Yeonsu Song

Cognitive Behavioral Therapy for Insomnia in Older Veterans Using Nonclinician Sleep Coaches: Randomized Controlled Trial

To test a new cognitive behavioral therapy for insomnia (CBT‐I) program designed for use by nonclinicians.

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

Study Objective To test the effectiveness of a 4‐week behavioral Sleep Intervention Program (SIP: sleep compression, modified stimulus control, and sleep hygiene) compared to a 4‐week information‐only control (IC) among older adults attending a VA Adult Day Health Care (ADHC) program in a double‐blind, randomized, clinical trial. Methods Forty‐two individuals (mean age: 77 years, 93% male) enrolled in a VA ADHC program were randomized to receive SIP or IC. All completed in‐person sleep and health assessments at baseline, post‐treatment and 4‐months follow‐up that included 3 days/nights of wrist actigraphy, the Pittsburgh Sleep Quality Index (PSQI), and the Insomnia Severity Index (ISI). Mixed repeated measures analysis was used to compare sleep outcomes at post‐treatment and 4‐months follow‐up, with baseline values as covariates. Results SIP participants (n = 21) showed significant improvement on actigraphy sleep efficiency (p = .007), number of nighttime awakenings (p = .016), and minutes awake at night (p = .001) at post‐treatment, compared to IC participants (n = 21). Benefits were slightly attenuated but remained significant at 4‐month follow‐up (all ps < .05). There were no differences in total sleep time between groups. There was significant improvement on PSQI factor 3 (daily disturbances) at 4‐month follow‐up (p = .016), but no differences were observed between SIP and IC on other PSQI components or ISI scores at post‐treatment or 4‐month follow‐up. Conclusions A short behavioral sleep intervention may have important benefits in improving objectively measured sleep in older adults participating in ADHC. Future studies are needed to study implementation of this intervention into routine clinical care within ADHC.

Cognitive expectancies for hypnotic use among older adult veterans with chronic insomnia

ABSTRACT Objectives: To examine relationships between cognitive expectancies about sleep and hypnotics and use of medications commonly used for insomnia (hypnotics). Methods: We analyzed baseline data from older veterans who met diagnostic criteria for insomnia and were enrolled in a trial comparing CBTI delivered by a supervised, sleep educator to an attention control condition (N = 159; 97% male, mean age 72 years). We classified individuals as hypnotic users (N = 23) vs. non-users (N = 135) based upon medication diaries. Associations between hypnotic status and Dysfunctional Beliefs and Attitudes about Sleep-16 (DBAS) total score (0–10, higher = worse) and two DBAS medication item scores (Item 1: “…better off taking a sleeping pill rather than having a poor night’s sleep;” Item 2: “Medication… probably the only solution to sleeplessness”; 0–10, higher = worse) were examined in logistic regression models. Results: Higher scores on the DBAS medication items (both odds ratios = 1.3; p-values < .001) were significantly associated with hypnotic use. DBAS-16 total score was not associated with hypnotic use. Conclusion: Cognitive expectancy (dysfunctional beliefs) about hypnotics was associated with hypnotic use in older adults with chronic insomnia disorder. Clinical Implications: Strategies that specifically target dysfunctional beliefs about hypnotics are needed and may impact hypnotic use in older adults.

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

ABSTRACT 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

ABSTRACT 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.

Patient-Reported Usability of Positive Airway Pressure Equipment Is Associated With Adherence in Older Adults

Study objectives To examine the usability of positive airway pressure (PAP) devices and its association with PAP adherence among older adults with sleep-disordered breathing. Methods We mailed questionnaires to patients aged ≥65 years prescribed PAP therapy during the prior 36 months from two large healthcare systems. Survey participants completed the Usability of Sleep Apnea Equipment-Positive Airway Pressure (USE-PAP) questionnaire, which assessed the usability of their PAP device. Other questionnaire items included demographics and self-rated health. We also abstracted adherence data (mean nightly hours of PAP use available from one site) and interface type from the electronic health record. Results Five hundred sixty-four patients completed the survey (response rate = 33%). The mean USE-PAP score (0 = best to 100 = worst) was 20 (SD ± 20). Mean duration of PAP use (available in 189 respondents) was 5.2 hours per night (SD ± 2.0). In a nested regression model predicting nightly hours of PAP use, a 10-point (0.5 SD) increase in USE-PAP score corresponded to a 0.37 hour/night reduction in PAP use. The model including the USE-PAP score explained a significant proportion (R2 = 15%) of the variation in nightly hours of PAP use above and beyond demographics, self-reported health, and interface type (∆R2 = 12%). Conclusions Our results demonstrate that PAP usability varies among older patients and is associated with PAP adherence, above and beyond other predictors of adherence. These results support measuring and improving PAP usability to further improve PAP adherence for older patients.

Self-reported sleep duration mitigates the association between inflammation and cognitive functioning in hospitalized older men

Examination of predictors of late-life cognitive functioning is particularly salient in at-risk older adults, such as those who have been recently hospitalized. Sleep and inflammation are independently related to late-life cognitive functioning. The potential role of sleep as a moderator of the relationship between inflammation and global cognitive functioning has not been adequately addressed. We examined the relationship between self-reported sleep duration, inflammatory markers, and general cognitive functioning in hospitalized older men. Older men (n = 135; Mean age = 72.9 ± 9.7 years) were recruited from inpatient rehabilitation units at a VA Medical Center to participate in a cross-sectional study of sleep. Participants completed the Mini-Mental State Examination and Pittsburgh Sleep Quality Index, and underwent an 8 a.m. blood draw to measure inflammatory markers [i.e., C-reactive protein (CRP), tumor necrosis factor alpha (TNFα), soluble intercellular adhesion molecule-1 (sICAM-1), and interleukin-6 (IL-6)]. Hierarchical regression analyses (controlling for age, education, race, depression, pain, health comorbidity, and BMI) revealed that higher levels of CRP and sICAM are associated with higher global cognitive functioning in older men with sleep duration ≥6 h (β = −0.19, β = −0.18, ps < 0.05, respectively), but not in those with short sleep durations (ps > 0.05). In elderly hospitalized men, sleep duration moderates the association between inflammation and cognitive functioning. These findings have implications for the clinical care of older men within medical settings.

Caregiving-Related Sleep Problems and Their Relationship to Mental Health and Daytime Function in Female Veterans

ABSTRACT Objective/Background: To identify caregiving-related sleep problems and their relationship to mental health and daytime function in female Veterans. Participants: Female Veterans (N = 1,477) from cross-sectional, nationwide, postal survey data. Methods: The survey respondent characteristics included demographics, comorbidity, physical activity, health, use of sleep medications, and history of sleep apnea. They self-identified caregiving- related sleep problems (i.e., those who had trouble sleeping because of caring for a sick adult, an infant/child, or other respondents). Patient Health Questionnaire (PHQ-4) was used to assess mental health, and daytime function was measured using 11 items of International Classification of Sleep Disorders-2 (ICSD-2). Results: Female Veterans with self-identified sleep problems due to caring for a sick adult (n = 59) experienced significantly more symptoms of depression and anxiety (p < 0.001) and impairment in daytime function (e.g., fatigue, daytime sleepiness, loss of concentration, p < 0.001) than those with self-identified sleep problems due to caring for an infant or child (n = 95) or all other respondents (n = 1,323) after controlling for the respondent characteristics. Conclusions: Healthcare providers should pay attention to assessing sleep characteristics of female Veterans with caregiving responsibilities, particularly those caregiving for a sick adult.