A Four-Session Sleep Intervention Program Improves Sleep for Older Adult Day Health Care Participants: Results of a Randomized Controlled Trial

Sleep Disturbance, Mental Health Symptoms, and Quality of Life: A Structural Equation Model Assessing Aspects of Caregiver Burden

OBJECTIVES

The present study sought to examine the association between sleep disturbance, mental health symptoms, and quality of life among informal caregivers. The study also aimed to assess whether greater caregiver demands (i.e., hours spent providing care per week) altered the associations between these physical and mental health outcomes.

METHODS

530 informal caregivers participated in an online study of sleep and health across the lifespan. Sleep disturbance was assessed via the Insomnia Severity Index and RU-SATED. Mental health was measured using the PHQ-2, GAD-2, and the PANAS. Quality of life was assessed via the Satisfaction with Life Scale.

RESULTS

Results revealed an indirect association between sleep disturbance and quality of life via increased mental health symptoms (β = -.21, p =.001). This indirect association was moderated by caregiver demands (β =.33, p =.002), with higher caregiving demands increasing the association between sleep disturbance and quality of life.

CONCLUSIONS

Findings highlight the adverse outcomes associated with sleep disturbance among caregivers and suggest that higher caregiving demands increases the effect of sleep disturbance on quality of life.

CLINICAL IMPLICATIONS

Increased caregiving is associated with adverse physical and mental health consequences. Assessing and treating sleep disturbance among caregivers is needed and may lead to improvements in mental health and quality of life.

A game-based learning approach to sleep hygiene education: a pilot investigation

Introduction

Sleep hygiene education (SHE) consists of environmental and behavioral practices primarily intended to reduce sleep problems. Currently considered ineffective as a stand-alone treatment, the manner in which the education is typically delivered may be ineffective for the acquisition of new knowledge. The purpose of this study was to determine if a more engaging teaching medium may improve the efficacy of sleep hygiene education. This study examined the use of game-based learning to teach SHE to individuals with sleep problems.

Methods

35 participants played the SHE games for 30 days. Differences in pre- and post-state anxiety and sleep quality measures were examined.

Results

Participants had significant improvements in sleep quality and state anxiety after using the app for 30 days, although scores for the majority of patients remained elevated.

Discussion

This pilot investigation provides initial evidence for the efficacy of a game-based approach to SHE.

The feasibility of a sleep education program for informal dementia care dyads: A pilot randomized controlled trial

BACKGROUND

Untreated sleep problems in both persons living with dementia (PLWD) and their family care partners (CP) impact their health and quality of life. This pilot study tested a sleep intervention program for both dyad members.

METHODS

Thirty dyads were randomized to a 5-session Care2Sleep intervention (n = 15 dyads) or an information-only control group (n = 15 dyads) delivered in-person or by video-telehealth by trained sleep educators. Care2Sleep is a manual-based program, incorporating key components of cognitive behavioral therapy for insomnia, daily light exposure and walking, and problem-solving for dementia-related behaviors. Adherence with Care2Sleep recommendations was assessed. Sleep outcomes included actigraphy-measured sleep efficiency (SE) and total wake time (TWT) for dyads, and the Pittsburgh Sleep Quality Index (PSQI) for CP. Other outcomes for CP included the Zarit Burden Interview (ZBI) and positive aspects of caregiving (PAC). Outcomes were measured at baseline, posttreatment, and 3-month follow-up. A 2 (group) by 3 (time) mixed model analysis of variance tested treatment effects.

RESULTS

Study feasibility was demonstrated, with 13 dyads completing all five sessions of Care2Sleep program and 14 completing the control condition. In the Care2Sleep group, the dyads adhered to recommended sleep schedules of 76% for bedtime and 72% for get-up time for PLWD, and 69% for bedtime and 67% for get-up time for CP. There were several nonsignificant trends in outcomes from baseline to 3-month follow-up between the two groups. For example, SE increased by 3.2% more for PLWD and 3.2% more for CP with Care2Sleep versus control. TWT decreased by 14 min more for PLWD and 12 min more for CP with Care2Sleep versus control at the 3-month follow-up. CP in Care2Sleep also showed improvement in the PSQI, ZBI, and PAC scores.

CONCLUSIONS

A dyadic approach to sleep improvement is feasible. Larger trials are needed to test effects of this intervention for PLWD and their family CP.

CLINICALTRIALS

gov: NCT03455569.

