Strong Support for CBT as First-Line Treatment for Insomnia in Seniors

Dr Rajesh R. Tampi

NEW ORLEANS – Cognitive behavioral therapy (CBT) should be the first-line therapy for insomnia in seniors, but many clinicians are unaware of its benefits, experts say.

“The lack of awareness among clinicians who take care of older adults that CBT for insomnia (CBT-I) is an effective treatment for insomnia is an issue,” Rajesh R. Tampi, MD, professor and chairman of the Department of Psychiatry, Creighton University School of Medicine, in Omaha, Nebraska, told Medscape Medical News.

Tampi was among the speakers during a session at the American Association for Geriatric Psychiatry (AAGP) 2023 Annual Meeting addressing the complex challenges of treating insomnia in older patients, who tend to have higher rates of insomnia than their younger counterparts.

The prevalence of insomnia in older adults is estimated to be 20% to 40%, and medication is frequently the first treatment choice, a less than ideal approach, said Tampi.

“Prescribing sedative and hypnotics, which can cause severe adverse effects, without a thorough assessment that includes comorbidities that may be causing the insomnia” is among the biggest mistakes clinicians make in the treatment of insomnia in older patients, Tampi told Medscape Medical News.

“It’s our duty as providers to first take a good assessment, talk about polymorbidity, and try to address those conditions, and judiciously use medications in conjunction with at least components of CBT-I,” he said.

Long-Term Safety, Efficacy Unclear

About one third of older adults take at least one form of pharmacological treatment for insomnia symptoms, said Ebony Dix, MD, assistant professor of psychiatry at the Yale University School of Medicine in New Haven, Connecticut, in a separate talk during the session. This, despite the low-risk profile of CBT and recommendations from various medical societies that CBT should be tried first.

Dix noted that medications approved for insomnia by the US Food and Drug Administration, including melatonin receptor agonists, heterocyclics, and dual orexin receptor antagonists (DORAs), can play an important role in the short-term management of insomnia, but their long-term effects are unknown.

Dr Shilpa Srinivasan

“Pharmacotherapeutic agents may be effective in the short term, but there is a lack of sufficient, statistically significant data to support the long-term safety and efficacy of any [sleep] medication, especially in aging adults, due to the impact of hypnotic drugs on sleep architecture, the impact of aging on pharmacokinetics, as well as polypharmacy and drug-to-drug interactions,” Dix said. She noted that clinical trials of insomnia drugs rarely include geriatric patients.

The American Academy of Sleep Medicine recommends CBT-I as first-line treatment for insomnia, with the key benefit being its exemplary safety profile, said Shilpa Srinivasan, MD, a professor of clinical psychiatry at the University of South Carolina School of Medicine Columbia, who also presented during the session.

“The biggest [attribute] of CBT-I management strategies is the low risk of side effects,” she said. “How many medications can we say that about?”

The CBT-I intervention includes a focus on key components of lifestyle and mental health issues to improve sleep. These include:

  • Strictly restricting sleep hours for bedtime and arising (with napping discouraged)

  • Control of stimulus to disrupt falling asleep

  • Cognitive therapy to identify and replace maladaptive beliefs

  • Control of sleep hygiene for optimal sleep

  • Relaxation training

Keys to Success

Srinivasan noted one recent study of CBT-I among patients aged 60 and older with insomnia and depression. Of 156 participants randomized to receive weekly 120-minute CBT-I sessions over 2 months were significantly less likely to develop new or recurrent major depression versus their counterparts randomized to receive sleep education (hazard ratio, 0.51; P = .02).

However, CBT-I is more labor intensive than medication and requires provider training and motivation, and commitment on the part of the patient, to be successful.

“We really need to ensure that even when patients are receiving pharmacologic interventions for insomnia that we provide psychoeducation. At the end of the day, some of these nonpharmacologic components can make or break the success of pharmacotherapy,” said Srinivasan.

Whether using CBT-I alone or in combination with pharmacotherapy, the intervention does not necessarily have to include all components to be beneficial, she told Medscape Medical News.

“I think one of the challenges in incorporating CBT-I is the misconception that it is an all-or-nothing approach wherein every modality must be utilized,” she said. “While multicomponent CBT-I has been shown to be effective, the individual components can be incorporated into patient encounters in a stepped approach.”

Informing patients that they have options other than medications and involving them in decision-making is key, she added.

“In the case of insomnia, this is particularly relevant because of the physical and emotional distress that it causes,” Srinivasan said. “Patients often seek over-the-counter medications or other nonprescribed agents to try to obtain relief even before seeking treatment in a healthcare setting. There is less awareness about evidence-based and effective nonpharmacologic treatments such as CBT-I.”

Tampi, Dix, and Srinivasan have reported no relevant financial relationships.

American Association for Geriatric Psychiatry (AAGP) 2023 Annual Meeting. Presented March 5, 2023.

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