Effects of Brief Behavioral Treatment for Insomnia on Daily Associations between Self-Reported Sleep and Objective Cognitive Performance in Older Adults

Nurse-delivered brief behavioral treatment for insomnia in cancer survivors: a randomized controlled trial

PURPOSE

To determine the efficacy of nurse-delivered brief behavioral treatment for insomnia (BBTI) compared to an attention control, in a heterogeneous sample of cancer survivors to reduce insomnia symptom severity.

METHODS

We recruited 132 participants from cancer care clinics, who had an Insomnia Severity Index (ISI) score ≥ 8. Participants were randomized into two groups: an experimental BBTI group and a healthy eating attention control group. Demographics survey at baseline, and sleep-related questionnaires, self-reported sleep diaries, and wrist-worn actigraphy at baseline, 1, 3, and 12 months were collected. Statistical analyses used analysis of covariance (ANCOVA) models with two-sided 0.05 nominal significance level for treatment effect for primary outcome of insomnia severity at 1 month.

RESULTS

Participants were cancer survivors with a mean age of 63.7 years, 55% female, 88.6% white, with breast, prostate, colorectal, and lung cancer. Statistically significant group differences were observed at all time points for ISI and sleep quality (ISI effect sizes 0.56, 0.59, and 0.54 respectively). Additionally, at 1 month, those in insomnia remission (ISI ≤ 8) were higher for the BBTI (55.1%) compared to the control group (43.3%). Secondary outcomes from sleep diary measures (i.e., sleep efficiency, sleep onset latency, wake after sleep onset) were significant at 1 month.

CONCLUSION

The BBTI group was significantly effective in reducing insomnia severity and improving sleep quality over time compared to the control among cancer survivors.

CLINICAL TRIAL REGISTRATION

Clinical trials identifier: http://ClinicalTrials.gov , NCT03810365.

IMPLICATIONS FOR CANCER SURVIVORS

Implementing BBTI in survivorship settings can effectively address and manage insomnia symptoms, thus bridging a crucial gap in care for cancer survivors.

Improving Sleep in People with HIV and Chronic Pain: A Pilot Study of Brief Behavioral Treatment for Insomnia

OBJECTIVES

Insomnia and chronic pain are common symptoms in people with HIV. Poor sleep has been associated with chronic pain. While cognitive behavioral therapy for insomnia improves insomnia in clinical populations, there are barriers to people with HIV accessing treatment including the lack of trained providers and lengthy sessions. Only one study has examined the efficacy of brief behavioral treatment for insomnia (BBTI) in people with HIV. This study examined BBTI effects on sleep and pain in people with HIV.

METHODS

Ten adults with HIV and chronic pain completed a 4-week, telephone-delivered BBTI treatment. A control group (n = 10) completed a brief mindfulness training (BMT). The Insomnia Severity Index and Brief Pain Inventory were used to assess insomnia severity and pain outcomes, respectively.

RESULTS

There was a significant interaction between intervention and time on insomnia severity, F (2,14) = 5.7, p = .02, partial η2 = 0.45). The BBTI group demonstrated significant improvements in insomnia severity from pre- to post-intervention (p < .001) and from pre-intervention to one-month post-intervention (p = .001) compared to the BMT group. There was a significant interaction between intervention and time on pain interference, F (1,18) = 4.9, p = .02, partial η2 = 0.27). The BBTI group demonstrated a significant decrease in pain interference from pre- to post-intervention (p < .001) compared to the BMT group.

CONCLUSIONS

This pilot study demonstrated that BBTI improved insomnia in people with HIV for up to one-month post-treatment. Novel preliminary evidence suggests that BBTI may also improve pain outcomes in people with HIV.

Sleep disturbances and change in multiple cognitive domains among older adults: a multicenter study of five Nordic cohorts

STUDY OBJECTIVES

We examined and compared cross-sectional and longitudinal associations between self-reported sleep disturbances and various cognitive domains in five separate Nordic European longitudinal aging studies (baseline N = 5631, mean age = 77.7, mean follow-up = 4.16 years).

METHODS

Comparable sleep parameters across studies included reduced sleep duration/quality, insomnia symptoms (sleep latency, waking up at night, and early awakenings), short and long sleep duration, and daytime napping. The cognitive domains were episodic memory, verbal fluency, perceptual speed, executive functioning, and global cognition (aggregated measure). A series of mixed linear models were run separately in each study and then compared to assess the level and rate of change in cognitive functioning across each sleep disturbance parameter. Models were adjusted for age, sex, education, hypnotic usage, depressive symptoms, lifestyle factors, cardiovascular, and metabolic conditions. By using a coordinated analytic approach, comparable construct-level measurements were generated, and results from identical statistical models were qualitatively compared across studies.