The effectiveness of exercise interventions targeting sleep in older adults with cognitive impairment or Alzheimer's disease and related dementias (AD/ADRD): A systematic review and meta-analysis

Sleep loss is associated with reduced health and quality of life, and increased risk of Alzheimer's disease and related dementias. Up to 66% of persons with Alzheimer's disease and related dementias experience poor sleep, which can predict or accelerate the progression of cognitive decline. Exercise is a widely accessible intervention for poor sleep that can protect against functional and cognitive decline. No previous systematic reviews have investigated the effectiveness of exercise for sleep in older adults with mild cognitive impairment or Alzheimer's disease and related dementias. We systematically reviewed controlled interventional studies of exercise targeting subjectively or objectively (polysomnography/actigraphy) assessed sleep in persons with mild cognitive impairment or Alzheimer's disease and related dementias. We conducted searches in PubMed, Embase, Scopus and Cochrane-Library (n = 6745). Nineteen randomised and one non-randomised controlled interventional trials were included, representing the experiences of 3278 persons with mild cognitive impairment or Alzheimer's disease and related dementias. Ten had low-risk, nine moderate-risk, and one high-risk of bias. Six studies with subjective and eight with objective sleep outcomes were meta-analysed (random-effects model). We found moderate- to high-quality evidence for the beneficial effects of exercise on self-reported and objectively-measured sleep outcomes in persons with mild cognitive impairment or Alzheimer's disease and related dementias. However, no studies examined key potential moderators of these effects, such as sex, napping or medication use. Our results have important implications for clinical practice. Sleep may be one of the most important modifiable risk factors for a range of health conditions, including cognitive decline and the progression of Alzheimer's disease and related dementias. Given our findings, clinicians may consider adding exercise as an effective intervention or adjuvant strategy for improving sleep in older persons with mild cognitive impairment or Alzheimer's disease and related dementias.

Tailoring cognitive behavioural therapy for insomnia across contexts, conditions, and individuals: What do we know, where do we go?

Cognitive behavioural therapy for insomnia (CBT-I) is considered the front-line treatment for insomnia. Despite the demonstrated effectiveness of CBT-I, it is necessary to consider how CBT-I may be tailored to different individuals. The purpose of the present review is to provide a summary of literature on tailoring CBT-I to different individuals and provide directions for future research. This review focused on the following domains of adaptation: (i) tailoring CBT-I components to individuals with comorbid mental or physical health conditions such as comorbid depression and pain; (ii) adapting CBT-I delivery for different contexts in which individuals exist, such as inpatient, educational, and different social/cultural settings, (iii) adapting CBT-I to specific individuals via case-formulation in clinical settings. We highlight current gaps in the exploration of tailored CBT-I, including a lack of research methodology to evaluate tailored interventions, a need for the integration of ongoing individualised assessment to inform treatment, and the necessary involvement of consumers and stakeholders throughout the research and treatment development process. Together, this review showed abundant adaptations in CBT-I already exist in the literature. Future research is needed in understanding when and how to apply adaptations in CBT-I and evaluate the benefits of these adaptations.

Long-term associations between objective sleep quality and quantity and verbal memory performance in normal cognition and mild cognitive impairment

Introduction

Although the link between sleep and memory function is well established, associations between sleep macrostructure and memory function in normal cognition and Mild Cognitive Impairment remain unclear. We aimed to investigate the longitudinal associations of baseline objectively assessed sleep quality and duration, as well as time in bed, with verbal memory capacity over a 7-9 year period. Participants are a well-characterized subsample of 148 persons (mean age at baseline: 72.8 ± 6.7 years) from the Cretan Aging Cohort. Based on comprehensive neuropsychiatric and neuropsychological evaluation at baseline, participants were diagnosed with Mild Cognitive Impairment (MCI; n = 79) or found to be cognitively unimpaired (CNI; n = 69). Sleep quality/quantity was estimated from a 3-day consecutive actigraphy recording, whereas verbal memory capacity was examined using the Rey Auditory Verbal Learning Test (RAVLT) and the Greek Passage Memory Test at baseline and follow-up. Panel models were applied to the data using AMOS including several sociodemographic and clinical covariates.

Results

Sleep efficiency at baseline directly predicted subsequent memory performance in the total group (immediate passage recall: β = 0.266, p = 0.001; immediate word list recall: β = 0.172, p = 0.01; delayed passage retrieval: β = 0.214, p = 0.002) with the effects in Passage Memory reaching significance in both clinical groups. Wake after sleep onset time directly predicted follow-up immediate passage recall in the total sample (β = -0.211, p = 0.001) and in the MCI group (β = -0.235, p = 0.02). In the total sample, longer 24-h sleep duration was associated with reduced memory performance indirectly through increased sleep duration at follow-up (immediate passage recall: β = -0.045, p = 0.01; passage retention index: β = -0.051, p = 0.01; RAVLT-delayed recall: β = -0.048, p = 0.009; RAVLT-retention index:β = -0.066, p = 0.004). Similar indirect effects were found for baseline 24-h time in bed. Indirect effects of sleep duration/time in bed were found predominantly in the MCI group.

