3

Evidence-Based Treatments for

Insomnia in Older Adults
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Haley R. Dillon, Ryan G. Wetzler, and Kenneth L. Lichstein

Insomnia is the most common sleep problem in the general population,

with chronic insomnia being most prevalent in older adults (Foley et al., 1995;
Lichstein, Durrence, Riedel, Taylor, & Bush, 2004; Morphy, Dunn, Lewis,
Boardman, & Croft, 2007; Ohayon, 2002). Insomnia is defined as a complaint
of difficulty falling asleep, difficulty staying asleep, early morning awakenings,
and/or nonrestorative sleep, which results in daytime consequences (Diagnos-
tic and Statistical Manual of Mental Disorders, 4th ed., text revision; DSM–IV–
TR; American Psychiatric Association, 2000). Particularly in older adults,
consequences of insomnia can include increased risk for the onset of depres-
sion and anxiety, substance abuse, cognitive decline, falls, and reduced quality
of life (Jelicic et al., 2002; Perlis et al., 2006; Stone, Ensrud, & Ancoli-Israel,
2008; Taylor, Lichstein, & Durrence, 2003; Zammit, Weiner, Damato, Sillup,
& McMillan, 1999).
Although insomnia is generally more prevalent, more chronic, and
more impairing in older adults, poor sleep is not an inevitable result of aging.
Instead, sleep disturbances in older adults are associated with high levels of
medical and psychiatric comorbidities (Foley, Ancoli-Israel, Britz, & Walsh,
2004; Foley, Monjan, Simonsick, Wallace, & Blazer, 1999; Taylor et al., 2007;
Vitiello, Moe, & Prinz, 2002). Medications used to treat these concurrent health

47

http://dx.doi.org/10.1037/13753-003
Making Evidence-Based Psychological Treatments Work With Older Adults, edited by
F. Scogin and A. Shah
Copyright © 2012 American Psychological Association. All rights reserved.
 problems can further impair sleep in older adults, as can circadian rhythm
disturbances and other primary sleep disorders (i.e., obstructive sleep apnea,
periodic leg movement disorder) that are more common with increasing age
(Ancoli-Israel & Cooke, 2005; Vaz Fragoso & Gill, 2007).
Normal age-related changes in sleep structure and pattern can also
render an individual more susceptible to sleep disturbance (Morgan, 2000).
Sleep becomes lighter with age, as the amount of time spent in Stages 1
and 2 sleep increases and deep slow-wave sleep (Stages 3–4) decreases.
The shifts between sleep stages are more frequent, and combined with the
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greater propensity for light sleep, this leads older adults to experience more
nighttime awakenings and arousals. Average duration of nighttime sleep is
reduced in older adults, although their sleep need has typically not changed.
Finally, circadian rhythm changes can affect the timing and resilience of the
24-hour sleep–wake cycle. For example, the sleep phase of older adults tends
to advance, with typical sleep onset and wake-up times that are several hours
earlier than desired. Changes in activity level, napping behavior, and light
exposure can also influence the sleep–wake cycle. As a result, older adults
may need to adjust their expectations and habits to continue obtaining the
sleep they need.
Over the past 2 decades, psychological treatments for sleep distur-
bances have increasingly focused on older adults, with several reviews and
meta-analyses reporting beneficial effects of cognitive behavioral treat-
ments for late-life insomnia (e.g., Irwin, Cole, & Nicassio, 2006; Mont-
gomery & Dennis, 2004; Nau, McCrae, Cook, & Lichstein, 2005). In
spite of this progress, however, sleep disorders remain a significant public
health concern (Colten & Altevogt, 2006). In addition, there is often
a gap between research and actual clinical practice (Persons, 1995). To
address these concerns, McCurry, Logsdon, Teri, and Vitiello (2007) con-
ducted a review of the insomnia treatment literature to identify the most
efficacious psychological treatments for older adults. Following the criteria
specified by the American Psychological Association’s (APA) Commit-
tee on Science and Practice for Clinical Psychology (Weisz & Hawley,
2001), McCurry et al. identified two evidence-based treatments (EBTs)
for insomnia in older adults; sleep restriction-compression therapy and
multicomponent cognitive behavioral therapy for insomnia (CBT-I). A
third treatment, stimulus control therapy, was partially supported as an
EBT for insomnia in older adults.
This chapter aims to facilitate the implementation of EBTs for insom-
nia in older adults by reviewing both research and clinical application. The
first part of the chapter presents the identified EBTs for late-life insomnia and
summarizes current research support. The remainder of the chapter addresses
the application of these psychological treatments in clinical settings. A certi-

48    dillon, wetzler, and lichstein

 fied behavioral sleep medicine (BSM) specialist shares his experiences as a
clinician and presents a case example to illustrate how EBTs can be provided
in clinical practice. Finally, the chapter concludes with sample treatment
materials and patient handouts.

The Evidence
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Haley R. Dillon and Kenneth L. Lichstein

This section describes the EBTs for sleep disturbances in older adults
that were identified in the original article by McCurry et al. (2007). In addi-
tion, we review the most recent evidence from an updated literature search
(from January 2006 through December 2008).

Sleep Restriction—Sleep Compression Therapy

Sleep restriction therapy (Spielman, Saskin, & Thorpy, 1987) is a behav-

ioral treatment for insomnia designed to improve sleep consolidation. Many
people with insomnia spend too much time in bed in an effort to recover lost
sleep. However, this practice often leads to an increase in sleep fragmentation
and time spent awake in bed, which can heighten sleep performance anxiety
and perpetuate the sleep difficulty. The goal of sleep restriction therapy is to
maximize sleep efficiency (SE; ratio of time spent asleep to time spent in bed ×
100), by limiting the time spent in bed to match the actual or estimated
amount of sleep reported by the client. Any mild sleep deprivation that is
experienced by restricting time in bed will increase homeostatic drive and
make it easier to fall asleep and stay asleep during the allotted time period in
bed, thus consolidating sleep.
Sleep restriction therapy begins with having clients complete 2 to
3 weeks of sleep diaries (see the example diary in Appendix 3.1), which pro-
vides a daily record of the client’s self-reported sleep. The initial time in bed
(TIB) prescription is then set to be roughly equal to the average total sleep
time (TST) calculated from the baseline sleep diaries. On the basis of the
prescribed amount of TIB, a sleep schedule with a fixed bedtime and arise
time is set for the following week. The client continues to keep sleep diaries
throughout the course of treatment, and the amount of time allowed in bed
is subsequently increased or decreased based on the client’s reported sleep
efficiencies, until an optimal sleep schedule is reached. (See Wohlgemuth

insomnia in older adults    49

 & Edinger, 2000, for detailed instructions on implementing sleep restriction
therapy.)
Sleep compression therapy is a modified version of sleep restriction that
gradually restricts TIB to match TST instead of making this change immedi-
ately. In sleep compression (Lichstein, Thomas, & McCurry, 2010; Riedel,
Lichstein, & Dwyer, 1995), the client’s self-reported average TST and aver-
age TIB are calculated from 2 weeks of baseline sleep diaries. The difference
between the average TIB and average TST is then divided equally among
a prespecified number of sessions to gradually reach the same goal as sleep
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restriction therapy, where TIB matches TST.