RESULTS

While the pattern of statistically significant results varied across studies, subjective sleep disturbances were consistently associated with worse cognition and steeper cognitive decline. Insomnia symptoms were associated with poorer episodic memory and participants sleeping less or more than 7-8 hours had a steeper decline in perceptual speed. In addition, daytime napping (>2 hours) was cross-sectionally and longitudinally associated with all examined cognitive domains. Most observed associations were study-specific (except for daytime napping), and a majority of association estimates remained significant after adjusting for covariates.

CONCLUSION

This rigorous multicenter investigation further supports the importance of sleep disturbance, including insomnia, long and short sleep duration, and daytime napping on baseline cognitive functioning and rate of change among older adults. These sleep factors may be targeted in future lifestyle interventions to reduce cognitive decline.

Self-reported cognition in older adults with insomnia: Associations with sleep and domain specific cognition

Poor subjective evaluation of cognition and sleep are associated with cognitive decline in older adults. Relationships among self-reported cognition, sleep, and cognitive domains remain unclear. We evaluated the interactive associations of objective cognition and subjective sleep with self-reported cognition in older adults with insomnia. Fifty-one older adults (M_age  = 69.19, SD = 7.95) with insomnia completed 14 days of self-reported cognition ratings (0-very poor, 100-very good), sleep (total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO), sleep efficiency), and daily cognitive tasks: Letter series (reasoning), word list delayed recall (verbal memory), Symbol Digit Modalities Test (SDMT) (attention/processing speed), and number copy (processing speed). Multiple regressions for each cognitive task determined whether average objective cognition or sleep were independently/interactively associated with average self-reported cognition, controlling for age, education, and depression. The interaction between SDMT performance and TST was associated with self-reported cognition. Specifically, the relationship between scores and self-reported cognition was congruent in those with the shortest TST. Similarly, the interactions between SDMT and WASO, as well as sleep efficiency, were associated with self-reported. Specifically, the relationship between scores and self-reported cognition was congruent in those with longest and average WASO, as well as shortest and average sleep efficiency. The findings suggest, in an older adult population with insomnia, a congruent association exists between attention/processing speed and self-reported cognition in those with worse subjective sleep (shorter TST, longer WASO, and lower SE). Insomnia symptoms should be taken into consideration when examining the relationship between objective cognition and self-reported cognition.

Brief Behavioral Treatment for Insomnia: A Meta-Analysis

PURPOSE

The current study aims to quantify the effect of brief behavioral treatment for insomnia (BBTI) studies through meta-analysis.

METHOD

Searches were performed from inception to February 2020, reporting on the effects of BBTI using randomized controlled trials (RCT) (adults aged 32 to 84). The main outcome measures were sleep onset latency (SOL), wake after sleep onset (WASO), sleep efficiency (SE%), and total sleep time (TST).

RESULTS

BBTI showed improved SOL compared with control group in mean difference at early (-15.42 [95% CI: -33.05 to -12.01; I2 =49%]) and late follow-up (-10.52 [95% CI: -1.12 to 0.54; I2=93%]). This was statistically significant at early follow-up, but not at late follow-up. The improvement of WASO by BBTI over the control group was shown at early follow-up (-17.47 [95% CI: -2.67 to 0.45; I2=90%]), and was statistically significant. For WASO, a non-statistically significant improvement of BBTI over the control group was shown at late follow-up (-12.77 [95% CI: -22.47 to -3.08; I2=0%]). SE% was shown improved statistically significant by BBTI over control group at early (4.47 [95% CI: -0.35 to 9.29; I2=98%]) and at late follow-up (6.52 [95% CI: -4.00 to 17.05; I2=89%]). The TST was shown no improvement by BBTI at early follow-up in mean difference (-2.97 [95% CI -38.83 to 32.90; I2=96%]). At late follow-up, TST was shown improvement in BBTI with mean difference (14.52 [95% CI: -31.64 to 60.68; I2=94%]) compared with the control group.

CONCLUSION

Current evidence suggests that BBTI can be considered preliminarily efficacious and can be used for samples of middle-aged and older adults.

A Perspective: Challenges in Dementia Research

Although dementia is a common and devastating disease that has been studied intensely for more than 100 years, no effective disease modifying treatment has been found. At this impasse, new approaches are important. The purpose of this paper is to provide, in the context of current research, one clinician's perspective regarding important challenges in the field in the form of specific challenges. These challenges not only illustrate the scope of the problems inherent in finding treatments for dementia, but can also be specific targets to foster discussion, criticism and new research. One common theme is the need to transform research activities from small projects in individual laboratories/clinics to larger multinational projects, in which each clinician and researcher works as an integral part. This transformation will require collaboration between researchers, large corporations, regulatory/governmental authorities and the general population, as well as significant financial investments. However, the costs of transforming the approach are small in comparison with the cost of dementia.

Sleep and Cognition: A Narrative Review Focused on Older Adults

Little is known regarding sleep's association with the traditional developmental course of late-life cognitive functioning. As the number of older adults increases worldwide, an enhanced understanding of age-related changes in sleep and cognition is necessary to slow decline and promote optimal aging. This review synthesizes the extant literature on sleep and cognitive function in healthy older adults, older adults with insomnia, and older adults with sleep apnea, incorporating information on the potential promising effects of treating poor sleep on cognitive outcomes in older adults. Unifying theories of the sleep-cognition association, possible mechanisms of action, and important unanswered questions are identified.

