Behavioral Treatment of Chronic Insomnia in Older Adults: Does Nocturia Matter?

BEHAVIORAL TREATMENT OF CHRONIC INSOMNIA IN OLDER ADULTS: DOES NOCTURIA MATTER? http://dx.doi.org/10.5665/sleep.3568 Behavioral Treatment of Chronic Insomnia in Older Adults: Does Nocturia Matter? Shachi Tyagi, MD1; Neil M. Resnick, MD1; Subashan Perera, PhD1; Timothy H. Monk, PhD, DSc2; Martica H. Hall, PhD2; Daniel J. Buysse, MD2 1 Division of Geriatrics and Gerontology, Department of Medicine, School of Medicine University of Pittsburgh, Pittsburgh, PA; 2Sleep & Chronobiology Center, Western Psychiatric Institute & Clinic, University of Pittsburgh, Pittsburgh, PA Objective: To evaluate the impact of nocturia on the therapeutic response of chronic insomnia to behavioral treatment in older adults. Methods: Secondary analysis of a randomized clinical trial designed to assess the efficacy of brief behavioral treatment of insomnia (BBTI) vs. an information-only control (IC) in 79 community-dwelling older adults with chronic insomnia. For the current analysis, participants were stratified into 2 groups: those with self-reported nocturia at baseline i.e., ≥ 1 void/night (N = 30; 16 IC, 14 BBTI) and those without nocturia (N = 49; 24 IC, 25 BBTI). We then determined the impact of BBTI on sleep, sleep quality, and nocturia as assessed by self-report, actigraphy, and polysomnography Results: Individuals without baseline nocturia responded well to BBTI with significant decrease in sleep latency, wake after sleep onset, and total sleep time assessed by sleep diary and actigraphy; these changes were significantly greater than those in the IC group. In comparison, changes in the same sleep parameters among participants with nocturia were not significantly different from the IC control. Although BBTI showed significant improvement in sleep quality in groups with and without nocturia (as assessed by PSQI and sleep diary), the effect size of these improvements was larger in those without nocturia than in those with nocturia (PSQI d = 0.82 vs. 0.53, diary sleep quality d = 0.83 vs. 0.51). Conclusions: These secondary analyses suggest that brief behavioral treatment of insomnia may be more efficacious in improving insomnia in participants without nocturia. Addressing nocturia may improve the efficacy of behavioral insomnia treatment. Keywords: Chronic insomnia, nocturia, elderly Citation: Tyagi S; Resnick NM; Perera S; Monk TH; Hall MH; Buysse DJ. Behavioral treatment of chronic insomnia in older adults: does nocturia matter? SLEEP 2014;37(4):681-687. INTRODUCTION Insomnia is common. It is characterized by persistent difficulty initiating or maintaining sleep or by non-restorative sleep sufficient to cause daytime distress and impaired social or occupational functioning.1 Difficulty maintaining sleep is a particularly common feature among older adults, with a prevalence of 40% to 70%.2,3 There are many reasons for geriatric insomnia, including other sleep disorders (e.g., sleep apnea), spending too much time in bed, and an age-related decrease in sleep continuity and depth, as well as changes in circadian rhythms.4,5 Exogenous factors, such as medications, and excessive light or noise can contribute, as can endogenous factors such as pain, anxiety and stress.6 Reduced arousal threshold also contributes to insomnia in the elderly.7,8 One of the most common causes of insomnia in older adults is nocturia. Nocturia is defined by the International Continence Society (ICS) as waking at least once nightly to void, with each void preceded and followed by sleep.9 Three-quarters of participants in a survey of US residents 18 years or older cited the need to void as the most frequent reason for nocturnal awakenings.10 The proportion of participants reporting nocturia as the primary reason for nighttime awakening increased with age: 39.9% in those aged 18-44 years, 57.6% in those aged 45-64 years, and 77.1% in those aged 65 or above.10 Nocturia is an A commentary on this article appears in this issue on page 631. Submitted for publication June, 2013 Submitted in final revised form September, 2013 Accepted for publication September, 2013 Address correspondence to: Shachi Tyagi, MD, University of Pittsburgh, School of Medicine, Division of Geriatric Medicine, 3471 Fifth Avenue, Suite 500, Kaufmann Building, Pittsburgh, PA 15213; Tel: (412) 692-2364; Fax: (412) 692-2370; E-mail: SLEEP, Vol. 37, No. 4, 2014 681 independent predictor of both insomnia (75% increased risk) and reduced sleep quality (71% increased risk).11 Patients bothered by nocturia also report difficulty returning to sleep after an awakening. In addition, among nocturia patients, wakefulness after sleep onset is increased, subsequent awakenings tend to last longer, and subjective restedness after sleep is significantly decreased.11-14 Despite this growing evidence, the role of nocturia in the etiology and treatment of geriatric insomnia has been largely neglected. In fact, early epidemiologic studies examining sleep complaints in older adults sometimes excluded participants who reported waking to void.2 Although insomnia and nocturia are intricately linked, to our knowledge no study has explored the impact of nocturia on treatment of insomnia. Therefore, we conducted a secondary analysis of a randomized controlled trial of behavioral treatment of chronic insomnia in older adults. We postulated that therapeutic response to behavioral treatment of chronic insomnia would be reduced among individuals with concurrent nocturia. METHODS Study Design The primary study was a randomized controlled trial designed to test the short-term efficacy of brief behavioral treatment of insomnia (BBTI) as compared with an information-only control condition (IC) among older individuals with chronic insomnia.15 After baseline clinical evaluation, participants were randomly assigned to BBTI or IC. Primary outcomes were assessed at the end of a 4-week intervention. Participants Study procedures have been described previously.15 Briefly, 82 older adults who met the criteria for primary insomnia in the Diagnosis and Statistical Manual of Mental Disorders, Fourth Does Nocturia Matter?—Tyagi et al Parent Study n = 39 + 40 (BBTI + IC) Participants with no evidence of nocturia n = 49 BBTI (n = 25) (BBTI −N) IC (n = 24) (IC −N) Participants with nocturia n = 30 BBTI (n = 14) (BBTI +N) IC (n = 16) (IC +N) Figure 1—Analytic design. BBTI, brief behavioral treatment of insomnia; IC, information-only control; −N, without nocturia; +N, with nocturia. Edition, Text Revision [DSM-IV-TR])16 were recruited from the community via advertisement (n = 61) and from primary care practices (n = 21). The diagnosis of primary insomnia was based on response to questionnaires and structured clinician interviews. The criteria for insomnia included difficulty initiating or maintaining sleep for at least one month despite adequate opportunity and circumstances for sleep, as well as associated daytime symptoms causing impairment in social, occupational, or other importan (...truncated)