Longitudinal trends in late-life insomnia: implications for prescribing

The Relationships between Sleep and Mental and Physical Health of Chinese Elderly: Exploring the Mediating Roles of Diet and Physical Activity

Sleep quality, diet quality, and physical activity are significant factors influencing physical and mental health. However, few studies have explored their underlying mechanisms, especially among the elderly population in East Asia, where people have food culture and lifestyles distinct from those living in Western countries. Therefore, the current study aimed to explore the relationships among sleep quality, diet quality, physical activity, and physical and mental health in a Chinese elderly sample. Sleep quality, diet quality, physical activity, physical health, and mental health were investigated among 313 Chinese elderly (aged 51-92 years, M = 67.90, SD = 7.94). Mediation analysis was used to examine the empirical model based on previous theories and literature. Close positive relationships were observed between all factors investigated (r = 0.22~0.73, p < 0.001). The relationships between sleep quality and physical and mental health were partially mediated by diet quality and physical activity. In clinical interventions, sleep quality, diet quality, and physical activity can be targeted to improve physical and mental health among the older adult populations.

Electroacupuncture for treatment-resistant insomnia: study protocol for a randomised, controlled, assessor-blinded, pilot clinical trial

INTRODUCTION

A considerable number of insomnia patients experience sleep disturbance even with long-term use of hypnotic medication. Previous studies have indicated that electroacupuncture (EA) could be an efficacious treatment for managing insomnia. However, few trials have been conducted to evaluate the effectiveness and safety of EA for treatment-resistant insomnia. This pilot study aims to explore the feasibility and preliminary effectiveness and safety of EA as an adjunct treatment for treatment-resistant insomnia.

METHODS AND ANALYSIS

This is a multicentre, randomised, usual care controlled and assessor-blinded pilot study protocol. Fifty patients presenting with sleep problems who have been taking hypnotic medication for more than 3 months will be randomly allocated to either an EA group or a usual care group at a 1:1 ratio. The EA group will undergo 12 EA treatment sessions twice a week for 6 weeks whereas the usual care group will not receive EA treatment. All the participants will receive a brochure containing educational information on sleep hygiene. The primary outcome will be the measured mean change of the total score of the Insomnia Severity Index from the baseline to week 7. The secondary outcome regarding sleep quality will be measured using the Pittsburgh Sleep Quality Index, a sleep diary and actigraphy. Moreover, we will assess the quality of life, the direct and indirect cost of treating insomnia for economic evaluation. After 4 weeks, the subjects will visit the research sites for a follow-up assessment.

ETHICS AND DISSEMINATION

Ethical approval of this study protocol was established by the institutional review boards of the each involved study site. All potential subjects will be provided written informed consent. The results of this study will be accessible in peer-reviewed publications and be presented at academic conference.

TRIAL REGISTRATION NUMBER

KCT0003235.

Sleep physiology and disorders in aging and dementia

Sleep problems occur commonly in normal and pathologic aging. Older adults typically have more difficulty falling asleep and remaining asleep, report more daytime napping, and have an increased prevalence of primary sleep disorders such as insomnia, parasomnias, sleep apnea, and sleep-related movement disorders. Medical and psychiatric disorders as well as medications used to treat them also contribute to sleep disturbances in aging. Patients with mild cognitive impairment and dementia have more severe sleep problems, and disturbed sleep and sleep disorders contribute to earlier onset and more rapid progression of neurodegenerative disorders. Approaches to diagnosing and treating sleep disorders in the elderly are discussed.

Group cognitive-behavioral therapy in insomnia: a cross-sectional case-controlled study

BACKGROUND

Group cognitive-behavioral therapy (GCBT) might meet the considerable treatment demand of insomnia, but its effectiveness needs to be addressed.

PARTICIPANTS

This study recruited 27 insomnia patients treated with 16-weeks of zolpidem (zolpidem group), 26 patients treated with 4-weeks of zolpidem and also treated with 12-weeks of GCBT (GCBT group), and 31 healthy control volunteers.

