Insomnia symptoms are common in older Veterans, and are associated with poor health outcomes, increased depressive symptoms and other adverse effects on quality of life. Prior research has demonstrated that behavioral sleep interventions, especially cognitive behavioral therapy for insomnia (CBTI), are effective in treating insomnia among older people, including individuals with significant medical and psychiatric comorbidity. Unfortunately, these safe and effective interventions are not widely available, in part due to limited availability of behavioral sleep medicine (BSM) specialists to provide these interventions. In an effort to increase access to CBTI, we developed and tested a manualized CBTI program that could be delivered by trained masters-level health educators, under the supervision of a BSM specialist, to older Veterans with insomnia.
The specific aims of this project were to: 1) test the feasibility of two different, novel methods (i.e., provided in a group or as an individual) using masters-level health educators to provide behavioral treatment for insomnia among older outpatient Veterans; 2) determine if these interventions improve sleep/wake patterns, depressive symptoms and quality of life among older outpatient Veterans with insomnia at 6-months follow-up; and 3) determine if these interventions maintain improvements in sleep/wake patterns, depressive symptoms and quality of life at 12-months follow-up. Additional objectives were added to the project as a modification, including: 4) develop a patient screening algorithm that can be used to identify patients who are appropriate for this intervention; 5) use quantitative and qualitative methods to describe participants' experiences, attitudes and adherence with the intervention, and identify potential facilitators and barriers to implementation of the intervention; and 6) develop an implementation package for use in older Veterans. The long-term objective of this work is to identify ways to improve access to behavioral sleep interventions for older Veterans with insomnia in order to improve their sleep and other measures of well-being and quality of life.
This randomized controlled trial was conducted among older Veterans (60 years and older) receiving outpatient services within the VA Greater Los Angeles Healthcare System. Veterans were screened for insomnia using a postal survey. Those who met diagnostic criteria for insomnia of more than three month's duration and who did not have obstructive sleep apnea were enrolled into the study. Participants were randomized to one of three groups: Individual-Behavioral Sleep Intervention (iCBTI, n=54), Group-based Behavioral Sleep Intervention (gCBTI, n=52), or attention control (n=53). Both active treatment conditions (iCBTI and gCBTI) combined sleep restriction, stimulus control and cognitive therapy; and were provided by masters-level health educators with weekly telephone supervision by a BSM specialist. The attention control condition involved general sleep education without individualized recommendations. Each group met for 5 sessions over a 6 week period. Outcome measures were collected at baseline, post-treatment, and at 6-months (i.e., the primary endpoint) and 12-months following randomization. A priori primary outcome measures included 7-day sleep diary measures (sleep onset latency [SOL-d], wake after sleep onset [WASO-d] and sleep efficiency (SE-d]), 7-day wrist actigraphy (sleep efficiency, SE-a), sleep quality (Pittsburgh Sleep Quality Index [PSQI] total score), depressive symptoms (Patient Health Questionnaire-9), and health-related quality of life (Short Form-12). Analyses were performed comparing the outcomes for the iCBTI versus controls, and for gCBTI versus controls, at both six and twelve months follow-up. Analyses were intent-to-treat, ANCOVA, adjusted for baseline values.
At the completion of the study, four focus groups were held with iCBTI and gCBTI participants who completed the intervention. Note-based analysis of transcripts was performed to identify themes and domains using standard qualitative methodology.
Participants (N=159) had a mean age of 72.1 years (SD 7.7 range 60 - 91 years), 96.9% were male, and 79% identified themselves as non-Hispanic white. Comparison of baseline data revealed no significant differences between intervention and control participants in key descriptive characteristics. Follow-up assessments were completed for 91% of randomized participants at six months, and for 88% of randomized participants at twelve months follow-up.
AIM 1: Participation in the intervention or control conditions was high. Ninety-five percent of the 159 participants received all of the intervention/control content.
AIM 2: At 6-months follow-up, compared to controls, participants randomized to either active intervention (iCBTI or gCBTI) had shorter (i.e., better) SOL-d (iCBTI 19.3 minutes, p=.002; gCBTI 22.5 minutes, p=.017; controls 32.8 minutes) and greater (better) SE-d (iCBTI 85.5%, p<.001; gCBTI 84.3%, p=.005; controls 78.6%). PSQI scores also improved (iCBTI 5.8, p=.005; gCBTI 5.6, p=.002; controls 7.7). WASO-d and SE-a did not differ between groups. Depressive symptoms and health-related quality of life were not different between groups at 6-months follow-up.