McCurry et al. (2007) identified three studies that provide evidence-
based support for sleep restriction–compression therapy in older adults with
insomnia. One study used sleep restriction (Friedman et al., 2000), whereas
the other two studies used sleep compression (Lichstein, Riedel, Wilson, Lester,
& Aguillard, 2001; Riedel et al., 1995). The mean effect size (ES) relative
to controls across the three studies was 0.77. No new studies meeting EBT
criteria have tested sleep restriction–compression as a stand-alone treatment
for insomnia in older adults.

Multicomponent CBT

As noted in another review of psychological treatments for insomnia,

there is a growing trend for combining two or more individual therapies into
a single package treatment (Morin et al., 2006). Multicomponent CBT-I
is a popular combination treatment that meets evidence-based criteria for
treating late-life insomnia. Although specific techniques can vary, CBT-I
typically includes sleep hygiene education, stimulus control, sleep restriction–
compression, relaxation training, and cognitive therapy.
Sleep hygiene is a standard component of multicomponent CBT-I that
refers to a set of behaviors and lifestyle practices that can affect sleep. Exam-
ples include avoiding caffeine and/or alcohol use near bedtime and keep-
ing a comfortable sleep environment (i.e., dark room, cool temperature,
reduced noise). There is not a standard set of recommendations for good sleep
hygiene, but a sample patient handout of common guidelines is included in
Appendix 3.2.
Behavioral interventions such as sleep restriction–compression and
stimulus control therapy are the mainstay of CBT-I. Stimulus control therapy
(Bootzin, 1977; Bootzin & Epstein, 2000) is based on the idea that the bed
and bedroom can become associated with states of wakefulness (e.g., tossing
and turning, watching television, reading, worrying). Over time, the bed and
bedroom can become conditioned cues for arousal and wakefulness instead of

50    dillon, wetzler, and lichstein

 sleep. Stimulus control therapy includes a set of behavioral instructions (see
Appendix 3.3) designed to break these maladaptive associations between the
bed and sleep-incompatible behaviors, and strengthen the bed and bedroom
as discriminative stimuli for sleep.
Relaxation training is often included as a way to help reduce physi-
ological and/or cognitive arousal that may interfere with sleep. A variety of
relaxation procedures have been used in CBT-I, including progressive muscle
relaxation, passive relaxation, guided imagery, autogenic training, medita-
tion, and biofeedback (Manber & Kuo, 2002). A verbatim script for a hybrid
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relaxation procedure that involves passive relaxation and autogenic phrases

can be found in Lichstein (2000).
Finally, most CBT-I treatment packages include a cognitive or edu-
cational component that addresses sleep-related beliefs and attitudes, as
well as treatment motivation and compliance. People with insomnia often
hold dysfunctional beliefs and unrealistic expectations about their sleep that
can lead to sleep-incompatible behaviors (e.g., spending excessive time in
bed, increased arousal and bedtime worry about sleep loss) that maintain
the sleep disturbance. Formal cognitive restructuring therapy (described in
Morin, Savard, & Blais, 2000) helps clients identify, challenge, and replace
dysfunctional cognitions with a more realistic and rational view. The degree
of sleep education that is shared with clients can aid in this goal. Particularly
with older adult populations, information about normal age-related changes
is essential.
The original review of EBTs for late-life insomnia identified seven studies
that support CBT-I in older adults (Hoelscher & Edinger, 1988; Lichstein, Wil-
son, & Johnson, 2000; McCurry, Logsdon, Vitiello, & Teri, 1998; Morin, Col-
ecchi, Stone, Sood, & Brink, 1999; Morin, Kowatch, Barry, & Walton, 1993;
Rybarczyk et al., 2005; Rybarczyk, Lopez, Benson, Alsten, & Stepanski, 2002).
An updated literature search identified one additional study that contributed
to the evidence base for CBT-I (Sivertsen et al., 2006). Table 3.1 lists treat-
ment components and between-group ESs at posttreatment for all eight trials
that support CBT-I. Across the eight studies, the mean ES for CBT relative to
control was large at 1.03.
In the newly added study, Sivertsen et al. (2006) found beneficial effects
for CBT-I when comparing it with pharmacotherapy and placebo treatment
in 46 older adults. At 6 weeks posttreatment, objective measures of sleep
(polysomnography) showed that the CBT-I group had significantly less total
wake time at night than both the pharmacotherapy (ES = 1.23) and placebo
(ES = 1.61) groups and had a significantly better sleep efficiency than the
placebo group (ES = 1.32). An important finding to note is that beneficial
effects in the CBT-I group were actually stronger at the 6-month follow-up
than at posttreatment.

insomnia in older adults    51

 Copyright American Psychological Association. Not for further distribution.