METHODS

Before treatment and 16 weeks after intervention, participants were evaluated using the Patient Health Questionnaires (Patient Health Questionnaire-9 [PHQ-9] and Patient Health Questionnaire-15 [PHQ-15]), the Dysfunctional Beliefs and Attitudes about Sleep-16 (DBAS-16), and the Pittsburgh Sleep Quality Index (PSQI).

RESULTS

Compared to the zolpidem and healthy control groups, the scale scores of PHQ-9, PHQ-15, DBAS-16 and PSQI were significantly reduced after intervention in the GCBT group. Regarding the score changes, there were correlations between PSQI, DBAS-16, PHQ-9, and PHQ-15 scales in the zolpidem group, but there were limited correlations between PSQI and some DBAS-16 scales in the GCBT group.

CONCLUSION

Our results indicate that GCBT is effective to treat insomnia by improving sleep quality and reducing emotional and somatic disturbances; thus, the study supports the advocacy of applying group psychotherapy to the disorder.

Psychological treatment of hypnotic-dependent insomnia in a primarily older adult sample

OBJECTIVE

This study tested cognitive behavior therapy (CBT) in hypnotic-dependent, late middle-age and older adults with insomnia.

METHOD

Seventy volunteers age 50 and older were randomized to CBT plus drug withdrawal, placebo biofeedback (PL) plus drug withdrawal, or drug withdrawal (MED) only. The CBT and PL groups received eight, 45 min weekly treatment sessions. The drug withdrawal protocol comprised slow tapering monitored with about six biweekly, 30 min sessions. Assessment including polysomnography (PSG), sleep diaries, hypnotic consumption, daytime functioning questionnaires, and drug screens collected at baseline, posttreatment, and 1-year follow-up.

RESULTS

Only the CBT group showed significant sleep diary improvement, sleep onset latency significantly decreased at posttreatment. For all sleep diary measures for all groups, including MED, sleep trended to improvement from baseline to follow-up. Most PSG sleep variables did not significantly change. There were no significant between group differences in medication reduction. Compared to baseline, the three groups decreased hypnotic use at posttreatment, down 84%, and follow-up, down 66%. There was no evidence of withdrawal side-effects. Daytime functioning, including anxiety and depression, improved by posttreatment. Rigorous methodological features, including documentation of strong treatment implementation and the presence of a credible placebo, elevated the confidence due these findings.

CONCLUSIONS

Gradual drug withdrawal was associated with substantial hypnotic reduction at posttreatment and follow-up, and withdrawal side-effects were absent. When supplemented with CBT, participants accrued incremental self-reported, but not PSG, sleep benefits.

Sleep quality, depression, and quality of life in elderly hemodialysis patients

OBJECTIVE

Both the incidence and the prevalence of end-stage renal disease (ESRD) in elderly patients are increasing worldwide. Elderly ESRD patients have been found to be more prone to depression than the general population. There are many studies that have addressed the relationship between sleep quality (SQ), depression, and health related quality of life (HRQoL) in ESRD patients, but previous studies have not confirmed the association in elderly hemodialysis (HD) patients. Therefore, the aim of the present study was to demonstrate this relationship in elderly HD patients.

PATIENTS AND METHODS

Sixty-three elderly HD patients (32 females and 31 males aged between 65 and 89 years) were included in this cross-sectional study. A modified Post-Sleep Inventory (PSI), the Medical Outcomes Study 36-item short form health survey, and the Beck Depression Inventory (BDI) were applied.