Discussion

Findings corroborate and expand previous work suggesting that poor sleep quality and long sleep duration predict worse memory function in elderly. Timely interventions to improve sleep could help prevent or delay age-related memory decline among non-demented elderly.

A comparison of sleep restriction and sleep compression on objective measures of sleep: A sub-sample from a large randomised controlled trial

Sleep restriction therapy is a central component of cognitive behavioural therapy for insomnia, but can lead to excessive sleepiness, which may impede treatment adherence. Sleep compression therapy has been suggested as a possibly gentler alternative. The aim of this study was to compare the effects of sleep restriction therapy and sleep compression therapy on objective measures of sleep, with a focus on magnitude and timing of effects. From a larger study of participants with insomnia, a sub-sample of 36 underwent polysomnographic recordings, before being randomised to either sleep restriction (n = 19) or sleep compression (n = 17) and receiving online treatment for 10 weeks. Assessments with polysomnography were also carried out after 2, 5, and 10 weeks of treatment. Data were analysed with multilevel linear mixed effect modelling. As per treatment instructions, participants in sleep restriction initially spent shorter time in bed compared with sleep compression. Participants in sleep restriction also showed an initial decrease of total sleep time, which was not seen in the sleep compression group. Both treatments led to improvements in sleep continuity variables, with a tendency for the improvements to come earlier during treatment in sleep restriction. No substantial differences were found between the two treatments 10 weeks after the treatment start. The results indicate that homeostatic sleep pressure may not be as important as a mechanism in sleep compression therapy as in sleep restriction therapy, and an investigation of other mechanisms is needed. In conclusion, the treatments led to similar changes in objective sleep at a somewhat different pace, and possibly through different mechanisms.

The evolving role of quantitative actigraphy in clinical sleep medicine

Actigraphy has a consolidated role in Insomnia and Circadian Rhythm Sleep-Wake Disorders (CRSWD) and recent studies have highlighted the use of actigraphy for narcolepsy and REM sleep behaviour disorder (RBD). This review aims at summarising the results of studies published over the last decade regarding the use of actigraphy. Thirty-five studies proved eligible, and results were analysed separately for insomnia, narcolepsy and RBD. Actigraphy showed to consistently differentiate insomnia patients from healthy controls. Furthermore, the application of advanced analytical techniques has been shown to provide both unique insights into the physiology of insomnia and sleep misperception and to improve the specificity of actigraphy in detecting wakefulness within sleep periods. Regarding narcolepsy, several studies showed that actigraphy can detect peculiar sleep/wake disruption and the effects of pharmacological treatments. Finally, although the number of studies in RBD patients is still limited, the available evidence indicates a reduced amplitude of the activity pattern, sleep-wake rhythm dysregulation and daytime sleepiness. Therefore, the potential use of these markers as predictors of phenoconversion should be further explored. In conclusion, quantitative actigraphy presents a renewed interest when considering the possibility of using actigraphy in clinical sleep medicine to diagnose, monitor, and follow sleep disorders other than CRSWD.

A low-threshold sleep intervention for improving sleep quality and well-being

BACKGROUND

Approximately one-third of the healthy population suffer from sleep problems, but only a small proportion of those affected receive professional help. Therefore, there is an urgent need for easily accessible, affordable, and efficacious sleep interventions.

OBJECTIVE

A randomized controlled study was conducted to investigate the efficacy of a low-threshold sleep intervention consisting of either (i) sleep data feedback plus sleep education or (ii) sleep data feedback alone in comparison with (iii) no intervention.

MATERIAL AND METHODS

A total of 100 employees of the University of Salzburg (age: 39.51 ± 11.43 years, range: 22-62 years) were randomly assigned to one of the three groups. During the 2-week study period, objective sleep parameters were assessed via actigraphy. In addition, an online questionnaire and a daily digital diary were used to record subjective sleep parameters, work-related factors, as well as mood and well-being. After 1 week, a personal appointment was conducted with participants of both experimental group 1 (EG1) and experimental group 2 (EG2). While the EG2 only received feedback about their sleep data from week 1, the EG1 additionally received a 45-min sleep education intervention containing sleep hygiene rules and recommendations regarding stimulus control. A waiting-list control group (CG) did not receive any feedback until the end of the study.

RESULTS

Results indicate positive effects on sleep and well-being following sleep monitoring over the course of 2 weeks and minimal intervention with a single in-person appointment including sleep data feedback. Improvements are seen in sleep quality, mood, vitality, and actigraphy-measured sleep efficiency (SE; EG1), as well as in well-being and sleep onset latency (SOL) in EG2. The inactive CG did not improve in any parameter.

CONCLUSION

Results suggest small and beneficial effects on sleep and well-being in people being continuously monitored and receiving (actigraphy-based) sleep feedback when paired with a single-time personal intervention.

