A systematic review of non-pharmacological therapies for sleep problems in later life

doi:10.1016/S1087-0792(03)00026-1

Sleep Medicine Reviews

Volume 8, Issue 1, February 2004, Pages 47-62

https://doi.org/10.1016/S1087-0792(03)00026-1 Get rights and content

Abstract

Sleep problems become more common with age, affect quality of life for individuals and their families, and can increase healthcare costs. Older people are often prescribed a range of drugs for their health problems, many of which have side effects. Side effects are just one reason why there is an argument to be made for clinical use of non-pharmacological treatments.

This review considers the effectiveness of three interventions, cognitive behavioural therapy (CBT), bright light, and physical exercise. It considers sleep quality, duration and efficiency as primary outcome measures. Randomised controlled trials were selected where 80% or more of participants were over 60 and had a diagnosis of primary insomnia and where investigators had taken care to screen participants for dementia and/or depression.

The data suggest a mild effect of CBT for sleep problems in older adults, best demonstrated for sleep maintenance insomnia. It may be that the provisions of ‘top-up’ or ‘refresher’ sessions of CBT training to improve durability of effect are worthy of investigation. Evidence of the efficacy of bright light and exercise were so limited that no conclusions about them can be reached as yet; however, in view of the promising results of bright light therapy in other populations with problems of sleep timing, further research into its effectiveness with older adults would seem justifiable. Exercise, though not appropriate for all in this population, may enhance sleep. Research involving exercise programmes designed with the elderly in mind is needed.

Section snippets

Prevalence

The prevalence of sleep problems in adulthood increases with age.1., 2., 3., 4., 5. In the general population the most common types of sleep problems reported are insomnia (both difficulties in initiating and maintaining sleep) and early morning waking with an inability to return to sleep. Older adults primarily report difficulty in maintaining sleep and, while not all sleep changes are pathological in later life, severe sleep disturbances may lead to depression (see below), cognitive

Cognitive and behavioural treatments

These aim to improve sleep by changing poor sleep habits and challenging negative thoughts, attitudes and beliefs about sleep. These strategies include a broad range of treatments, from educational packages to purely behavioural strategies, including:

•
sleep hygiene31., 32.
•
stimulus control33., 34.
•
muscle relaxation therapy35., 36., 37.
•
sleep restriction therapy38., 39.
•
and cognitive therapy for insomnia⁴⁰

Meta-analyses of these treatments with younger people41., 42. have suggested that these

Types of studies

Following work which has reported that randomized controlled trials (RCTs) tend to provide more conservative estimates of treatment effect than non-RCTs, and that the enthusiasm of researchers for their findings is often in inverse proportion, we chose only to include RCTs in this review.⁵¹ We further selected only trials where the control groups were waiting-list control groups or placebo.

Types of participants

In determining a cut-off point for age in this review, the age of 60 years was chosen as being most

Incomplete data

With the exception of the outcome of ‘loss to follow up’, we did not use data where the drop-out rate was higher than 30% as those were considered to be too prone to bias. This gave rise to the exclusion of an entire trial from the review of CBT (see Puder et al. 1983)⁶¹ which has been used elsewhere to support claims for the efficacy of non-pharmacological treatment of late-life insomnia.¹⁶

Multiple treatment arms

Where studies contained more than one eligible therapy versus a control group, the Ns, means and standard

Description of studies

Six trials met the inclusion criteria for CBT (Davies et al. 1986,⁵⁹ Lichstein et al. 2001,⁶² McCurry et al. 1998,⁶³ Morin and Azrin 1988,⁶⁴ Morin et al. 1993,⁶⁵ Morin et al. 1999a⁷) and data were requested from an unpublished dissertation⁶⁶ as well as a trial in which the mix of ages necessitates that individual patient data be obtained.⁶⁰ No trials met the criteria for bright light although clarification from investigators concerning the trial design and age of participants investigated is

Results

Most of the information below is summarised in Table 3.

The results of this review of the effects of cognitive-behavioural treatments on sleep are mixed. Total sleep duration appears to show a modest improvement at post-treatment (14.6 min CI −36.13, 7.01), which is robust (at least subjectively) at one-year follow-up. Similarly, night waking (WASO) shows a clinically important improvement (a decrease for the treatment group of 22 min (95% CI=−37.30, −6.38), although sleep onset latency (SOL, or

Methodological quality of included studies

We contacted authors of all included studies to acquire details both of the method of randomisation and that of allocation concealment, because no such information was given within the published papers. Three responses have been received (King et al. 1997,⁶⁸ Lichstein et al. 2001,⁶² McCurry 1998⁶³). The latter trials both reach adequate criteria for randomisation but pose doubt for allocation concealment, owing to the use of random numbers tables.

