We Can Help our Seniors Sleep Better Without Dangerous Pills
Abstract & Commentary
By Joseph E. Scherger, MD, MPH, Vice President, Primary Care, Eisenhower Medical Center, Clinical Professor, Keck School of Medicine, University of Southern California. Dr. Scherger reports no financial relationships relevant to this field of study.
Synopsis: A brief amount of face-to-face and telephone counseling helps seniors sleep better without prescription medications. Direct counseling is superior to giving reading materials.
Source: Buysse DJ, et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med 2011;171:887-895.
Any primary care physician treating seniors has patients asking for various pills for sleep. Most of these are sedatives or hypnotics that are on the danger list for seniors due to increased falls and mental health complications. Seniors are often insistent to get these prescriptions in order to get a good night's sleep. We make other suggestions for better sleep but usually these fall on deaf ears.
In this encouraging study, 79 seniors with chronic insomnia were recruited from one primary care clinic and the community to participate in a randomized trial of brief behavior therapy or receiving reading materials to improve their sleep. The seniors were willing to keep a sleep diary and have in-home polysomnography. They were randomly assigned to receive two brief sessions with a nurse practitioner with no special training in cognitive behavior therapy to discuss methods for better sleep, and received two follow-up phone calls. The other group received reading materials that discussed better sleep methods and received one follow-up phone call.
After 4 weeks, 55% of the brief therapy group reported "no insomnia" compared with 13% of the reading group. Sixty-seven percent of the brief therapy group had a positive response to the treatment compared with 25% of the reading group. There was no change in the polysomnography. These improvements were maintained after 6 months.
This study group is part of the Sleep Medicine Institute in the Department of Psychiatry at the University of Pittsburgh. The authors believe that the face-to-face intervention made the difference in treatment, giving patients time and instruction. No special therapy was required for the results. Obviously, a major limitation of the study was that the patients were motivated to enroll in such a study. The study did not focus on any change in use of medications, and there was no difference between the two study groups on medication use.
Getting seniors off sleeping pills and avoiding them in the first place takes special effort and I work on it diligently with some success. We teach children how to go to sleep, a challenge of early parenting, but it seems that adults and seniors often forget how to fall asleep effectively. They have trouble disconnecting their current troubles from their mind and going to a place that is hypnotic. Declining melatonin levels with age may also play a role in decreased sleep for many seniors.
Behavioral treatment for chronic insomnia has a long research history.1 This study shows that a modest amount of effort is effective in helping seniors overcome insomnia and sleep better. No special training is required attention, good advice, and follow-up is all that's needed. Personally, I am fairly liberal with the use of melatonin as an optional sleep aid to go along with this counseling. I explain to seniors about the pineal gland that secretes melatonin and how it often calcifies with age with decreased melatonin levels. Melatonin is not a "knock-out" pill, but if taken 30 minutes or more before sleep in an effective dose (usually 5-6 mg), it helps the senior struggling to sleep to do so more effectively, for 6 hours or longer.
Sleep is important for cognitive function, cardiac health, and patient safety, just to mention a few of its many benefits. I've heard sleep described as the "third pillar" of a healthy lifestyle along with nutrition and physical activity. Focusing effectively on healthy sleep for our patients is of major importance to primary care, and this study provides a good way for us to do that.
1. Irwin MR, et al. Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age. Health Psychol 2006;25:3-14.