Behavioral treatment of chronic insomnia in older adults: does nocturia matter?

Is the insomnia phenotype the common denominator in LUTS during transition periods? An expert NOPIA research group review

AIMS

As people age, sleep stages and characteristics transition over time, but sleep deficits can profoundly impact health and cognitive functioning. Chronic sleep deprivation is linked to impaired attention and productivity, weakened immunity, increased risk of cardiovascular disease, obesity, and mental health disorders. Insomnia, obstructive sleep apnea syndrome, hormonal changes, nocturia, neurological disorders, and life events interfere with sleep patterns and some are linked to lower urinary tract symptoms (LUTS). This NOPIA symposium on Lifelong LUTS aimed to analyze the literature on associations between sleep and LUTS, generate ideas for future research, and explore whether there is support for the concept of lifelong LUTS in relation to changes in sleep throughout the lifespan.

METHODS

An international panel of experts took part in an online meeting addressing the role of lifelong LUTS in relationship to sleep and the brain organized by the NOPIA research group. The manuscript summarizes existing literature, hypotheses, future research ideas, and clinical recommendations.

RESULTS

Insomnia, sleep fragmentation, hyperarousal, and sensory processing disorders emerged as potential factors in the relationship between sleep and LUTS. Insomnia is often a persistent factor and may have been the initial symptom; however, it is often unrecognized and/or unaddressed in healthcare settings. By recognizing insomnia as a primary driver of various health issues, including nocturia, transitional care aims to address root causes and underlying problems earlier to initiate appropriate treatment.

CONCLUSIONS

A multidisciplinary approach with collaboration between healthcare professionals from various disciplines, such as urology, sleep medicine, gynecology, pediatrics, and geriatrics, is needed and should include validated measurements such as the insomnia severity index and sleep and voiding diaries. Ensuring ongoing follow-up and monitoring through transitional care is crucial for individuals with persistent sleep problems and LUTS, allowing issues that arise or fluctuate over the lifespan to be addressed.

The role of renal circadian biorhythms in lifelong LUTS

INTRODUCTION

This article delves into the intricate relationship between kidney function, diuresis, and lower urinary tract symptoms (LUTS) throughout the transitions of the human lifespan. It explores circadian regulation of urine production, maturation of renal function from birth to adulthood, and effects of aging on kidney function and LUTS. The complex connections between these factors are highlighted, offering insights into potential interventions and personalized management strategies.

METHODS

An international panel of seven experts engaged in online discussions, focusing on kidney function, diuresis, and LUTS throughout life. This manuscript summarizes expert insights, literature reviews, and findings presented during a webinar and subsequent discussions.

RESULTS

Renal function undergoes significant maturation from birth to adulthood, with changes in glomerular filtration rate, diuresis, and tubular function. A circadian rhythm in urine production is established during childhood. Adolescents and young adults can experience persistent enuresis due to lifestyle factors, comorbidities, and complex physiological changes. In older adults, age-related alterations in kidney function disrupt the circadian rhythm of diuresis, contributing to nocturnal polyuria and LUTS.

CONCLUSION

The interplay between kidney function, diuresis, and LUTS is crucial in understanding lifelong urinary health. Bridging the gap between pediatric and adult care is essential to address enuresis in adolescents and young adults effectively. For older adults, recognizing the impact of aging on renal function and fluid balance is vital in managing nocturia. This holistic approach provides a foundation for developing innovative interventions and personalized treatments to enhance quality of life for individuals with LUTS across all stages of life.