RESULTS

The prevalence of poor sleepers (those with a PSI total sleep score [PSI-4 score] of 4 or higher) was 71% (45/63), and the prevalence of depression was 25% (16/63). Of the 45 poor sleepers, 15 had depression, defined as a BDI score of 17 or higher. Poor sleepers had a significantly higher rate of diabetes mellitus (P = 0.03), significantly higher total BDI scores, and lower Physical Component Scale scores (ie, lower HRQoL) than good sleepers. The PSI-4 score correlated negatively with Physical Component Scale (r = -0.500, P < 0.001) and Mental Component Scale scores (r = -0.527, P < 0.001) and it correlated positively with the BDI score (r = 0.606, P < 0.001). In multivariate analysis, independent variables of PSI-4 score were BDI score (beta value [β] = 0.350, P < 0.001), Mental Component Scale score (β = -0.291, P < 0.001), and age (β = 0.114, P = 0.035).

CONCLUSION

Poor SQ is a very common issue and is associated with both depression and lower HRQoL in elderly HD patients.

Patients' and clinicians' experiences of consultations in primary care for sleep problems and insomnia: a focus group study

BACKGROUND

Insomnia affects around one-third of adults in the UK. Many sufferers seek help from primary care.

AIM

To explore patients' and primary care practitioners' expectations, experiences, and outcomes of consultations for sleep difficulties, as a basis for improving the treatment of insomnia in primary care.

DESIGN OF STUDY

A qualitative phenomenological approach.

METHOD

Separate focus groups for GPs and nurse prescribers and patients recruited from eight general practices that were in a quality improvement collaborative. Constant comparative analysis was used.

RESULTS

Emergent themes from 14 focus groups comparing participating patients (n = 30) and practitioners (n = 15), provided insights on presentation, beliefs, expectations, and management of sleep problems. Patients initially tried to resolve insomnia themselves; consulting was often a last resort. Patients felt they needed to convince practitioners that their sleep difficulties were serious. They described insomnia in terms of the impact it was having on their life, whereas clinicians tended to focus on underlying causes. By the time patients consulted, many expected a prescription. Clinicians often assumed this was what patients wanted, and felt this would hamper patients' ability to take non-drug treatments seriously. Clinicians expected patients who were already on sleeping tablets to be resistant to stopping them, whereas patients were often open to alternatives.

CONCLUSION

Better management of insomnia should take into account the perceptions and interactions of patients and practitioners. Practitioners need to empathise, listen, elicit patients' beliefs and expectations, assess sleep better, and offer a range of treatments, including cognitive and behavioural therapies, tailored to individual needs. Practitioner education should incorporate understanding of patients' decision-making processes, the clinicians' role during the consultation, and how to negotiate and deliver strategies for resolving sleep problems.

Adolescence sleep disturbances as predictors of adulthood sleep disturbances--a cohort study

PURPOSE

The present study aimed to estimate whether sleep disturbances in adolescence predicted sleep disturbances in later years.

METHOD

Our sample included 7,781 cohort members from the United Kingdom's National Child Development Study. Sleep disturbances at ages 16, 23, 33, and 42 were measured by asking whether cohort members had difficulties in falling/maintaining sleep or waking unnecessarily early in the morning.

RESULTS

Multivariate regression analyses indicated that sleep disturbance at age 16 was a significant predictor of sleep disturbances at ages 23, 33, and 42. Continuity of a number of risk factors, especially depression, accounted for some of the persistence of sleep disturbances over time but did not explain a significant part of ongoing sleep disturbance.

CONCLUSIONS

Our findings suggest that many sleep disturbances start in adolescence and continue into later years.

A 12-week, randomized, double-blind, placebo-controlled study evaluating the effect of eszopiclone 2 mg on sleep/wake function in older adults with primary and comorbid insomnia

BACKGROUND

Longer-term pharmacologic studies for insomnia in older individuals are sparse.

OBJECTIVE

To evaluate the efficacy and safety of 12 weeks of nightly eszopiclone in elderly outpatients with insomnia.