52   
Table 3.1
Studies That Contribute to the Evidence-Based Status of Multicomponent Cognitive Behavioral Therapy
for Insomnia in Older Adults
Study Treatment conditions Length and format M ES
Hoelscher & Edinger, 1988 Multicomponent (SC, SR, education) (multiple 4 individual sessions 1.12
baseline design)
Lichstein, Wilson, & Johnson, 2000 Multicomponent (SH, SC, RE) vs. wait-list 4 individual sessions 0.76
control
McCurry, Logsdon, Vitiello, & Teri, 1998 Multicomponent (SH, SC, SCO, RE) vs. wait- 4–6 sessions (4 individual, 0.74
list control 6 group)
Morin, Kowatch, Barry, & Walton, 1993 CBT (SH, SC, SR, CT) vs. wait-list control 8 group sessions 1.01

dillon, wetzler, and lichstein

Morin, Colecchi, Stone, Sood, & Brink, CBT (SH, SC, SR, CT) vs. medication vs. 8 group sessions 1.07
1999 combination CBT–medication vs. placebo
Rybarczyk, Lopez, Benson, Alsten, CBT (SH, SC, SR, CT, RE) vs. HART vs. wait- 8 group sessions 1.36
& Stepanski, 2002 list control
Rybarczyk et al., 2005 CBT (SH, SC, SR, CT, RE) vs. SMW–placebo 8 group sessions 0.76
Sivertsen et al., 2006 CBT (SH, SC, SR, CT, RE) vs. medication vs. 6 individual sessions 1.39
placebo
Note. ES = effect size; SC = stimulus control therapy; SR = sleep restriction therapy; SH = sleep hygiene; RE = relaxation therapy; SCO = sleep compression therapy;
CT = cognitive therapy; CBT = cognitive behavior therapy; HART = home audiotape relaxation therapy; SMW = stress management and wellness.
 The new search also yielded two studies testing abbreviated versions of
CBT-I in older adults. According to the APA coding manual, two versions
of a treatment program are considered to be the same treatment if study
authors judge the treatment to be essentially the same and treatment dura-
tion is at least 75% of the longer version. Because of the much shorter dura-
tion of the abbreviated version, it will be considered a separate treatment
from the four- or eight-session CBT-I previously described.
Abbreviated CBT-I could not be classified as a separate EBT because
there was not a minimum of 30 participants who represented the active treat-
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ment across the two studies. However, both studies found the brief multicom-
ponent treatment to be superior to sleep hygiene education–information-only
control groups. Germain et al. (2006) delivered a combination of sleep
restriction, stimulus control, and sleep hygiene education (n = 17) in one
initial treatment session that was followed up 2 weeks later with a 30-minute
“booster session.” McCrae et al. (2007) used two in-person treatment ses-
sions and two follow-up phone calls to administer a multicomponent treat-
ment composed of sleep restriction, stimulus control, and relaxation training
(n = 11). Corroborating evidence is needed to provide further support for
the use of abbreviated CBT-I in older adults. Future studies should also
explore whether variations in the length–duration of CBT-I affect treat-
ment outcome.

Treatments Requiring Additional Evidence

Stimulus control therapy, as previously described, is a behavioral

intervention for insomnia that can be used in combination with other
techniques or as a standalone treatment. McCurry et al. (2007) identified
two studies (Morin & Azrin, 1988; Puder, Lacks, Bertelson, & Storandt,
1983) that revealed group stimulus control therapy with older adults to be
superior to wait-list/delayed-treatment control conditions, but the number
of participants across studies that received stimulus control did not meet
evidence-based criteria of 30 participants in the active treatment condi-
tion. An updated search of the literature did not yield additional studies by
using stimulus control as an individual treatment, so it remains a partially
supported treatment. However, the lack of evidence for classifying stimulus
control therapy as an EBT for late-life insomnia is likely due in part to the
growing popularity of combination treatments for insomnia. It should be
noted that stimulus control is considered an empirically supported treat-
ment for younger adults (Morin et al., 2006) and was included in all eight
of the studies supporting CBT-I as an evidence-based treatment (EBT) for
older adults.

insomnia in older adults    53

 Multicomponent Treatments
With Special Populations

There is substantial heterogeneity across the older adult population

with the increasing prevalence of chronic diseases, medical comorbidity, and
cognitive impairment. This section discusses variations of multicomponent
CBT-I that have been studied in special populations of older adults. Because
the following studies tailored treatment implementation and outcomes to
meet the unique needs of their target population, these studies were not
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included in the formal evidence-based review. However, they provide further

support for the use of multicomponent CBT-I in older adults and should be
considered worthy of further investigation.
Older adults with insomnia are more likely than other age groups to be
prescribed benzodiazepine hypnotics (Stewart et al., 2006), which increase
the risk of falls and other adverse effects and can lead to hypnotic-dependent
insomnia. As a result, several treatment studies have targeted sleep interven-
tions at chronic users of sleep medications. Morgan et al. (2003) found that
hypnotic-dependant older adults treated with CBT-I in a primary care setting
had greater reductions in medication use and greater sleep improvements
than those who received usual care. Two studies found that adding CBT-I
to a benzodiazepine-tapering program facilitated medication withdrawal in
older adults with insomnia (Baillargeon et al., 2003; Morin et al., 2004). Fur-
ther support for the efficacy of psychological treatments for late-life insomnia
comes from a recent study that indicated that CBT-I leads to sleep improve-
ments in hypnotic-dependant older adults even when sleep medication con-
sumption is held constant (Soeffing et al., 2008).
Researchers have also adapted CBT interventions to address sleep–wake
disturbances in older adults with dementia. Treatments for this population
are usually multidimensional, involving a variety of behavioral and nonphar-
macological techniques aimed at increasing social and physical activity and
decreasing daytime sleep. For example, Alessi et al. (2005) used a combina-
tion of behavioral activation, daytime light exposure, reduced daytime spent
in bed, and basic sleep hygiene (i.e., structured bedtime routine, reduction of
nighttime noise and light) in a randomized controlled trial with nursing home
residents. In comparison with residents who received usual care (n = 56), the
5-day intervention led to modest improvements in sleep–wake rhythms and
wakefulness during the night for the intervention group (n = 58).
Treatment setting is of particular importance with this population, as
many older adults with dementia reside in nursing homes or long-term-care
facilities that can present additional challenges (e.g., nighttime noise). To our
knowledge, only one study has been conducted outside of an inpatient setting.
McCurry et al. (2005) administered a multicomponent treatment for insomnia

54    dillon, wetzler, and lichstein

 to community-dwelling older adults with Alzheimer’s disease and their family
caregivers. The 8-week intervention (consisting of daily physical activity, daily
light therapy, and sleep hygiene education for participants and their caregivers)
led to reductions in both the frequency and duration of nighttime awakenings.