The effectiveness of the behavioural components of cognitive behavioural therapy for insomnia in older adults: A systematic review

Insomnia is more prevalent in older adults (> 60 years) than in the general population. Cognitive behavioural therapy for insomnia is the gold-standard treatment; however, it may prove too cognitively taxing for some. This systematic review aimed to critically examine the literature exploring the effectiveness of explicitly behavioural interventions for insomnia in older adults, with secondary aims of investigating their effect on mood and daytime functioning. Four electronic databases (MEDLINE - Ovid, Embase - Ovid, CINAHL, and PsycINFO) were searched. All experimental, quasi-experimental and pre-experimental studies were included, provided they: (a) were published in English; (b) recruited older adults with insomnia; (c) used sleep restriction and/or stimulus control; (d) reported outcomes pre-and-post intervention. Database searches returned 1689 articles; 15 studies, summarising the results of 498 older adults, were included - three focused on stimulus control, four on sleep restriction, and eight adopted multicomponent treatments comprised of both interventions. All interventions brought about significant improvements in one or more subjectively measured facets of sleep although, overall, multicomponent therapies demonstrated larger effects (median Hedge's g = 0.55). Actigraphic or polysomnographic outcomes demonstrated smaller or no effects. Improvements in measures of depression were seen in multicomponent interventions, but no intervention demonstrated any statistically significant improvement in measures of anxiety. This corroborates with the existing consensus that multicomponent approaches confer the most benefit, and adds to the literature by demonstrating this to be the case in brief, explicitly behavioural interventions. This review guides future study of treatments for insomnia in populations where cognitive behavioural therapy for insomnia is not appropriate.

Sleep Disorders, Comorbidities, Actions, Lower Urinary Tract Dysfunction, and Medications ("Sleep C.A.L.M.") in the evaluation and management of nocturia: A simple approach to a complex diagnosis

INTRODUCTION

Nocturia arises from a fundamental mismatch between nocturnal urine production, storage capacity, and sleep architecture, which may be driven by abnormalities of the genitourinary tract, but also by sleep disorders, medical diseases, patient actions/lifestyle factors, or medications. This article introduces a novel system for organizing the complex differential diagnosis for nocturia, as proposed by an international collective of practicing urologists, physician specialists, and sleep experts: "Sleep CALM"-Sleep Disorders, Comorbidities, Actions, Lower Urinary Tract Dysfunction, and Medications.

METHODS

Narrative review of current evidence regarding the relevance of each "Sleep CALM" factor to nocturia pathogenesis, evaluation, and management.

RESULTS

Nocturia and sleep disorders are highly intertwined and often bidirectional, such that nocturnal awakenings for reasons other than a sensation of bladder fullness should not be used as grounds for exclusion from nocturia treatment, but rather leveraged to broaden therapeutic options for nocturia. Nocturia is an important potential harbinger of several serious medical conditions beyond the genitourinary tract. Urologists should have a low threshold for primary care and medical specialty referral for medical optimization, which carries the potential to significantly improve nocturnal voiding frequency in addition to overall health status. Adverse patient actions/lifestyle factors, lower urinary tract dysfunction, and medication use commonly coexist with disordered sleep and comorbid medical conditions, and may be the primary mediators of nocturia severity and treatment response, or further exacerbate nocturia severity and complicate treatment.

CONCLUSION

"Sleep CALM" provides a memorable and clinically relevant means by which to structure the initial patient history, physical exam, and clinical testing in accordance with current best-practice guidelines for nocturia. Although not intended as an all-encompassing diagnostic tool, the "Sleep CALM" schema may also be useful in guiding individualized ancillary testing, identifying the need for specialty referral and multidisciplinary care, and uncovering first-line treatment targets.

Brief behavioral treatment for insomnia decreases trauma-related nightmare frequency in veterans

STUDY OBJECTIVES

Trauma-related nightmares are highly prevalent among veterans and are associated with higher severity insomnia and PTSD. Cognitive behavioral therapy for insomnia (CBT-I, typically 6-8 sessions) has been shown to reduce trauma-related nightmares. Brief behavioral treatment for insomnia (BBTI, 4 sessions) has been found to be comparable to CBT-I in decreasing insomnia severity; however, the effects of BBTI on nightmares have not been investigated. The current study tested the effects of BBTI on both trauma-related nightmares and non-trauma-related bad dreams using an active control group, progressive muscle relaxation therapy (PMRT). Additionally, we tested whether baseline trauma-related nightmare frequency and baseline non-trauma-related bad dream frequency moderated changes in insomnia severity.

