Early to Bed? Maybe Not Such a Good Idea
Abstract & Commentary
By Barbara A. Phillips, MD, MSPH, Professor of Medicine, University of Kentucky; Director, Sleep Disorders Center, Samaritan Hospital, Lexington. Dr. Phillips is a consultant for Cephalon, and serves on the speakers bureaus for Resmed and Respironics.
Synopsis: Brief behavioral intervention significantly relieved insomnia in a group of older adults.
Source: Buysse DJ, et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med 2002 Jan 24; Epub ahead of print.
This report is the result of a randomized trial of 79 adults, mostly women, whose mean age was about 72 years. Subjects were recruited from newspaper ads and clinics, and were self-identified with insomnia. To be included in the study, participants had to have a sleep complaint lasting for at least a month, adequate opportunity and circumstances for sleep, and significant distress or daytime impairment. Consistent with most clinical definitions of insomnia, there were no requirements for objective documentation of sleep latency, duration, or disturbance for inclusion in the study (though these things were measured and used as outcome measures). Insomnia was (as it usually is) defined simply on the basis of the patients' dissatisfaction with their sleep.1,2 Potential participants were excluded if they had dementia, untreated psychiatric, substance use, or other sleep disorders, recent hospitalization, ongoing cancer treatment, or life expectancy less than 6 months. These investigators did not exclude those with treated depressive or anxiety disorders (the two conditions most commonly associated with chronic insomnia2,3).
After screening, participants were randomized to either an Information Control (IC) or a Brief Behavioral Therapeutic Intervention (BBTI). This Behavioral Intervention included a 45- to 60-minute individual session followed by a 30-minute follow-up session 2 weeks later and 20-minute telephone calls after weeks 1 and 3. The Behavioral Intervention (which was called BBTI by the authors of this paper) included sleep education and four main recommendations: 1) reduce time in bed; 2) get up at the same time every day, regardless of sleep duration; 3) do not go to bed unless sleepy; and 4) do not stay in bed unless asleep. Napping was discouraged. Total time in bed was limited to average self-reported sleep time + 30 minutes, with a minimum of 6 hours. The Information Control group got three fairly standard pamphlets (with content that overlapped that received by the BBTI group) and a brief follow-up phone call. All the interventions were delivered by a single master's level mental health nurse practitioner. Participants completed a variety of questionnaires and diaries, and underwent polysomnography (sleep study) and actigraphy (indirect measure of sleep) at the beginning and 6 months after the intervention.
There were several possible criteria for improvement: 1) response (change in the Pittsburgh Sleep Quality Index score of ≥ 3 points or increase in sleep diary sleep efficiency of ≥ 10%); 2) remission (response criterion plus final Pittsburgh Sleep Quality Index score of < 5 and sleep diary sleep efficiency of > 85%, corresponding to "good sleep" values; 3) partial response (improvement in Pittsburgh Sleep Quality Index or sleep efficiency but worsening in the other measures); and 4) nonresponse (change in Pittsburgh Sleep Quality Index of < 3 points and increase in sleep diary sleep efficiency of < 10%). These are reasonable criteria, given the subjective, self-reported nature of insomnia itself.
The BBTI produced significantly better outcomes in self-reported sleep and health, sleep diary, and actigraphy (all P < 0.001), but not polysomnography. Improvements were maintained at 6 months.
Categorically defined response improvement and the proportion of participants without insomnia (55% vs 13%) were significantly higher for BBTI than for IC. The number needed to treat was 2.4 for each outcome. No differences were found according to hypnotic or antidepressant use, sleep apnea, or recruitment source.
Commentary
This was a real world study! Older women with self-reported sleep complaints and likely underlying mood disturbance make up the largest group of insomniacs in practice,2,4 as they did in this study. The authors measured sleep objectively, but defined insomnia response based on self-report, as typically happens in clinical practice. And the time investment by clinicians (about 2 hours) was not extreme. Furthermore, the actual intervention was performed by a nurse practitioner. This is doable! The behavioral interventions used by the investigators are based on established principles of sleep restriction and stimulus control techniques, the efficacy of which has been well documented.5,6 Notably, a key component of the behavioral intervention was to get participants to spend less time in bed, which should increase sleep homeostatic pressure and reduce the conditioned anxiety associated with being in bed not sleeping. Older adults tend to fall asleep earlier, which may lead to middle of the night wakefulness. Indeed, middle of the night wakefulness (biphasic sleep) may have been common in our ancestors and may be a normal response to long winter nights.7,8 However, our current culture views this with alarm. Reassurance and a later bedtime are probably as effective and certainly safer than chronic use of sleeping pills in the older population.9
References
1. American Academy of Sleep Medicine. The International Classification of Sleep Disorders: Diagnostic and Coding Manual. 2nd ed. Darien, IL: American Academy of Sleep Medicine; 2005.
2. Ohayon MM. Epidemiology of insomnia: What we know and what we still need to learn. Sleep Med Rev 2002;6:97-111.
3. Simon GE, VonKorff M. Prevalence, burden, and treatment of insomnia in primary care. Am J Psychiatry 1997;154:1417-1423.
4. Taylor DJ, et al. Comorbidity of chronic insomnia with medical problems. Sleep 2007;30:213-218.
5. Smith MT, et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry 2002;159:5-11.
6. Morin CM, et al. Nonpharmacological interventions for insomnia: A meta-analysis of treatment efficacy. Am J Psychiatry 1994;151:1172-1180.
7. Ekirch AR. Sleep we have lost: Pre-industrial slumber in the British Isles. Am Hist Rev 2001;106:343-386.
8. Wehr TA. In short photoperiods, human sleep is biphasic. J Sleep Res 1992;1:103-107; doi:10.1111/j.1365-2869.1992.tb00019.x.
9. Glass J, et al. Sedative hypnotics in older people with insomnia: Meta-analysis of risks and benefits. BMJ 2005;331:1169-1174.
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