Interv C-c Trast Del Sueño en Adultos Mayores 60 Años

Cognitive behavioural interventions for sleep problems in

adults aged 60+ (Review)

Montgomery P, Dennis JA

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library

2009, Issue 1

http://www.thecochranelibrary.com

Cognitive behavioural interventions for sleep problems in adults aged 60+ (Review)

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 1.1. Comparison 1 Sleep quality: cognitive-behavioural therapy vs. no-treatment control or placebo, Outcome 1

Sleep onset latency (SOL) as reported in participants’ diaries. . . . . . . . . . . . . . . . . . 25


Sleep onset latency (SOL) as measured by polysomnography. . . . . . . . . . . . . . . . . . 26


Wake after sleep onset (WASO) as reported in participants’ diaries. . . . . . . . . . . . . . . . 27


Wake after sleep onset (WASO) as measured by polysomnography. . . . . . . . . . . . . . . . 28


Total wake time (TWT) as reported in participants’ diaries. . . . . . . . . . . . . . . . . . . 29


Total wake time (TWT) as measured by polysomnography. . . . . . . . . . . . . . . . . . . 30


Sleep duration (total, in minutes) as reported in participants’ diaries. . . . . . . . . . . . . . . . 31


Sleep duration (total, in minutes) as measured by polysomnography. . . . . . . . . . . . . . . . 32


Early morning wakening (as defined by trialist) as reported in participants’ diaries. . . . . . . . . . . 33

Analysis 1.10. Comparison 1 Sleep quality: cognitive-behavioural therapy vs. no-treatment control or placebo, Outcome

10 Early morning wakening (as defined by trialist) as measured by polysomnography. . . . . . . . . . 34


11 Sleep efficiency (ratio of time asleep/ time in bed) as reported in participants’ diaries. . . . . . . . . 35


12 Sleep efficiency (ratio of time asleep/ time in bed) as measured by polysomnography. . . . . . . . . 36


13 Pittsburgh Sleep Quality Index (PSQI) -- global score. . . . . . . . . . . . . . . . . . . . 37

37APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iCognitive behavioural interventions for sleep problems in adults aged 60+ (Review)


[Intervention Review]

Cognitive behavioural interventions for sleep problems inadults aged 60+

Paul Montgomery1 , Jane A Dennis2

1The Centre for Evidence-Based Intervention, University of Oxford, Oxford, UK. 2School for Policy Studies, University of Bristol,

Bristol, UK

Contact address: Paul Montgomery, The Centre for Evidence-Based Intervention, University of Oxford, Barnett House, 32 Wellington

Square, Oxford, OX1 2ER, UK. [email protected].

Editorial group: Cochrane Developmental, Psychosocial and Learning Problems Group.

Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009.

Review content assessed as up-to-date: 2 February 2002.

Citation: Montgomery P, Dennis JA. Cognitive behavioural interventions for sleep problems in adults aged 60+. Cochrane Database

of Systematic Reviews 2003, Issue 1. Art. No.: CD003161. DOI: 10.1002/14651858.CD003161.


A B S T R A C T

Background

The prevalence of sleep problems in adulthood increases with age. While not all sleep changes are pathological in later life, severe

disturbances may lead to depression, cognitive impairments, deterioration of quality of life, significant stresses for carers and increased

healthcare costs. The most common treatment for sleep disorders (particularly insomnia) is pharmacological. The efficacy of non-drug

interventions has been suggested to be slower than pharmacological methods, but with no risk of drug-related tolerance or dependency.

Cognitive and behavioural treatments for sleep problems aim to improve sleep by changing poor sleep habits, promoting better sleep

hygiene practices and by challenging negative thoughts, attitudes and beliefs about sleep.

Objectives

To assess the efficacy of cognitive-behavioural interventions in improving sleep quality, duration and efficiency amongst older adults

(aged 60 and above).

Search methods

The following databases were searched: The Cochrane Library (Issue 1, 2002); MEDLINE (1966 - January 2002); EMBASE (1980

- January 2002), CINAHL (1982 - January 2002); PsycINFO (1887 to 2002); National Research Register (NRR) (2002, Issue 1 .

Bibliographies of existing reviews in the area, as well as of all trial reports obtained, were searched. Experts in the field were consulted.

Selection criteria

Randomised controlled trials of cognitive behavioural treatments for primary insomnia where 80% or more of participants were over

60. Participants must have been screened to exclude those with dementia and/or depression.

Data collection and analysis

Abstracts of studies identified in searches of electronic databases were read and assessed to determine whether they might meet the

inclusion criteria. Data were analysed separately depending on whether results had been obtained subjectively or objectively.

1Cognitive behavioural interventions for sleep problems in adults aged 60+ (Review)


mailto:[email protected]

Main results

Six trials, including 282 participants with insomnia, examined the effectiveness of cognitive-behavioural treatments (CBT) for sleep

problems in this population. The final total of participants included in the meta-analysis was 224. The data suggest a mild effect of

CBT for sleep problems in older adults, best demonstrated for sleep maintenance insomnia.

Authors’ conclusions

When the possible side-effects of standard treatment (hypnotics) are considered, there is an argument to be made for clinical use of

cognitive-behavioural treatments. Research is needed to establish the likely predictors of success with such treatments. As it may well be

the case that the treatment efficacy of cognitive-behavioural therapy itself is not durable, the provision of “top-up” (“refresher” sessions

of CBT training to improve durability of effect are worthy of investigation.

P L A I N L A N G U A G E S U M M A R Y

Cognitive behavioural therapy for older adults (aged 60+) with sleep problems

Sleep problems become more common with age, affect quality of life for individuals and their families, and can increase healthcare costs.

Older people are often prescribed a range of drugs for their health problems (including with sleep) many of which have side effects.

This review considered the effectiveness of cognitive and behavioural treatments (CBT). These aim to improve sleep by changing poor

sleep habits and by challenging negative thoughts, attitudes and beliefs about sleep. Reviewers report that there is only limited evidence

available, and what data there is suggests a mild effect of CBT.

B A C K G R O U N D

Description of the condition

The prevalence of sleep problems in adulthood increases with age

(Brabbins 1993; National Commission on Sleep Disorders Re-

search (NCSDR 1993); Bliwise 1993; Foley 1995; Ford 1989). In

the general population the most common types of sleep problems

reported are insomnia (both difficulties in initiating and maintain-

ing sleep) and early morning waking with an inability to return

to sleep. Older adults primarily report difficulty in maintaining

sleep and, while not all sleep changes are pathological in later life

(Morin 1989; Bliwise 1993), severe sleep disturbances may lead to

depression and cognitive impairments (Ford 1989). Night waking

produces significant stresses for carers and is a common cause for

demands that institutional living arrangements be made (Pollak

1990).

Prevalence rates of insomnia in people aged 65 and over range

between 12 and 40% (Morin 1999b). There are reports that the

impact of chronic sleep disturbance impairs waking functions

(e.g. mood, energy, performance) and life quality (Borkovec 1982;

Morin 1989). There is evidence that sleep disturbances contribute

significantly to healthcare costs (Stoller 1994; Simon 1997). Over-

all, the aetiology of sleep problems in the elderly remains uncer-

tain. There may be a developmental perspective to sleep in this

population as the question of whether older adults need less sleep

has not yet been answered (Bliwise 1993). Prevalence rates of in-

somnia are even higher when co-existing medical or psychiatric ill-

ness is taken into account (Ford 1989; Mellinger 1995). Lifestyle

changes related to retirement, the increased incidence of health

problems, and the use of medication, all place older people at in-

creased risk of disrupted sleep (Morgan 1988).

The relationship between sleep problems and depression in the el-

derly is particularly strong, but difficult to disentangle. It has been

reported in a large study by Ford and Kamerow that depression

can predict future sleep disturbance, and that unremitting insom-

nia can itself cause depression (Ford 1989). However, amongst the

eight symptoms of major depressive disorder which may predict

development of the full syndrome, sleep disturbance is not the

most predictive. Sleep disturbances may also be comorbid with

impending dementia, but that does not mean they are the cause.

Alzheimer-related deterioration of suprachiasmatic nucleus neu-

rons could cause comorbid sleep disturbance in sleep-wake cycle

disorders in particular (Kripke 2001). Despite the high prevalence

of sleep disorders and their negative impact, it is estimated that

fewer than 15% of patients with chronic insomnia receive treat-

ment (Mellinger 1995). This may be due to a lack of knowledge

about sleep and its disorders amongst health professionals. It is



reported that the median amount of time spent on sleep issues in

medical training in the UK is five minutes (Stores 1998) and that

in clinical psychology it is no better (Wiggs 1996).

The most common treatments for sleep disorders are pharmaco-

logical, particularly for insomnia (Hohagen 1994; Kupfer 1997;

Morin 1999b). Lack of knowledge about non-drug treatment and

limited access to other forms of professional help are cited by physi-

cians as the main reason for prescribing sleeping pills (Baillargeon

1996); however, the long-term efficacy of this approach, which

usually involves the administration of hypnotics (typically benzo-

diazepines) is not certain. Two consensus conferences sponsored

by the National Institute of Health (NIH 1983; NIH 1990) con-

cluded that short-term use of hypnotic medications may be useful

for acute and situational insomnia across all age groups, but that

long-term use remains controversial because of the potential risk

of tolerance and dependency. The same NIH studies indicate that

the drug of choice for the symptomatic treatment of insomnia is a

benzodiazepine receptor agonist (e.g. temazepam, zolpidem etc).