METHODS

Participants were 91 military veterans with insomnia disorder randomized to BBTI or PMRT. Participants reported insomnia severity on the Insomnia Severity Index and reported trauma-related nightmare frequency and non-trauma-related bad dream frequency on the Pittsburgh Sleep Quality Index--PTSD Addendum.

RESULTS

We found that BBTI significantly reduced trauma-related nightmares from baseline to post-treatment while PMRT did not. However, reductions in trauma-related nightmares were not maintained at six month follow up. Neither BBTI nor PMRT reduced non-trauma-related bad dreams from baseline to post-treatment. We also found that neither baseline trauma-related nightmare frequency nor baseline non-trauma-related bad dream frequency moderated changes in insomnia symptom severity.

CONCLUSIONS

Findings from the current study suggest that BBTI may help to reduce trauma-related nightmares. Further research is needed to better understand potential mechanisms underlying how improved sleep may reduce trauma-related nightmares.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Brief Behavioral Insomnia Treatment Study (BBTI); Identifier: NCT02571452; URL: https://clinicaltrials.gov/ct2/show/NCT02571452.

Considerations for integrated cognitive behavioural treatment for older adults with coexisting nocturia and insomnia

Nocturia and chronic insomnia disorder are common conditions that frequently coexist in older adults. Existing medication treatments for each condition have risks, particularly in older adults. While treatment guidelines recommend starting with behavioural therapy for each condition, no existing program simultaneously addresses nocturia and insomnia. Existing behavioural interventions for nocturia or insomnia contain concordant and discordant components. An expert panel (including geriatricians with sleep or nocturia research expertise, sleep psychologists and a behavioural psychologist) was convened to combine and reconcile elements of behavioural treatment for each condition. Concordant treatment recommendations involve using situational self-management strategies such as urge suppression or techniques to influence homeostatic drive for sleep. Fluid modification such as avoiding alcohol and evening caffeine and regular self-monitoring through a daily diary is also appropriate for both conditions. The expert panel resolved discordant recommendations by eliminating overnight completion of voiding diaries (which can interfere with sleep) and discouraging routine overnight voiding (a stimulus control strategy). The final product is an integrated cognitive behavioural treatment that is delivered by advanced practice providers weekly over 5 weeks. This integrated program addresses the common scenario of coexisting nocturia and chronic insomnia disorder.

Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

INTRODUCTION

The purpose of this systematic review is to provide supporting evidence for a clinical practice guideline on the use of behavioral and psychological treatments for chronic insomnia disorder in adult populations.

METHODS

The American Academy of Sleep Medicine commissioned a task force of 9 experts in sleep medicine and sleep psychology. A systematic review was conducted to identify randomized controlled trials that addressed behavioral and psychological interventions for the treatment of chronic insomnia disorder in adults. Statistical analyses were performed to determine if the treatments produced clinically significant improvements in a range of critical and important outcomes. Finally, the Grading of Recommendations Assessment, Development, and Evaluation process was used to evaluate the evidence for making specific treatment recommendations.

RESULTS

The literature search identified 1,244 studies; 124 studies met the inclusion criteria, and 89 studies provided data suitable for statistical analyses. Evidence for the following interventions is presented in this review: cognitive-behavioral therapy for insomnia, brief therapies for insomnia, stimulus control, sleep restriction therapy, relaxation training, sleep hygiene, biofeedback, paradoxical intention, intensive sleep retraining, and mindfulness. This review provides a detailed summary of the evidence along with the quality of evidence, the balance of benefits vs harms, patient values and preferences, and resource use considerations.

Brief behavioral treatment for insomnia improves psychosocial functioning in veterans: results from a randomized controlled trial

STUDY OBJECTIVES

Our goal was to compare brief behavioral treatment for insomnia (BBTI) to a progressive muscle relaxation training (PMRT) control condition among veterans with insomnia, examining psychosocial functioning as a primary outcome and sleep-related outcomes, mood, cognition, and pain as secondary outcomes.