Effect of Sleep Intervention Programs during Cardiac Rehabilitation on the Sleep Quality of Heart Patients

Materials and Methods

In this quasi-experimental study with unequal control group design, 35 individuals participated in the cardiac rehabilitation program as the experimental group and 35 served as the control group. The program included 12 weeks of exercise, 3 sessions per week, 3 sessions of training programs each lasting for 45 minutes, and a special two-session sleep improvement program. Data were collected using the Pittsburgh Sleep Quality Index and analysed with descriptive and inferential statistical methods.

Results

There were not any significant differences between the two groups in age, sex, marital status, smoking, and indication for cardiac rehabilitation (P > 0.05). The scores of sleep quality of patients were 9.2 ± 1.58 before and 4.40 ± 1.14 after intervention in the experimental group and 9.02 ± 2.56 before and 7.48 ± 1.86 after intervention in the control group. There was no significant difference between the two groups before intervention (P = 0.73). yet there was a significant difference after intervention (P = 0.0001). In addition, scores of sleep quality of patients were significantly different in the experimental and control groups before and after intervention (P = 0.0001).

Conclusion

Findings indicated that the quality of sleep of cardiac patients improved after the sleep intervention program during the cardiac rehabilitation program. Therefore, it is suggested to implement sleep improvement programs for cardiac patient care as an effective, easy, and feasible technique. In addition, it is necessary to pay more attention to the sleep improvement program in cardiac rehabilitation. Trial Registration. The trial was retrospectively registered on https://en.irct.ir/trial/50799 on 14 September 2020 (14.09.2020) with registration number IRCT20140307016870N6.

Posttraumatic Stress Disorder Risk and Benzodiazepine Dependence in Older Veterans with Insomnia Symptoms

OBJECTIVES

To measure the rate of benzodiazepine receptor agonist (BZA) dependence in older veterans with insomnia symptoms chronically using BZAs and to assess for associations between high posttraumatic stress disorder (PTSD) risk and BZA dependence.

METHODS

A cross-sectional study was conducted among veterans aged 55 years and older with insomnia symptoms (current or historical) and chronic use of BZAs (≥3 months). Measurements included the Primary Care-PTSD screen (score >2 indicates high PTSD risk) and Benzodiazepine Dependence Questionnaire. Logistic regression was used to test for associations between PTSD risk and BZA dependence.

RESULTS

A high PTSD risk was observed in 40% of the participants (N = 33). One-fifth (21.7%, N = 18) of participants met the criteria for benzodiazepine dependence (score ≥23 on Benzodiazepine Dependence Questionnaire). Veterans with high PTSD risk were significantly more likely to have BZA dependence (odds ratio 10.09, 95% CI [2.39, 42.54], p = .002).

CONCLUSIONS

In older veterans with insomnia symptoms and chronic use of BZAs, high PTSD risk is associated with elevated risk for BZA dependence, which may make discontinuation of these medications difficult.

CLINICAL IMPLICATIONS

Clinicians should consider the strong association between PTSD symptoms and benzodiazepine dependence when developing plans to taper a BZA in veterans with these symptoms.

Mental Health Needs of Aging Veterans: Recent Evidence and Clinical Recommendations

Objectives: Large numbers of older Americans have a history of military service, which may be positively or negatively associated with mental health in late life. We reviewed literature with the aim of better understanding the mental health needs of older Veterans.Methods: Articles included those published in 2009-2018 and focused on prevalence/risk for mental illness and suicide among older Veterans; utilization of mental health services; effectiveness of evidence-based behavioral treatments; and pertinent care delivery models.Results: Older Veterans are generally resilient. A significant minority experience mental health concerns that are associated with poor outcomes including a substantial number of suicides. Most published research is based on the approximately one third of Veterans who use the Veterans Health Administration (VHA) for care. Older Veterans with mental health diagnoses are less likely to utilize mental health services compared to younger Veterans, but as likely to benefit once engaged. Integrated care models in primary and geriatric care settings are promising.Conclusions: Aging Veterans are a large subset of Americans whose mental health needs are complex and deserve attention.Clinical Implications: Clinicians should ask about history of military service (i.e., Veteran status) and utilize available resources when providing care for older Veterans.

Development and palliative care staff reactions to a sleep regulation educational intervention

Background

In palliative care, sleep and circadian rhythm problems are common symptoms. Nonpharmacological interventions are available; however, health care providers are not aware of these or lack the knowledge to effectively implement in practice. This study reports the content and design development of the PRIME™ (Program for Improving & Managing Environments for Sleep) sleep online educational intervention as well as the evaluation of the intervention by practicing nurses with a focus on perceived acceptability and satisfaction.