AIM 3: Significant sleep improvements at 6-months were maintained at 12 months follow-up (all p<.05), but there were no differences in depressive symptoms or health-related quality of life.
A total of 35 intervention participants attended the focus groups. The major themes that emerged from the focus groups were: 1) master's level health educators were legitimate and credible CBTI providers; 2) CBTI was acceptable and personally helpful whether delivered in individual or group format; 3) CBTI should be available outside of a mental health clinic setting (e.g., primary care, sleep center); 4) Screening for insomnia should occur in primary care; and 5) Patients should be able to self-refer for CBTI.
These findings suggest that this model of insomnia care (which uses masters-level health educators to provide behavioral treatment for insomnia among older outpatient Veterans), either individually or in a group, is effective, feasible, and acceptable to older Veterans. This model could improve insomnia care, particularly among Veterans who don't have access to a behavioral sleep medicine specialist. We believe this model provides a safer alternative to medication treatment of insomnia in older Veterans.
- Ryden AM, Martin JL, Matsuwaka S, Fung CH, Dzierzewski JM, Song Y, Mitchell MN, Fiorentino L, Josephson KR, Jouldjian S, Alessi CA. Insomnia Disorder Among Older Veterans: Results of a Postal Survey. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2019 Apr 15; 15(4):543-551.
- Yeung T, Martin JL, Fung CH, Fiorentino L, Dzierzewski JM, Rodriguez Tapia JC, Song Y, Josephson K, Jouldjian S, Mitchell MN, Alessi C. Sleep Outcomes With Cognitive Behavioral Therapy for Insomnia Are Similar Between Older Adults With Low vs. High Self-Reported Physical Activity. Frontiers in aging neuroscience. 2018 Sep 13; 10:274.
- Hughes JM, Song Y, Fung CH, Dzierzewski JM, Mitchell MN, Jouldjian S, Josephson KR, Alessi CA, Martin JL. Measuring Sleep in Vulnerable Older Adults: A Comparison of Subjective and Objective Sleep Measures. Clinical Gerontologist. 2018 Mar 1; 41(2):145-157.
- Fung CH, Martin JL, Josephson K, Fiorentino L, Dzierzewski JM, Jouldjian S, Song Y, Rodriguez Tapia JC, Mitchell MN, Alessi CA. Cognitive Expectancies for Hypnotic Use among Older Adult Veterans with Chronic Insomnia. Clinical Gerontologist. 2018 Mar 1; 41(2):130-135.
- Alessi C, Martin JL, Fiorentino L, Fung CH, Dzierzewski JM, Rodriguez Tapia JC, Song Y, Josephson K, Jouldjian S, Mitchell MN. Cognitive Behavioral Therapy for Insomnia in Older Veterans Using Nonclinician Sleep Coaches: Randomized Controlled Trial. Journal of the American Geriatrics Society. 2016 Sep 1; 64(9):1830-8.
- Fung CH, Martin JL, Igodan U, Jouldjian S, Alessi C. The association between difficulty using positive airway pressure equipment and adherence to therapy: a pilot study. Sleep & Breathing = Schlaf & Atmung. 2013 May 1; 17(2):853-9.
- Fung CH, Martin J, Josephson K, Fiorentino L, Dzierzewski JM, Jouldjian S, Song Y, Rodriguez Tapia J, Mitchell MN, Alessi C. Predictors of sleeping medications use and impact of cognitive behavioral therapy for insomnia on sleeping medication use among older adults with chronic insomnia. Poster session presented at: Associated Professional Sleep Societies Annual Meeting (SLEEP); 2016 Jun 11; Denver, CO.
- Ryden AM, Matsuwaka S, Fung CH, Song Y, Mitchell MN, Dzierzewski JM, Martin J, Alessi C. Predictors of talking to a doctor about sleep problems among older veterans with insomnia. Poster session presented at: Associated Professional Sleep Societies Annual Meeting (SLEEP); 2016 Jun 11; Denver, CO.
- Fung CH, Martin J, Jouldjian S, Josephson K, Alessi CA. Difficulty with Use of Positive Airway Pressure Equipment and Adherence to Therapy Among Older Veterans: A Pilot Study. Poster session presented at: Associated Professional Sleep Societies, LLC Annual Meeting; 2012 Jun 9; Boston, MA.
Mental, Cognitive and Behavioral Disorders, Aging, Older Veterans' Health and Care, Health Systems
Treatment - Observational
Managed care, Outcomes - Patient, Quality of Life, Sleep disorders