METHODS

Veterans were randomly assigned to either BBTI or PMRT (N = 91; 24-74 years; M = 49 years). BBTI consisted of two in-person (60-min and 30-min sessions) and two telephone sessions (20-min each), and the PMRT control condition was matched to BBTI for session duration and type. Veterans were assessed through clinical interview at baseline and self-report measures at pre-, mid-, and posttreatment, as well as 6-month follow-up for the BBTI condition to assess sustained response. Measures also included continuous sleep monitoring with sleep diary.

RESULTS

Intent-to-treat analyses demonstrated that individuals who completed BBTI versus PMRT reported greater improvements in work, home, social and cognitive functioning, insomnia symptom severity, mood, and energy. Improvements in psychosocial functioning, insomnia symptoms, and mood were maintained 6-months following BBTI treatment completion.

CONCLUSIONS

Veterans who received BBTI improved and maintained gains in psychosocial functioning, insomnia, and mood. BBTI is a treatment that can be implemented in primary care, mental health, or integrated care settings and provide symptom relief and improved functioning among those with insomnia, one of the most commonly reported mental health problems among veterans.

CLINICAL TRIAL REGISTRATION

NCT02571452.

Beyond the bladder: poor sleep in women with overactive bladder syndrome

BACKGROUND

Nocturnal bladder symptoms and sleep disruption commonly coexist in middle-aged and older women. Although sleep disruption is often attributed to nocturnal bladder symptoms in women with overactive bladder syndrome, nonbladder factors also may influence sleep in this population. Many women with overactive bladder are eager to identify nonpharmacologic strategies for both bladder symptoms and sleep disruption, given the potential adverse effects of sedative and anticholinergic bladder medications in this population.

OBJECTIVES

To provide greater insight into the complex relationship between nighttime overactive bladder symptoms and sleep disruption, and to evaluate the effects of a guided slow-paced respiration intervention on sleep outcomes in women with overactive bladder.

STUDY DESIGN

We conducted an ancillary study within a randomized trial of slow-paced respiration in women with overactive bladder symptoms. Ambulatory community-dwelling women who reported ≥3 episodes/day of urgency-associated voiding or incontinence were randomized to use either a portable biofeedback device (RESPeRATE; Intercure, Ltd) to practice guided slow-paced respiration exercises daily for 12 weeks (N=79) or an identical-appearing device programmed to play nonrhythmic music without guiding breathing (N=82). At baseline and after 12 weeks, bladder symptoms were assessed by voiding diary, sleep duration, and disruption were assessed by sleep diary corroborated by wrist actigraphy, and poor sleep quality was determined by a Pittsburgh Sleep Quality Index global score >5.

RESULTS

Of the 161 women randomized, 31% reported at least twice-nightly nocturia, 26% nocturnal incontinence, and 70% poor sleep quality at baseline. Of the 123 reporting any nighttime awakenings, 89% averaged 1 or more nighttime awakenings, and 83% attributed at least half of awakenings to using the bathroom. Self-reported wake time after sleep onset increased with increasing frequency of nocturnal bladder symptoms (P=.01 for linear trend). However, even among women without nocturia, average sleep quality was poor (Pittsburg Sleep Quality Index global score mean of 7.3; 95% confidence interval, 6.0-8.6). Over 12 weeks, women assigned to slow-paced respiration (N=79) experienced modest improvements in mean nocturnal voiding frequency (0.4 fewer voids/night), sleep quality (1.1 point score decrease), and sleep disruption (1.5% decreased wake time after sleep onset). However, similar improvements were detected in the music control group (N=81), without significant between-group differences.

CONCLUSIONS

Many women with overactive bladder syndrome experience disrupted sleep, but not all nocturnal awakenings are attributable to bladder symptoms, and average sleep quality tends to be poor even in women without nocturia. Findings suggest that clinicians should not assume that poor sleep in women with overactive bladder syndrome is primarily caused by nocturnal bladder symptoms. Guided slow-paced respiration was associated with modest improvements in nocturia frequency and sleep quality in this trial, but the results do not support clinician recommendation to use this technique over other behavioral relaxation techniques for improving sleep.