Methods

Development of the education employed a multi-step process that assesses the current state of the science in this area (literature reviews), the needs of regional target recipients (hospice/palliative care staff), expert recommendations and views of a national pool of hospice/palliative workers. A cross-sectional, descriptive study with key staff informants evaluated the acceptability and usability of the modules using both scale-response items to rate the content and design of the modules and overall satisfaction and five open-response questions to suggest changes to the educational intervention.

Results

Among 31 palliative care professionals, most rated the content and design favorably. A total of 20 participants provided suggestions to improve the educational intervention. Their comments were categorized into six themes: Integration into Practice; Content, Exercises and Material Provided by Modules; User Interface and Design; and Adapt and Expand Modules for Public, Family and Caregivers.

Conclusions

The data suggest that the PRIME™ educational intervention can be an effective tool to train direct-care palliative care professionals on interventions for use in their daily practice. We also demonstrated that the educational intervention is feasible to deliver online and that the online modules appealed to respondents, suggesting that future delivery of the educational intervention can use the same or similar modes of presentation.

Sleep efficiency affecting the occurrence of falls among the frail older adults

The purpose of this study is to clarify whether reduced sleep efficiency affects the occurrence of falls among the frail older adults. This was a prospective cohort study. The subjects were frail older adult individuals living within a community, attending an older adult care center. Variables assessed include sleep efficiency, walking ability, history of cerebrovascular disease, depressive symptoms, cognitive impairment, chronic pain, frequency of sleeping medication use, and frequency of nocturnal urination. A fall calendar was used to record daily falls over a 6-month period beginning after administering a baseline survey. The Mann-Whitney U test was used to analyze the association between sleep efficiency and the occurrence of falls. Logistic regression analysis showed a significant association between falls and sleep efficiency. In conclusion, after adjusting for multiple confounders, reduced sleep efficiency did affect the occurrence of falls. Accordingly, approaches for improving sleep efficiency could offer new strategies toward fall prevention.

The Impact of Cognitive Behavioral Therapy for Insomnia on Sleep Log and Actigraphy Outcomes in People with Multiple Sclerosis: A Secondary Analysis

PURPOSE

While studies indicate cognitive behavioral therapy for insomnia (CBT-I) improves self-report sleep outcomes from questionnaires in people with multiple sclerosis (MS), it is unclear if CBT-I improves outcomes from a sleep log or sleep assessed objectively via actigraphy in people with MS. This study aimed to determine if CBT-I improves sleep log and actigraphy outcomes in individuals with MS.

PATIENTS AND METHODS

Twenty-five participants (Mage = 53.04, SD= 10.90) were included in this secondary analysis of data from a pilot randomized control study to assess the feasibility and treatment effect of CBT-I in individuals with MS. Participants were asked to maintain a sleep log and wear an actigraph for a week at baseline and post-intervention. Participants were randomized into one of three groups (CBT-I, active control, or one-time brief education control group). One-way ANOVAs were used to assess for group differences and within group change in sleep latency, sleep efficiency (SE), time in bed, total sleep time (TST), wake after sleep onset, variability of SE, and variability of TST.

RESULTS

CBT-I resulted in an increase in sleep efficiency (SE) and decrease in time in bed (TIB) and variability of SE from the sleep log. The CBT-I group also experienced a decrease in TIB and total sleep time (TST) from actigraphy. The active control group demonstrated an increase in variability of SE from actigraphy.

CONCLUSION

This study indicates that individuals with MS may experience an improvement in sleep log and actigraphy sleep outcomes following CBT-I, but findings need to be replicated in a larger prospective study. The decrease in TST from actigraphy mirrors results from prior studies.

Sleep-Based Interventions in Alzheimer's Disease: Promising Approaches from Prevention to Treatment along the Disease Trajectory

The multifactorial nature of Alzheimer’s disease (AD) has led scientific researchers to focus on the modifiable and treatable risk factors of AD. Sleep fits into this context, given the bidirectional relationship with AD confirmed by several studies over the last years. Sleep disorders appear at an early stage of AD and continue throughout the entire course of the pathology. Specifically, sleep abnormalities, such as more fragmented sleep, increase in time of awakenings, worsening of sleep quality and primary sleep disorders raise with the severity and progression of AD. Intervening on sleep, therefore, means acting both with prevention strategies in the pre-clinical phase and with treatments during the course of the disease. This review explores sleep disturbances in the different stages of AD, starting from the pre-clinical stage. Particular attention is given to the empirical evidence investigating obstructive sleep apnea (OSA) disorder and the mechanisms overlapping and sharing with AD. Next, we discuss sleep-based intervention strategies in the healthy elderly population, mild cognitive impairment (MCI) and AD patients. We mention interventions related to behavioral strategies, combination therapies, and bright light therapy, leaving extensive space for new and raising evidence on continuous positive air pressure (CPAP) treatment effectiveness. Finally, we clarify the role of NREM sleep across the AD trajectory and consider the most recent studies based on the promising results of NREM sleep enhancement, which use innovative experimental designs and techniques.