Other Psychological Treatments

Three other psychological interventions (i.e., relaxation training, biofeed-

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back, and paradoxical intention) have been shown to be effective stand-alone

treatments for adults with chronic insomnia (Morin et al., 2006). However,
because of the lack of research on these treatments in older insomnia popula-
tions, they were not included in the current evidence-based review. Similarly,
other nonpharmacological treatments for insomnia that were excluded from
this review may hold promise for treating late-life insomnia. Most comple-
mentary and alternative medicine (CAM) treatments were not reviewed here
because they do not meet the definition for “psychological treatments” that was
put forth by APA’s 2005 Presidential Task Force on Evidence-Based Practice.
However, there is a growing literature on using CAM to treat sleep disturbances
in older adults, including techniques such as bright-light therapy, exercise and
physical activity, massage, acupressure, and tai chi (see Gooneratne, 2008, for
a review). The evidence supporting these types of treatments, however, is still
too preliminary to yield conclusions about their efficacy.
For treatment providers interested in more information and details on
implementing specific treatment components, we recommend the following
books:
1. Treatment of Late-Life Insomnia (Lichstein & Morin, 2000)
2. Insomnia: Psychological Assessment and Management (Morin,
1993)

Adapting EBT for Clinical Settings

Ryan G. Wetzler

Before discussing specific strategies and challenges to implementing

EBTs, it may be helpful to know a bit about my practice setting and train-
ing. I am currently a full-time clinician, working in an independent sleep
disorders center in Louisville, Kentucky. Our group has three sleep labs, eight
physicians, and currently one psychologist. The group is highly specialized,

insomnia in older adults    55

 with our physicians being board certified in internal medicine, pulmonary
and critical care medicine, as well as sleep medicine. My particular area of
focus is on applying psychological principles to the evaluation and treat-
ment of the full spectrum of sleep disorders, including insomnia, circadian
rhythm sleep disorders, narcolepsy–hypersomnia, nightmares–parasomnias,
and other sleep-related difficulties (i.e., difficulty adhering to continuous
positive airway pressure for treating sleep apnea).
I was originally trained in health psychology and completed a fellow-
ship in sleep medicine–BSM, leading up to certification in the practice of
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BSM. As such, my clinical perspective is very much informed by a health psy-

chology perspective, and my treatment focus is typically on the patient’s sleep
problems. In addition, most of my training and experience occurred within
medical settings, and hence I hope to share the challenges I experienced
when integrating a psychological approach in an established medical setting.
I realize that other chapters have focused on challenges to adapting
EBT protocols–manuals to clinical practice settings, and I do plan to discuss
this in brief. However, before we jump into the nuts and bolts of this, I believe
we need to first consider the bigger picture. The bigger picture is one in which
very few psychologists are integrated into settings where they can even have
an opportunity to practice in this way. I have the luxury of being able to apply
such strategies due at least in part to the specialized nature of my treatment
setting. In my opinion, the only way to proliferate the practice of EBTs is to
develop opportunities for psychology to work in specialized clinics, which are
most commonly medically based. As such, the following review first addresses
issues related to practice opportunity and only then discusses the practice
itself. Significant challenges we have encountered include
77 limited community understanding of evidence-based psycho-
logical intervention,
77 difficulty in establishing consistent referral sources,
77 reimbursement challenges, and
77 difficulty in applying a research model of treatment to complex
clinical populations.
Following is a more detailed discussion of these challenges and adaptations
we found successful in managing them.

Limited Community Understanding

Until its establishment as a subspecialty of health psychology and clin-

ical sleep medicine in 2003, BSM was not a term familiar to many. Even
with the decades of research support for cognitive behavioral intervention

56    dillon, wetzler, and lichstein

 strategies for insomnia, far too few recognize the value of a BSM specialist.
The challenge of disseminating the value of evidence-based behavioral inter-
ventions for sleep disorders remains decades behind their availability to the
public. The problem of dissemination runs deep and is a frequently discussed
topic. The challenge is multifaceted and includes misinformation and limited
understanding amongst medical providers, the general public, and even fel-
low mental health providers. There is often a lack of awareness that EBTs
for insomnia even exist. In my experience, several strategies have positively
impacted the challenge of dissemination. These efforts have included devel-
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oping patient brochures, presenting at local conferences, publishing in local

journals, and most important, having face-to-face discussions with health care
providers. Taking a proactive stance on community education can go a long
way in increasing the sustainability of an empirically based practice and can
have a positive impact on establishing consistent referrals.

Difficulty Establishing Referral Sources

Establishing a new business is never easy and is no different than estab-

lishing a new service line highlighting empirically supported treatments. As
much as we might like to ignore the financial realities of clinical practice,
the bottom line in the success of any service is profitability. To put this in
perspective, the first BSM program I was involved in failed within 2 years due
to lack of funding. The program was staffed by a practicum student, and it
was discontinued because the hospital was not willing to pay the $2,000 per
year for supervision of the student to maintain the program. Lesson learned:
No matter how valuable and effective a treatment may be, if the service can-
not financially sustain itself, it is sure to perish. As such, an important step
in establishing a successful BSM practice is to develop consistent referral
sources. Developing consistent referral sources can be challenging, and it hinges
on (a) choosing the correct location to set up a practice and (b) marketing of
the service.
The first step in establishing a referral basis is deciding where to estab-
lish the practice. This decision is made on a variety of factors, and for BSM
the most logical place would seem to be the sleep disorders center or through
affiliation with a sleep disorders center. Because few are familiar with CBT-I
or other BSM services, it may be difficult to establish a practice outside of the
environment in which many with sleep problems would seek help. Although
it may appear equally logical to set up shop in a primary care office, psycholo-
gists in such settings typically serve more as generalists than specialists, and
financial barriers continue to exist that may interfere with the financial sus-
tainability of a primary care–based practice. In an established specialty clinic,

insomnia in older adults    57

 it is more likely that the other health care providers will have an understand-
ing of the services being provided and may even seek out such professionals
to round out their practices. In addition, being located in such a setting may
legitimize the service in the eyes of those who would otherwise be unlikely to
follow through on a referral to a BSM specialist. Setting up shop in an estab-
lished specialty clinic also has a proven track record with success in a variety
of other health psychology subspecialties, including chronic pain, headaches,
and weight loss.
The second and most challenging aspect of developing consistent
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referral sources is marketing. Historically, marketing has been a dirty word

in the field of psychology due at least in part to traditional psychology prac-
tices really not needing to market their services. As such, many involved
in traditional psychological practice continue to frown on the marketing
of psychologically based treatments. It must be recognized that the prac-
tice of clinical health psychology specialties is different from traditional
practice in a variety of ways. Intervention strategies are brief and effective,
and, hence, turnover is great. Because BSM providers do not hold onto
patients for years, open spots are frequent. To sustain such a practice, a
consistent number of referrals (at least 15 per month) is needed. As such,
it becomes increasingly important to get out of the office and discuss BSM
services in the community. The most effective strategy we have found
is to use the same tactics that have been developed and proven by the
pharmaceutical industry. This includes staff lunches and individualized
discussion with community primary care and specialty health care provid-
ers. Our experience has been that we are welcomed into such practices and
our message is received very well. Such providers seem hungry for a differ-
ent message than are given by drug reps and see BSM services as a highly
valued community resource.

