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Behavior Change Can Help Seniors Sleep Without Drugs

June 22, 2017

A new study lays to rest the notion that sleepless seniors might respond poorly to treatments that emphasize behavioral therapy over drugs.

Behavioral interventions for insomnia offer "a very powerful strategy" in people over 55, said Michael Irwin, M.D., of UCLA, the lead author of a systematic evidence review. "Their benefits may be greater than pharmacologic treatments, because they can persist for a longer period of time."

Treating insomnia with drugs may impair functioning, create dependency and worsen sleep after they are discontinued, he says.

Poor sleep is one of the more common complaints among adults, and the prevalence rate among the elderly is almost double that of younger adults. Moreover, researchers are now recognizing the importance of sleep to overall health.

"Insomnia is increasingly implicated as a predictor of cardiovascular and noncardiovascular disease mortality," says the review.

This review is the first in a new series of to be published in Health Psychology. Each evidence-based review will center on a specific psychological assessment or treatment conducted in the context of a physical disease process or risk reduction effort.

The systematic review included 23 randomized controlled trials involving more than 500 participants. The various non-drug treatments - cognitive behavioral therapy, relaxation and changes in sleep behavior - yielded "robust improvements" in a variety of common problems such as poor sleep quality, difficulty falling asleep and awakening during the night.

Overall, effect sizes calculated in the review "are at the moderate-to-large level, which is very comparable to the kind of benefits that you see with pharmacologic treatments," says Irwin.

A particularly encouraging finding is that older insomniacs who suffer from frequent nighttime awakenings - the most common complaint in this group - report a better-than-average response to behavioral treatments. This indicates that "for the kind of insomnia that the elderly have, not only is this equally efficacious it's better," said Michael L. Perlis, director of the University of Rochester Sleep Research Laboratory.

The review emphasizes that the risks of behavioral treatments are negligible compared to those of potentially addictive sleeping pills. Yet non-drug therapies do have some downsides, cautioned Perlis.

The central component of modern cognitive behavioral therapy for insomnia is sleep restriction therapy, which in the first few weeks seeks to improve sleep quality by reducing quantity. The initial result is often severe fatigue.

"To a group that already has a problem with daytime sleepiness - the elderly - it is really misleading to say we need to do more [sleep restriction] because it's safer," says Perlis.

Perlis is investigating a treatment program that combines sleep restriction therapy with a short-term course of daytime stimulants. This approach would minimize the use of medications while preserving patients' ability to function safely during the day. "I think in the elderly in particular that's going to be a strategy that needs to be considered," he said.

The review authors note that only eight studies on people over age 55 met a high standard of statistical reliability, "a frightfully low number in view of the high prevalence of insomnia complaints in this population."

All of the included studies relied on patient reports of sleep improvements. The authors call for more research that collects objective evaluations of sleep using electroencephalograms.

Most of the included studies followed patients for only a few months, said Irwin. "We need studies that have follow-ups of a year or longer that can determine whether the improvements in sleep persist."

Irwin laments today's "drug-driven culture," in which clinicians focus primarily on initial treatment costs. "What's not being calculated into that equation is the cost of the drug in the long term, the cost of the drug in terms of its potential health risks and the cost of the drugs to society because they have to be continually taken."

Irwin M, Cole JC, Nicassio PM. Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in adults and in older adults 55 + years. Health Psychology, Jan 2006.

"Evidence-based Treatment Reviews" is a new series initiated within Health Psychology, an official journal of the American Psychological Association. These articles are intended to inform health psychology practice, add to teaching and mentoring resources, and inspire further evidence-based research and questions.

By Laura Kennedy, Contributing Writer
Health Behavior News Service

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Center for the Advancement of Health