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Behavior therapy offers best insomnia relief for seniors, study finds

Wednesday, March 17, 1999

By Anita Srikameswaran, Post-Gazette Staff Writer

When middle-aged and elderly people suffer from chronic insomnia, long-term relief can't be found in a pill bottle, a new study says.

Several weeks of behavior therapy, though, can help people put themselves to sleep even two years after the initial treatment.

Experts estimate that sleep problems keep as many as one out of four seniors awake at night because of normal brain alterations that come with aging, lifestyle changes that accompany retirement and effects from medications and diseases.

"Oftentimes, people tend to minimize the consequences of insomnia," said study leader and clinical psychologist Charles Morin, of Laval University in Quebec City. But people who don't get enough sleep can be plagued by fatigue and problems with concentration and memory.

More than 70 people who were 55 and older and had at least six months of insomnia participated in the study, which appears in today's Journal of the American Medical Association. Doctors excluded people who had medical or psychological problems that caused their sleep disturbances.

One group received just a sleeping pill, a second had just cognitive behavior therapy and a third were given medications and behavior treatment simultaneously. The last group was given a placebo.

At first, insomnia lessened within two or three weeks for all four groups.

Three months later, the researchers found that the participants were still sleeping better, except for those who had taken placebos.

But at one and two years after treatment, only people who got behavior therapy alone were still sleeping soundly. The medication benefit was gradually lost, and those who received a combination therapy had variable results, with some doing well but others significantly worse off than before.

"Our speculation is whenever you prescribe a sleep medication, whether alone or combined with behavioral intervention, you run the risk that people will attribute their initial gains to the medications," Morin explained. "When you take [the pills] away, they are at greater risk for relapse."

Behavior therapy was used to change the participants' beliefs about sleep, such as the myth that a person needs eight hours of uninterrupted sleep every night. Individual differences and aging can affect how much rest is needed.

Once those differences were taken into account, though, people were asked to maintain a strict individual sleep schedule, with emphasis on rising the same time every morning.

"Some people tend to stay in bed too long in the morning to compensate for the previous night's sleep that was poor," Morin said. "We also discouraged people from taking naps to compensate for a poor night's sleep."

Other "rules" included using the bedroom only for sleep and sex, going to bed only when sleepy, and leaving the room if the person was unable to fall asleep within 20 minutes. Bed should be associated with sleep, rather than with the anxiety of trying to sleep, the researchers said.

In an editorial accompanying the study, Drs. Charles Reynolds III, Daniel Buysse and David Kupfer, of the Sleep and Chronobiology Center at Western Psychiatric Institute and Clinic in Oakland, called the results of the drugless therapy "remarkable."

Because chronic insomnia is common, recurs frequently, and can lead to other diseases such as depression, it is important to find new strategies to manage the disease, Buysse said in an interview.

"This is really... the best carefully conducted study of behavioral treatment for insomnia," he said.

The demonstration that behavior therapy is an effective, lasting solution for insomnia sounds like a dream come true, but there is a caveat: An eight-week program run by health professionals can be expensive and time-consuming. And while psychologists have the training to do behavior therapy, not many of them are sleep experts; many physicians have sleep expertise, but are not trained to change patient behavior.

"There is something of a bind there," Buysse said. The proof it works exists, but "what we don't have is the widespread availability of this treatment."

Morin said he is studying ways to compress the therapy into a shorter time and hopes health care practitioners can be trained to provide it.

"Another study we'll be starting soon is to find a better way of integrating the drug and non-drug model," he added.

People might take a sleeping pill initially to provide immediate relief, and then, as they are taken off the medication, the behavioral techniques could get under way to provide lasting benefits.

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