Reimbursement Challenges

Many trailblazers in the practice of health psychology have encountered

significant obstacles in getting paid by insurance for the services they provide.
This challenge continues, yet it has been offset slightly by the advent of
the health and behavior codes. Although far from perfect, these codes have
enabled psychologists to provide empirically supported psychological inter-
vention strategies to many with debilitating medical conditions. Of course,
there are downsides to these codes. The first is that they are not consistently
reimbursed as well as traditional psychological practice codes. Second, there
continues to be mass confusion in regard to their use, both among insurance
carriers as well as psychologists and health care systems. For the past 5 years

58    dillon, wetzler, and lichstein

 we have grappled with the most appropriate manner to bill for BSM services
and have concluded that there is no single best method.

From the Bench to the Bedside

The final and perhaps most daunting obstacle to the proliferation of

BSM and other EBTs is clinician resistance. This resistance takes many forms.
Common themes of this resistance include (a) the practicality of developing
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such services, (b) difficulties adapting the research-based treatment proto-

cols to clinical practice, and (c) concerns regarding the applicability of such
protocols to complex clinical cases. Some may find it difficult to devote the
countless hours it takes to develop and implement such programs. As a now-
established EBT provider, I can reflect with certainty that the preliminary
time spent in program development was well worth a few sleepless nights
along the way. The good news is that once the initial time investment is
made, maintaining and expanding the program become much easier. Inci-
dentally, since we developed our initial insomnia treatment program 6 years
ago, it has been completely overhauled three times.

Adapting BSM to Clinical Settings

Most of the evidence available in regard to psychological treatments

comes in the form of efficacy trials. Such trials are conducted on highly spe-
cific populations and highly specific problems. With regard to the insomnia
literature, many of the studies are on primary insomnia, a condition infre-
quently encountered in clinical practice. The most common patient in our
clinic presents with chronic insomnia as well as a myriad of coexisting health
conditions. Unfortunately, the efficacy literature does not necessarily speak
to this more complex presentation. The way in which we have adapted these
protocols was through first understanding our population. This may be done
through discussions with others who are practicing in the area, or in our
case through formal program evaluation procedures. What we found in our
patients were high rates of depression, anxiety, chronic pain, and other stress-
related medical problems.
The treatment protocols used in efficacy studies of multicomponent
CBT-I typically focus on sleep hygiene education, sleep restriction therapy,
and stimulus control therapy. In adapting this to our clinical population, we
added more in-depth cognitive therapy, relaxation training, and mindful-
ness training to our clinical treatment protocol. We also added supplemental
EBT’s to address specific coexisting conditions that we encounter frequently,

insomnia in older adults    59

 such as behavior activation therapy for depression, disrupted homeostatic
sleep drive, or both; interoceptive desensitization for panic disorder; cogni-
tive therapy for generalized anxiety disorder; prolonged exposure therapy for
posttraumatic stress disorder; activity–rest–pacing for chronic pain; and a
variety of others. Finally, we developed complementary programs for other
commonly encountered sleep disorders, including programs for continuous
positive airway pressure adherence, narcolepsy–hypersomnia, and circadian
rhythm sleep disorders.
Other adaptations involve the way in which EBTs are administered.
Copyright American Psychological Association. Not for further distribution.

Treatment protocols used in research studies are highly standardized, with

little flexibility in procedures or treatment timeline. In clinical settings, it is
nearly impossible to move at the same pace with every patient. For example,
we occasionally see highly motivated and well-educated patients who quickly
grasp the treatment concepts and readily comply with our instructions. After
the first few sessions with these patients, they need little guidance from us,
and remaining sessions can be spread out over time. However, most of our
patients, particularly those with more complex presentations and comorbidi-
ties, have difficulty with treatment adherence and need a higher level of sup-
port and accountability.
Treatment resistance and noncompliance often stem from the
patient’s lack of understanding as to why he or she is being asked to fol-
low certain instructions. For this reason, we spend a lot of time explaining
the rationale behind each intervention that is presented. We encourage
patient questions, which aid in identifying and troubleshooting potential
problem areas. Common issues with older adults include difficulties staying
awake until the prescribed bedtime and unintentional napping during the
day due to lack of activity. Additionally, older adults may be resistant to
following a strict sleep schedule because they no longer have to wake up to
get to work on time or take care of children. Many older adults we see are
adjusting to recent life changes, such as retirement or loss of a spouse. In
these cases, we frequently use complementary treatment strategies, such as
behavioral activation, to help increase patient’s activity level and amount
of social interaction. As you will see in the case example, compromise is
often necessary to get the patient on board with even attempting to follow
treatment recommendations.
Sleep logs are a final issue to mention. Although sleep logs are the pri-
mary way in which we track treatment adherence and progress, patients are
not always compliant. Commonly encountered problems include patients
not understanding how to fill out the sleep logs, as well as patients having
concerns about filling the logs out “accurately.” To combat these issues, I
spend a significant amount of time upfront with the patient, explaining the
purpose of the sleep diaries and the correct way to fill them out. I emphasize

60    dillon, wetzler, and lichstein

 that the logs are designed to capture the patient’s perception of their sleep
and that we want the patient’s best estimate of their sleep pattern the night
before, not the specific clock times.
When a patient fails to bring in a completed sleep log or complains that
it made her or his sleep “worse,” I probe the patient’s approach. With forget-
ful patients, simple strategies such as leaving the sleep log and a pencil by the
bed or on the breakfast table can help them be more consistent. I have also
found that most patients who report that keeping the sleep log is interfering
with their sleep are overly concerned with recording exact times and are fill-
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ing it out incorrectly. For example, patients may be fixating on the clock in
an attempt to record their exact bedtime or getting up during every nighttime
awakening to record it on the sleep log. Redirecting the patient’s approach to
the sleep logs and reassuring them that we do not expect perfection can often
resolve the issue. However, we still have to make compromises with many
patients. Instead of keeping ongoing sleep logs throughout the duration of
treatment, we may have patients record their sleep every other week or every
other session. When patients are greatly opposed to keeping sleep logs, we
have devised other ways to track their compliance, such as short daily check-
lists of the most important treatment goals (e.g., patients check yes or no as
to whether they actually got up at their prescribed wake-up time, whether
they napped during the day).
In the next section, we describe a prototypical case example of an older
woman being treated for chronic insomnia in our BSM clinic.