One study by Nowell et al found that these drugs improve sleep

latency (the time between going to bed and going to sleep), num-

ber of awakenings, total sleep time and total sleep quality (Nowell

1997). Post-treatment problems were not adequately investigated,

as follow-up in this study only extended to one to two nights fol-

lowing discontinuation of the drug’s administration. Other drugs,

e.g. zaleplon, one of the most popular current benzodiazepine ag-

onists, do not even significantly increase total sleep time. Ulti-

mately, both consensus conferences clearly recommended against

long term use of hypnotics.

It has been reported that older people are more likely to be af-

fected by daytime residual effects of these types of drugs (Morgan

1988; Prinz 1990; Kripke 2000); that these drugs may increase the

likelihood of patients developing sleep apnoea (Kripke 1983), as

well as increasing the risk for falls and fractures (Wettstein 1992;

Meyer 1998). Constipation has been correlated positively with

hypnotic use (Campbell 1993). Despite this, data have suggested

that persons over 60 years of age in the USA are prescribed seda-

tive-hypnotic drugs at more than twice the rate of people 40-59

years of age (Baum et al 1986). Survey data suggest that older

adults in France, Italy, Germany and Canada are even more likely

to use hypnotics than Americans (Morin 1999b). The effects of

non-drug interventions has been suggested to be slower but more

durable than pharmacological methods (McClusky 1991;Milby

1993; Hauri 1997). In view of the potential risks of tolerance and

dependency and the frequently high numbers of other drugs that

older people may be taking, an evidence-based non-drug approach

would be of interest.

Description of the intervention

This is the first of four interrelated reviews investigating non-drug

treatments for sleep problems in the older adult. In addition to the

present review on cognitive behavioural treatments, subsequent re-

views will cover physical treatments (Montgomery 2002b), bright

light therapy (Montgomery 2002a) and hypnosis. A paper sum-

mary review will set out the evidence for the full range of non-

drug treatments in an effort to answer the clinical question “What

alternatives to medication exist for sleep problems in the older

adult? ”

Cognitive and behavioural treatments for sleep problems aim to

improve sleep by:

1. changing poor sleep habits

2. challenging negative thoughts attitudes and beliefs about sleep

Cognitive-behavioural interventions include a broad range of

treatments, from educational packages to purely behavioural

strategies. Those included within this review are:

Sleep Hygiene Education

Sleep hygiene education aims to teach individuals about the im-

pact of lifestyle habits such as diet, exercise and drug use and the

influence of environmental factors e.g. light, noise and temper-

ature (Hauri 1991). While these issues are unlikely to cause in-

somnia (Reynolds 1991) they may well exacerbate it. Studies gen-

erally advocate (1) the avoidance of caffeine and nicotine (both

stimulants) in the 6 hours before bed; (2) the avoidance of alcohol

around bedtime (alcohol may facilitate sleep onset but it tends to

cause fragmentation of sleep and nightmares); (3) the avoidance of

a heavy meal before sleep (although a light meal may be helpful);

(4) the avoidance of exercise close to bed-time (even though in

general exercise is helpful for sleep); and (5) the minimisation of

noise, light and excessive heat during the sleep period. Sleep hy-

giene also includes information concerning age-appropriate sleep

duration to ensure realistic expectations.

Stimulus Control

Stimulus control (Bootzin 1991) involves a set of instructions

aimed at helping the individual to re-associate the bed, bedtime

and bedtime stimuli with sleep rather than with the frustration

or anxiety resulting from lying in bed trying to sleep. Participants

are instructed to (1) only go to bed when sleepy; (2) only to use

the bed for sleeping and sex; (3) to leave the bed if they have not

gone to sleep within 15-20 minutes and to go back only when

feeling sleepy again, to be repeated as often as necessary through

the night; (4) to get up at the same time each morning regardless

of the amount of sleep achieved in the previous night; and (5)

not to sleep during the day. “Countercontrol treatment” (Zwart

1979) can be seen as a version of stimulus control. It was designed

to “disrupt sleep-incompatible activities” but omitted introducing

other features of classical stimulus control, e.g. leaving the bed.

Muscle Relaxation Therapy



Relaxation therapy consists of alternating tension and relaxation

of various muscle groups in sequence (Woolfolk 1983). “The Pro-

gressive Muscle Relaxation technique” as devised by Edmund Ja-

cobson involved systematic training in tensing and relaxing groups

of muscles, first separately, then with the aim of relaxing the whole

body at once (Jacobson 1974). Some studies have added imagery

to the relaxation (Borkovec 1978).

Sleep Restriction Therapy

A common treatment is sleep restriction therapy (Spielman 1987).

This method limits the time spent in bed at night and restricts

sleep during the day. Participants estimate an allowable time in bed

from the diaries kept over the previous two weeks. For example

if a person spends eight hours in bed and only actually sleeps

for six of them, their allowed time in bed would be six hours.

Weekly adjustments are made to this amount by looking at the

individual’s sleep efficiency (ratio of total sleep time to time spent

in bed). When sleep efficiency reaches 90%, the time allowed in

bed increases by 15-20 minutes. These adjustments continue until

the expected optimal amount of sleep time is reached. The urge to

sleep will be increased during each stage of the treatment and in

this way it is thought to increase the homeostatic drive for sleep.

This type of treatment is considered likely to be effective with

older people, many of whom may have tried to compensate for

their poor sleep by spending more time in bed (Miles 1980).

How the intervention might work

Cognitive therapy for insomnia (Morin 1993) consists of identi-

fying, challenging and altering a set of dysfunctional belief and

attitudes about sleep and its impact on day-to-day life. It encom-

passes many aspects of the above treatments. The object is to break

the vicious cycle of insomnia; dysfunctional cognitions and emo-

tional distress that leads to further sleep disturbance. For example,

commonly misplaced beliefs include “I cannot function unless I

sleep for 8 hours per night” and “if I try harder I will eventually

fall asleep”.

Why it is important to do this review

Meta-analyses of these treatments with younger people (Morin

1994; Murtagh 1995) have suggested that these interventions im-

prove sleep in 70-80% of such people with insomnia and restoring

sleep latency and time awake after sleep onset to near normative

values.

O B J E C T I V E S

To assess the efficacy of cognitive-behavioural interventions in

improving sleep quality, duration and efficiency amongst older

adults (aged 60 and above).

M E T H O D S

Criteria for considering studies for this review

Types of studies

All relevant randomised controlled trials in which participants had

been randomly allocated to an intervention group and a control

group. The control groups were either waiting-list control groups

or placebo.

Types of participants

In determining a cut-off point in age for this review, the age of

60 was chosen as being most clinically relevant, following con-

sultation (DPOA 2000). Trials whose focus was explicitly on the

older adult were included where 80% or more of participants were

recorded as being over the age of 60. Participants must have been

diagnosed with sleep problems via standardised measures (e.g. the

PSQI [PSQI 1989]), objective measures in sleep laboratory (e.g.

polysomnography, actigraphy) or by participants’ own sleep diaries

or reports/diaries kept by partners or nursing staff. Participants

must also have been screened to exclude those with dementia and/

or depression by the use of psychometrically sound measures such

as the Mini Mental State Examination (MMSE) (Folstein 1975 ),

Beck Depression Inventory (Groth-Marnat 1990) or comparable

instrument(s). This was to avoid the confounding effects of these

conditions.

Sleep problems addressed in this, and related reviews include:

Primary sleep problems:

• difficulties in initiating and maintaining sleep

• sleep efficiency

• sleep latency

• delayed or advanced sleep phase problems

• parasomnias

• impaired daytime functioning

As sleep apnoea is primarily treated as a respiratory condition,

trials whose participants who had been diagnosed as having sleep

apnoea were excluded. Those with secondary insomnia or sleep

disturbance caused by a psychiatric or medical disorder were also

excluded.



Types of interventions

All forms of cognitive-behavioural therapy, including sleep hy-

giene, stimulus control, muscle relaxation, sleep restriction and

cognitive therapies, were included.

Types of outcome measures

Outcomes measures of interest to the review question include:

• Sleep onset latency (time taken to fall asleep)

• Wake after sleep onset (WASO)

• Total wake-time (TWT)

• Sleep duration (total)

• Early morning wakening (defined by the trialist)

• Sleep efficiency (ratio of time asleep / over time in bed)

• Self-report of sleep satisfaction

• Scales related to sleep, e.g.. the Pittsburgh Sleep Quality

Index (PSQI (PSQI 1989)); the Sleep Impairment Index (Morin

1993a).

• Daytime functioning (as measured by attentional tasks

tests, self-report using a standardised measure, e.g. the Stanford

Sleepiness Scale (Hoddes 1973), the Epworth Sleepiness Scale

(Johns 1991)).

• Quality of life, as measured by validated scales

Outcomes were divided, where possible, into immediate post-

treatment, medium term (3-12 months), and long term (more

than 12 months).

Search methods for identification of studies

Electronic searches

The following electronic databases were searched: The Cochrane

Controlled Trials Register (The Cochrane Library, Issue 1, 2002),

MEDLINE (1966 - January 2002); EMBASE (1980 - January

2002); CINAHL ( 1982 - January 2002); PsycINFO Journal Ar-

ticles and Chapter/Books (1887 to 2002); National Research Reg-

ister (NRR) (2002, Issue1) ; and the sleep bibliography available

at www.websciences.org/bibliosleep/ (1991 - 2002).

The search terms used to isolate controlled trials are shown in

Appendix 1 and were used to search the Cochrane Library. They

were modified as necessary for the other databases.

Searching other resources

Reference lists of articles identified through database searches were

examined to identify further relevant studies. Bibliographies of

systematic and non-systematic review articles were also examined

to identify relevant studies and experts in the field were consulted.

Data collection and analysis

Selection of studies

All reports of studies identified as above were inspected indepen-

dently by the two reviewers. Disagreements regarding relevance

were resolved by acquisition and reading of the full article and

discussion between the reviewers. All selected articles were inde-

pendently assessed to determine if they met inclusion criteria in-

cluding limits on age, diagnosis and screening for comorbid con-

ditions. The reviewers were not blinded to the names of the au-

thors, institutions or journal of publication. Provision was made

for arbitration by a third reviewer although this was not required.

