"I Can't Sleep": A Better Treatment for Insomnia

"Doctor: I am having trouble sleeping."

This has got to be one of the most common complaints we here from our older patients. Older patients often feel doctors don't take their sleep problems seriously. And perhaps this criticism that doctors dont take sleep complaints seriously enough is justified. After all, insomnia has major effects on quality of life in older persons. It is incredibly anxiety provoking to lay in bed night after night and not be able to fall asleep. And the general fatigue one feels after a sleepless night is awful.

One reason health providers may downplay sleep complaints is because they few sleep problems as less serious, and more minor than the diseases on a patient's list of diagnoses. But often, insomnia may have greater effects on quality of life than the diseases on the diagnosis list.

But another reason may be the discomfort health providers feel with the medicines used to treat insomnia. In particular many providers are concerned with the side effects of these medicines. Some of them are associated with higher rates of falling and hip fracture. And while most treatments are only recommended for short term use, once started, many patients end up on sleep medicines for prolonged periods of time.

A recent study published in the Archives of Internal Medicine, led by Dr. Daniel Buysse, from the University of Pittsburgh Department of Psychiatry suggests there may be a better way to treat insomnia. The study showed that a behavioral approach that did not use drugs was very effective.

A type of behavioral intervention known as cognitive behavioral therapy has long been known to be an effective treatment for insomnia. However, few patients ever actually receive this treatment. Few providers are trained in its use, and it is too cumbersome for many patients.

This pragmatic study examined whether a simplified brief behavioral treatment would work. They designed a brief treatment that could be administered by a nurse practioner with no previous training in sleep disorders.

The intervention focused on teaching patients to avoid common habits that conspire to promote insomnia and establish habits that promote normal sleep rhythms. These were the 4 key principles that were taught to patients:

1. Reduce the amount of time spent in bed. Only stay in bed for sleep or sexual activity
2. Get up at the same time everyday, regardless of sleep duration.
3. Do not go to bed unless sleepy
4. Do not stay in bed unless asleep

Patients were given a prescription for low stimulation activities they could do while not in bed that would promote sleepiness.

79 older persons (average age of 72) were randomly assigned to either receive this treatment or receive the equivalent of usual care. The main components of the intervention were administered by the nurse practioner in a 60 minute session. To boost the effect of this session, the nurse did a follow-up phone call one week later, met with the patient for 30 minutes at 2 weeks, and phoned the patient at 3 weeks. All in all, the intervention required about 2 hours of the nurse's time. So this is a really inexpensive treatment.

But while the intervention did not cost much, the benefits were very impressive:

• After 4 weeks, 67% of patients getting treatment were significantly better. Only 25% of usual care patients were significantly better.
• After 4 weeks, 55% of patients getting treatment no longer met diagnostic criteria for insomnia. In contrast, only 13% of usual care patients no longer had insomnia.
• There was some evidence the benefits persisted for six months after the intervention. Of the patients who were examined at 6 months, 64% did not have insomnia. However, the number of patients not followed at 6 months was high. This limits the abilty to know for sure how durable the intervention was.

One interesting question posed by interventions like this is whehter they work if used by providers other than the study investigators. On the one hand, the approaches used here seem very pragmatic and easy to incorporate into clinical practice. It is easy to imagine large health systems like Kaiser or the VA implementing something like.

On the other hand, behavioral interventions such as this seem to always have a "black box." In this case, I believe the black box is the nurse who trained the patients to improve their sleep habits. It is one thing to have an intervention manual with a list of steps an intervention nurse should take. It is another thing to successfully deliver the intervention. I suspect that there was something very special about the nurse used in this study. I suspect she had a remarkable bed side manner, and an empathic approach that won the trust of her patients. This empathy and trust make it much more likely patients will successfully change their sleep habits.

This raises an important issue for both this and other behavioral interventions. In addition to describing the mechanical steps of the intervention, the studies need to tell us more about the people who delivered the intervention. It would be nice to know the qualities that made this nurse successful. In short, we also need a guide that tells us who to hire to administer the intervention.

Are we ready to recommend this program for general use? Probably not quite yet. The study was small, the exclusion criteria were too stringent, it was done at just one site, and the evidence of durability was somewhat limited. But we certainly have enough evidence to justify a large multicenter randomized trial that will provide definitive evidence. Hopefully the NIH will see the wisdom of sponsoring such a trial.

In the meantime, the study gives guidance to health providers and older patients about practical steps that can be taken to improve sleep in persons suffering from insomnia. And the study gives hope that we can effectively treat insomnia in many patients without the use of medicines.
by: Ken Covinsky