Brief, individualised counselling improves sleep in older adults with insomnia

A brief behavioural treatment consisting of two in-person sessions and two phone calls appears to alleviate insomnia in older adults for at least six months, according to a report posted online today that will be published in the May 23 print issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

An estimated 15 percent to 35 percent of older U.S. adults have insomnia, according to background information in the article. Individuals with the condition have difficulty falling asleep or staying asleep, non-restorative sleep and symptoms during waking hours that include fatigue, trouble concentrating and mood disturbances. Insomnia is associated with falls and hip fractures among older adults. Even though pharmacologic and behavioural treatments are approximately equally effective, older adults are prescribed hypnotic agents at disproportionate rates and are also more likely than younger patients to experience adverse drug effects.

Daniel J. Buysse, M.D., of University of Pittsburgh School of Medicine, and colleagues conducted a randomised clinical trial of a brief behavioural treatment involving 79 older adults (average age 71.7) with insomnia. Thirty-nine received the treatment, consisting of individualised behavioural 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 behavioural treatment showed a favourable 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 favourably 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 behavioural treatment for insomnia shares many features with other behavioural insomnia treatments, some particular features make it an especially attractive option,' the authors write. The program's strong behavioural 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.

'Thus, brief behavioural treatment for insomnia possesses efficacy, efficiency and acceptability - three characteristics of a successful 'entry level' treatment in a stepped care approach to behavioural management of insomnia,' they conclude. 'Future studies should examine the feasibility of educating nurses and other health professionals in brief behavioural treatment for insomnia and the effectiveness of brief behavioural treatment for insomnia delivered in actual practice settings on symptom-based, functional and health care economic outcomes.'