March 23, 2011

USA: Simple Rules for Better Sleep

NEW YORK / The New York Times / Health / March 23, 2011

The New Old Age
Caring & Coping


This sounds way too good to be true: a quick, effective solution to the insomnia that plagues an estimated 15 to 30 percent of older adults — without drugs, without even needing to consult a physician.

But a University of Pittsburgh team, testing its method on 79 seniors with chronic insomnia (average age: 72), has reported very encouraging results. The treatment required just two explanatory sessions (the first lasts 45 to 60 minutes, the second about half an hour) with a nurse-practitioner, plus two brief follow-up phone calls, over the course of a month.

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Afterward, the researchers recently reported in The Archives of Internal Medicine, two-thirds of those treated reported a clearly measurable improvement in sleep, compared with 25 percent of those in a control group.

“Their total sleep time improved,” the lead author, Dr. Daniel Buysse, a psychiatry professor and sleep specialist, told me in an interview. Indeed, 55 percent of those treated no longer had insomnia at all. And six months later, three-quarters of those tested had maintained or improved their better sleep patterns.                                                 

So what was this potential wonder nondrug? That’s the interesting part. The treatment was a “brief behavioral treatment intervention” known to be an effective antidote to insomnia, as documented by extensive research for over 30 years. It’s a change in what you do, not in what you ingest. Emphasis on brief.

“If behavioral treatments are ever to become widespread, they have to be simple and quick and produce noticeable results,” Dr. Buysse explained. “If you don’t see substantial improvement in a month or so, patients’ motivation to persevere will diminish” — which often happens with behavioral treatments offered by clinical psychologists, which generally involve six to eight sessions.

So the researchers distilled those principles into four simple rules, came up with a workbook and sleep diaries to help patients follow them, and trained a nurse-practitioner to explain the regimen and the physiology behind it.

Insomnia, like other sleep disorders, can take a serious toll on seniors’ health. It’s associated with depression, with falls and fractures, with higher mortality — and its prevalence increases with age. So doctors take insomnia seriously and prescribe medications to help patients sleep.

But sedatives can create problems of their own. In older patients, sleep drugs can cause daytime drowsiness and impair memory, and they’re also associated with falls. A review of 24 studies of these “sedative hypnotics” in older people with insomnia, published in the British Medical Journal in 2005, concluded that while the drugs improved sleep, their effects were small and the hazards significant. “In people over 60, the benefits of these drugs may not justify the increased risk,” the researchers wrote.

An intervention not involving drugs would therefore be a great boon to seniors and their caregivers.

Traditionally, chronic insomnia is treated using sedatives, which can cause drowsiness and falls, resulting in death or injury. The new study offers a behavioural option, which is safe for the aged and their caregivers.

“In an ideal health care system, one would expect behavioral treatment for insomnia to be widely disseminated because of the data showing efficacy,” not to mention the cost savings from reduced drug use and fewer side effects and injuries, Thomas C. Neylan, a psychiatrist at the University of California, San Francisco, wrote in a commentary accompanying the study.

So why isn’t this method commonly prescribed? Dr. Buysse’s hypothesis: “I believe the biggest barriers are that people think the interventions are complicated and costly. So we really tried to distill the proven techniques into the simplest possible form.” The method will need testing on a larger scale, and nurses or other professionals will need training before they can help patients use it — but not a lot of training. Dr. Buysse estimates that groups of instructors can be prepared with an eight-hour course.

The idea is to stick to a schedule that maximizes your “sleep efficiency” — the amount of time in bed you spend sleeping, instead of tossing and hoping that sleep will descend. That involves four rules: Reduce the time spent in bed. Get up at the same time every day. Don’t go to bed until you feel sleepy. Don’t stay in bed if you’re not sleeping.

The nurse instructing patients in the technique uses diagrams and examples, describes the physiology involved, cautions that people may feel tired and sleep-deprived for the first few weeks but usually go on to deeper, more restful sleep that comes more quickly. Still, that’s about all that needs to be said — not much. In the study, three brochures given to the control group contained a lot of the same information, but just reading about better sleep habits didn’t do the trick.

However obvious the strategy may sound, “the reality is, people gravitate toward the exact opposite behavior,” Dr. Buysse said. “It’s common to see older adults spend 10 or 12 hours in bed in order to get five hours of sleep. It’s very frustrating.”

But it’s also frustrating to think that a potentially safe and effective answer to a widespread problem might once more fail to make its way out of an academic journal and into physicians’ offices and people’s bedrooms. Maybe it needs a jazzier name than “brief behavioral treatment intervention” — something incorporating “Medicare” and “cost-cutting.”

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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