Cognitive behavioural interventions for sleep problems in adults aged 60+. Cochrane Database of Systematic Reviews, 1, CD003161
The University of Oxford Section of Child and Adolescent Psychiatry, Park Hospital, Old Road, Headington, Oxford, UK, OX3 7LQ. Cochrane database of systematic reviews (Online)
(Impact Factor: 6.03).
02/2003; 1(1):CD003161. DOI: 10.1002/14651858.CD003161
The prevalence of sleep problems in adulthood increases with age. While not all sleep changes are pathological in later life, severe disturbances may lead to depression, cognitive impairments, deterioration of quality of life, significant stresses for carers and increased healthcare costs. The most common treatment for sleep disorders (particularly insomnia) is pharmacological. The efficacy of non-drug interventions has been suggested to be slower than pharmacological methods, but with no risk of drug-related tolerance or dependency. Cognitive and behavioural treatments for sleep problems aim to improve sleep by changing poor sleep habits, promoting better sleep hygiene practices and by challenging negative thoughts, attitudes and beliefs about sleep.
To assess the efficacy of cognitive-behavioural interventions in improving sleep quality, duration and efficiency amongst older adults (aged 60 and above).
The following databases were searched: MEDLINE (1966 - October 2001); EMBASE (1980 - January 2002), CINAHL ( 1982 - January 2002; PsychINFO 1887 to 2002; The Cochrane Library (Issue 1, 2002); National Research Register (NRR ). Bibliographies of existing reviews in the area, as well as of all trial reports obtained, were searched. Experts in the field were consulted.
Randomised controlled trials of cognitive behavioural treatments for primary insomnia where 80% or more of participants were over 60. Participants must have been screened to exclude those with dementia and/or depression.
Abstracts of studies identified in searches of electronic databases were read and assessed to determine whether they might meet the inclusion criteria. Data were analysed separately depending on whether results had been obtained subjectively or objectively.
Six trials, including 282 participants with insomnia, examined the effectiveness of cognitive-behavioural treatments (CBT) for sleep problems in this population. The final total of participants included in the meta-analysis was 224. The data suggest a mild effect of CBT for sleep problems in older adults, best demonstrated for sleep maintenance insomnia.
When the possible side-effects of standard treatment (hypnotics) are considered, there is an argument to be made for clinical use of cognitive-behavioural treatments. Research is needed to establish the likely predictors of success with such treatments. As it may well be the case that the treatment efficacy of cognitive-behavioural therapy itself is not durable, the provision of "top-up" ("refresher" sessions of CBT training to improve durability of effect are worthy of investigation.
Available from: Robert Zachariae
- "They are usually not curative, leading to long-term treatment over many years despite lack of safety and efficacy data beyond 1-2 years  . In contrast, cognitive-behavioral therapy for insomnia (CBT-I) has, in several meta-analyses, been found efficacious in improving sleep outcomes    with acute effects comparable or superior to those found for pharmacotherapy , and these effects have been maintained for up to 3 years . While CBT-I has been shown efficacious and desired by many patients preferring non-pharmacological approaches  , the challenge remains to make it available and accessible to meet population needs  due to the limited availability of trained therapists and the relatively high costs of CBT-I delivered face-to-face  . "
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ABSTRACT: Cognitive-behavioral therapy for insomnia (CBT-I) has been shown efficacious, but the challenge remains to make it available and accessible in order to meet population needs. Delivering CBT-I over the internet (eCBT-I) may be one method to overcome this challenge. The objective of this meta-analysis was to evaluate the efficacy of eCBT-I and the moderating influence of various study characteristics. Two researchers independently searched key electronic databases (1991 to June 2015), selected eligible publications, extracted data, and evaluated methodological quality. Eleven randomized controlled trials examining a total of 1460 participants were included. Results showed that eCBT-I improved insomnia severity, sleep efficiency, subjective sleep quality, wake after sleep onset, sleep onset latency, total sleep time, and number of nocturnal awakenings at post-treatment, with effect sizes (Hedges's g) ranging from 0.21 to 1.09. The effects were comparable to those found for face-to-face CBT-I, and were generally maintained at 4-48 wk follow-up. Moderator analyses showed that longer treatment duration and higher degree of personal clinical support were associated with larger effect sizes, and that larger study dropout in the intervention group was associated with smaller effect sizes. In conclusion, internet-delivered CBT-I appears efficacious and can be considered a viable option in the treatment of insomnia.