Data extraction and management

Data were extracted independently by each reviewer, and com-

pared using data extraction sheets and the “double entry” feature

in RevMan 4.1. Where it was not possible to extract any data be-

cause they were not available or further information was needed,

the first author of the trial was contacted for clarification. Where

it was possible to extract relevant data, comments on the methods,

participants, interventions and outcomes were presented in the

“Included Studies” table. Individual patient data were requested

from authors of all trials identified from our searches in which par-

ticipants had a wide spread of ages amongst their participants and

a mean age over 50 (e.g., Davies 1986; Engle-Friedman 1992).

The authors of the former trial have reported that lost data from

their trial has recently been located and individual data from nine

participants over 60 in the treatment arm and seven in the wait-list

control group have been supplied and these data were then entered

into the outcome (WASO, immediate post-treatment) for which

they were appropriate. If the authors of the latter trial respond and

it proves possible to isolate data for participants over the age of

60, such data will be entered.

Assessment of risk of bias in included studies

Assessment of methodological quality

Quality assessment was made of all included studies, to consider

the following questions:

• Was the assignment to treatment groups truly random?

• Was allocation adequately concealed?

• How complete was follow-up?

• How were the outcomes considered for people who

withdrew?

• Were they included in the analysis?

• Were those assessing outcomes blind to the treatment

allocation?



The Cochrane Collaboration Handbook criteria are based on the

evidence of a strong relationship between the potential for bias in

the results and allocation concealment and are defined as below:

A. Low risk of bias (adequate allocation concealment)

B. Moderate risk of bias (some doubt about the results)

C. High risk of bias (inadequate allocation concealment)

We contacted authors of all the included studies to acquire de-

tails both of the method of randomisation and that of allocation

concealment. For the purpose of the analysis in this review, it was

decided that trials would only be included if they met criteria A

(adequate) or B (unclear) of the Handbook.

Measures of treatment effect

Continuous (including scale) data

Rating scales: a range of instruments are available to measure sleep

quality and the aspects of mental health which are associated with

it (see for example Hoddes 1973; PSQI 1989; Johns 1991). For

outcome instruments some minimum standards were required: (i)

the psychometric properties of the instrument should have been

described in a book or peer-reviewed journal; (ii) the instrument

should either have been: (a) a self report, or (b) a report com-

pleted by an independent rater, bed-partner or relative/carer (not

the therapist); and (iii) the instrument should be either a global

assessment of an area of functioning or a specific feature of sleep

quality, duration or timing.

Combining mean treatment effects is straightforward when all

measurements are comparable and on the same scale. The fixed

effect estimate of the overall treatment effect can be computed as

the weighted mean of the individual study effects, “...where the

weights are equal to the individual study specific variance esti-

mates. On other occasions it is necessary to transform the mean

effect from each study to a standardised value by dividing by the

sample standard deviation within each study. This was not neces-

sary in the current version of this review.

Normal data: to avoid the pitfall of applying parametric tests to

non-normally distributed data the following standards were ap-

plied to all data before inclusion: (i) standard deviations and means

had to be reported in the paper or obtained from the authors; (ii)

when a scale starts from a finite number (such as 0), the standard

deviation had to be less than the mean (otherwise the mean was

considered unlikely to be an appropriate measure of the centre of

the distribution). Data which did not meet the second standard

were not entered on RevMan software (which assumes a normal

distribution).

Dealing with missing data

With the exception of the outcome of ’loss to follow up’, if attrition

rates were greater than 30%, these data were not used as they were

considered to be too prone to bias. This caused the exclusion of

an entire trial (see Puder 1983) which has been used elsewhere to

support claims for the efficacy of non-pharmacological treatment

of late-life insomnia (Morin 1999b; Pallesen 1998).

Assessment of heterogeneity

Statistical heterogeneity was assessed using the chi-squared test for

heterogeneity along with visual inspection of the graph. A signif-

icance level of less than 0.10 was interpreted as evidence of het-

erogeneity. For data where heterogeneity was found the reviewers

looked for an explanation. When studies with heterogeneous re-

sults were found to be comparable, the statistical synthesis of the

results was performed using a random effects model; where they

were not comparable, no meta-analysis was undertaken.

Assessment of reporting biases

Data from all identified and selected trials were entered into a

funnel graph where appropriate (trial effect vs. variance) in an

attempt to investigate the likelihood of overt publication bias.

Data synthesis

General

In all cases the data were entered into RevMan in such a way that

the area to the left of the ’line of no effect’ indicates a favourable

outcome for the relevant behavioural intervention. In outcomes

where a higher number indicated a benefit to the participant when

compared to a lower number (e.g., total sleep duration as mea-

sured in minutes) data were entered as negative numbers.Multiple

treatment armsWhere studies contained more than one eligible

CBT therapy versus a control group, the Ns, means and standard

deviations were pooled for use in the analysis. This was required

in the case of McCurry 1998, where data for CBT delivered in-

dividually and by group therapy were combined, and in Lichstein

2001, where treatment arms included sleep restriction, relaxation

and control, although only data from the relaxation arm were used

in the outcome ”total sleep time“. This decision was taken because

sleep restriction is a paradoxical intervention where, during treat-

ment, total sleep-time is limited. In another trial, data were com-

bined from both intervention arms in a trial comparing stimulus

control, imagery training and wait-list control (Morin 1988).

R E S U L T S

Description of studies



See: Characteristics of included studies; Characteristics of excluded

studies; Characteristics of ongoing studies.

Results of the search

Following searches in the Cochrane Library, MEDLINE, EM-

BASE, CINAHL and PsychINFO, 2677 references were located.

Titles and abstracts were examined by both reviewers and 45 papers

acquired. Six trials met the inclusion criteria (Davies 1986; Morin

1988; Morin 1993; McCurry 1998; Morin 1999a; Lichstein 2001)

and data are being sought from three unpublished dissertations

(Espie 1987; Epstein 1994; Creti 1998) as well as a trial in which

the mix of ages necessitates that individual patient data be ob-

tained (Engle-Friedman 1992).

Included studies

Specific details of each study are reported in the ’Characteristics of

included studies’ table. The six studies included in this review were

published between 1986 and 2001 (Davies 1986; Morin 1988;

Morin 1993; McCurry 1998; Morin 1999a; Lichstein 2001). Five

trials were conducted in the United States (Davies 1986; Morin

1993; McCurry 1998; Morin 1999a; Lichstein 2001) and one in

Canada (Morin 1988). All participants were recruited from media

advertisements, which suggests a highly-motivated (because self-

selected) participant population. Included studies were relatively

small, with a total of 282 participants, of whom 224 were used

in the analysis in this review. Data from a further trial (Engle-

Friedman 1992) and three unpublished dissertations (Espie 1987;

Epstein 1994; Creti 1998) are still being sought.

The stated purpose of each included study was to improve sleep in

the older adult with sleep problems through behavioural or cogni-

tive techniques. In two studies (McCurry 1998 and Morin 1988)

trialists permitted participants to remain on hypnotics during the

trials, but only if the participants had stabilised on their courses of

medication for at least six weeks prior to the start of the trial. Four

trials positively excluded those participants who had an ”inability

or unwillingness to discontinue medication“ (Davies 1986; Morin

1993; Morin 1999a; Lichstein 2001).

Severity of sleep problems at baseline was measured by partici-

pants’ sleep diaries (used for two weeks before the trials) in all cases

(Davies 1986; Morin 1988; Morin 1993; Morin 1999a; McCurry

1998; Lichstein 2001). Two trials also used pre-test polysomnog-

raphy (Morin 1993; Lichstein 2001;) to help establish baseline

severity. Trialists from all studies claimed to have screened par-

ticipants for dementia, depression, sleep apnoea and other po-

tential causes of secondary insomnia, via interviews and admin-

istration of psychiatric tests, although one trial (McCurry 1998)

permitted one participant in its control group to remain in the

trial despite being prescribed a tricyclic anti-depressant. Three

trials randomised participants in severity blocks (Morin 1988;

Morin 1999a; Lichstein 2001). All trialists attempted to screen

for comorbid conditions such as Alzheimer disease, psychoses and

dementia, the effects of which have a known impact on sleep.

Morin 1999a used the Mini Mental State Examination (MMSE),

a structured clinical interview and screening tests for sleep apnoea

and periodic limb movement problems (Folstein 1975). McCurry

1998 excluded potential participants if they reported or were ”sus-

pected to be at risk“ of sleep apnoea and emphysema and were

also screened for depression using the Clinical Center for Epi-

demiologic Studies Depression scale (CES-D) (Radloff 1977) .

Morin 1988 screened for depression using the Beck Depression

Inventory (BDI) (Groth-Marnat 1990). Davies 1986 used the

Minnesota Multiphasic Personality Inventory (MMPI 1943) and

the Zung Self-Rating Depression Scale (Zung 1965), as well as

personal interviews calculated to gain information on ”serious,

painful medical conditions (e.g. arthritis), psychopathology, sleep

apnoea, or nocturnal myoclonus“ (Davies 1986). Symptomatic

evidence of sleep apnoea and restless leg syndrome or periodic limb

movements was also sought. Lichstein 2001 screened for sleep ap-

noea (using polysomnography ), as well as for depression, anxiety

and dementia, using the MMSE, the Cornell Medical Index, the

State-Trait Anxiety inventory and the Geriatric Depression Scale

(Folstein 1975; Spielberger 1983; Yesavage 1983; Brodman 1986).