METHODS

Participants (65-85 years) met DSM-IV-TR criteria for insomnia with total sleep times (TST) < or = 6 h, and wake time after sleep onset (WASO) > or = 45 min. Participants were randomized to 12 weeks of eszopiclone 2 mg (n = 194) or placebo (n = 194), followed by a 2-week single-blind placebo run-out. Subject-reported measures of sleep (sTST, sleep latency [sSL], sWASO) and daytime function (alertness, concentration, wellbeing, ability to function) were assessed. AEs were monitored.

RESULTS

Subjects treated with 2 mg eszopiclone slept longer at night on average and at every individual time point compared to baseline than placebo subjects, as measured by TST over the 12-week double-blind period (P < 0.0001). Mean sTST over the double-blind period for eszopiclone-treated subjects was 360.08 min compared to 297.86 min at baseline, a mean change of 63.24 min. Over the double-blind period, eszopiclone-treated subjects also experienced a significantly greater improvement in sSL compared to placebo, with a mean decrease of 24.62 min versus a mean decrease of 19.92 min, respectively (P = 0.0014). Eszopiclone subjects also experienced a significantly greater decrease in WASO (mean decrease of 36.4 min) compared to placebo subjects (decrease of 14.8 min) (P < 0.0001). Post-discontinuation, sleep parameters were statistically improved versus baseline for eszopiclone (P-values < or = 0.01), indicating no rebound. The most common AEs (> or = 5%) were headache (eszopiclone 13.9%, placebo 12.4%), unpleasant taste (12.4%, 1.5%), and nasopharyngitis (5.7%, 6.2%).

CONCLUSION

In this Phase IV trial of older adults with insomnia, eszopiclone significantly improved patient-reported sleep and daytime function relative to placebo. Improvements occurred within the first week and were maintained for 3 months, with no evidence of rebound insomnia following discontinuation. The 12 weeks of treatment were well tolerated.

CLINICAL TRIAL INFORMATION

A Long-Term Safety and Efficacy Study of Eszopiclone in Elderly Subjects With Primary Chronic Insomnia; Registration #NCT00386334; URL - http://www.clinicaltrials.gov/ct2/show/NCT00386334?term=eszopiclone&rank=24

Magic bullets for insomnia? Patients' use and experiences of newer (Z drugs) versus older (benzodiazepine) hypnotics for sleep problems in primary care

BACKGROUND

Little is known about patients' perceptions of newer hypnotics.

AIM

To investigate use, experience, and perceptions of Z drug and benzodiazepine hypnotics in the community.

DESIGN OF STUDY

Cross-sectional survey of general practice patients who had received at least one prescription for a Z drug or benzodiazepine in the previous 6 months.

SETTING

Lincolnshire, UK.

METHOD

Self-administered postal questionnaire.

RESULTS

Of 1600 surveys posted, 935 (58.4%) responses were received, of which 705 (75.4%) were from patients taking drugs for insomnia. Of those 705 patients, 87.9% (n = 620) were first prescribed a hypnotic by their GP, and 94.9% (n = 669) had taken a sleeping tablet for 4 weeks or more. At least one side effect was reported in 41.8% (n = 295); 18.6% wished to come off hypnotic medication; and 48.5% had tried to stop treatment. Patients on Z drugs were more likely to express a wish to stop (22.7% versus 12.3%; odds ratio [OR] = 1.67, 95% confidence interval [CI] = 1.13 to 2.49), or to have attempted to come off medication, than those on benzodiazepines (52.4% versus 41.0%; OR = 1.54, 95% CI = 1.12 to 2.12). The two groups did not differ significantly in respect of benefits or adverse effects.

CONCLUSION

There were no significant differences in patients' perceptions of efficacy or side-effects reported by those on Z drugs compared to patients taking benzodiazepines. Side-effects were commonly reported, which may have contributed to a high proportion of responders, particularly patients on Z drugs who were wishing to stop, or who had previously tried to stop taking this medication. Reported prescribing practices were often at variance with the licence for short-term use.