Case Example

“Ms. Insomnia” is a 70-year-old, African American woman who com-

pleted our multicomponent CBT-I program in 2008. Her case represents a
prototypical case seen in our clinic.

Presenting Complaint and Sleep History

Ms. Insomnia presents with reports of not being able to sleep at night,
feeling her sleep is “restless,” and waking up approximately every 2 hours
with difficulty getting back to sleep. She describes “anxiety” that causes her
to have to go to the hospital. She explains that during these experiences she
has an increasing heart rate, sweating, feelings of the “chills,” and feeling
dizzy. She has experienced this difficulty for the past 2 years, having pre-
sented multiple times to the hospital with what appears to be panic attacks.
She describes trouble getting to sleep and staying asleep for at least the past
3 months.

insomnia in older adults    61

 Ms. Insomnia reports a history of using lorazepam to help her sleep. She
describes the medication as having minimal impact on her ability to sleep
at night, which resulted in her discontinuing its use against medical advice.
She is currently taking Tylenol PM on a nightly basis with minimal efficacy.

Family and Social History

Ms. Insomnia currently resides in Louisville, Kentucky, and has been

living by herself for the past couple of years. She worked for 35 years as a nurs-
Copyright American Psychological Association. Not for further distribution.

ing assistant and has been on Social Security disability for the past 9 years
secondary to cardiovascular disease and cancer. She completed 9 years of
education. She is currently separated and reports two previous marriages that
ended in divorce. She has five children and 12 grandchildren. She reports
that relations with family members are generally “good” with no ongoing
problems or conflicts mentioned. When asked about her social life, she states,
“I go to church and do not go out anywhere else.”

Medical and Psychiatric History (as Reported by the Client)

77 Surgical history: Cardiac bypass in 2005, mastectomy in 2006

77 Medical conditions: Allergies or asthma, arthritis in her shoul-
der and both knees, history of breast cancer, hypertension, and
ongoing pain condition rated as an 8 on a scale from 0 to 10,
with 10 indicating the most severe pain she could imagine
77 Current medications: Metformin, Crestor, warfarin, aspirin,
diltiazem, isosorbide, sotalol, potassium, metoclopramide, and
over-the-counter medication (e.g., acetaminophen)
77 Psychiatric history: She reports a history of some depression and
anxiety following divorce from her first husband in 1978. At
that point, she saw a psychiatrist and was prescribed antidepres-
sant medication. She denies any other history of psychiatric
treatment. However, she had presented to the emergency room
approximately 12 times over the past 2 years for panic symptoms.

Mental Status Exam

Ms. Insomnia presented for the evaluation as oriented × 3. Her interac-

tional style was pleasant and cooperative. Eye contact was good. Speech was
relevant and organized. Affect appeared within normal limits. She denies sig-
nificant memory problems or problems with concentration or attention. She
describes a recent decrease in appetite. Ms. Insomnia denies current suicidal
or homicidal ideation or intent.

62    dillon, wetzler, and lichstein

 Summary of Results From Assessment Measures

Sleep History Questionnaire (see Appendix 3.4)

Currently, Ms. Insomnia reports taking 4 hours to fall asleep most
nights. She reports an average of six awakenings per night, with approxi-
mately 5 hours spent awake during the night. She estimates her average TST
is 3 hours per night, but she feels like she needs at least 6 hours of sleep to
feel rested the next day.
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Ms. Insomnia reports signs and symptoms suggestive of possible obstruc-

tive sleep apnea syndrome, insomnia, restless legs syndrome, and circadian
rhythm sleep disorder. She denies signs or symptoms suggestive of narcolepsy,
significant parasomnia, or bruxism. Review of sleep-scheduling practice sug-
gests that she does not maintain a regular sleep–wake schedule and has a
tendency to sleep in approximately 2 hours on weekends.

Sleep Hygiene Practice Scale (Lacks, 1987)

Ms. Insomnia reports engaging in five of seven counterproductive con-
ditioning behaviors, six of 10 general sleep hygiene practices, and experienc-
ing one of four interfering environmental factors. Results suggest that poor
sleep hygiene practices may be having an impact on her ability to sleep at
night.

Insomnia Severity Index (Morin, 1993)

Total score = 20, suggestive of moderate insomnia.

Pre-Sleep Arousal Scale (Nicassio, Mendlowitz, Fussell, & Petras, 1985)

Total cognitive arousal score = 25, suggestive of conditioned cogni-
tive arousal to her bedroom. Total somatic arousal score = 22, suggestive of
conditioned somatic arousal to her bedroom as well. Overall results suggest
conditioning factors may be a playing a major role in her ongoing difficulty
sleeping.

Daytime Alertness (Regestein Hyperarousal) Scale (Regestein, Dambrosia,

Hallett, Murawski, & Paine, 1993)
Total score = 39, suggestive of mild physiologic hyperarousal.

Epworth Sleepiness Scale (Johns, 1991)

Total score (0–24) = 13, suggestive of excessive daytime sleepiness,
which is likely associated with sleep deprivation. However, this score also

insomnia in older adults    63

 may suggest a need for an overnight sleep study to rule out obstructive sleep
apnea syndrome if she does not respond to treatment for insomnia.

Dysfunctional Beliefs and Attitudes About Sleep Questionnaire (Morin, 1993)

Total score = 28, suggestive of sleep-related worry and maladaptive
sleep-related beliefs, which are likely contributing to her ongoing sleep
disturbance.
Copyright American Psychological Association. Not for further distribution.

Motivation for Change Index1

Review suggests adequate motivation for change, and, thus, it is believed
that Ms. Insomnia would likely benefit from cognitive behavioral interven-
tion for her insomnia.

Personality Assessment Inventory (Morey, 1991)

Validity of test results: questionable. Results should be viewed with cau-
tion. Ms. Insomnia’s profile showed clinical elevations on the Depression
scale, Paranoia scale, and Schizophrenia scale. Subclinical elevations were
found on the Somatization scale, Anxiety scale, Anxiety-Related Disorder
scale, and Borderline Personality scale.

