Psychological treatment of hypnotic-dependent insomnia in a primarily older adult sample.

OBJECTIVE: This study tested cognitive behavior therapy (CBT) in hypnotic-dependent, late middle-age and older adults with insomnia. METHOD: Seventy volunteers age 50 and older were randomized to CBT plus drug withdrawal, placebo biofeedback (PL) plus drug withdrawal, or drug withdrawal (MED) only. The CBT and PL groups received eight, 45 min weekly treatment sessions. The drug withdrawal protocol comprised slow tapering monitored with about six biweekly, 30 min sessions. Assessment including polysomnography (PSG), sleep diaries, hypnotic consumption, daytime functioning questionnaires, and drug screens collected at baseline, posttreatment, and 1-year follow-up. RESULTS: Only the CBT group showed significant sleep diary improvement, sleep onset latency significantly decreased at posttreatment. For all sleep diary measures for all groups, including MED, sleep trended to improvement from baseline to follow-up. Most PSG sleep variables did not significantly change. There were no significant between group differences in medication reduction. Compared to baseline, the three groups decreased hypnotic use at posttreatment, down 84%, and follow-up, down 66%. There was no evidence of withdrawal side-effects. Daytime functioning, including anxiety and depression, improved by posttreatment. Rigorous methodological features, including documentation of strong treatment implementation and the presence of a credible placebo, elevated the confidence due these findings. CONCLUSIONS: Gradual drug withdrawal was associated with substantial hypnotic reduction at posttreatment and follow-up, and withdrawal side-effects were absent. When supplemented with CBT, participants accrued incremental self-reported, but not PSG, sleep benefits.

Personality disorder features and insomnia status amongst hypnotic-dependent adults.

OBJECTIVE: To determine the prevalence of personality disorders and their relation to insomnia parameters among persons with chronic insomnia with hypnotic dependence. METHODS: Eighty-four adults with chronic insomnia with hypnotic dependence completed the SCID-II personality questionnaire, two-weeks of sleep diaries, polysomnography, and measures of insomnia severity, impact, fatigue severity, depression, anxiety, and quality of life. Frequencies, between-subjects t-tests and hierarchical regression models were conducted. RESULTS: Cluster C personality disorders were most prevalent (50%). Obsessive-Compulsive personality disorder (OCPD) was most common (n=39). These individuals compared to participants with no personality disorders did not differ in objective and subjective sleep parameters. Yet, they had poorer insomnia-related daytime functioning. OCPD and Avoidant personality disorders features were associated with poorer daytime functioning. OCPD features were related to greater fatigue severity, and overestimation of time awake was trending. Schizotypal and Schizoid features were positively associated with insomnia severity. Dependent personality disorder features were related to underestimating time awake. CONCLUSIONS: Cluster C personality disorders were highly prevalent in patients with chronic insomnia with hypnotic dependence. Features of Cluster C and A personality disorders were variously associated with poorer insomnia-related daytime functioning, fatigue, and estimation of nightly wake-time. Future interventions may need to address these personality features.

Psychological treatment of insomnia in hypnotic-dependant older adults.

BACKGROUND: The existing literature does not address the question of whether cognitive-behavioral therapy would have an impact on insomnia in older adults who are chronic users of sleep medication and have current insomnia, but are also stable in their quantity of medication usage during treatment. The present report seeks to answer this question. METHODS: Hypnotic-dependant older adults, who were stable in their amount of medication usage and still met the criteria for chronic insomnia put forth by American Academy of Sleep Medicine, were treated using a cognitive-behavioral intervention for insomnia. The three-component treatment included relaxation training, stimulus control, and sleep hygiene instructions. Participants were randomly assigned to either the active treatment group or a comparably credible placebo control group, and were instructed not to alter their pattern of hypnotic consumption during treatment. RESULTS: The active treatment group had significantly better self-report measures of sleep at post-treatment. Statistically significant improvement was paralleled by clinically meaningful improvement for key sleep variables. As planned, there was no significant change in sleep medication usage from pre- to post-treatment. CONCLUSIONS: The findings support the use of cognitive-behavioral therapy for insomnia in hypnotic-dependant older adults.

Actigraphy validation with insomnia.

STUDY OBJECTIVE: Actigraphy, a method of inferring sleep from the presence or absence of wrist movement, has been well validated against polysomnography in trials with people without insomnia. However, the small amount of literature on validation with insomniacs has revealed an actigraphy bias toward overscoring sleep. The current validation trial with insomniacs used the largest number of subjects to date in such research and attracted participants with diverse demographic characteristics. DESIGN: People with insomnia slept 1 night in the laboratory while simultaneously being monitored by polysomnography, actigraphy (high-sensitivity algorithm of the Mini Mitter AW64 Actiwatch), and morning sleep diary. SETTING: Sleep disorders center. PARTICIPANTS: Participants were 57 volunteers from the community, 26 men and 31 women, ranging in age from 21 to 87 years. All participants satisfied conservative criteria for insomnia. The sample included subjects with primary insomnia, subjects with comorbid insomnia, and hypnotic users with current insomnia complaints. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Actigraphy was successfully validated on 4 measures of sleep pattern--number of awakenings, wake time after sleep onset, total sleep time, and sleep efficiency percentage--based on nonsignificant mean differences and significant correlation between actigraphy and polysomnography. Sleep-onset latency with actigraphy was not significantly different from polysomnography but was weakly correlated with polysomnography. Hypnotic use contributed to actigraphic overscoring of sleep. CONCLUSIONS: Actigraphy proved to be a satisfactory objective measure of sleep on 4 of 5 sleep parameters, but these results are specific to this particular instrument using this particular algorithm and should not be construed as a blanket endorsement of actigraphy for measuring insomnia.

Treatment of insomnia in older adults.

Insomnia outcome studies from the last 15 years show consistent success for behavioral treatment with older adults. The present review of evaluation and treatment covers the effects of aging on ability to sleep, the insomnia classification system, the treatment efficacy database, and critical outcome research methodology. Clinical trial methodology with older adults includes familiar challenges; for example, the need for placebo controls, and frequent failures to document the adequacy of treatment implementation. Recommendations for improving methodology are offered. A new review of treatment for primary insomnia in older adults shows strong improvement and consistent results for popular behavioral treatments. Older adult clinical trials show proven efficacy of behavioral treatment for primary insomnia, efficacy for secondary insomnia, and efficacy for insomnia associated with hypnotic dependency.