing evidence suggests that this is a familial disorder with many underlying genetic associations. New findings from brain imaging and polysomnography imply that FMS may be a disorder of premature neurologic aging. A conceptual model at the molecular level is proposed to explain many of the observed features of FMS. The model can also explain anticipated responses to FDA approved pharmacologic therapies.

Depression in older adults

Depression is less prevalent among older adults than among younger adults, but it can have serious consequences. More than half of cases represent a first onset in later life. Although suicide rates in the elderly are declining, they are still higher than in younger adults and are more closely associated with depression. Depressed older adults are less likely to endorse affective symptoms and more likely to display cognitive changes, somatic symptoms, and loss of interest than are depressed younger adults. Risk factors leading to the development of late-life depression likely comprise complex interactions among genetic vulnerabilities, cognitive diathesis, age-associated neurobiological changes, and stressful events. Insomnia is an often overlooked risk factor for late-life depression. We suggest that a common pathway to depression in older adults, regardless of which predisposing risks are most prominent, may be curtailment of daily activities. Accompanying self-critical thinking may exacerbate and maintain a depressed state. Offsetting the increasing prevalence of certain risk factors in late life are age-related increases in psychological resilience. Other protective factors include higher education and socioeconomic status, engagement in valued activities, and religious or spiritual involvement. Treatments including behavioral therapy, cognitive-behavioral therapy, cognitive bibliotherapy, problem-solving therapy, brief psychodynamic therapy, and life review/reminiscence therapy are effective but are too infrequently used with older adults. Preventive interventions including education for individuals with chronic illness, behavioral activation, cognitive restructuring, problem-solving skills training, group support, and life review have also received support.

Chronic insomnia and cognitive functioning among older adults

Chronic insomnia and cognitive impairment are both common complaints among older adults. This study explores the association between chronic insomnia and changes in cognitive functioning among older adults. The study population comprised two groups: 64 older adults without insomnia and 35 older adult insomniacs. The cognitive capacity of each participant was tested at the participant's home using the computerized "MindFit" test (CogniFit, Inc.). In five categories of cognitive functioning, older adult insomniacs displayed impaired performance compared to older adult good sleepers. Specifically, significant differences were found between insomniacs and good sleepers on memory span, allocating attention to a target, time estimation, executive functioning, and integration of two dimensions (visual and semantic) tests. The findings imply that insomnia may have detrimental effects on some cognitive functions in healthy older adults.

Sleep disturbances in caregivers of persons with dementia: contributing factors and treatment implications

Estimates suggest that there are more than 10 million adult caregivers of persons with dementia, two-thirds of who experience some form of sleep disturbance during the course of their caregiving career. Health care professionals are in the best position to detect and address this significant public health problem. Three major contributors to caregiver sleep disturbance are discussed in this paper: (1) the presence of caregiver disrupted sleep routines; (2) caregiver burden and depression; and, (3) the caregiver's physical health status. Successful treatment of a caregiver's sleep disturbance requires careful consideration of each of these contributors. We review and analyze the scientific literature concerning the multiple complex factors associated with the development and maintenance of sleep disturbances in caregivers. We provide a clinical vignette that illustrates the interplay of these contributing factors, and close by providing recommendations for clinicians and researchers treating and investigating the development and maintenance of sleep problems in family caregivers.