Case Conceptualization

Overall results of Ms. Insomnia’s evaluation suggest severe sleep onset

and sleep maintenance insomnia, with sleep state misperception. Our clinic
conceptualizes insomnia cases according to the behavioral model of insom-
nia. According to this model, insomnia is viewed as a function of three
interconnected factors; predisposing, precipitating, and perpetuating factors.
These factors are summarized for Ms. Insomnia as follows.

Predisposing Factors
Ms. Insomnia presents reporting a strong worry proneness and rumina-
tive tendency. She also reports being more of a lark versus an owl, suggesting
a natural propensity for circadian phase advance. Factors such as these fre-
quently render individuals vulnerable to the experience of insomnia.

Precipitating Factors
Ms. Insomnia describes the onset of significant anxiety and panic
approximately 2 years ago, which coincides with her mastectomy and cardiac

1
Contact author R.W. for scale information.

64    dillon, wetzler, and lichstein

 bypass. At the same point, Ms. Insomnia’s children moved out of the home,
leaving her with few social supports.

Perpetuating–Maintaining Factors
A review of assessment results suggests a variety of factors involved
in her ongoing sleep disturbance, including poor sleep hygiene practices,
mild physiologic hyperarousal, severe cognitive arousal, severe conditioned
cognitive and somatic arousal, circadian disruption, limited social support,
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moderate-to-severe anxiety, and possible underlying sleep disorders.

Treatment Plan

We plan to meet with Ms. Insomnia in 1 to 2 weeks to review and discuss

all assessment results in detail. At that time, we will discuss treatment options,
including both pharmacologic and psychological treatment approaches. If she
is interested in cognitive behavioral intervention, we will initiate the treatment
process at that time. We will then see this patient two to 10 times on a weekly
or biweekly basis and provide her with our empirically supported, multicompo-
nent, cognitive behavioral treatment process. Specific intervention strategies
will include a combination of some or all of the following interventions based on
her particular needs: sleep hygiene education, sleep restriction therapy, stimulus
control therapy, sleep specific cognitive therapy, relaxation training, thermal
biofeedback, bright-light therapy, and others as clinically indicated. We will
monitor treatment progress using sleep logs on a session-by-session basis.

Other Treatment Considerations

1. Although the patient’s primary complaint is insomnia, she also

reports possible symptoms of sleep apnea. If Ms. Insomnia does
not respond to insomnia treatment, or if she continues to report
poor sleep and excessive daytime sleepiness despite improve-
ments in her sleep quantity, we will consider the need for an
overnight sleep study to rule out underlying or co-occurring
sleep disorders.
2. We will continue to evaluate Ms. Insomnia’s anxiety and depres-
sion during the course of treatment. We plan to focus more
attention in the treatment process for her insomnia on stress
management and may add interoceptive desensitization for
panic as clinically indicated. If adequate treatment gains are not
forthcoming and her anxiety and depression symptoms persist or
worsen, we will consider referral for assessment and treatment of
a possible anxiety–mood disorder.

insomnia in older adults    65

 3. Throughout treatment, we will encourage Ms. Insomnia to
begin increasing her level of social activity and social inter-
action. We will explore the potential benefits of her getting
involved at her local senior center.

Session-by-Session Outline

Treatment sessions were conducted with Ms. Insomnia on a biweekly

basis, and treatment outcomes were tracked by using weekly sleep logs with
Copyright American Psychological Association. Not for further distribution.

ratings of daytime stress and sadness. In the sections below, we present an

overview of each treatment session and a brief rationale for the interventions
used. Each session overview is followed by a synopsis of the sleep log scores for
that visit. For clarification, sleep-onset latency refers to the average amount of
time it took to initiate sleep, with anything less than 30 minutes being nor-
mal. Nightly awakenings refer to the average number of times the individual
was aware of waking up throughout the night. Wake time after sleep onset refers
to the average amount of time a person spent awake in the night following
awakenings, with anything less than 30 minutes being normal. Total sleep time
refers to the average amount of time the patient reports sleeping each night.
Finally, sleep efficiency percentage is a calculation of the amount of time an
individual reports sleeping divided by the amount of time they spent in bed,
with greater than 85% being normal. To monitor Ms. Insomnia’s mood, her
sleep log included daily ratings of daytime stress and sadness (ratings from
0–10, with 10 = severe).

Session 1: Diagnostic Interview and Psychological Testing

During this initial visit the goal is to establish rapport with the patient
and determine whether he or she would be likely to benefit from BSM
services. In this visit, we review all of our intake questionnaires and have
the patient complete all psychological testing procedures. You may have
noticed that our evaluation process is highly specialized and makes use of
a number of assessment materials. The rationale for this comprehensive
approach is multifaceted. The first reason is that many patients we see have
had sleep problems for a long time and had their sleep problems dismissed
on multiple occasions. We do not want the patient to feel as though we
are minimizing his or her difficulty; instead, we want patients to see that
we have thoroughly evaluated their sleep problem and understand it inside
and out. The extensive evaluation process is the first step in this direction.
Second, psychological testing procedures serve to identify specific social,
cognitive, behavioral, and psychophysiological factors involved in perpet-
uating, maintaining, or exacerbating the presenting problem. These fac-
tors represent modifiable therapeutic targets for cognitive and behavioral

66    dillon, wetzler, and lichstein

 intervention. Testing also specifies other potential contributors, including
comorbid psychiatric disturbances, that may warrant clinical attention.
Third, and perhaps most important, the testing enables the clinician to
communicate in a direct and comprehensive fashion the reasons why an
individual is not sleeping and thereby the rationale for cognitive behavioral
intervention. On the basis of Ms. Insomnia’s assessment results (discussed
previously), she appears to be a reasonable candidate for cognitive behav-
ioral intervention for insomnia.
Copyright American Psychological Association. Not for further distribution.

Sleep Log Data From Session 1:

Sleep-onset latency = 274 minutes
Wake time after sleep onset = 80 minutes
Nightly awakenings = 4.6
Estimated total sleep time = 2.6 hours
Sleep efficiency (%) = 21
Daytime stress rating* = 7.5
Daytime sadness rating* = 6.5

*Daytime ratings on scale from 0 to 10, with 10 being severe.

