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CBT or Medication for Chronic Insomnia in the Elderly
Behaviorally focused treatment worked extremely well in elderly subjects.
Chronic insomnia involves sleep disturbances and daytime functional impairment, resulting in substantial individual and societal costs. It is treated infrequently although some individuals self-medicate with alcohol or over-the-counter products. Meta-analyses and direct comparisons suggest that cognitive-behavioral therapy is safer and more effective than hypnotics in young and middle-age individuals, but evidence is limited in older individuals, who are much more likely to have chronic insomnia (see JAMA 1999; 281:991). In this randomized trial conducted in Norway, 46 subjects 55 or older with severe insomnia but no associated psychopathology received six weekly sessions of CBT (focusing on sleep hygiene, sleep restriction, stimulus control, and cognitive therapy), the hypnotic zopiclone (not marketed in the U.S.), or placebo. Zopiclone recipients could continue treatment after 6 weeks.
Sleep was measured objectively and subjectively (polysomnography and sleep diaries) at 6 weeks and 6 months. At 6 weeks, reductions in total wake time were significantly greater with CBT (52%) than with medication (16%) or placebo (4%). Only the CBT group showed significantly improved sleep efficiency on polysomnography. CBT recipients had significant mean increases in slow-wave sleep; medicated patients had significant reductions. Changes in sleep efficiency and total wake time persisted at 6 months. Adherence was high to regimens overall and was 100% in the CBT group.
Comment: This small study demonstrates that nonpharmacologic, behaviorally focused treatment works extremely well in elderly subjects and increases slow-wave sleep, which some studies have associated with reports of a refreshing night’s sleep. Surprisingly, hypnotic medication was found ineffective. Numerous placebo-controlled studies show efficacy for zopiclone and for the active isomer of this racemic compound, eszopiclone (Lunesta), at a dose equivalent to that used here. The current finding could be accounted for by the small sample size, enrollment of older subjects, the assessment’s duration (4-week studies are more common), and atypical patient characteristics (e.g., motivated enough to attend all CBT sessions).
— Peter Roy-Byrne, MD
Published in Journal Watch Psychiatry July 11, 2006
Citation(s):
Sivertsen B et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: A randomized controlled trial. JAMA 2006 Jun 28; 295:2851-8.
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