Addressing Insomnia in Older Adults with Cognitive Behavioral Therapy Instead of Drugs

Approximately 30% to 50% of adults experience problems with insomnia. The prevalence of insomnia is more common in older adults and is often chronic. Insomnia is associated with risk of stroke, falls, and cognitive decline. Treatment guidelines for insomnia recommend behavioral therapy as a first-line management strategy. However, access to behavioral therapy can be difficult due to the limited number of clinicians and the stigma associated with visiting a mental health professional for assistance. Older adults are more likely to take sedative-hypnotic medications to treat their insomnia, which are unfortunately associated with increased risk for falls, fractures, and even mortality.

Subjective sleep measures and self-reported sleep quality in older adults with chronic insomnia were both improved in individuals participating in the Cognitive Behavioral Therapy Intervention (CBT-I) treatment groups.1 The CBT-I groups had significant improvements in the average time it took them to fall asleep, measured between baseline and post-treatment (23.4 minute greater decrease than control). The CBT-I groups also experienced a decrease in the minutes they spent awake throughout the night, as compared to the controls (68.4 minutes). Also, sleep efficiency improved 10.5% more in the CBT-I groups than in the control group. Significant effects were also found for self-reported sleep quality in the CBT-I groups. The participants experienced these improvements for up to 12-months.

The study population consisted of adult veterans, age 60 and older, who were living in a community setting. All were classified as having chronic insomnia, meaning 3 or more months of insomnia disorder.  Subjective and objective measures of sleep were taken at baseline, post-treatment, and 6 and 12 months after the treatment. Potential study participants were identified using the VA database, identifying veterans living within 30 miles of the testing facility who had at least one out-patient visit in the previous 18-months. All identified participants were mailed a 25-item questionnaire that assessed insomnia disorder.  Of the 9080 veterans mailed a questionnaire, 4,717 returned a completed survey and 1,663 of those were screened for study eligibility over the phone. Of the 1,663 phone respondents, 519 completed the in-person eligibility screening and ultimately 159 were randomized into study groups (n=52 group CBT-1, n=54 individual CBT-1, and n=53 control).

A unique attribute of the program was that the sleep treatments were delivered by non-clinician sleep coaches who possessed a master’s degree in public health, social work, or communications. The researchers wanted to determine if cognitive behavioral therapy delivered by a non-clinician could result in significant improvements in insomnia, as using a sleep coach who was not a clinician or a mental health provider may increase the access for sleep treatment for more people, especially those with concerns about seeing a mental health provider for the treatment of insomnia.

The intervention involved 5 one-hour sessions over 6 weeks, with a phone check-in at week 5, which focused on stimulus control, sleep restriction, cognitive therapy, and sleep hygiene. The control was a manual based generalized sleep education program, delivered by an individual without CBT-I training. Data was collected using a sleep journal, wrist actigraphy, and sleep questionnaire,

There were not significant differences between the participants who received the individual or group cognitive behavioral therapy, so they were pooled together for analyses. CBT-I participants reported improved Pittsburgh Sleep Quality Index scores (3.4 points posttreatment, 2.4 points at 6-months follow-up and 2.1 points at 12-months follow-up) compared to controls. The treatment group had a 23.4 minute decrease in the time it took them to fall asleep from baseline to post-treatment as compared to the control group, decrease in time awake once they fell asleep was 17.7 minutes greater, decrease in time awake throughout the night was 68.4 minutes greater, and sleep efficiency improved 10.5% more.

  1. Alessi C., Martin JL, Fiorentino J, et al. Cognitive Behavioral Therapy for Insomnia in Older Veterans Using Nonclinician Sleep Coaches: Randomized Controlled Trial. Journal of the American Geriatrics Society. 2016; 64:1830–1838.

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