Cultural adaptations of psychological interventions for prevalent sleep disorders and sleep disturbances: A systematic review of randomized controlled trials in the United States

Psychological interventions for sleep-wake disorders have medium-to-large effect sizes, however whether behavioral randomized controlled trials (RCTs) targeted underserved populations or addressed contextual and cultural factors is unknown. We conducted a systematic review to: (a) examine sociodemographic characteristics of behavioral RCTs for prevalent sleep-wake disorders and sleep disturbances that targeted undeserved adults, (b) identify types of cultural adaptations (surface-level, deep-level), and (c) describe intervention effectiveness on primary sleep outcomes. Overall, 6.97% of RCTs (56 studies) targeted underserved groups (veterans, women, racial/ethnic minorities, low socioeconomic status, disability status); 64.29% made surface-level and/or deep-level cultural adaptations. There was a lack of racial/ethnic, socioeconomic, sexual orientation, and linguistic diversity. Most cultural adaptations were made to behavioral therapies, and cognitive behavioral therapy for insomnia (CBT-I). Surface-level cultural adaptations to the delivery modality and setting were most common. Deep-level cultural adaptations of the content and core intervention components were also typical. Intervention effectiveness varied by type of adapted intervention and participant population. RCTs of adapted CBT-I interventions among participants with a definite sleep disorder or sleep disturbance showed consistent significant reductions in adverse sleep outcomes versus control. These findings have important implications for the use of cultural adaptations to address behavioral sleep medicine disparities.

Reporting of adverse events in cognitive behavioural therapy for insomnia: A systematic examination of randomised controlled trials

Adverse events are undesirable events that can occur during medical or psychological treatment. There has been limited attention to adverse events in psychological treatment trials relative to pharmacotherapy trials. Cognitive behavioural therapy (CBTI) is the first line treatment for insomnia but studies have reported potential negative effects during acute implementation. This review aimed to understand the extent to which adverse events are monitored for and reported in the CBTI trial literature. Ninety-nine randomised controlled trials were identified for inclusion, with findings showing that 32.3% (n = 32) of studies addressed adverse events in some way, while only 7.1% (n = 7) of studies met all criteria for adequate reporting of adverse events. For studies that reported on adverse events by group, there did not appear to be consistent differences between trial arms, however the limited evidence-base coupled with marked heterogeneity in monitoring and reporting makes it difficult to draw clear conclusions at this time. We outline recommendations for the field aimed at improving prospective monitoring and reporting of adverse events in psychological/behavioural treatment trials.

Quetiapine augmentation of prolonged exposure therapy in veterans with PTSD and a history of mild traumatic brain injury: design and methodology of a pilot study

BACKGROUND

Selective serotonergic reuptake inhibitors (SSRIs) are first-line pharmacologic treatments for patients with posttraumatic stress disorder (PTSD), but must be given over extended period of time before the onset of action. The use of SSRIs in PTSD patients with mild traumatic brain injury (mTBI) is problematic since SSRIs could exacerbate post-concussion syndrome (PCS) symptoms. VA/DOD guidelines identify trauma-focused psychotherapy as the best evidence-based treatment for PTSD, but overall effectiveness is limited by reduced levels of patient engagement and retention. A previous study from this research group suggested that quetiapine monotherapy, but not risperidone or valproate, could increase engagement in trauma-focused psychotherapy.

METHODS

We report the study protocol of a pilot study funded under the South-Central Mental Illness Research, Education, and Clinical Center pilot study program from the U.S. Department of Veterans Affairs. This randomized, open-label study was designed to evaluate the feasibility of completing a randomized trial of quetiapine vs. treatment as usual to promote patient engagement in PTSD patients with a history of mTBI.

DISCUSSION

We expect that the success of this ongoing study should provide us with the preliminary data necessary to design a full-scale randomized trial. Positive efficacy results in a full- scale trial should inform new VA guidelines for clinical practice by showing that quetiapine-related improvements in patient engagement and retention may be the most effective approach to assure that VA resources achieve the best possible outcome for veterans.

TRIAL REGISTRATION

NCT04280965 .

Development of a dyadic sleep intervention for Alzheimer's disease patients and their caregivers

PURPOSE

This study aimed to refine a behavioral sleep intervention program targeting patients with Alzheimer's disease and their caregivers.

METHODS

In this case series, key components of the sleep program were built upon previous intervention studies of patients with cognitive impairment/dementia. The intervention consisted of five weekly sessions covering sleep hygiene, sleep compression, stimulus control, daily walking/light exposure, relaxation/mindfulness, and caregiver training to manage patients' behavioral problems. The materials and structure were iteratively refined based on feedback from caregivers and sleep educators. Sleep diaries were used to evaluate sleep outcomes.