Available from: Bradley E. Karlin
- "Moreover, CBT-I has been shown to be as effective as medication in the short term and more effective in the long term (Jacobs et al., 2004). Cognitive behavioral therapy for insomnia has been examined and shown to be efficacious specifically in the context of late-life insomnia (Morin et al., 1999a; Montgomery and Dennis, 2003). A meta-analysis of the efficacy of CBT-I and its core behavioral components for treating insomnia in older adults found moderate mean effects sizes for diary outcomes of latency to sleep onset, time awake after sleep onset, sleep efficiency, and self-rated sleep quality (Irwin et al., 2006). "
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Limited research has examined the effects of cognitive behavioral therapy for insomnia (CBT-I) among older adults (age >65 years) receiving treatment in real-world clinical settings and even less has examined effects on outcomes beyond reducing insomnia, such as improved quality of life. The current article examines and compares outcomes of older versus younger (age 18-64 years) veterans receiving CBT-I nationally in nonsleep specialty settings.Method
Patient outcomes were assessed using the Insomnia Severity Index, Beck Depression Inventory-II, and the World Health Organization Quality of Life-BREF. Therapeutic alliance was assessed using the Working Alliance Inventory—Short Revised.ResultsA total of 536 younger veterans and 121 older veterans received CBT-I; 77% of older and 64% of younger patients completed all sessions or finished early due to symptom relief. Mean insomnia scores declined from 19.5 to 9.7 in the older group and from 20.9 to 11.1 in the younger group. Within-group effect sizes were d = 2.3 and 2.2 for older and younger groups, respectively. CBT-I also yielded significant improvements in depression and quality of life for both age groups. High and increasing levels of therapeutic alliance were observed for both age groups.Conclusions
Older (and younger) patients receiving CBT-I from nonsleep specialists experienced large reductions in insomnia and improvements in depression and quality of life. Effects were similar for both age groups, and the rate of dropout was lower among older adults. The results provide strong support for the effectiveness and acceptability of CBT-I for older adults receiving care in routine treatment settings. Copyright © 2014 John Wiley & Sons, Ltd.
Available from: Wen Liu
- "Beginning with the seminal works by Morin et al.  and Murtagh & Greenwood , nine meta-analyses of the effects of CBT-I on primary insomnia [26,28,30,31,78e82] were examined, summarized in Table 5. The magnitude of effect of CBT-I on TST in our sample was similar to the effect found in studies of primary insomnia in older adults   , but smaller than that found in studies of younger adults   . Results for SOL and WASO were similar to those for TST. "
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ABSTRACT: s u m m a r y Cognitive behavioral therapy for insomnia (CBT-I) is effective for treatment of primary insomnia. There has been no synthesis of studies quantifying this effect on insomnia comorbid with medical and psy-chiatric disorders using rigorous selection criteria. The objective of this study was to quantify the effect of CBT-I in studies including patients with medical or psychiatric disorders. Studies were identified from 1985 through February 2014 using multiple databases and bibliography searches. Inclusion was limited to randomized controlled trials of CBT-I in adult patients with insomnia diagnosed using standardized criteria, who additionally had a comorbid medical or psychiatric condition. Twenty-three studies including 1379 patients met inclusion criteria. Based on weighted mean differences, CBT-I improved subjective sleep quality post-treatment, with large treatment effects for the insomnia severity index and Pittsburgh sleep quality index. Sleep diaries showed a 20 min reduction in sleep onset latency and wake after sleep onset, 17 min improvement in total sleep time, and 9% improvement in sleep efficiency post-treatment, similar to findings of meta-analyses of CBT-I in older adults. Treatment effects were durable up to 18 mo. Results of actigraphy were similar to but of smaller magnitude than subjective measures. CBT-I is an effective, durable treatment for comorbid insomnia.
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