Treatment of insomnia in older adults

Insomnia outcome studies from the last 15 years show consistent success for behavioral treatment with older adults. The present review of evaluation and treatment covers the effects of aging on ability to sleep, the insomnia classification system, the treatment efficacy database, and critical outcome research methodology. Clinical trial methodology with older adults includes familiar challenges; for example, the need for placebo controls, and frequent failures to document the adequacy of treatment implementation. Recommendations for improving methodology are offered. A new review of treatment for primary insomnia in older adults shows strong improvement and consistent results for popular behavioral treatments. Older adult clinical trials show proven efficacy of behavioral treatment for primary insomnia, efficacy for secondary insomnia, and efficacy for insomnia associated with hypnotic dependency.

Factors associated with incidence and persistence of symptoms of disturbed sleep in an elderly cohort: the Cardiovascular Health Study

BACKGROUND

There are limited data pertaining to the factors influencing the incidence and persistence of sleep symptoms in the elderly. The purpose of this study was to determine the incidence and nonremission rates of the following sleep symptoms: trouble falling asleep (TFA), frequent awakenings (FA), and excessive daytime sleepiness (EDS) in the Cardiovascular Health Study (CHS), a prospective multicenter study of cardiovascular disease in a large cohort of elderly adults. Factors influencing these rates were assessed as well.

METHODS

4467 participants in CHS were surveyed for the presence of TFA, FA, and EDS as well as other health problems at their baseline examination and at a follow-up examination 1 to 4 years later.

RESULTS

Annualized incidence and nonremission rates were the following: TFA (2.8% and 15.4%), FA (12.3% and 22.7%), and EDS (4.4% and 13.4%). Women were more likely to have incident and persistent TFA. Depression was the primary factor predicting the incidence of all three sleep symptoms. However, other health conditions, including respiratory symptoms and cardiovascular disease, and limitation in activities of daily living were important as well. Depression also was the most important factor associated with persistence of these sleep symptoms. The role of other health conditions in determining nonremission was much more limited.

CONCLUSIONS

Incidence of sleep disturbances in the elderly is related to depression, health conditions, and physical functioning. However, persistence of sleep disturbances is best predicted by the presence of depression.

Insomnia in General Practice

Insomnia is an extremely common condition with major social and economic consequences worldwide. Two large epidemiological studies (Morfeo 1 and Morfeo 2) recently performed in Italy provided much-needed novel data on the impact of insomnia in patients whose primary healthcare is provided by general practitioners (GPs). These studies found that insomnia is managed relatively well by GPs in Italy, although diagnosis and treatment can be compromised because of the lack of standardised criteria. Although a number of consensus reports on insomnia have been published, these are mainly highly specific documents that are difficult to implement in general practice. To address this, a consensus group involving 695 GPs and over 60 specialists from the Italian Association of Sleep Medicine was established. The major objectives of the consensus study were to establish basic knowledge for the diagnosis and treatment of insomnia, and to produce guidelines for the management of insomnia by GPs. This is the first time that GPs have been directly involved in producing insomnia guidelines of this type, and this approach reflects their pivotal role in the diagnosis and management of this condition. Participants were carefully selected to ensure adequate representation of sleep specialists and GPs, with the group being headed by a steering committee and an advisory board. Guideline statements were selected following careful literature review and were voted on using formalised consensus procedures. This review describes current views on the diagnosis and management of insomnia from the perspective of the GP. In addition, the results of the consensus study are presented. They include recognition of the following principles: (i) insomnia is a genuine pathology that must be appropriately diagnosed and treated; (ii) when concomitant pathologies are present, additional significance should be given to treatment of insomnia since it can influence prognosis of coexistent disorders; (iii) appropriate treatment should consider the cause of insomnia as well as the characteristics of available pharmacological agents; (iv) with regard to hypnotic drugs, preference should be given to medications with a short half-life in order to limit residual effects; (v) non-benzodiazepine hypnotics are preferred to classic benzodiazepines as they have higher selectivity and present a lower risk of undesirable effects; (vi) tablets are preferable to liquid preparations as they are less likely to lead to dependence and to overdosing by the patient; and (vi) once treatment has been initiated, insomnia patients should be carefully followed up. These statements provide much needed criteria for better management of insomnia by GPs in Italy.