RESULTS

Five out of six enrolled dyads completed the sessions. Several revisions were made during testing: the last session was changed from telephone to in-person; some components (e.g., sleep scheduling, mindfulness) were rearranged within or across sessions; sleep educator guidelines for sleep scheduling, light exposure, and walking were revised. After the fifth dyad, no additional issues were identified by the caregiver or the sleep educator. Four patients and three caregivers had improved sleep at the last session.

CONCLUSIONS

The iterative refinement process was successful in finalizing the intervention program, with evidence of sleep improvements. Formal pilot testing of the program will provide further information on feasibility and effectiveness.IMPLICATIONS FOR REHABILITATIONOur dyadic behavioral sleep program can be tailored to various types of sleep problems among patients with Alzheimer's disease and their family caregivers, with the goal of improving daytime function by reducing sleep disturbances at night.Caregiver training and participation of both members of the dyad in sleep management may benefit the patients' sleep and other health outcomes, reduce caregiver stress and burden, and ultimately delay or prevent institutionalization of Alzheimer's disease patients.

The impact of cognitive behavioural therapy for insomnia on objective sleep parameters: A meta-analysis and systematic review

It is well-established that cognitive behavioural therapy for insomnia (CBT-I) improves self-reported sleep disturbance, however the impact on objective sleep is less clear. This meta-analysis aimed to quantify the impact of multi-component CBT-I on objective measures of sleep, indexed via polysomnography (PSG) and actigraphy. Fifteen studies met inclusion criteria. Following appraisal for risk of bias, extracted data were meta-analysed using random-effects models. The quality of the literature was generally high, although reporting of methodological detail varied markedly between studies. Meta-analyses found no evidence that CBT-I reliably improves PSG-defined sleep parameters. Actigraphy evidence was more mixed; with a small effect for reduction in sleep onset latency (Hedge's g = -0.28 [95% confidence interval (CI) -0.51 to -0.05], p = 0.018) and a moderate effect for reduction in total sleep time (TST) (Hedge's g = -0.51 [95% CI -0.75 to -0.26], p < 0.001). In contrast, and consistent with recent meta-analyses, CBT-I was associated with robust improvements in diary measures of sleep initiation and maintenance (Hedge's g range = 0.50 to 0.79) but not TST. While the literature is small and still developing, the sleep benefits of CBT-I are more clearly expressed in the subjective versus objective domain.

Delivering Cognitive Behavioral Therapy for Insomnia in Military Personnel and Veterans

Insomnia is commonly reported by military populations, especially those with comorbid mental and physical health conditions. Co-occurring conditions result in an altered presentation of insomnia symptoms, and complicate provision of cognitive-behavioral therapy for insomnia (CBT-I), requiring supplementary assessment or modifications to traditional techniques. CBT-I has consistently demonstrated positive outcomes for active-duty service members and veterans, even in the context of significant comorbidities such as post-traumatic stress disorder, depression, sleep apnea, and chronic pain. Despite its promise, studies of CBT-I in some populations, including women and individuals with substance use disorders, remain relatively understudied in active-duty and veteran populations.

Partial-body cryostimulation after training improves sleep quality in professional soccer players

Objective

The aim of the present investigation was to determine whether using cryostimulation (partial-body cryostimulation) impacts sleep quality in professional soccer players. Different exposure durations at − 180 °C were tested randomly after standardized training sessions in nine professional soccer players (no cryostimulation, 180-s exposure, two 90-s exposures separated by a 5-min rest at room temperature, and 90-s exposure), and the effects on sleep quality using 3-dimensional accelerometers worn during sleep were assessed.

Results

The number of movements during the night after partial-body cryostimulation was significantly reduced only in the 180-s exposure condition (p < 0.05, very large effect size) compared with the control condition. Partial-body cryostimulation seems to induce a positive impact on sleep quality that may be dose-dependent.

Trial registration Australia and New Zealand Clinical Trials Registry (ANZCTR), ACTRN12619000330145, date of registration: 4/03/2019. Retrospectively registered

Impact Of Spinal Cord Injury On Sleep: Current Perspectives

Sleep disorders are commonly encountered in people living with spinal cord injury (SCI). Primary sleep disorders such as sleep-disordered breathing (SDB), sleep-related movement disorders, circadian rhythm sleep-wake disorders, and insomnia disorder are common conditions after SCI but remain under-recognized, underdiagnosed and therefore remain untreated for a majority of patients. Sleep disturbances in people living with SCI are associated with significant impairments of daytime function and quality of life. Previous reviews have described findings related mainly to SDB but have not examined the relationship between other sleep disorders and SCI. This narrative review examines various sleep abnormalities and related functional and physical impairments in people living with SCI. It discusses new evidence pertaining to management, highlights existing limitations in the literature and recommends future directions for research.

