Title

A non-pharmacological treatment of insomnia in older individuals: Cognitive refocusing

Abstract

Although physiological changes in sleep architecture have been documented, the etiology of sleep complaints in older individuals has yet to be established. Intrusive cognitive activity has been implicated and cognitive behavioral interventions for insomnia have been found effective^,. We believe that interference with troubling and intrusive thoughts is effective because this both disrupts cognitive activity which prevents sleep as well as alters perceptions of the passage of time, making time awake seem shorter and less aversive. Our intervention technique aims at refocusing attention away from negative, obsessive or intrusive thoughts to an external stimulus which demands sufficient attention to block self-generated negative thoughts, while being sufficiently neutral in affect to lower cognitive arousal.

A comparative evaluation of our technique was conducted on 42 participants (mean age = 67). The 28 women and 14 men met the minimal criteria for psychological insomnia set by the International Classification of Sleep Disorders and manifested disorders of initiating and/or maintaining sleep (DIMS) for a mean duration of 15.5 years. Subjects were randomly assigned to 3 conditions: 1) Self-Monitoring Only Control group (N=13), 2) Cognitive Refocusing: Audiobook (N=14), and 3) Cognitive Refocusing: Relaxation (N=15). In conditions 2 and 3, either audiotaped novels or audiotaped passive relaxation instructions were used as the external refocusing stimuli. Participants were asked to use a tape recorder and a pillow speaker to listen to audiotapes whenever they were unable to fall asleep or return to sleep within 15 minutes during the night. In contrast to the popular Stimulus Control technique, they were not required to leave the bedroom, but were instructed to remain in bed, in a comfortable position, with the lights out.

All participants completed a daily sleep diary for a 2 week baseline period and a 2 week treatment phase. The participants in the Self-Monitoring Only condition were asked to delay treatment for 4 weeks and to monitor their sleep during this time period. They underwent all the same evaluation procedures before and after the waiting period. After 4 weeks of monitoring, subjects were randomly assigned to one of the cognitive refocusing conditions. In addition to the daily sleep diaries, participants completed an extensive battery of measures as part of a larger study. Questionnaires were completed before baseline self monitoring, after the treatment phase and again following a two week follow-up (i.e. when use of the cognitive refocusing intervention was optional). The sleep-wake variables assessed included: sleep onset latency, frequency of nocturnal arousals, waking after sleep onset, total sleep time, sleep efficiency, subjects' rating (1-10) of the frequency of insomnia and total number of occurrences of the sleep problems per week. The cognitive-affective variables assessed included: frequency of distressing insomnia episodes, sleep self-efficacy, sleep somatic arousal, sleep cognitive arousal and overall distress about insomnia (1-10 rating).

Results indicate improvement in all sleep parameters except in frequency of nocturnal arousal for each of the treatment conditions. Two cognitive-affective variables: frequency of distress and sleep self-efficacy improved as well. The more global cognitive affective variables (cognitive and somatic sleep arousal and overall distress) did not change over time.

The present findings suggest that very brief cognitive-behavioral interventions which involve minimal therapist contact and are portable and inexpensive can be effective in improving sleep in older individuals.

Author

Laura Creti, Eva Libman and Catherine S. Fichten

Source

Proceedings: 8th Annual Meeting of the Association of Professional Sleep Societies, 1994, p. 106. Reprinted in Sleep Research, 23, p. 250.