The "Counseling+" Roles of the Speech-Language Pathologist Serving Older Adults With Mild Cognitive Impairment and Dementia From Alzheimer's Disease

Purpose

Persons with dementia and mild cognitive impairment (MCI) are major consumers of services provided by speech-language pathologists (SLPs). These services include not only direct assessment and treatment of communication and swallowing but also counseling, collaboration, prevention, and wellness. These "counseling+" activities can be especially challenging for SLPs to deliver because of the lack of evidence, as well as the complex nature of Alzheimer's disease (AD) and other conditions that cause MCI and dementia.

Method

This tutorial is written by a speech-language pathologist, a neuropsychologist, and a geriatric psychiatrist to provide education, resources, and recommendations for SLPs delivering counseling+ activities to patients with MCI and dementia from AD and related disorders.

Results and Conclusions

We describe counseling+ activities across the continuum of care ranging from educating and conducting cognitive screenings with adults experiencing age-related cognitive decline to supporting end-of-life wishes. Because of their expertise in communication, SLPs can provide an array of important leading and supporting services to patients, their family, and other health care professionals on the care team, such as providing patients with appropriate feedback following a cognitive screening and helping caregivers identify the communicative intent of a responsive behavior. The demand for SLP services for patients with MCI and dementia will grow significantly over the next few decades, necessitating more systematic research and clinical evidence in this area.

Association of insomnia and multidimensional frailty in community-dwelling older adults: A cross-sectional survey

OBJECTIVE

To evaluate the relationship between insomnia and multidimensional frailty.

BACKGROUND

Frailty has major implications on adverse health outcomes of older adults. In recent years, multidimensional nature of frailty has been increasingly recognised. Many frail older adults also suffer from insomnia.

METHODS

This was a cross-sectional observational study including 454 community-dwelling adults aged 60 and older. Insomnia was defined as a subjective experience of inadequate sleep duration or quality that affects social functioning during the day, based on the Athens Insomnia Scale (AIS), and multidimensional frailty was based on Tilburg Frailty Indicator (TFI). The STROBE checklist was used to guide the submission.

RESULTS

Mean age was 69.1 years old, 211 (46.5%) of participants suffered from insomnia, and 185 (40.7%) of participants were frail. There was a significant relationship between insomnia and multidimensional frailty (physical, psychological and social dimensions). Insomnia was associated with frailty, adjusting for sociodemographic characteristics and comorbidity OR of 6.863 (95% CI: 4.237-11.116).

CONCLUSION

Frailty was independently predicted by insomnia. Future researches should determine whether there is a causal relationship between insomnia and multidimensional frailty, with the ultimate goal of providing interventions to reverse or prevent frailty.

RELEVANCE TO CLINICAL PRACTICE

This study emphasises the importance of assessment and treatment of insomnia, potentially contributing to the reversion and prevention of frailty in community-dwelling older adults.

A brief behavioral treatment for unresolved insomnia in adolescents: a single-case multiple baseline pilot study, evaluating self-reported outcomes of efficacy, safety, and acceptability

STUDY OBJECTIVES

Insomnia is a significant problem for many adolescents and often is associated with detrimental effects on physical and mental health. Drawing on emerging models of intervention in the adult literature, this pilot study investigated the efficacy, safety, and acceptability of a novel, brief (3-week) behavioral intervention among adolescents with unresolved chronic insomnia.

METHODS

A multiple baseline (staggered start) A-B with follow-up single-case design (n = 2) was used to evaluate intervention outcomes across treatment and at 2-month follow-up in the domains of sleep, mood and affect, fatigue, and parent-child conflict. Outcomes were indexed with multi-informant data collected using adolescent reports on mood/affect and sleep diaries, and parent reports on parent-child conflict.

RESULTS

Posttreatment and 2-month follow-up data indicated improvements in self-reported sleep quality, including sleep onset latency and increased sleep efficiency. Indicators related to participant mood, stress, and parent-child interactions remained relatively stable over the course of treatment, suggesting that the sleep restriction component of the intervention did not produce adverse effects for the adolescents or their families.

CONCLUSIONS

A brief 3-week intervention adapted from the adult literature was associated with improved sleep-wake cycles in adolescents with chronic insomnia. Change during the treatment phase was particularly rapid and maintained over time. In conjunction with low observed risk and adverse effects, the potential for this treatment to provide a safe, acceptable, and cost-effective manualized treatment for adolescent insomnia warrants larger-scale clinical evaluation.

CLINICAL TRIAL REGISTRATION

Registry: Australian New Zealand Clinical Trials Registry; Title: Does a one month brief behavioral treatment improve sleep for high school adolescents (ages 12-17): an open label pilot study; Identifier: ACTRN12618000835246; URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375102.