Self-help CBT-I in the management of insomnia symptoms associated with chronic disease in older adults: A randomized controlled trial
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Objectives: The increasing prevalence of insomnia symptoms with age is closely associated with levels of chronic disease, presenting a challenge for sleep management. Manualised self-help CBT-I has been reported to be effective among younger patients with primary insomnia, but has not been used to address comorbid insomnia symptoms in older people. Methods: Participants were recruited from the community, aged 55+, diagnosed with chronic conditions (e.g. arthritis, asthma, diabetes, stroke, COPD), were not taking neuroleptic medication, and scored > 5 on the Pittsburgh Sleep Quality Index. Randomisation (treatment v control) followed an initial assessment. Treatment comprised 6 weekly -accessible' booklets covering: 1) insomnia and self-monitoring; 2) sleep hygiene; 3) sleep medications; 4) sleep restriction/stimulus control; 5) cognitive strategies; and 6) maintaining progress. Treatment group participants also had access to a telephone helpline for queries relating to the booklets. Control participants received sleep hygiene advice (as a printed sheet), in line with UK clinical guidelines. Treatment materials were sent by post. Assessments were conducted: prior to treatment (baseline); 1 week after the dispatch of booklet 6 to the treated group, or 7 weeks after baseline for the control group (post-treatment); and 3 months after post-treatment. Assessment materials, which included the PSQI (the principal outcome) and the Brief Pain Inventory (BPI), were sent and returned by post (using telephone prompts). Results: Of 192 participants (age 55-87) at baseline, 132 (70 treatment; 62 controls) completed post-treatment, and 122 (69 treatment; 53 controls) completed 3-month assessments. Analyses were conducted on an -intention to treat' basis. Adjusting for BDI scores and age, treated patients showed significantly improved PSQI scores relative to controls at post-treatment (F = 6.48, df = 1, 128, P = 0.01) and 3-months (F = 4.70, df = 1,118, P = 0.03), with moderate effect sizes (Cohen's d = 0.4 & 0.4 respectively). Conclusion: Self-help CBT-I, appropriately designed and supported, can provide practical and effective treatment for comorbid insomnia symptoms associated with chronic disease.