Sleep disorders: an overview

Although sleep disorders medicine is a relatively young discipline, understanding of the diagnosis, pathophysiology, and treatment of sleep disorders is evolving at a rapid pace. This overview discusses the history of the development of sleep disorders medicine, tracing changes in the diagnostic classification of sleep disorders as well as the role of polysomnography in diagnosis. This evolution is most evident for insomnia, one of the major sleep disturbances. The accumulation of epidemiologic data on the prevalence and temporal course of insomnia and emerging information regarding its pathophysiology derived from laboratory assessments have led to the development of new therapeutic approaches for primary insomnia and insomnia associated with medical and psychiatric disorders.

Sleepiness and sleep in elderly persons with tinnitus

The aim of this study was to evaluate the relation of tinnitus to sleep and daytime sleepiness (DS) in a group of elderly men and women. A questionnaire survey was undertaken among 10,216 elderly subjects in northern Sweden. The mean (+/-s.d.) ages of the men and women were 73.0+/-6.0 and 72.6+/-6.7 years, respectively. Tinnitus was reported by 14.9% of the men and 12.0% of the women. The relative number with tinnitus was not related to age in men, but increased with age in women. Poor sleep was reported by 14.4% of the men and 27.9% of the women. Among subjects with tinnitus poor sleep and frequent waking were more common in both sexes, while difficulties in falling asleep after awakening at night were reported more often by women. DS was more common in subjects with tinnitus and the frequency was even more increased in those with both tinnitus and poor sleep. There was no further increase in DS in men and women on sleep medication. Thus, DS in elderly persons with tinnitus may due both to tiring effect of the annoying sound itself but also the negative effect by tinnitus on sleep.

Daytime activity and risk factors for late-life insomnia

Laboratory evidence linking exercise with improved sleep quality raises the possibility that the lower levels of physical activity characteristic of older age groups may contribute to late-life insomnia. While support for this hypothesis appears to come from epidemiological surveys, few such studies have distinguished satisfactorily between social and physical activities which differ widely in terms of energy cost and theoretical significance. The present analyses were, therefore, designed to assess the independent influence of physical and social activity levels on the prevalence and natural history of late-life insomnia. Survivors from a nationally representative UK sample (n = 1042) of elderly people originally interviewed in 1985 were reassessed in 1989 (n = 690) and 1993 (n = 410). Detailed assessments of physical and social activities, mental and physical health status, and sleep quality were made at each survey wave. Logistic regression models, adjusted for age, sex and health status, were used to assess relationships between activity levels and the prevalence, remission/persistence, and incidence of late-life insomnia. Lower physical health, depressed mood and lower physical (but not social) activity levels consistently emerged as significant risk factors for prevalent, persistent and incident insomnia. Age was unrelated to insomnia variables in all the cross-sectional models, but did emerge as a significant risk for cumulative 4-8-year insomnia incidence. These findings suggest that, independent of those activities more closely associated with social engagement, higher levels of customary physical activity per se appear to be protective against incident and chronic late-life insomnia.

Common stressors experienced by the well elderly. Clinical implications

The purposes of the article are twofold--first, to report on a study that determined the 10 most commonly experienced stressors in individuals 65 years of age and older, and second, to present nursing interventions for each of the top 10 stressors. The research was conducted on a convenience sample of 200 healthy older adults living in the community using the Stokes/Gordon Stress Scale. The two most commonly experienced stressors were slowing down and concern for world conditions. Others among the top 10 were constant or recurring pain or discomfort, time too short with children or grandchildren, and wishing parts of one's life had been different. Interventions discussed included careful planning of each day's activities, joining discussion groups on world events, participating in a political campaign, using e-mail and other technological communication methods, using reminiscence therapy, and implementing the use of various complementary therapies.