Drop-out rates varied from 0–29% between studies

CBT

Specific cognitive-behavioural interventions and the mode and quality of therapist delivery vary and this may, among other factors, explain the heterogeneity in the results of the review of cognitive behavioural interventions. Some research has suggested that the efficacy of CBT declines with age (McCurry et al. 1998,⁶³ Morin 1994⁴¹). Morin 1994⁴¹ also reported that sleep restriction resulted in a worsening of sleep duration at least in the short-term, or alternatively that sleep efficiency had

Limitations

There is considerable overlap between many cognitive behavioural interventions and it is therefore not possible to determine which parts of these therapies are most effective. A similar criticism of exercise may be made due to the possible confounding effects of daylight (if exercise is taken outside, as in King et al. 1997⁷²). There is also disagreement regarding mechanisms for a connection between exercise and sleep.⁴⁷ Studies did not refer to standard AASM criteria for diagnosing patients'

CBT

Overall, the results of this review suggest that cognitive-behavioural treatments for sleep problems in people aged 60 and over are mildly effective for some aspects of sleep; however, the durability of the effect of these treatments remains unproven. Moreover, it is clear that studies excluded from this review almost invariably reported more significant treatment gains than included ones (see Table 2). The lack of effect at follow-up in this review (even for those sleep variables for which CBT

Acknowledgements

The authors would like to thank Julian Higgins, Geraldine Macdonald, Harriet Montgomery, Kevin Morgan, Alex Richardson, and Megan Theodoulou. There is no potential conflict of interest on the part of the authors.

Glossary

Bias: A systematic error or deviation in results or inferences. In studies of the effects of healthcare bias can arise from systematic differences in the groups that are compared (selection bias), the care that is provided, or exposure to other factors apart from the intervention of interest (performance bias), withdrawals or exclusions of people entered into the study (attrition bias) or how outcomes are assessed (detection bias). Bias does not necessarily carry an imputation of prejudice, such

References (92)

C.M Morin et al.
Nonpharmacological treatment of late-life insomnia
J Psychosom Res
(1999)
D.F Kripke
Chronic hypnotic use: deadly risks, doubtful benefit
Sleep Med Rev
(2000)
T.D Borkovec et al.
The role of physiological attention-focusing in the relaxation treatment of sleep disturbance, general tension, and specific stress reaction
Behav Res Ther
(1978)
S.S Campbell
Exposure to light in healthy elderly subjects and Alzheimer's patients
Physiol Behav
(1988)
H.S Driver et al.
Exercise and sleep
Sleep Med Rev
(2000)
D.J Buysse
The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research
Psychiatr Res
(1989)
R Puder
Short-term stimulus control treatment of insomnia in older adults
Behav Ther
(1983)
S.-D Halpern
Prospective preference assessment: a method to enhance the ethics and efficiency of randomized controlled trials
Control Clin Trials
(2002)
Wake up America: a national sleep alert
D.L Bliwise
Sleep in normal aging and dementia
Sleep
(1993)

C.J Brabbins

Insomnia in the elderly: prevalence, gender differences and relationships with morbidity and mortality

Int J Geriatr Psychiatry

(1993)

D.J Foley

Sleep complaints among elderly persons: an epidemiologic study of three communities

Sleep

(1995)

D.E Ford et al.

Epidemiologic study of sleep disturbances and psychiatric disorders

JAMA

(1989)

C.M Morin et al.

Sleep patterns and aging: comparison of older adults with and without insomnia complaints

Psychol Aging

(1989)

C.M Morin

Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial

JAMA

(1999)

T.D Borkovec

Insomnia

J Consul Clin Psychol

(1982)

G Simon et al.

Prevalence, burden and treatment of insomnia in primary care

Am J Psychiatry

(1997)

M.K Stoller

The economic effects of insomnia

Clin Ther

(1994)

G.D Mellinger et al.

Insomnia and its treatment

Arch Gen Psychiatry

(1995)

K Morgan

Prevalence, frequency, and duration of hypnotic drug use among elderly living at home

BMJ

(1988)

Kripke, DF, Personal communication (email)....

G Stores et al.

Medical student education in sleep and its disorders

J R Coll Physicians London

(1998)

R Stores et al.

Sleep education in clinical psychology courses in the UK

Clin Psychol Forum

(1998)

D.J Kupfer et al.

