Sleep Discrepancy in a Randomized Controlled Trial of Brief Behavioral Therapy for Chronic Insomnia in Older Adults.

Background/Objective: Some older adults with insomnia experience sleep discrepancy, often characterized by greater subjective sleep difficulties and shorter subjective sleep duration than the estimates derived from objective measures. The present study examined whether a brief behavioral therapy for insomnia (BBTi) is efficacious for reducing sleep discrepancy in older adults. Methods: This study is a secondary analysis of a randomized controlled trial of BBTi for community dwelling older adults with chronic insomnia (N = 62). Thirty-two participants received BBTi, delivered in four individual face-to-face sessions. Thirty received the self-monitoring control (SMC). They all completed daily sleep diaries and wore an actigraph from baseline to posttreatment, and for 2 weeks at 3-month follow-up. Sleep discrepancy was calculated by subtracting diary from actigraphy estimates of sleep onset latency (SOL), wake after sleep onset (WASO), and total sleep time (TST). Mixed modeling was used to analyze data. SOL discrepancy decreased significantly in BBTi participants compared to SMC participants. The decreases in SOL discrepancy were explained by changes in diary-assessed SOL and subjective sleep quality but not changes in actigraphy-assessed SOL. Although WASO discrepancy and TST discrepancy decreased from baseline to posttreatment and follow-up, the Time by Group interaction effects were not significant indicating that BBTi participants did not experience greater reductions in WASO discrepancy and TST discrepancy than SMC participants. In conclusion, BBTi is efficacious for reducing SOL discrepancy in older adults with chronic insomnia.

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

OBJECTIVE: Behavioral treatments for insomnia improve sleep in older adults, but research documenting their effects on cognitive performance is mixed. We explored whether a brief behavioral treatment for insomnia (BBTi) impacts daily associations between sleep parameters and next day cognition. METHODS: Sixty-two older adults (Mage = 69.45 years, SD = 7.71) with insomnia completed either 4 weeks of BBTi or self-monitoring control (SMC). At baseline, post-treatment, and 3 month follow-up, participants completed 14 days of diaries measuring sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), and sleep efficiency (SE), as well as daily cognitive tests measuring processing speed (i.e., symbol digit modalities test, SDMT), and reasoning (i.e., letter series). At each time period, associations between sleep parameters and daily cognition, controlling for age, education, insomnia duration, use of sleep medications, and depression (i.e., Beck Depression Inventory-2nd Edition scores), were examined through multilevel modeling. RESULTS: At post-treatment, we observed an interactive fixed effect of treatment condition (i.e., BBTi/SMC) and TST on daily SDMT and letter series performance. For BBTi, longer TST was associated with better letter series performance, and did not predict SDMT performance. For SMC, longer TST was associated with worse SDMT, and was not associated with letter series performance. Greater WASO (regardless of group) was associated with better SDMT performance at post-treatment. Associations were not maintained at follow-up. CONCLUSIONS: Sleep duration may play an important role in BBTi-related improvements in daily higher order cognition. Maintenance of these associations may be facilitated by booster sessions following post-treatment. CLINICAL TRIAL IDENTIFIER: NCT02967185.

"Estoy viejo" [I'm old]: internalized ageism as self-referential, negative, ageist speech in the Republic of Panama.

Ageism is a form of discrimination that anyone may experience at some point in life (Palmore 2004). Yet ageism is rarely the focus of behavioral research (Nelson 2005). Age can be understood as a social construct that reflects social norms (Lemus and Exposito 2005). Based on our review of the published literature, there were two studies on perceptions of aging among Latina/os in the United States (Beyene et al. 2002; Sarkisian et al. 2006). These studies investigated perceptions and expectations of aging among older Latina/o adults rather than direct experiences of ageism. It is important to note that Latina/os are not a homogenous group and that there are within-group differences. For this reason, this study explored internalized, negative ageism specifically in the Republic of Panama. Although Panama has unique characteristics, it also reflects Central American culture and therefore should provide initial insights regarding Central American self-referential, negative, ageist talk, which we labeled "Estoy viejo." Flanagan's Critical Incident Technique was used to access and understand participants' (ages 18-65) negative ageist talk (n=159). Participants who reported engaging in "Estoy viejo." (46.3% of those sampled) were significantly younger than participants who did not (p< .05). One potential explanation is that younger participants may have been more influenced by North American culture and its strongly negative ageist stereotypes than older participants, who may have identified primarily with Central American culture.