Sleep Dysfunction in Alzheimer's Disease and Other Dementias

Changes in sleep architecture and circadian rhythms, including increased sleep latency and nighttime awakenings, decreased slow-wave sleep, rapid eye movement sleep, and total sleep time, and increased daytime napping are widespread in people with dementia. In addition, cyclic agitation episodes ("sundowning"), nightmares or hallucinations, sleep attacks, and nocturnal behavioral outbursts are associated with specific dementia syndromes. Sleep hygiene recommendations, particularly those aimed at reducing daytime sleep and improving the sleep environment and routine, can offset the circadian disturbances of some dementia patients. However, they can be burdensome for caregivers to implement, and must be targeted to the specific patterns of sleep disturbances patients are experiencing. Pharmacologic treatments may be useful for symptomatic treatment of insomnia and nighttime behavioral disturbances in dementia patients, but there have been few controlled trials demonstrating their efficacy or long-term safety. Clonazepam is highly effective for treating the nighttime behaviors associated with rapid eye movement behavior disorder. For most dementia patients, however, the side effect risks of prolonged use of sedating medications must be weighed against the potential benefits. Dementia patients should be evaluated for common primary sleep disorders that may contribute to nighttime behavioral disturbances and impact treatment decisions. Continuous positive airway pressure, the gold standard for treating obstructive sleep apnea, can be tolerated by mild to moderately demented individuals with support from supervising caregivers. Increased daily light exposure and physical activity may help normalize circadian rest-activity rhythms in some dementia patients, although the frequency and dose needed to maintain treatment effects is currently not known.

Predicting longer-term outcomes following psychological treatment for hypnotic-dependent chronic insomnia

OBJECTIVES

To identify predictors of treatment adherence, patient dropout, and treatment response among long-term hypnotic users recruited into a randomized controlled trial of psychological treatment for insomnia.

METHODS

Of 108 treatment and 101 control patients initially recruited, 37 treatment group patients (34.3%) failed to complete all 6 sessions (i.e., were nonadherent), while across both groups 61 (29.2%) patients failed to return postal assessments at 3-month follow-up (i.e., dropped out). Relationships between baseline characteristics and adherence (adherent vs. nonadherent) and attrition (dropout vs. nondropout) were examined in discriminant models. Relationships between baseline characteristics and treatment response (sleep quality, sleep latency, sleep efficiency, and hypnotic drug use) were examined in a series of multiple regression models.

RESULTS

Adherent patients showed a significantly greater severity of pretreatment sleep disturbance, as measured by the Pittsburgh Sleep Quality Index (PSQI). Dropout at 3 months was associated with significantly lower perceived health status at baseline. In the regression models, lower Cure/Control subscale scores from the Illness Perception Questionnaire (IPQ) predicted greater posttreatment improvements in sleep efficiency and PSQI scores, while lower baseline anxiety scores predicted a posttreatment increase in hypnotic-free nights/week.

CONCLUSION

In routine clinical practice settings, higher anxiety and a less positive attitude towards symptom control were associated with poorer treatment response. Adherence and attrition show a different pattern of associations, with greater need (as indexed by insomnia severity) predicting higher levels of service uptake and poorer general health predicting a higher likelihood of dropout.

The impact of insomnia on cognitive functioning in older adults

OBJECTIVES

To examine whether self-reported symptoms of insomnia independently increase risk of cognitive decline in older adults.

DESIGN

Longitudinal cohort study.

SETTING

The four sites of the Established Populations for Epidemiologic Studies of the Elderly.

PARTICIPANTS

Six thousand four hundred forty-four community-dwelling men and women age 65 and older who had no more than one error on the Short Portable Mental Status Questionnaire (SPMSQ) at baseline and an in-person interview at the third annual follow-up (FU3).