Morin 1993 screened for cognitive impairments using the MMSE

(Folstein 1975), periodic limb movements (using polysomnogra-

phy) and also reported having screened for depression, alcohol

abuse and ”multiple medical problems“, without describing the

tests used.

The oldest trial we included (Davies 1986) compared countercon-

trol behavioural therapy to wait-list control. The most recent trial

included (Lichstein 2001) compared relaxation with sleep com-

pression against a placebo described as ”quasi-densensitisation“. As

relaxation training and sleep compression are forms of CBT, data

from both groups have been pooled within the analysis. McCurry

used a combination of information and sleep hygiene together

with sleep compression techniques (McCurry 1998). Morin and

Azrin chose to compare stimulus control with imagery training

against a no-treatment control group and as with Lichstein et al,

data from both arms have been pooled for analysis in this review

(Morin 1988; Lichstein 2001;). Morin 1993 used a combined

treatment of sleep hygiene, sleep compression, stimulus control

and cognitive therapy, and compared this with a wait-list control

group. Morin 1999a compared a combination of sleep hygiene,

sleep compression, stimulus control and cognitive therapy, ver-

sus temazepam, versus both the combined cognitive-behavioural

treatments with temazepam, versus a placebo hypnotic (only data

from the first and last arms described are used within this review,

i.e. cognitive-behavioural treatments and placebo).

Three studies used sleep latency as an outcome measure (Morin

1988; Morin 1993; McCurry 1998) although data from one study

were unusable as no data were reported for the control group



(McCurry 1998). Four studies recorded data on the amount of

time participants managed to remain asleep before first waking,

known as ”wake after sleep onset“ (WASO) (Davies 1986; Morin

1993; Morin 1999a; Lichstein 2001); one on total wake-time

(Morin 1993); four on sleep duration (Morin 1988; Morin 1993;

Morin 1999a; Lichstein 2001); one on early morning waken-

ing (Morin 1993); three on sleep efficiency (Morin 1993; Morin

1999a; Lichstein 2001), one on validated scales related to sleep, i.e.

the Pittsburgh Sleep Quality Index (PSQI 1989) and the patients’

and clinicians’ versions of the Sleep Impairment Index (Morin

1993a; McCurry 1998; Morin 1999a) although data supplied for

the latter outcome were inadequate for inclusion in the analyses for

this review. Various non-validated scales developed by individual

trialists were reported but not included in this review’s analysis.

Triallists used a five-point scale for ”previous night’s sleep quality“

and a five-point scale for ”how I felt upon awakening“ (McCurry

1998), a five-point scale for ”patient’s outcomes ratings“, includ-

ing ”severity, interference and noticeability“ of sleeping problems

(Morin 1988; Morin 1993), a five-point scale for the views of ”sig-

nificant others“ on participants’ sleep (Morin 1988; Morin 1993)

and a five-point rating scale measuring ”perceived quality of sleep“

(Lichstein 2001). Morin 1988 included a ”treatment reliability

measure“ which was constituted of anonymous ratings by treated

participants of expectancies for success, treatment plausibility and

confidence in recommending treatment to an insomniac friend;

similarly, Lichstein 2001 assessed ”treatment credibility“ includ-

ing dimensions such as ”reasonableness of treatment, opinion of

the therapist and willingness [of participant] to recommend treat-

ment to a friend“.

Follow-up data were sought after four weeks in one study (Davies

1986) (though data has not been presented in published or unpub-

lished form); after three months in four of the six studies (McCurry

1998, Morin 1988; Morin 1993; Morin 1999a ), after one year

in five studies (Davies 1986; McCurry 1998; Morin 1993; Morin

1999a; Lichstein 2001) and after two years in one study (Morin

1999a). In all but two studies (Morin 1999a and Lichstein 2001)

the use of a wait-list control group rendered follow-up data unus-

able for meta-analyses, as by time of follow-up the control groups

were also receiving a CBT intervention.

Excluded studies

Please see Characteristics of excluded studies for details.

Risk of bias in included studies

Allocation

We contacted authors of all the six included studies to acquire

details both of the method of randomisation and that of alloca-

tion concealment, because no such information was given within

the published papers. Two responses have been received (McCurry

1998; Lichstein 2001). The latter trials both merit ”A“s for ran-

domisation and ”Bs“ for allocation concealment, due to the use

of random numbers tables. The remainder of the studies are rated

at ”B“ for both randomisation and allocation concealment until

further information is supplied by the trialists.

Blinding

Only one trial reported that those who assessed outcomes were

blind to treatment allocation (McCurry 1998).

Incomplete outcome data

Drop-out rates varied from 0 - 29% between studies (for details

see Table of Included Studies). Follow-up times tended to group

at similar intervals across studies and included post-treatment, in

one study (Davies 1986) to three months in four of the five studies

(Morin 1988; Morin 1993; McCurry 1998; Morin 1999a) to one

year in four studies (McCurry 1998; Morin 1993; Morin 1999a;

Lichstein 2001) and after two years in one study (Morin 1999a).

As to how outcomes of people who withdrew from trials were

considered by trialists, reports varied enormously. Lichstein 2001

and Morin 1999a considered the outcomes of participants who

withdrew from the study between post-treatment and follow-up

separately and no information is available concerning McCurry

1998. As Morin 1988 had no drop-out rate at all, the issue is not

applicable.

Other potential sources of bias

Three groups of trialists attempted to distribute potential con-

founders equally by randomising in blocks according to severity

of sleep problems (Morin 1988; Morin 1993; Lichstein 2001).

Samples need to be of sufficient size for differences between groups

to become statistically significant. Small samples can obscure treat-

ment effects and result in an unequal distribution of confounders.

Critical appraisal of study sizes was made. Sample sizes varied from

16 to 83 patients per trial that could be included in this analysis .

There was no reason to think that there was a particular problem

with publication bias even in view of the asymmetry of the funnel

plot, which is likely to be due to the small numbers of studies in

this field of research.

Effects of interventions

Sleep onset latency

Sleep onset latency was used as an outcome measure in three studies

included in the post-treatment analysis (Morin 1988 and Morin

1993; Lichstein 2001, total n = 135), and in one study at one



year + follow-up (Lichstein 2001, total n = 74 ). The overall effect

estimate immediately at post-treatment was very mild as measured

by sleep diaries (estimate of reduction of time to sleep onset = -3

minutes, 95% CI = -8.92, 2.92; Analysis 1.1) (Morin 1988; Morin

1993; Lichstein 2001;). When measured by PSG (Morin 1993, n

= 24) the effect was also slight (estimate reduction of time to sleep

onset, -4.4 minutes, 95% CI = -13.29, 4.55; Analysis 1.2) .

After a year or more, the effect is reported in one trial has improved

slightly (estimate favours treatment group, who fall asleep 11.5

minutes faster than control, 95% CI = -23.54, 0.58; Analysis

1.1) (Lichstein 2001). This was not supported by PSG, where

the improvement was only 2.5 minutes (95% CI = -3.24, 8.22;

Analysis 1.2).

Wake after sleep onset (WASO)

Wake after sleep onset (WASO) as measured by sleep diaries

was used as an outcome measure in four studies included in the

post-treatment analysis (Davies 1986; Morin 1993; Morin 1999a;

Lichstein 2001, total n = 159), in two studies at three-month fol-

low-up (Morin 1993; Morin 1999a, total n = 50) and in two stud-

ies at one year + follow-up (Morin 1993; Lichstein 2001, total n

= 98). The overall effect immediately post-treatment was modest,

as measured by sleep diaries, with patients in the treatment group

decreasing their time of being awake after the onset of sleep by

21.9 minutes (95% CI = -37.30, -6.38; Analysis 1.3). This effect

was more marked when measured by PSG in the two trials which

used this instrument (Morin 1993; Morin 1999a, total n = 59)

where participants showed a decrease in WASO of 24.4 minutes

(95% CI = -41.14, -7.57; Analysis 1.4).

At three-month follow-up, the improvement is good when mea-

sured by sleep diaries, with the treatment group now 33 minutes

better off than control (95% CI = -57.19, -8.35; Analysis 1.3)

(Morin 1999a). After a year or more (in a different trial) the ef-

fect appears more modest, with WASO decreased by 13 minutes

the treated group (95% CI = -28.8, 3.42; Analysis 1.3) (Lichstein

2001). Lichstein 2001 (n = 74) also used PSG twelve months after

treatment and in this trial the effect appears to support the diary

results (decrease of WASO by 10.1 minutes, [95% CI = -34.27,

14.17; Analysis 1.4).

Total wake-time (in minutes)

Total wake-time was used as an outcome measure in only one

(small) study (Morin 1993, n = 24). Total wake-time was measured

at all of the three outcome periods (immediate post-treatment,

three-month, and one year+). The overall effect immediately post-

treatment was encouraging as measured by sleep diaries, with par-

ticipants in the control group spending an hour less awake during

the night than control (decrease of 62.22 minutes, (95% CI = -

107.94, -16.50; Analysis 1.5), but the very wide confidence inter-

vals mean this should be interpreted cautiously. When measured

by PSG, this effect appeared weaker, but still significant (decrease

of 38 minutes, (95% CI = -68.08, -7.76; Analysis 1.6).

Sleep duration (in minutes)

Sleep duration, or ”total sleep time“ was used as an outcome mea-

sure in four studies included in the post-treatment analysis (Morin

1988; Morin 1993; Morin 1999a; Lichstein 2001, n = 143), in

one study at three-month follow-up (Morin 1999a ) and in one

study at one year + follow-up (Lichstein 2001, n = 54). For this

outcome, only data from one of the two treatment arms involved

in Lichstein 2001 has been used. This is because relaxation tech-

niques (in the first arm) were used to increase total sleep time,

while the second arm (sleep compression) involves a paradoxical

technique in which participants’ time in bed is limited. Thus a

lower N is shown for Lichstein 2001 for all data measurement

points.