Semantic Intrusion Error Ratio Distinguishes Between Cognitively Impaired and Cognitively Intact African American Older Adults.

BACKGROUND: Semantic intrusion errors on memory tests may represent very early cognitive changes associated with elevated Alzheimer's disease pathology within the brain, including amyloid-ß (Aß). Subscales that measure proactive semantic interference (PSI) and intrusions related to PSI on the Loewenstein Acevedo Scales of Semantic Interference and Learning (LASSI-L) have been associated with high levels of brain amyloid load, structural changes on brain MRI in Hispanic and non-Hispanic groups. It is presently unknown whether intrusion errors or other measures of the LASSI-L can differentiate between African-American (AA) older adults diagnosed with amnestic mild cognitive impairment (aMCI) or classified as cognitively normal (CN). OBJECTIVE: This study examined the extent to which a high percentage of semantic intrusion errors on LASSI-L subscales susceptible to PSI and other LASSI-L measures could differentiate between AA aMCI and CN groups. METHODS: Forty-eight AA older adults were recruited (27 CN and 21 aMCI) and received a through clinical and neuropsychological evaluation. The LASSI-L was administered independent of diagnostic classification. RESULTS: With and without statistical adjustment for literacy, AA aMCI participants scored lower on all LASSI-L measures. ROC analyses revealed an area under the curve exceeding 90% and correctly classified 86% of AA aMCI with 82% specificity for AA CN participants. CONCLUSIONS: Percentage of intrusion errors on the LASSI-L subscales susceptible to PSI differentiated AA aMCI from AA CN. This adds to emerging evidence indicating that the LASSI-L may be culturally appropriate and can differentiate between aMCI and CN in diverse ethnic/cultural groups.

Efficacy of brief behavioral treatment for insomnia in older adults: examination of sleep, mood, and cognitive outcomes.

OBJECTIVE: The aim of the present study was to examine the effects of a brief behavioral intervention for insomnia (BBTi) on sleep parameters, mood, and cognitive functioning in older adults. METHODS: Older adults (aged 65 years or more) underwent four weekly sessions of BBTi or self-monitoring control (SMC). Participants completed 14 days of sleep diaries and actigraphy measuring sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), sleep efficiency (SE), and sleep quality ratings at baseline, post-treatment, and three month follow-up. Participants also completed mood scales (Geriatric Depression Scale [GDS]; Beck Depression Inventory-II; and State Trait Anxiety Inventory) and neuropsychological testing (measuring global cognition, language, memory, attention and processing speed, and executive function) at the three timepoints. RESULTS: Significant condition (BBTi vs. SMC) x time (baseline vs. post-treatment vs. follow-up) interactions revealed that BBTi improved relative to baseline in sleep diary-reported SOL, WASO, SE, and sleep quality, and these improvements were maintained at follow-up. SMC showed no change in these measures. A main effect of time showed that actigraphy-measured WASO improved from baseline for both BBTi and SMC at post-treatment. A main effect of time revealed that both BBTi and SMC patients endorsed fewer GDS symptoms relative to baseline at post-treatment and follow-up. We observed no change in performance on neuropsychological measures. CONCLUSIONS: A four-week BBTi is an efficacious intervention for reducing insomnia symptoms in older adults. BBTi does not selectively improve mood or cognitive functioning. Future work should examine effects of BBTi on physiological measures of sleep architecture and day-to-day cognition. CLINICAL TRIAL IDENTIFER: NCT02967185.

Night-to-Night Sleep Variability in Older Adults With Chronic Insomnia: Mediators and Moderators in a Randomized Controlled Trial of Brief Behavioral Therapy (BBT-I).