Development of the Nocturia Sleep Quality Scale: a patient-reported outcome measure of sleep impact related to nocturia

BACKGROUND/OBJECTIVE

Nocturia's impact on sleep causes significant burden for patients. This study aimed to develop a novel patient-reported outcome (PRO) measure, the Nocturia Sleep Quality Scale (NSQS), for the assessment of the impact of nocturia (defined as ≥2 nocturnal voids/night) on sleep.

METHODS

Sleep-related concepts were identified through a targeted literature review, after which in-depth concept elicitation interviews with patients with a clinical diagnosis of nocturia were conducted. Draft items were generated to address concepts identified as important, meaningful, and relevant. Items were further refined through three iterative sets of cognitive debriefing interviews to optimize instructions, question wording, and response options. Two sleep research experts also provided input.

RESULTS

The literature review and data from 18 concept elicitation interviews provided the basis for a comprehensive set of concepts. Constant comparative analysis was used to identify themes and support item development. The draft questionnaire consisted of 14 items with item-specific response scales. Wording and scaling of the items was optimized based on feedback from the 22 cognitive debriefing interviews and expert input. The results confirmed the completeness and relevance of the NSQS, providing support for the content validity and ability of items to reflect patient perception of nocturia-related sleep impacts.

CONCLUSIONS

The 6-item NSQS assesses the impact of nocturia on sleep by evaluating nighttime awakenings, sleep quantity, and sleep quality. The NSQS is self-administered and is intended to assess change in nocturia's impact on sleep after treatment in a standardized manner. Psychometric evaluation is under way to describe key measurement properties.

Overnight Urge Perception in Nocturia Is Independent of Depression, PTSD, or Anxiety in a Male Veterans Administration Population

STUDY OBJECTIVES

The goal of this study was to compare the urge perception associated with nocturnal voiding at the time of voiding in individuals with and without depression, posttraumatic stress disorder (PTSD), or anxiety diagnoses to test the hypothesis that patients with such diagnoses are more likely to experience insomnia-driven convenience voiding during the sleep period.

METHODS

A database of voiding diaries with urge perception grades (UPGs) from 429 adult males seeking treatment for nocturia at a Veterans Affairs-based urology clinic was analyzed. The UPG categorizes perception for urinating from 0 (out of convenience) to 4 (desperate urge). Diaries completed by males age 18 years and older showing ≥ 2 nocturnal voids were included. Those included (n = 178) were divided into two cohorts based on the presence (n = 62) or absence (n = 116) of one or more previously established mental health diagnoses (depression, PTSD, or anxiety). The chi-square test was used to determine significance between groups.

RESULTS

Patients with a mental health diagnosis were more likely to report convenience voiding compared to those without depression, PTSD, or anxiety (14.5% versus 0.8%, P < .01). However, most voids in both groups were associated with the perception of urinary urgency. There were no differences in urinary volumes or hourly rates of urine production between the groups.

CONCLUSIONS

A relatively small subset of urology patients experience nocturnal voiding because they are awake for reasons other than the urge to void. Mental health factors had a substantial, albeit minimal, effect. Most nocturia reflects urgency to urinate rather than voiding by convenience.

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.

Use of Actigraphy for the Evaluation of Sleep Disorders and Circadian Rhythm Sleep-Wake Disorders: An American Academy of Sleep Medicine Systematic Review, Meta-Analysis, and GRADE Assessment

INTRODUCTION

The purpose of this systematic review is to provide supporting evidence for a clinical practice guideline on the use of actigraphy.

METHODS

The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of actigraphy, sleep logs, and/or polysomnography. Statistical analyses were performed to determine the clinical significance of using actigraphy as an objective measure of sleep and circadian parameters. Finally, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence for making recommendations.

RESULTS

The literature search resulted in 81 studies that met inclusion criteria; all 81 studies provided data suitable for statistical analyses. These data demonstrate that actigraphy provides consistent objective data that is often unique from patient-reported sleep logs for some sleep parameters in adult and pediatric patients with suspected or diagnosed insomnia, circadian rhythm sleep-wake disorders, sleep-disordered breathing, central disorders of hypersomnolence, and adults with insufficient sleep syndrome. These data also demonstrate that actigraphy is not a reliable measure of periodic limb movements in adult and pediatric patients. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations.