Management of insomnia

N Engl J Med

(1997)

F Hohagen

Prevalence of insomnia in elderly general practice attenders and the current treatment modalities

Acta Psychiatr Scand

(1994)

L Baillargeon

Study on insomnia treatment by family physicians

Canadian Fam Physician

(1996)

P.D Nowell

Benzodiazepines and zolpidem for chronic insomnia: a meta-analysis of treatment efficacy

JAMA

(1997)

Drugs and insomnia: the use of medications to promote sleep

NIH Consens Statement

(1983)

The treatment of sleep disorders of older people

NIH Consens Statement

(1990)

P.N Prinz

Geriatrics: sleep disorders and aging

N Engl J Med

(1990)

T.J Meyer

Evaluation and management of insomnia

Hosp Pract (Off Ed)

(1998)

A Wettstein

Falls as a side-effect of drugs

Schweizerische Rundschau fur Medizin Praxis

(1992)

C Baum

Food and drug Administration

(1986)

H.Y McClusky

Efficacy of behavioral versus triazolam treatment in persistent sleep-onset insomnia

Am J Psychiatry

(1991)

J.B Milby

Effectiveness of combined triazolam-behavioral therapy for primary insomnia

Am J Psychiatry

(1993)

P.J Hauri

Can we mix behavioral therapy with hypnotics when treating insomniacs?

Sleep

(1997)

P.J.E Hauri

Case studies in insomnia

(1991)

C.F Reynolds

Subtyping DSM III-R primary insomnia: a literature review by the DSM IV work group on sleep disorders

Am J Psychiatry

(1991)

R.R Bootzin et al.

C.A Zwart et al.

An analysis of stimulus control treatment of sleep-onset insomnia

J Consult Clin Psychol

(1979)

R.L Woolfolk et al.

Relaxation treatment for insomnia: a component analysis

J Consult Clin Psychol

(1983)

E Jacobson

Progressive relaxation

(1974)

A.J Spielman et al.

Treatment of chronic insomnia by restriction of time in bed

Sleep

(1987)

L.E Miles et al.

Sleep and aging

(1980)

C.M Morin

Insomnia: psychological assessment and management

(1993)

C.M Morin et al.

Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy

Am J Psychiatry

(1994)

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CLINICAL REVIEWA systematic review of non-pharmacological therapies for sleep problems in later life

Abstract

Section snippets

Prevalence

Cognitive and behavioural treatments

Types of studies

Types of participants

Incomplete data

Multiple treatment arms

Description of studies

Results

Methodological quality of included studies

CBT

Limitations

CBT

Acknowledgements

Glossary

J Psychosom Res

Sleep Med Rev

Behav Res Ther

Physiol Behav

Sleep Med Rev

Psychiatr Res

Behav Ther

Control Clin Trials

Wake up America: a national sleep alert

Sleep in normal aging and dementia

Sleep

Insomnia in the elderly: prevalence, gender differences and relationships with morbidity and mortality

Int J Geriatr Psychiatry

Sleep complaints among elderly persons: an epidemiologic study of three communities

Sleep

Epidemiologic study of sleep disturbances and psychiatric disorders

JAMA

Sleep patterns and aging: comparison of older adults with and without insomnia complaints

Psychol Aging

Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial

JAMA

Insomnia

J Consul Clin Psychol

Prevalence, burden and treatment of insomnia in primary care

Am J Psychiatry

The economic effects of insomnia

Clin Ther

Insomnia and its treatment

Arch Gen Psychiatry

Prevalence, frequency, and duration of hypnotic drug use among elderly living at home

BMJ

Medical student education in sleep and its disorders

J R Coll Physicians London

Sleep education in clinical psychology courses in the UK

Clin Psychol Forum

Management of insomnia

N Engl J Med

Prevalence of insomnia in elderly general practice attenders and the current treatment modalities

Acta Psychiatr Scand

Study on insomnia treatment by family physicians

Canadian Fam Physician

Benzodiazepines and zolpidem for chronic insomnia: a meta-analysis of treatment efficacy

JAMA

Drugs and insomnia: the use of medications to promote sleep

NIH Consens Statement

The treatment of sleep disorders of older people

NIH Consens Statement

Geriatrics: sleep disorders and aging

N Engl J Med

Evaluation and management of insomnia

Hosp Pract (Off Ed)

Falls as a side-effect of drugs

Schweizerische Rundschau fur Medizin Praxis

Food and drug Administration

Efficacy of behavioral versus triazolam treatment in persistent sleep-onset insomnia

Am J Psychiatry

Effectiveness of combined triazolam-behavioral therapy for primary insomnia

Am J Psychiatry

Can we mix behavioral therapy with hypnotics when treating insomniacs?

Sleep

Case studies in insomnia

Subtyping DSM III-R primary insomnia: a literature review by the DSM IV work group on sleep disorders

Am J Psychiatry

CLINICAL REVIEW
A systematic review of non-pharmacological therapies for sleep problems in later life