STUDY OBJECTIVES: Sleep variability is a clinically significant variable in understanding and treating insomnia in older adults. The current study examined changes in sleep variability in the course of brief behavioral therapy for insomnia (BBT-I) in older adults who had chronic insomnia. Additionally, the current study examined the mediating mechanisms underlying reductions of sleep variability and the moderating effects of baseline sleep variability on treatment responsiveness. METHODS: Sixty-two elderly participants were randomly assigned to either BBT-I or self-monitoring and attention control (SMAC). Sleep was assessed by sleep diaries and actigraphy from baseline to posttreatment and at 3-month follow-up. Mixed models were used to examine changes in sleep variability (within-person standard deviations of weekly sleep parameters) and the hypothesized mediation and moderation effects. RESULTS: Variabilities in sleep diary-assessed sleep onset latency (SOL) and actigraphy-assessed total sleep time (TST) significantly decreased in BBT-I compared to SMAC (Pseudo R2 = .12, .27; P = .018, .008). These effects were mediated by reductions in bedtime and wake time variability and time in bed. Significant time × group × baseline sleep variability interactions on sleep outcomes indicated that participants who had higher baseline sleep variability were more responsive to BBT-I; their actigraphy-assessed TST, SOL, and sleep efficiency improved to a greater degree (Pseudo R2 = .15 to .66; P < .001 to .044). CONCLUSIONS: BBT-I is effective in reducing sleep variability in older adults who have chronic insomnia. Increased consistency in bedtime and wake time and decreased time in bed mediate reductions of sleep variability. Baseline sleep variability may serve as a marker of high treatment responsiveness to BBT-I. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, Identifier: NCT02967185.

Research Evaluating Brief Behavioral Sleep Treatments for Rural Elderly (RESTORE): a preliminary examination of effectiveness.

OBJECTIVE: To test the effectiveness of brief behavioral intervention for insomnia in rural elderly. METHODS: Twenty older insomniacs (> or =65 years of age) were randomly assigned to sleep hygiene education (SHE; N = 9) or multicomponent behavioral treatment (MBT; N = 11). Rural care providers individually administered treatment (two in-person sessions/two telephone follow-ups). Training involved a two-day workshop. RESULTS: At posttreatment, 10 MBT participants no longer met criteria for insomnia compared to 3 SHE participants. CONCLUSION: Brief behavioral intervention for late-life insomnia can be quickly taught and effectively delivered by "real-world" care providers in rural primary care settings.

Eszopiclone for late-life insomnia.

Insomnia, the most common sleep disturbance in later life, affects 20%-50% of older adults. Eszopiclone, a short-acting nonbenzodiazepine hypnotic agent developed for the treatment of insomnia, has been available in Europe since 1992 and in the US since 2005. Although not yet evaluated for transient insomnia in older adults, eszopiclone has been shown to be safe and efficacious for short-term treatment (2 weeks) of chronic, primary insomnia in older adults (64-91 years). Clinical studies in younger adults (mean = 44 years) have shown eszopiclone can be used for 6-12 months without evidence of problems. Because the oldest participant in these longer-term trials was 69, it not known whether eszopiclone is effective for older adults [particularly the old old (75-84 years) and oldest old (85+)] when used over longer periods. This is unfortunate, because older individuals frequently suffer from chronic insomnia. Cognitive-behavioral therapy for insomnia, which effectively targets the behavioral factors that maintain chronic insomnia, represents an attractive treatment alternative or adjuvant to eszopiclone for older adults. To date, no studies have compared eszopiclone to other hypnotic medications or to nonpharmacological interventions, such as cognitive-behavioral therapy for insomnia, in older adults. All of the clinical trials reported herein were funded by Sepracor. This paper provides an overview of the literature on eszopiclone with special emphasis on its use for the treatment of late-life insomnia. Specific topics covered include pharmacology, pharmacodynamics, pharmacokinetics, clinical trial data, adverse events, drug interactions, tolerance/dependence, and economics/cost considerations for older adults.