Psychological Interventions for Late-life Insomnia: Current and Emerging Science

Purpose of Review

Late-life insomnia is a serious medical condition associated with many untoward consequences. The high prevalence of late-life insomnia, along with the concomitant risks inherent in the use of hypnotic medications in older adults necessitates non-pharmacological (i.e., psychological) treatment options. We aim to summarize and evaluate the state-of-the-science of psychological treatment options for late-life insomnia.

Recent Findings

Cumulative scientific evidence suggests the efficacy of psychological treatment of late-life insomnia. During the previous decade, trials of psychological treatments for insomnia have begun to test various modifications to treatments that have the potential to improve access for older adults, along with expanding their focus to include individuals with comorbid conditions that are common to older adults. While these modifications represent positive advances in the science of treatment for late-life insomnia, the evidence is still largely explanatory/efficacious in nature.

Summary

Psychological strategies represent the best approaches for the treatment of late-life insomnia. Future investigations would be wise to progressively move towards increasingly pragmatic/effectiveness investigations, adding to the literature base regarding the treatment of late-life insomnia under usual/real-world conditions as opposed to ideal/artificial conditions.

Recent Developments in the Management of Insomnia in Later Life

Purpose of review

Insomnia impacts a significant proportion of older adults yet is not an inevitable consequence of aging and is amenable to intervention. The aim of this narrative review is to provide an overview of recent recommendations and empirical findings regarding the management of insomnia in older adults.

Recent findings

The treatment of insomnia with cognitive behavioral therapy for insomnia (CBT-I) continues to be empirically supported and the recommended first-line intervention for adults. Accumulating evidence indicates that other non-pharmacological therapies for insomnia, such as mindfulness-based therapies, light therapy, and physical activity interventions, as well as treatment delivered by non-clinician "sleep coaches" also positively impact insomnia symptoms. Finally, recent systematic reviews offer guidelines and recommendations for pharmacological management of insomnia.

Summary

CBT-I remains the recommended first-line treatment for insomnia across adult ages. There is a continued need to increase the availability and optimize the delivery of CBT-I and other therapies for older adults with insomnia to maximize treatment benefits. There is also evidence for some benefit of pharmacological agents to treat insomnia; however, these are not without risks, particularly in the geriatric population.

Measuring Sleep in Vulnerable Older Adults: A Comparison of Subjective and Objective Sleep Measures

OBJECTIVES

This study compared subjective (questionnaire) and objective (actigraphy) sleep assessments, and examined agreement between these methods, in vulnerable older adults participating in a Veterans Administration Adult Day Health Care (ADHC) program.

METHODS

59 ADHC participants (95% male, mean age = 78 years) completed sleep questionnaires and 72 continuous hours of wrist actigraphy. Linear regression was used to examine agreement between methods and explore discrepancies in subjective/objective measures.

RESULTS

Disturbed sleep was common, yet there was no agreement between subjective and objective sleep assessment methods. Compared with objective measures, one-half of participants reported worse sleep efficiency (SE) on questionnaires while one-quarter over-estimated SE. Participants reporting worse pain had a greater discrepancy between subjective and objective SE.

CONCLUSIONS

Vulnerable older adults demonstrated unique patterns of reporting sleep quality when comparing subjective and objective methods. Additional research is needed to better understand how vulnerable older adults evaluate sleep problems.

CLINICAL IMPLICATIONS

Objective and subjective sleep measures may represent unique and equally important constructs in this population. Clinicians should consider utilizing both objective and subjective sleep measures to identify individuals who may benefit from behavioral sleep treatments, and future research is needed to develop and validate appropriate sleep assessments for vulnerable older adults.

Sleep and Caregiving Experiences among Caregivers of Veterans in an Adult Day Health Care Program: A Pilot Study

OBJECTIVES

This pilot study explored caregivers' attitudes toward core elements of a behavioral sleep intervention for managing sleep problems of older veteran care recipients and the caregivers, as an initial step for developing a dyadic sleep intervention program.

METHODS

Five caregivers (all women; age range, 66-75 years) participated in a focus group discussion. Data were collected at one Veterans Affairs, adult day health care program.

RESULTS

Caregivers' poor sleep was not necessarily explained by their caregiving responsibility. Caregivers felt that behavioral recommendations regarding sleep compression scheduling, increased indoor physical activity, and outdoor light exposure would be acceptable sleep interventions for themselves and the care recipients. Some challenges to the sleep recommendation were identified and they included limiting naptime of care recipients and change of their current sleep schedule.

CONCLUSIONS

Caregivers are receptive to some key components of behavioral approaches to improving sleep. Tailored sleep recommendation strategy is needed to address potential challenges.

CLINICAL IMPLICATIONS

If available within clinical care settings or delivered at the patient's home, caregivers of older veterans are likely to engage in behavioral sleep intervention programs.