MEASUREMENTS

Insomnia was defined as report of trouble falling asleep or waking up too early most of the time. Cognitive decline was defined as two or more errors on the SPMSQ at FU3. Logistic regression was used to determine risk of cognitive decline associated with insomnia, controlling for demographic, behavioral, and health-related factors. Analyses were stratified by sex and depressed mood.

RESULTS

Among nondepressed men, those reporting symptoms of insomnia at both baseline and FU3 had an adjusted odds ratio (OR) of 1.49 (95% CI = 1.03-2.14) for cognitive decline, relative to those with no insomnia at FU3. Men with insomnia at FU3 only were not at increased risk (OR = 1.16, 95% CI = 0.82-1.65). These relationships were not found in women. Men and women with depressive symptoms at FU3 were at increased risk for cognitive decline independent of insomnia.

CONCLUSION

Chronic insomnia independently predicts incident cognitive decline in older men. More sensitive measures of cognitive performance may identify more subtle declines and may confirm whether insomnia is associated with cognitive decline in women.

[Prevalence of sleep disorders in the elderly]

This study was performed with senior citizens in Greater Metropolitan Guadalajara, Mexico, who live in private homes, alone, or with family. Of these, 58% of men and 76% of women showed at least one symptom of sleep disorder according to the Goldberg General Health Questionnaire, while 8.5% were positive for all survey items. According to DSM IV criteria, 33.3% could be considered "cases" of sleep disorder, and none were under any type of treatment at the time of the study. These possible cases were apparently associated with gender and educational level, but not with marital status or age. In addition, no strong association was detected with the presence of depression, established according to Brink's Geriatric Depression Scale. Given the large amount of "possible cases" found that had not been previously detected and were not in any type of ad hoc treatment, we recommend promoting updated educational courses on this topic for health professionals (mainly doctors and nurses) in such a way as to facilitate timely case detection and thus increase and improve the accessibility of mental health services for the elderly population, increasing health education activities for this age group, their caregivers, and the general population.

Age-dependent cell death in the olfactory cortex: lack of transneuronal degeneration in neonates

Adult olfactory cortical neurons in layer IIa undergo fulminant transneuronal degeneration after removal of afferent olfactory bulb fibers (Price, '76, Neurosci Abst. 2:161; Heimer and Kalil, '78, J. Comp. Neurol. 178:559-609). This provides an unusual example of dependence of a mature population of neurons on axonal input. In order to investigate whether similar transneuronal degeneration occurs in immature animals, a series of rats were subjected to unilateral olfactory bulb removal at various ages during the first 3 postnatal weeks. The brains were examined for degeneration after short survivals by use of the de Olmos cupric silver method, which selectively stains degenerating neurons. In addition, animals with long survivals were examined with the HRP retrograde tracing method, in order to determine if cells that survive the acute effects of deafferentation develop normal patterns of connections. Young neurons are more resistant to the effects of olfactory bulb removal than more mature neurons. There was little degeneration of cortical neurons after bulb ablation during the first 2 postnatal weeks. Although layer IIa does not become distinct from layer IIb in these experimental animals, cells that have connections normally characteristic of the cells of layer IIa, and are situated at the superficial edge of layer II, were identified with the HRP method. The severity of transneuronal degeneration increases and becomes adultlike between the second and third postnatal weeks. This increase in transneuronal degeneration is temporally associated with a progressive reduction in axonal sprouting following deafferentation during the first 3 postnatal weeks, as described in the companion paper (Friedman and Price, '86). Thus, axon sprouting may "protect" the immature IIa neurons from the effects of removal of the fibers from the olfactory bulb. A period of normal cell death has also been identified in olfactory cortex by the use of the de Olmos cupric silver method. This cellular degeneration is much less severe and has a different time course and laminar distribution than the transneuronal degeneration produced by olfactory bulb ablation in adults. Although normal cell death appears to be potentiated by removal of the olfactory bulb on postnatal day 1, it is clearly a different process from the transneuronal reaction.