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Management of insomnia in older adults

  • Børge Sivertsen (a1) and Inger Hilde Nordhus (a1)

Summary

Complaints of insomnia are very common, especially in older adults. Although pharmacotherapy is the most common form of treatment, recent evidence shows cognitive–behavioural therapy to be superior in the short- and long-term management of insomnia. Low-threshold intervention programmes may reduce both the individual and societal burden of insomnia, coexisting with or without other mental or physical disorders.

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Copyright

Corresponding author

Dr Børge Sivertsen, Department of Clinical Psychology, University of Bergen, Christiesgt. 12, 5015 Bergen, Norway. Email: borge.sivertsen@psykp.uib.no

Footnotes

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Declaration of interest

None.

Footnotes

References

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Bastien, C. H., Morin, C. M., Ouellet, M. C., et al (2004) Cognitive-behavioral therapy for insomnia: comparison of individual therapy, group therapy, and telephone consultations. Journal of Consulting and Clinical Psychology, 72, 653659.
Buscemi, N., Vandermeer, B., Friesen, C., et al (2005) Manifestations and Management of Chronic Insomnia in Adults. Agency for Health care Research and Quality.
Espie, C. A., Inglis, S. J., Tessier, S., et al (2001) The clinical effectiveness of cognitive behaviour therapy for chronic insomnia: implementation and evaluation of a sleep clinic in general medical practice. Behaviour Research and Therapy, 39, 4560.
Glass, J., Lanctot, K. L., Herrmann, N., et al (2005) Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ, 331, 1169.
Harvey, A. G. & Tang, N. K. (2003) Cognitive behaviour therapy for primary insomnia: can we rest yet? Sleep Medicine Reviews, 7, 237262.
Irwin, M. R., Cole, J. C. & Nicassio, P. M. (2006) Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age. Health Psychology, 25, 314.
Montgomery, P. & Dennis, J. (2003) Cognitive behavioural interventions for sleep problems in adults aged 60+. Cochrane Database of Systematic Reviews, issue 2. Update Software.
Morgan, K., Dixon, S., Mathers, N., et al (2003) Psychological treatment for insomniain the management of long-term hypnotic drug use: a pragmatic randomised controlled trial. British Journal of General Practice, 53, 923928.
Morin, C., Beaulieu-Bonneau, S., LeBlanc, M., et al (2005) Self-help treatment for insomnia: a randomized controlled trial. Sleep, 28, 13191327.
Sivertsen, B., Omvik, S., Pallesen, S., et al (2006) Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA, 295, 28512858.
Stepanski, E. J. & Rybarczyk, B. (2006) Emerging research on the treatment and etiology of secondary or comorbid insomnia. Sleep Medicine Reviews, 10, 718.
Strom, L., Pettersson, R. & Andersson, G. (2004) Internet-based treatment for insomnia: a controlled evaluation. Journal of Consulting and Clinical Psychology, 72, 113120.

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Management of insomnia in older adults

  • Børge Sivertsen (a1) and Inger Hilde Nordhus (a1)
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eLetters

Future Directions in Cognitive-Behavioural Therapy in Older Insomniacs

B� Sivertsen, Psychologist
29 May 2007

In a response to our editorial, Dr. Prakash calls for the need of more training workshops in order to improve implementation of Cognitive Behaviour Therpapy (CBT) for older insomniacs.

Although we agree that there are much too few sleep specialists to cater for the needs, we believe that that the key to more effective implementation is to also provide the same training to other health professionals, including primary care nurses. While there is still no consensus on which component to be included in CBT for insomnia, our experience is that sleep restriction and stimulus control are both crucialand the most effective factors in improving sleep in this age cohort. These components can easily be adapted and used by most health professionals.

In Norway, we are also pleased to see that the Norwegian Medical Association has started offering training workshop on CBT for insomnia fortheir members, and also the Norwegian Psychological Association will soon follow this important initiative.

However, we share Dr Prakash concern that there is still insufficientresearch on how to optimize the treatment, and there is clearly a need forstudies to disentangle which component works best and for whom.
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Conflict of interest: None Declared

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Limitations of cognitive-behavioral therapy in sleep disorders in elderly

Om Prakash
02 May 2007

Title: Limitations of cognitive-behavioral therapy in sleep disordersin elderly

When the possible side effects of hypnotics are considered, there is an argument to be made for clinical use of alternative treatments in the elderly. In their editorial, Siversten & Nordhus1 emphasized the role of cognitive-behavioral approach in the management of sleep disorders in elderly. However, there are limitations in this approach too.

Mental health practitioners or physicians with formal sleep medicine training currently deliver cognitive Behavioral Therapy (CBT), but they are few in number and could not cater to the needy ones2. This could be the foremost reasons for prescribing hypnotics in geriatric population despite knowing their side-effect profile and abuse potential. Therefore, more training workshops are needed to mental health professionals so that they can incorporate those techniques in their routine care of elderly clientele.

No clear guideline exists about the optimum number and duration of sessions in sleep disorders more particularly for geriatric population. Itis unclear how long it continued to have changes in sleep hygiene. CBT refers to a number of varied non-pharmacologic treatments for insomnia, but which portion is more effective or having more impact need more research. There was insufficient evidence to recommend sleep hygiene education, imagery training and cognitive therapy as single therapies or when added to other specific approaches3.

In addition to CBT, research groups are also working on other effective non-pharmacological interventions for elderly population like acupressure4. Exercise5, though not appropriate for all in this population, may help in inducing sleep. Nevertheless, the editorial gave anew insight in this neglected area and formed an impetus to start more research for this geriatric population.

References

1.Sivertsen, B., Nordhus, I.H. (2007). Management of insomnia in older adults. British Journal of Psychiatry, 190, 285-6.2.Wetzler, R.G., Winslow, D.H. (2006). New solutions for treating chronicinsomnia: an introduction to behavioral sleep medicine. The Journal of theKentucky Medical Association, 104(11), 502-12. 3.Morgenthaler, T., Kramer, M., Alessi, C., et al (2006). Practice parameters for the psychological and behavioral treatment of insomnia:an update. An american academy of sleep medicine report. Sleep, 29(11), 1415-9. 4.Chen, M.L., Lin, L.C., Wu, S.C., Lin, J.G. (1999). The effectiveness ofacupressure in improving the quality of sleep of institutionalized residents. The journals of gerontology. Series A, Biological sciences and medical sciences, 54(8), M389-94. 5.Montgomery, P., Dennis, J.(2004). A systematic review of non-pharmacological therapies for sleep problems in later life. Sleep medicinereviews, 8(1), 47-62.
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Conflict of interest: None Declared

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