The overall effect immediately post-treatment was mild when mea-

sured by sleep diaries, with participants in the treatment group

having 14.6 minutes more sleep a night than control (95% CI =

-36.13, -7.01; Analysis 1.7). When measured by PSG, this effect

was not supported with overall effect reversing to favour control

(participants in the control group slept 19 minutes more a night

than treatment group, 95% CI = -38.96, 68.5; Analysis 1.7). It

should be noted that PSG was conducted at post-treatment in only

two of the four studies which measured sleep duration.

At three-month follow-up, participants in the treatment groups

appear 14.8 minutes worse off (sleeping less) than control group

(95% CI = -38.96, -68.5; Analysis 1.7). After a year or more, the

effect appears very positive according to diary reports (treatment

group reporting an increase in sleep per night of 32 minutes, 95%

CI = -71.11, -8.13; Analysis 1.7); however this is contradicted by

the PSG measurement used in one trial (Lichstein 2001, n = 50)

and in this trial the effect had reported that the control group was

sleeping almost 7 minutes more a night than the treatment group

(95% CI = -33.99, 47.37; Analysis 1.8).

Early morning wakening

”Early morning wakening“ was used as an outcome measure in

only one study (Morin 1993, n = 24). Early morning wakening

was measured at all of the three outcome periods. The overall ef-

fect immediately post-treatment was modest as measured by sleep

diaries, with the treatment group waking 17 minutes later than

the control group ( 95% CI = -34.22, 0.46; Analysis 1.9). When

measured by PSG, this effect was supported (overall effect report-

ing an increase of 14.9 minutes (95% CI = -32.23, 2.55; Analysis

1.10).

Sleep efficiency

Sleep efficiency was used as an outcome measure in three stud-

ies included in the post-treatment analysis (Morin 1993; Morin



1999a; Lichstein 2001, n = 143), in one study at three-month

follow-up (Morin 1999a) and in one study at one year + follow-up

(Lichstein 2001). The overall effect immediately post-treatment

was modest (albeit with wide confidence intervals) as measured by

sleep diaries, with participants showing an improvement of 7.5%

(95% CI = -15.45, 0.47; Analysis 1.11). When measured by PSG,

this effect was almost identical, and showed narrower confidence

intervals (6.25% improvement 95% CI = 10.18, 2.31; Analysis

1.12) (Morin 1993; Morin 1999a).

At three-month follow-up, the effect had improved slightly as mea-

sured by sleep diaries in the one included trial (Morin 1999a)

(9.6%, 95% CI = 18.21, 0.87; Analysis 1.11 ). After a year or

more, the effect was reduced further (4.4% improvement, 95% CI

= 9.85, -1.13; Analysis 1.13) (Lichstein 2001). Lichstein 2001’s

use of PSG did not support even this modest finding and the

treatment group appeared 2.4% worse, 95% CI = -3.36, -8.14;

Analysis 1.12).

Standardised scales

Only one study (McCurry 1998, n = 36) used the Pittsburgh

Sleep Quality Index (PSQI 1989) at post-treatment and at three-

month follow-up. This is a subjective measure of sleep quality,

ranging from 0 to 21. Any score above five is considered indicative

of sleep disturbance. Initial effect of CBT in this trial was good,

with participants scoring 7.8 in the treatment group as compared

with 10.6 in the control, overall effect -2.80, (95% CI = -5.44, -

0.16; Analysis 1.13). At three month follow-up, the effect of CBT

had improved further, although all participants were still above

the threshold of pathological sleep disturbance (treatment group

= 6.20, control group = 10.20). The overall effect at follow-up was

-4.00 (95% CI = -6.62, -1.38; Analysis 1.13).

D I S C U S S I O N

Summary of main results

Overall, the results of this review suggest that cognitive-be-

havioural treatments for sleep problems in people aged 60 and

over are mildly effective for some aspects of sleep according to the

patient diaries in the short term, but that the effect of these treat-

ments is not always durable. However, in general, beneficial effects

are not as great as for these treatments when used with younger

adults (see Pallesen 1998 for a review making this comparison)

which is consistent with other research into the efficacy of CBT

with older adults. The objective reports of sleep by polysomnog-

raphy do not always agree with the patient reports, which was

particularly notable in the data for sleep duration. It should be

recognised that there is a large variation in the interpretation of

many sleep variables (McGhie 1962) and so, both objective and

subjective measures have been included in this review.

The results of this review of the effects of cognitive-behavioural

treatments on sleep are mixed. Total sleep duration appears to

show a modest improvement at post-treatment, which declines

with time. Night waking (WASO) shows clinically important im-

provements, although these appear to diminish somewhat over

time. Sleep onset latency (SOL, or ”settling“) seems to change

very little as a result of the interventions investigated, while early

morning waking reduces slightly. Results for sleep efficiency (the

percentage of time in bed in which participants are actually asleep)

suggests a modest gain initially, which erodes over time.

Participant reports of total sleep duration are not supported by

polysomnography (PSG); in contrast, the substantial improve-

ments reported by participants for night waking (WASO) are ob-

jectively supported. Neither sleep onset latency, early morning

waking nor sleep efficiency have objective confirmation of partic-

ipant reports.

Results from the one trial which used the Pittsburgh Index of

Sleep Quality suggested that all participants in the trial remained

at pathological levels of sleep disturbance throughout the trial (a

finding which may at least partially be explained by the fact that

all were full-time partners or carers of people with Alzheimers’ dis-

ease). Nevertheless, whilst participants from the treatment group

improved their scores from baseline to follow-up (10.8 down to

6.20), the control group over the same time period improved only

from 11.9 to 10.2.

Overall completeness and applicability ofevidence

While some of the improvements reported here appear modest,

they might well be considered clinically useful and patient reports

indicate that they are both worthwhile and valued, particularly

when compared with drug-induced sleep (Giblin 1983). Some

studies have reported considerable reductions in hypnotic usage

following CBT for sleep problems and in a population whose us-

age of drugs is generally high this may be particularly important.

A prospective study examining 5-year mortality among hypnotic

drug users and respondents with subjective insomnia identified in

a longitudinal study of health, activity, and lifestyle (Nottingham

Longitudinal Study of Activity and Ageing) which involved 1042

survey respondents, aged over 65 years, concluded that the mortal-

ity rate of participants was significantly greater among those taking

some form of medication for sleep than for those not taking sleep

medication (Rumble 1992). Generally, research supports the idea

that when informed of options for the treatment of chronic insom-

nia, CBT treatments are welcomed (see Vincent 2001, wherein

the concept of treatment preference and patient satisfaction is in-

vestigated). Researchers reported that cognitive-behavioural ther-

apy was ”significantly preferred over pharmacological therapy at

pre-treatment ....“ The study further reported that, amongst the



treatment techniques used, participants ”least liked sleep restric-

tion and most liked sleep hygiene.“ Use of the model for PPA

(prospective preference assessment) described by Halpern might

also enhance participant satisfaction and adherence to treatment

(Halpern 2002).

Homogeneity

Specific cognitive-behavioural interventions and the mode and

quality of therapist delivery vary somewhat. It may be that these

differences can explain some of the heterogeneity in these results.

Moreover, research has suggested that the efficacy of CBT declines

with age (Morin 1994; McCurry 1998). Morin 1994 also reported

that sleep restriction (reducing time in bed to as near as possible to

time asleep) resulted in a worsening of sleep duration at least in the

short-term, or alternatively that sleep efficiency had improved (the

ratio of time asleep to time in bed) at the expense of sleep duration.

It should also be considered that there may be a developmental

perspective to sleep in this population as the question of whether

older adults need less sleep or cannot get more sleep has not yet

been answered (Bliwise 1993).

Limitations

There is considerable overlap between many cognitive behavioural

interventions such as aspects of sleep hygiene which may restrict

sleep. It is therefore not possible to determine which parts of these

therapies are effective. Studies did not refer to standard AASM

criteria for diagnosing patients sleep problems which may limit

the internal reliability of this meta-analysis (AASM 1990).

Agreements and disagreements with otherstudies or reviews

All treatment gains reported in this review are modest when com-

pared with those reported by others (Morin 1994; Pallesen 1998).

This can be explained partly by the rigorous inclusion criteria ap-

plied within this review; for example, our requirements that 80%

of the sample be over the age of 60; that dropout be less <30%; that

clear measures of the sleep problem at baseline be present and that

screening for psychiatric co-morbidities by standardised measures

take place. Excluded studies almost invariably reported more sig-

nificant treatment gains (see ”Characteristics of excluded studies“).

The lack of effect at follow-up in this review (even for those sleep

variables for which CBT did appear modestly effective) also con-

trasts with the findings of other reviews, possibly for the same rea-

sons. It may be that using written materials or videotapes would

help patients maintain or enhance the changes they had achieved

as shown in adults (Marrs 1995) in children (Montgomery 2001)

and more specifically in adult insomnia (Mimeault 1999- see be-

low, and Giblin 1983). Research into the effectiveness of ”booster

sessions“ for maintaining the benefits of a cognitive-behavioural

programme for insomnia for adults aged 20 - 75 reported no differ-

ence at follow-up between groups which received post-treatment

”booster sessions“ and those which did not (Cook 1986). How-

ever, it is highly likely that Cook’s timing (a mere two months’

after cessation of the CBT treatment programme) as well as the

fact that both groups were still showing significant improvement

in their sleep problems, suggests that ”booster sessions“ were not

yet required. Further testing is needed to show whether or not

”booster sessions“ at six months or a year from initial treatment

(when, as this review shows, benefit has markedly declined) might

maintain earlier improvements.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

The data suggest a mild effect of CBT for different aspects of

the sleep problems in older adults. The small number of studies

meeting the stringent criteria for inclusion in this review may also

influence the apparent efficacy. It is notable that a large number

of excluded studies reported positive results and that the main

reason for their exclusion was that their mean age was younger

than 60. While it may well be the case that the treatment efficacy

of cognitive-behavioural interventions seems to decline with the

age of participants, they may still be worthy of consideration by

clinicians, especially in a population for whom alternative treat-

ments may be limited. As some studies have reported that older

adults are more likely to be taking a wide range of medications for

other health problems and that many hypnotics have side-effects,

it is likely that reducing additional medication for sleep problems

would be a positive benefit to the health of older adults.