A nonpharmacologic approach to managing insomnia in primary care

Insomnia, or inadequate or poor sleep leading to significant distress or impairment in functioning, is a prevalent disorder treated by primary care providers (PCPs). With millions of people across the United States suffering from insomnia, PCPs must understand the disorder's pathophysiology, perpetuating factors, and treatment, as well as its effect on patient health and the economy. Although PCPs traditionally treat insomnia with pharmaceuticals, behavioral measures are effective and should be used whenever possible. This article reviews clinically relevant principles of diagnosing and treating insomnia, highlighting nonpharmacologic treatments.

Exploration of Circadian Rhythms in Patients with Bilateral Vestibular Loss

BACKGROUND

New insights have expanded the influence of the vestibular system to the regulation of circadian rhythmicity. Indeed, hypergravity or bilateral vestibular loss (BVL) in rodents causes a disruption in their daily rhythmicity for several days. The vestibular system thus influences hypothalamic regulation of circadian rhythms on Earth, which raises the question of whether daily rhythms might be altered due to vestibular pathology in humans. The aim of this study was to evaluate human circadian rhythmicity in people presenting a total bilateral vestibular loss (BVL) in comparison with control participants.

METHODOLOGY AND PRINCIPAL FINDINGS

Nine patients presenting a total idiopathic BVL and 8 healthy participants were compared. Their rest-activity cycle was recorded by actigraphy at home over 2 weeks. The daily rhythm of temperature was continuously recorded using a telemetric device and salivary cortisol was recorded every 3 hours from 6:00AM to 9:00PM over 24 hours. BVL patients displayed a similar rest activity cycle during the day to control participants but had higher nocturnal actigraphy, mainly during weekdays. Sleep efficiency was reduced in patients compared to control participants. Patients had a marked temperature rhythm but with a significant phase advance (73 min) and a higher variability of the acrophase (from 2:24 PM to 9:25 PM) with no correlation to rest-activity cycle, contrary to healthy participants. Salivary cortisol levels were higher in patients compared to healthy people at any time of day.

CONCLUSION

We observed a marked circadian rhythmicity of temperature in patients with BVL, probably due to the influence of the light dark cycle. However, the lack of synchronization between the temperature and rest-activity cycle supports the hypothesis that the vestibular inputs are salient input to the circadian clock that enhance the stabilization and precision of both external and internal entrainment.

Management of nocturia in the female

Nocturia is a common but overlooked lower urinary tract symptom that substantially reduces patient health and quality of life. Though traditionally viewed as occurring predominantly in males, nocturia has been found to be equally as prevalent in females. The recent emphasis on the importance of nocturia has resulted in a surge of research studies, providing a foundation for current and future management decisions. In this review, we describe the current recommendations for the female patient in light of the most recently published studies, including a unique interest in predicting treatment response.

Increases in duration of first uninterrupted sleep period are associated with improvements in PSQI-measured sleep quality

OBJECTIVE

Urology clinical trials assessing bladder function have relied on the self-reported duration of the first uninterrupted sleep period (FUSP) as a proxy outcome for sleep, but the relationship between this measure and more conventional self-reported measures of sleep is unknown. In this study, we examined the association between changes in FUSP and a widely used self-reported measure of sleep, the Pittsburgh Sleep Quality Index (PSQI).

METHODS

We conducted post hoc (secondary) analyses of unpublished data from a previously published randomized clinical trial (NCT00477490) of desmopressin (a medication used to treat nocturia) and examined relationships between baseline and 4-week change in FUSP and PSQI global and subscale scores for participants (N = 580 to N = 606) having complete data.

RESULTS

Data indicated strong associations between change in PSQI global score and FUSP change in six of seven subscale scores. A reduction of 1.8 points in the PSQI global score was associated with a 72-min lengthening of FUSP.

CONCLUSIONS

Results suggest that FUSP is a potentially valuable metric that correlates with changes in perceived sleep duration, depth, quality for the entire night, efficiency, latency, and daytime function. An increase in FUSP was related to improvement in nearly all PSQI subscales. The validity of this measure in the general population remains to be determined.