Insomnia and Other Sleep Disorders in Older Adults.

Sleep disruption is common in older adults and is associated with many poor health outcomes. It is vital for providers to understand insomnia and other sleep disorders in this population. This article outlines age-related changes in sleep, and medical, psychiatric, environmental, and psychosocial factors that may impact sleep. It addresses the evaluation of sleep symptoms and diagnosis of sleep disorders. It aims to examine the evidence for non-pharmacological and pharmacologic treatment options for insomnia while weighing factors particularly germane to the aging adult..

[Comparative study of effectiveness of cognitive-behavior therapy and zopiclone for chronic insomnia]. / Sravnitel'noe issledovanie éffektivnosti kognitivno-povedencheskoi terapii i zopiklona pri khronicheskoi insomnii.

Chronic insomnia is a widespread and therapy resistant sleep disorder associated with multiple diseases and worsening of its course. Cognitive-behavior therapy of insomnia (CBT-I) is a pathogenetically based method of chronic insomnia treatment. 42 patients (male 14, female 28, age from 29 to 80) matched ICSD-3 criteria of chronic insomnia participated in the crossover study including 2-week courses of treatment by CBT-I and Zopiclone. All participants underwent polysomnography. Effectiveness of treatment was evaluated by questionnaires: Insomnia severity index (ISI), Pittsburgh sleep quality index, Beck depression inventory, Disfunctional beliefs about sleep, Sleep hygiene index. Treatment with CBT-I and zopiclone produced simular improvement of sleep quality with Insomnia severity index decreased to 3,6 (from 17,7±5,3 to 12,8±5,1) and 4,9 (from 16,5±5,8 to 12,9±6,2) respectively (р<0,05) while after two weeks of stopping treatment the significant difference remained only for CBT-I comparing with zopiclone treatment (12,9±6,2 and 15,5±4,6 points by ISI respectively) (p<0,05). The use of CBT-I leads to decrease of level of depression from 11,8±6,9 to 8,5±7, Sleep hygiene index decreases from 26,9±7,5 to 23,9±5,7 and disfunctional beliefs about sleep level drops from 104,9±29,7 to 84,4±34,2 (all these differences were significant at p<0,05). Analysis of the characteristics of responders and nonresponders has shown that the mean age of the first ones was younger comparing with nonresponders (40,5±12,9 and 57,2±11,7, p<0,05 respectively) that allows us to consider young age as predictor of CBT-I effectiveness. Treatment of chronic insomnia by CBT-I has simular efficacy as pharmacotherapy, but additionally it leads to the emprovement of emotional state and its therapeutistic effects after discontinuation lasts longer.

Improved sleep quality in older adults with insomnia reduces biomarkers of disease risk: pilot results from a randomized controlled comparative efficacy trial.

IMPORTANCE: Sleep disturbances have been linked to increased morbidity and mortality, yet it is unknown whether improving sleep quality in older adult patients with insomnia alters biomarkers of diabetes and cardiovascular disease risk. OBJECTIVE: Determine the comparative efficacy of cognitive behavioral therapy (CBT), tai chi chih (TCC), and a sleep seminar control (SS) to reduce multisystem biomarkers of disease risk in older adults with insomnia. DESIGN: Randomized controlled comparative efficacy trial. SETTING: Los Angeles community. PARTICIPANTS: A population-based sample of 109 older adults with chronic and primary insomnia. INTERVENTION: Random assignment to CBT, TCC, or SS for 2-h group sessions weekly over 4 months with a 16-month evaluation (1 year after follow-up). MAIN OUTCOME(S) AND MEASURE(S): Multisystem biological risk comprised of 8 biomarkers: high-density lipoprotein, low-density lipoprotein, triglycerides, hemoglobinA1c, glucose, insulin, C-reactive protein, and fibrinogen. Using clinical laboratory cutoffs defined as abnormal, a multisystem risk score was computed representing a sum of the deviation around the cutoffs across the 8 biomarkers. In addition, high risk grouping was classified if subjects exhibited 4 or more biomarkers in the abnormal laboratory range. RESULTS: An interaction of time-by-treatment-by-high risk group was found (F(4, 197.2)=3.14, p=.02) in which both TCC (p=.04) and CBT (p=.001) showed significantly lower risk scores as compared to SS at 16-months. CBT reduced risk of being in the high risk group at 4-months (odds ratio [OR]=.21 [95% CI, .03-1.47], p<.10) and at 16-months (OR=.06 [95% CI, .005-.669]; p<.01). TCC reduced the risk at 16-months (OR=.10 [95% CI, .008-1.29]; p<.05) but not at 4 months. Of participants who were classified in the high risk category at baseline, improvements in sleep quality, as defined by a clinical severity threshold, reduced the likelihood of being in the high risk group at 16-months, OR=.08 (95% CI, .008-.78); p=.01. CONCLUSIONS AND RELEVANCE: Participants classified as having high multisystem biological risk at entry and assigned to CBT or TCC show improvements in risk scores after one year follow-up. Given that these clinical biomarkers are associated with cardiovascular, metabolic, and inflammatory disease risk, improving sleep quality has the potential to reduce the risk of chronic disease in older adults with insomnia. Clinical Trial Registration # and name­ClinicalTrials.gov: NCT00280020, Behavioral Treatment of Insomnia in Aging

New guidelines for diagnosis and treatment of insomnia / Novas diretrizes no diagnóstico e tratamento das insônias

The Brazilian Sleep Association brought together specialists in sleep medicine, in order to develop new guidelines on the diagnosis and treatment of insomnias. The following subjects were discussed: concepts, clinical and psychosocial evaluations, recommendations for polysomnography, pharmacological treatment, behavioral and cognitive therapy, comorbidities and insomnia in children. Four levels of evidence were envisaged: standard, recommended, optional and not recommended. For diagnosing of insomnia, psychosocial and polysomnographic investigation were recommended. For non-pharmacological treatment, cognitive behavioral treatment was considered to be standard, while for pharmacological treatment, zolpidem was indicated as the standard drug because of its hypnotic profile, while zopiclone, trazodone and doxepin were recommended.

A Associação Brasileira de Sono reuniu especialistas em medicina do sono com o objetivo de desenvolver novas diretrizes no diagnóstico e tratamento das insônias. Nós consideramos quatro níveis de evidência: padrão, recomendado, opcional e não recomendado. Os tópicos abordados foram: conceito, avaliação clínica e psicossocial, indicação da polissonografia, tratamento farmacológico, terapia comportamental cognitiva, comorbidades e insônia na infância. Para o diagnóstico da insônia, foi recomendada uma avaliação psicossocial e a realização da polissonografia, enquanto que no que se refere ao tratamento, foi estabelecido como padrão a indicação da terapia comportamental cognitiva, e, quanto ao tratamento farmacológico, foi indicado o uso do zolpidem como hipnótico padrão, e sendo recomendado o zopiclone, a trazodona e a doxepina.