Implications for research

Cognitive-behavioural therapy for insomnia has several related di-

mensions, as has been discussed in this review. It might be the

case that some aspects of it are of greater importance than others

and that research into the ’active ingredient(s)’ would be useful in

refining the treatment. In addition, cognitive-behavioural treat-

ments involve a considerable commitment on the parts of both

the patient and therapist since the apparent paradoxical interven-

tion (especially in sleep restriction) can make compliance difficult

to achieve. Research is needed to establish the likely predictors

of success with these treatments. In view of the high prevalence

of sleep problems and the common co-morbidity of them with

other disorders, notably anxiety and depression, particular atten-

tion must be paid to these conditions as potential confounders in

the older adult population.

Where such interventions are reported to have an effect, durability

must be considered. To increase durability of effect the provision

of either ”top-up“ sessions of CBT training at intervals of 6-12



months following initial treatment and/or the provision of written

materials and/or videocassettes for home use following treatment

should be tested. Cost-benefit analysis as regards these treatments

versus pharmacological treatments would be a particularly useful

addition to this area of study.

Finally, the role of cognitive-behavioural therapy in preventative

education for sleep disorders may also be worthy of investigation.

Given that the efficacy of CBT is known to reduce with age, it may

be that sound prevention programmes delivered in ”the middle

years“ might benefit adults as they age and become more prone to

sleep problems.

A C K N O W L E D G E M E N T S

The authors would like to thank Jo Abbott, Margaret Burke, Es-

ther Coren, Annemarie Courtiour, Lindsay Dow, Julian Higgins,

Daniel Kripke, Liz Lloyd, Stuart Logan, Geraldine Macdonald,

Gregory Stores, Katrina Williams and Philp Wilkinson for their

helpful comments and advice on this review. Thanks also to Brant

Riedel, Susan McCurry and Ruth Davies-Sulser for supplying data.

R E F E R E N C E S

References to studies included in this review

Davies 1986 {published data only}

Davies R, Lacks P, Storandt M, Bertelson AD.

Countercontrol treatment of sleep-maintenance insomnia

in relation to age. Psychology and Aging 1986;1(3):233–238.

Lichstein 2001 {published data only}

Lichstein KL, Riedel BW, Wilson NM, Lester KW,

Aguillard RN. Relaxation and sleep compression for late-life

insomnia: a placebo-controlled trial. Journal of Consulting

and Clinical Psychology 2001;69(2):227–239.

McCurry 1998 {published data only}

McCurry SM, Logsdon RG, Vitiello MV, Teri L. Successful

behavioral treatment for reported sleep problems in elderly

caregivers of dementia patients: a controlled study. Journal

of Gerontology 1998;53B(2):122–129.

Morin 1988 {published data only}

Morin CM, Azrin NH. Behavioral and cognitive treatments

of geriatric insomnia. Journal of Consulting and Clinical

Psychology 1988;56(5):748–753.

Morin 1993 {published data only}

Morin C, Kowatch RA, Barry T, Walton E. Cognitive-

behavior therapy for late-life insomnia. Journal of Consulting

Clinical Psychology 1993;61(1):137–46.

Morin 1999a {published data only}

Morin CM, Colecchi C, Stone J, Sood R, Brink D.

Behavioral and pharmacological therapies for late-life

insomnia: a randomized controlled trial. JAMA 1999;281

(11):991–9.

References to studies excluded from this review

Alperson 1979 {published data only}

Alperson J, Biglan A. Self-administered treatment of sleep

onset insomnia and the importance of age. Behavior Therapy

1979;10:347–356.

Anderson 1988 {published data only}

Anderson MW, Zendell SM, Rosa DP, Rubinstein ML,

Herera CO, Simons O, Caruso L, Spielman AJ. Comparison

of sleep restriction therapy and stimulus control in older

insomniacs: an update. Sleep Research 1988;17:141.

Friedman 1991 {published data only}

Friedman L, Bliwise DL, Yesavage JA, Salom SR. A

preliminary study comparing sleep restriction and relaxation

treatments for insomnia in older adults. Journal of

Gerontology 1991;46(1):1–8.

Giblin 1983 {published data only}

Giblin MJ, Clift AD. Sleep without drugs. Journal of the

Royal College of General Practitioners 1983;33(255):628–33.

Hoch 2001 {published data only}

Hoch CC, Reynolds CF, Buysse DJ, Monk TH, Nowell P,

Begley AE, Hall F, Dew MA. Protecting sleep quality in

later life: A pilot study of bed restriction and sleep hygiene.

Journals of Gerontology: Series B: Psychological Sciences and

Social Sciences 2001;56B(1):52–P59.

Puder 1983 {published data only}

Puder R, Lacks P, Bertelson AD, Storandt M. Short-term

stimulus control treatment of insomnia in older adults.

Behavior Therapy 1983;14:424–429.

Riedel 1995 {published data only}

Riedel BW, Lichstein KL, Dwyer WO. Sleep compression

and sleep education for older insomniacs: self-help versus

therapist guidance. Psychology of Aging 1995;10(1):54–63.

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C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Davies 1986

Methods Randomised controlled trial

Participants 34 participants (mean age of 58.59 [SD = 10.98]). Only data on the over-60s used in this review (9 in

treatment arm; 7 from control arm). Participants were judged to be insomniac following two weeks of

self-report data using sleep diaries, spouse reports (in some cases) and a history of ”sleep maintenance

insomnia“ of at least 6 months’ duration. Sleep maintenance insomnia was defined as WASO of at least

30. min. per night at least one night per week

Interventions Treatment 1: countercountrol therapy;

Treatment 2: wait-list control

Outcomes WASO, average number of awakenings per night, average number of awakenings of 10 minutes or more,

were the primary outcomes and the only ones for which data were reported. Sleep latency and post-

treatment use of hypnotics were also investigated, but no data reported

Notes Initial intake for randomisation was 43; 34 finished trial; 16 remained at one-year follow-up; however, no

data on the over-60s alone were available

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Unclear B - Unclear

Lichstein 2001

Methods Randomised controlled trial (participants randomised in 8 blocks following noting of gender and severity

of condition)

Participants 83 participants (mean age of 68.1 [SD= 8.3, 67.9 [SD = 6.8] and 68.0 [SD = 5.9] for the three arms of

the trial).

Participants were judged to be insomniac following two weeks of self-report data using sleep diaries

Interventions Treatment 1: relaxation;

Treatment 2: sleep compression;

Treatment 3:

”placebo“, defined as ”quasi-desensitisation“

Outcomes Sleep latency, no. of awakenings, WASO, total sleep time, sleep efficiency

Notes Initial intake for randomisation was 89; 83 finished trial; 74 remained at follow-up

Risk of bias



Lichstein 2001 (Continued)



McCurry 1998


Participants 36 participants (mean age of 68.7 [SD = 10.6]) who were caregivers of those with dementia and who had

”endorsed at least one sleep problem“ on a sleep problems screening questionnaire

Interventions Treatment 1: Group behavioural treatment (including sleep hygiene, stimulus control, sleep compression,

relaxation and education)

Treatment 2: Individual behaviour treatment (including sleep hygiene, stimulus control, sleep compres-

sion, relaxation and education)

Treatment 3: wait list control

Outcomes Sleep participant diaries (including onset and waking times) ; Pittsburgh Sleep Quality Index

Notes Initial intake at randomisation was 36; 35 finished trial; 29 completed 3-month follow-up.

Difficulties in this study include varying pharmacological treatments some participants (6/36) were on

throughout study. No data given on control group for any outcome except the PSQI

Risk of bias


Allocation concealment? Yes A - Adequate

Morin 1988

Methods Randomised controlled trial (participants randomised within severity blocks)

Participants 27 participants, non-institutionalised (mean age 67.4 [SD = 5.6]) with sleep-maintenance insomnia

(average duration 19 years)

Interventions Treatment 1: Stimulus control

Treatment 2: Imagery training

Treatment 3: Wait-list control

Outcomes Sleep diaries (including onset and waking times), hand-held switch-activated clock,

reports from bed partners

Notes Initial intake for randomisation was 27; 19 finished trial

Risk of bias



Morin 1988 (Continued)



Morin 1993

Methods Randomised controlled trial (participants randomised within severity blocks)

Participants 24 participants (mean age 67.1, SD 5.3) with sleep maintenance insomnia and at least one negative effect

(eg fatigue, poor functioning)

Interventions Treatment: Group-based cognitive- behaviour therapy

Control: wait-list control

Outcomes Sleep diaries (including onset and waking times) and polysomnography

Notes Initial intake for randomisation was 24; all finished trial; data for 23 were available at follow-up

Risk of bias



Morin 1999a


Participants 78 participants (mean age 65, SD 7) with chronic primary insomnia

Interventions Treatment 1: Cognitive behavior therapy (including stimulus control, sleep restriction, sleep hygiene and

cognitive therapy)

Treament 2: pharmacotherapy (temazepam 7.5 mg per night, gradually increased [up to 30mg])

Treatment 3: pharmacotherapy (temazepam) plus cognitive behavior therapy as described in Treatment 1

Treatment 4: placebo hypnotic

Outcomes Sleep diaries (including onset and waking times) and polysomnography

Reports from bed partners

Notes Initial intake for randomisation for the treatment arms examined in this analysis was 38; 36 finished trial;

23 remained at 12-month followup

Risk of bias




Morin 1999a (Continued)


Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Alperson 1979 This trial of relaxation and stimulus control is only a randomised controlled trial for participants under 55.

Participants under 55 were randomised to different treatments and a control group but all participants over 55

were given the same treatment. The main findings did show that sleep onset latency fell by an average of 25%,

although older participants improved less than younger ones

Anderson 1988 This study (comparing stimulus control and sleep restriction to control) was not randomised. Main findings did

suggest that active treatment improved WASO by 106 minutes and sleep efficiency by 21%

Friedman 1991 This study comparing sleep restriction and relaxation was not truly randomised (alternate allocation was used).

Furthermore, there was no control group. The study suggested sleep restriction therapy was superior to relaxation

in terms of total sleep time but latency and WASO were improved in both treatments

Giblin 1983 This RCT comparing autogenic relaxation techniques with a control group failed to screen participants for po-

tentially confounding co-morbid conditions, e.g. depression or dementia. Main findings were positive at three-

month follow-up, initial findings less so (probably because all participants had been on hypnotics until just before

the beginning of the trial)

Hoch 2001 This RCT evaluating sleep restriction and sleep hygiene sought to protect sleep quality in normal participants (aged

70-90) who had reported no symptoms of sleep problems. Furthermore, control group was ”archival.“

Puder 1983 Of 25 participants assigned to treatment in this RCT of short-term stimulus control, only 16 completed the

treatment (attrition rate = 36%, 6% higher than maximum allowed by inclusion criteria of this review). Main

findings included statistically significant improvement in sleep onset latency

Riedel 1995 This RCT relied upon self-report of insomnia for participant inclusion. Neither objective measures nor sleep diaries

were used

Schnelle 1999 This RCT includes participants whose sleep is described as ”fragmented“ largely as a result of their incontinence

care routines. As baseline sleep duration is over 11 hours on average, however, they were not considered to have a

primary sleep problem



Characteristics of ongoing studies [ordered by study ID]

Morgan 2002

Trial name or title Psychological treatment in the management of hypnotic dependent chronic insomnia in primary care

Methods

Participants 209 participants aged 31-92 who met DSM IV criteria for insomnia

Interventions Cognitive-behavioural therapy ”sleep clinic“ group

Outcomes Reduction in hypnotic use; PSQI

Starting date Unknown

Contact information K Morgan ( Loughborough University, UK); S Dixon, N Mathers, J Thompson (University of Sheffield, UK)

, M Tomeney (Nottinghamshire Healthcare Trust)

Notes Results due to be published in BMJ, February 2002



D A T A A N D A N A L Y S E S

Comparison 1. Sleep quality: cognitive-behavioural therapy vs. no-treatment control or placebo

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Sleep onset latency (SOL) as

reported in participants’ diaries

3 Mean Difference (IV, Random, 95% CI) Subtotals only

1.1 Short-term (immediately

post-treatment)

3 135 Mean Difference (IV, Random, 95% CI) -1.00 [-8.92, 2.92]

1.2 Medium-term follow-up

(3 months after treatment)

0 0 Mean Difference (IV, Random, 95% CI) Not estimable

1.3 Long-term follow-up

(12 months or more after

treatment)

1 74 Mean Difference (IV, Random, 95% CI) -11.48 [-23.54, 0.

58]

2 Sleep onset latency (SOL) as

measured by polysomnography



post-treatment)







treatment)

1 74 Mean Difference (IV, Random, 95% CI) 2.49 [-3.24, 8.22]

3 Wake after sleep onset (WASO)

as reported in participants’

diaries



post-treatment)

4 159 Mean Difference (IV, Random, 95% CI) -21.84 [-37.30, -6.

38]




35]



treatment)


42]

4 Wake after sleep onset

(WASO) as measured by

polysomnography



post-treatment)


57]






treatment)


17]

5 Total wake time (TWT) as

reported in participants’ diaries



post-treatment)

1 24 Mean Difference (IV, Random, 95% CI) -62.22 [-107.94, -

16.50]








treatment)


6 Total wake time (TWT) as




post-treatment)


76]






treatment)


7 Sleep duration (total, in minutes)

as reported in participants’

diaries



post-treatment)


01]



1 26 Mean Difference (IV, Random, 95% CI) 14.77 [-38.96, 68.

50]



treatment)


13]

8 Sleep duration (total, in

minutes) as measured by

polysomnography



post-treatment)







treatment)


9 Early morning wakening (as

defined by trialist) as reported

in participants’ diaries



post-treatment)


46]






treatment)


10 Early morning wakening (as

defined by trialist) as measured

by polysomnography



post-treatment)


55]








treatment)


11 Sleep efficiency (ratio of time

asleep/ time in bed) as reported

in participants’ diaries



post-treatment)




1 26 Mean Difference (IV, Random, 95% CI) -9.54 [-18.21, -0.87]



treatment)


12 Sleep efficiency (ratio of

time asleep/ time in bed) as




post-treatment)







treatment)


13 Pittsburgh Sleep Quality Index

(PSQI) -- global score



post-treatment)







treatment)


14 Stanford Sleepiness Scale 0 Mean Difference (IV, Random, 95% CI) Subtotals only


post-treatment)







treatment)


15 Sleep Impairment Index 0 Mean Difference (IV, Random, 95% CI) Subtotals only


post-treatment)







treatment)




Analysis 1.1. Comparison 1 Sleep quality: cognitive-behavioural therapy vs. no-treatment control or

placebo, Outcome 1 Sleep onset latency (SOL) as reported in participants’ diaries.

Review: Cognitive behavioural interventions for sleep problems in adults aged 60+

Comparison: 1 Sleep quality: cognitive-behavioural therapy vs. no-treatment control or placebo

Outcome: 1 Sleep onset latency (SOL) as reported in participants’ diaries

Study or subgroup CBT ControlMean

Difference WeightMean

Difference

N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Short-term (immediately post-treatment)

Lichstein 2001 56 21.44 (15.43) 27 24.15 (14.57) 75.3 % -2.71 [ -9.53, 4.11 ]

Morin 1988 18 33.08 (23.84) 10 30.98 (19.56) 13.1 % 2.10 [ -14.28, 18.48 ]

Morin 1993 12 20.62 (11.65) 12 31.18 (28.3) 11.7 % -10.56 [ -27.88, 6.76 ]

Subtotal (95% CI) 86 49 100.0 % -3.00 [ -8.92, 2.92 ]

Heterogeneity: Tau2 = 0.0; Chi2 = 1.11, df = 2 (P = 0.57); I2 =0.0%

Test for overall effect: Z = 0.99 (P = 0.32)

2 Medium-term follow-up (3 months after treatment)

Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]

Heterogeneity: not applicable

Test for overall effect: not applicable

3 Long-term follow-up (12 months or more after treatment)

Lichstein 2001 51 25.13 (17.6) 23 36.61 (27.04) 100.0 % -11.48 [ -23.54, 0.58 ]

Subtotal (95% CI) 51 23 100.0 % -11.48 [ -23.54, 0.58 ]



-100 -50 0 50 100

Favours treatment Favours control




placebo, Outcome 2 Sleep onset latency (SOL) as measured by polysomnography.



Outcome: 2 Sleep onset latency (SOL) as measured by polysomnography



Difference



Morin 1993 12 15.46 (10.41) 12 19.83 (11.84) 100.0 % -4.37 [ -13.29, 4.55 ]

Subtotal (95% CI) 12 12 100.0 % -4.37 [ -13.29, 4.55 ]




Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]




Lichstein 2001 51 13.38 (16.1) 23 10.89 (8.92) 100.0 % 2.49 [ -3.24, 8.22 ]

Subtotal (95% CI) 51 23 100.0 % 2.49 [ -3.24, 8.22 ]



-100 -50 0 50 100





placebo, Outcome 3 Wake after sleep onset (WASO) as reported in participants’ diaries.



Outcome: 3 Wake after sleep onset (WASO) as reported in participants’ diaries



Difference



Davies 1986 9 83.2 (66.16) 7 110.1 (35.81) 5.9 % -26.90 [ -77.62, 23.82 ]

Lichstein 2001 56 42.47 (29.04) 27 49.7 (28.15) 40.0 % -7.23 [ -20.29, 5.83 ]

Morin 1993 12 28.75 (16.55) 12 63.69 (51.35) 14.2 % -34.94 [ -65.47, -4.41 ]

Morin 1999a 18 22.29 (17) 18 51.73 (22.7) 39.9 % -29.44 [ -42.54, -16.34 ]

Subtotal (95% CI) 95 64 100.0 % -21.84 [ -37.30, -6.38 ]

Heterogeneity: Tau2 = 121.18; Chi2 = 6.66, df = 3 (P = 0.08); I2 =55%



Morin 1999a 16 28.37 (25.6) 10 61.14 (33.8) 100.0 % -32.77 [ -57.19, -8.35 ]

Subtotal (95% CI) 16 10 100.0 % -32.77 [ -57.19, -8.35 ]




Lichstein 2001 51 45.5 (39.1) 23 58.19 (29.4) 100.0 % -12.69 [ -28.80, 3.42 ]

Subtotal (95% CI) 51 23 100.0 % -12.69 [ -28.80, 3.42 ]



-100 -50 0 50 100





placebo, Outcome 4 Wake after sleep onset (WASO) as measured by polysomnography.



Outcome: 4 Wake after sleep onset (WASO) as measured by polysomnography



Difference



Morin 1993 12 35.35 (20.9) 12 53.85 (43.38) 38.0 % -18.50 [ -45.74, 8.74 ]

Morin 1999a 18 34.44 (22) 17 62.38 (39.4) 62.0 % -27.94 [ -49.25, -6.63 ]

Subtotal (95% CI) 30 29 100.0 % -24.36 [ -41.14, -7.57 ]




Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]




Lichstein 2001 51 64.73 (47.65) 23 74.78 (49.87) 100.0 % -10.05 [ -34.27, 14.17 ]

Subtotal (95% CI) 51 23 100.0 % -10.05 [ -34.27, 14.17 ]



-100 -50 0 50 100





placebo, Outcome 5 Total wake time (TWT) as reported in participants’ diaries.



Outcome: 5 Total wake time (TWT) as reported in participants’ diaries



Difference



Morin 1993 12 70.53 (28.92) 12 132.75 (75.45) 100.0 % -62.22 [ -107.94, -16.50 ]

Subtotal (95% CI) 12 12 100.0 % -62.22 [ -107.94, -16.50 ]




Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]




Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]



-100 -50 0 50 100





placebo, Outcome 6 Total wake time (TWT) as measured by polysomnography.



Outcome: 6 Total wake time (TWT) as measured by polysomnography



Difference



Morin 1993 12 63.1 (18.36) 12 101.02 (50.05) 100.0 % -37.92 [ -68.08, -7.76 ]

Subtotal (95% CI) 12 12 100.0 % -37.92 [ -68.08, -7.76 ]




Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]




Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]



-100 -50 0 50 100





placebo, Outcome 7 Sleep duration (total, in minutes) as reported in participants’ diaries.



Outcome: 7 Sleep duration (total, in minutes) as reported in participants’ diaries



Difference



Lichstein 2001 28 -397.79 (87.15) 27 -376.8 (54.92) 31.6 % -20.99 [ -59.35, 17.37 ]

Morin 1988 18 -357.52 (72.4) 10 -340.16 (70.29) 15.4 % -17.36 [ -72.28, 37.56 ]

Morin 1993 12 -341.4 (42.48) 12 -318.93 (70.34) 21.5 % -22.47 [ -68.96, 24.02 ]

Morin 1999a 18 -352 (52.4) 18 -350.7 (64.7) 31.4 % -1.30 [ -39.76, 37.16 ]

Subtotal (95% CI) 76 67 100.0 % -14.56 [ -36.13, 7.01 ]




Morin 1999a 16 -355.57 (54.34) 10 -370.34 (75.3) 100.0 % 14.77 [ -38.96, 68.50 ]

Subtotal (95% CI) 16 10 100.0 % 14.77 [ -38.96, 68.50 ]




Lichstein 2001 27 -404.39 (87.93) 23 -372.9 (53.01) 100.0 % -31.49 [ -71.11, 8.13 ]

Subtotal (95% CI) 27 23 100.0 % -31.49 [ -71.11, 8.13 ]



-100 -50 0 50 100





placebo, Outcome 8 Sleep duration (total, in minutes) as measured by polysomnography.



Outcome: 8 Sleep duration (total, in minutes) as measured by polysomnography



Difference



Morin 1993 12 -335.08 (38.82) 12 -362.15 (44.81) 41.7 % 27.07 [ -6.47, 60.61 ]

Morin 1999a 18 -360.7 (34.4) 17 -373.8 (49.5) 58.3 % 13.10 [ -15.29, 41.49 ]

Subtotal (95% CI) 30 29 100.0 % 18.93 [ -2.74, 40.60 ]




Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]




Lichstein 2001 27 -349.33 (83.66) 23 -356.02 (62.81) 100.0 % 6.69 [ -33.99, 47.37 ]

Subtotal (95% CI) 27 23 100.0 % 6.69 [ -33.99, 47.37 ]



-100 -50 0 50 100





placebo, Outcome 9 Early morning wakening (as defined by trialist) as reported in participants’ diaries.



Outcome: 9 Early morning wakening (as defined by trialist) as reported in participants’ diaries



Difference



Morin 1993 12 21.02 (16.02) 12 37.9 (26.12) 100.0 % -16.88 [ -34.22, 0.46 ]

Subtotal (95% CI) 12 12 100.0 % -16.88 [ -34.22, 0.46 ]




Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]




Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]



-100 -50 0 50 100





placebo, Outcome 10 Early morning wakening (as defined by trialist) as measured by polysomnography.



Outcome: 10 Early morning wakening (as defined by trialist) as measured by polysomnography



Difference



Morin 1993 12 12.83 (10.01) 12 27.67 (29.06) 100.0 % -14.84 [ -32.23, 2.55 ]

Subtotal (95% CI) 12 12 100.0 % -14.84 [ -32.23, 2.55 ]




Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]




Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]



-100 -50 0 50 100





placebo, Outcome 11 Sleep efficiency (ratio of time asleep/ time in bed) as reported in participants’ diaries.



Outcome: 11 Sleep efficiency (ratio of time asleep/ time in bed) as reported in participants’ diaries



Difference



Lichstein 2001 56 -79.64 (13.75) 27 -78.86 (8.76) 41.5 % -0.78 [ -5.67, 4.11 ]

Morin 1993 12 -82.81 (6.85) 12 -70.88 (15.2) 23.3 % -11.93 [ -21.36, -2.50 ]

Morin 1999a 18 -84.8 (7.2) 18 -73.49 (11.4) 35.2 % -11.31 [ -17.54, -5.08 ]

Subtotal (95% CI) 86 57 100.0 % -7.49 [ -15.45, 0.47 ]

Heterogeneity: Tau2 = 37.29; Chi2 = 8.68, df = 2 (P = 0.01); I2 =77%



Morin 1999a 16 -82.83 (9.9) 10 -73.29 (11.6) 100.0 % -9.54 [ -18.21, -0.87 ]

Subtotal (95% CI) 16 10 100.0 % -9.54 [ -18.21, -0.87 ]




Lichstein 2001 51 -80.5 (12.53) 23 -76.14 (10.48) 100.0 % -4.36 [ -9.85, 1.13 ]

Subtotal (95% CI) 51 23 100.0 % -4.36 [ -9.85, 1.13 ]



-100 -50 0 50 100





placebo, Outcome 12 Sleep efficiency (ratio of time asleep/ time in bed) as measured by polysomnography.



Outcome: 12 Sleep efficiency (ratio of time asleep/ time in bed) as measured by polysomnography



Difference



Morin 1993 12 -84.58 (4.83) 12 -78.21 (10.18) 45.9 % -6.37 [ -12.75, 0.01 ]

Morin 1999a 18 -86.08 (6.1) 17 -79.91 (8.7) 54.1 % -6.17 [ -11.17, -1.17 ]

Subtotal (95% CI) 30 29 100.0 % -6.25 [ -10.18, -2.31 ]




Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]




Lichstein 2001 51 81.01 (11.2) 23 78.62 (11.88) 100.0 % 2.39 [ -3.36, 8.14 ]

Subtotal (95% CI) 51 23 100.0 % 2.39 [ -3.36, 8.14 ]



-100 -50 0 50 100





placebo, Outcome 13 Pittsburgh Sleep Quality Index (PSQI) -- global score.



Outcome: 13 Pittsburgh Sleep Quality Index (PSQI) – global score



Difference



McCurry 1998 21 7.8 (3.3) 15 10.6 (4.4) 100.0 % -2.80 [ -5.44, -0.16 ]

Subtotal (95% CI) 21 15 100.0 % -2.80 [ -5.44, -0.16 ]




McCurry 1998 21 6.2 (3.6) 15 10.2 (4.2) 100.0 % -4.00 [ -6.62, -1.38 ]

Subtotal (95% CI) 21 15 100.0 % -4.00 [ -6.62, -1.38 ]




Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]



-100 -50 0 50 100


A P P E N D I C E S

Appendix 1. Cochrane Library search strategy

Cochrane Library searched Issue1, 2002

1) SLEEP-DISORDERS*:ME

2) INSOMNIA*

3) WAKEFULNESS

4) SLEEP near DISORDER*

5) SLEEP near PROBLEM*

6) SLEEP near PATTERN*

7) SOMNAMBUL*

8) ((((((#1 or #2) or #3) or #4) or #5) or 6) or 7)

9) GERIATRICS*:ME

10) GERIATRIC*

11) AGED*:ME

12) ELDERLY



13) (OLD* next PERSON*)

14) (SENIOR next CITIZEN*)

15) (OLD* next PEOPLE)

16) (((((( #9 or #10) or #11) or #12) or #13) or #14) or #15)

17) (#8 and #16)

W H A T ’ S N E W

Last assessed as up-to-date: 2 February 2002.

Date Event Description

19 July 2008 Amended Converted to new review format.

H I S T O R Y

Protocol first published: Issue 3, 2001

Review first published: Issue 2, 2002

Date Event Description

20 November 2002 New search has been performed Minor update

20 November 2002 New citation required and conclusions have changed Substantive amendment

C O N T R I B U T I O N S O F A U T H O R S

Both reviewers contributed to the searching of databases, selection of papers, data entry, data analysis and the writing of the text of the

reviews.

D E C L A R A T I O N S O F I N T E R E S T

None known.



N O T E S

This review is intended to be part of a series of linked reviews covering non-pharmacological treatments for sleep disorders in the older

adult, including chronotherapy (”bright light“ therapy) and physical treatments.

I N D E X T E R M SMedical Subject Headings (MeSH)

∗Cognitive Therapy; Age Factors; Randomized Controlled Trials as Topic; Sleep Disorders [∗therapy]; Treatment Outcome

MeSH check words

Aged; Humans; Middle Aged



Interv C-c Trast Del Sueño en Adultos Mayores 60 Años

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