Session 2: Evaluation Feedback and Treatment Initiation

The goal of this visit is to establish the rationale for the intervention
strategy. Here we review all psychological assessment results in detail. As
mentioned earlier, the goal is to let the individual know that we were com-
prehensive in our approach and understand what is going on. In addition,
we hope reviewing the material will help the patient to gain insight into
contributors to their sleep problem. Feedback is commonly provided in a
manner consistent with motivational interviewing.
My general approach to treatment is to provide a clear rationale for
an intervention strategy before suggesting anything. In this case, we set Ms.
Insomnia on a regular sleep–wake schedule to reentrain her circadian rhythm.
It was suspected her circadian rhythm was delayed because of her tendency
to “sleep in” 2 hours on the weekend. Prior to setting her on a schedule, I
discussed with her how the circadian timing system works and how sleeping
in as a means to catch up on sleep would not work and could just make things
worse. Then we collaboratively set her on a slightly restricted sleep schedule
from 12:30 a.m. to 7 a.m. The rationale for prescribing only 6.5 hours in bed
is that she had previously been spending 8.5 hours in bed but only sleeping
2.6 hours of this. Ideally, we would restrict the allowable time in bed further,

insomnia in older adults    67

 because she reports less than 3 hours of sleep a night. However, the patient
stated she could not remain awake until 2 a.m.; therefore, we compromised
by choosing a 12:30 a.m. bedtime (using sleep compression instead of sleep
restriction). We also provided a handout on general sleep information and
good sleep hygiene practices because of evidence from the evaluation that
suggested poor sleep hygiene practices.

Sleep Log Data From Session 2:

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Sleep-onset latency = 171 minutes

Wake time after sleep onset = 86 minutes
Nightly awakenings = 2.6
Estimated total sleep time = 3.3 hours
Sleep efficiency (%) = 32
Daytime stress rating = 3
Daytime sadness rating = 3

Session 3: Sleep Restriction Therapy

Review of Ms. Insomnia’s recent sleep diaries showed a decrease in time
to fall asleep and an increase in sleep efficiency. Because of the patient’s success
with the slight sleep compression implemented at the last visit and her toler-
ance of having a later bedtime, we introduced textbook sleep restriction therapy.
More or less, she saw the impact of the strategy on her sleep and was now willing
to go forth and take it to the next level. We limited her time in bed to 5.5 hours
and discussed the rationale behind sleep restriction therapy, which is to increase
drive toward sleep and increase confidence in her ability to fall asleep.

Sleep Log Data From Session 3:

Sleep-onset latency = 77 minutes
Wake time after sleep onset = 13 minutes
Nightly awakenings = 2.6
Estimated total sleep time = 4.1 hours
Sleep efficiency (%) = 51
Daytime stress rating = 1.5
Daytime sadness rating = 1.5

68    dillon, wetzler, and lichstein

 Session 4: Stimulus Control Therapy
The rationale for stimulus control therapy is to promote healthy
responses to difficulty getting to sleep or getting back to sleep. As a core
component of multicomponent CBT-I, it was implemented because of the
patient’s self-reported experience of conditioned wakefulness, as well as scores
from the Pre-Sleep Arousal Scale, suggesting counterproductive experiences
in bed. Frequently, those with insomnia will spend excessive amounts of time
in bed awake, which over time contributes to “conditioned wakefulness” or
the bed becoming a stronger cue for worry, stress, and anxiety versus sleep.
Copyright American Psychological Association. Not for further distribution.

Such patients will frequently report falling asleep on the couch, but being
wide awake as soon as they lie down in bed. In addition, the strategy provides
guidance for the patient on how to respond to a bad night to prevent relapse.
The rationale and instructions for stimulus control therapy (see Appen-
dix 3.3) were discussed in great detail with Ms. Insomnia to ensure under-
standing and some level of commitment. We emphasize to our patients that
stimulus control therapy is only effective when it is followed consistently over a
course of several weeks. We also remind patients that psychological treatments
for insomnia do not show immediate results, as do medications. Preparing the
patient for what he or she can expect over the course of treatment will help to
avoid unnecessary discouragement and premature termination of treatment.

Sleep Log Data From Session 4:

Sleep-onset latency = 31 minutes
Wake time after sleep onset = 57 minutes
Nightly awakenings = 1.7
Estimated total sleep time = 4.9 hours
Sleep efficiency (%) = 63
Daytime stress rating = 1.5
Daytime sadness rating = 1

Session 5: Relaxation Training With Focus on Identifying and Coping with Panic
Relaxation training was introduced because of the patient’s self-reported
history of panic attacks and her assessment results (she exhibited a general
vulnerability to anxiety on the Daytime Alertness Scale and had a moder-
ate elevation on the anxiety scale of the Personality Assessment Inventory).
In addition, the goal of CBT-I is not only to get people sleeping but also to
keep them sleeping. As such, relaxation strategies could potentially prevent
relapse because it is typically stressors that trigger bouts of insomnia.

insomnia in older adults    69

 Sleep Log Data From Session 5:
Sleep-onset latency = 20 minutes
Wake time after sleep onset = 13 minutes
Nightly awakenings = 1
Estimated total sleep time = 5 hours
Sleep efficiency (%) = 75
Copyright American Psychological Association. Not for further distribution.

Daytime stress rating = 1

Daytime sadness rating = 1

Session 6: Introduction to Cognitive Therapy for Insomnia

Cognitive therapy for insomnia was initiated because of Ms. Insomnia’s
responses on the Dysfunctional Beliefs and Attitudes About Sleep Question-
naire. What this instrument suggested is that a number of ways in which
the patient was thinking about sleep were just getting in the way. Education
about sleep and normal age-related changes in sleep was presented to help
Ms. Insomnia identify unrealistic expectations and beliefs she had about her
sleep. Cognitive restructuring was introduced as a means to correct these
beliefs to both decrease current worry about sleep and to promote healthy
coping with sleep disturbance in the future.

Sleep Log Data From Session 6:

Sleep-onset latency = 8 minutes
Wake time after sleep onset = 6 minutes
Nightly awakenings = 1
Estimated total sleep time = 6.1 hours
Sleep efficiency (%) = 72
Daytime stress rating = 0.5
Daytime sadness rating = 1

On examining the sleep logs Ms. Insomnia brought into Sessions 5 and
6, we see that the amount of time spent awake in bed (i.e., sleep-onset latency
and wake time after sleep onset) has markedly decreased since she began treat-
ment. However, her sleep-efficiency percentages remain lower than we would
expect with the corresponding reductions in wake time. This issue is likely due
to sleep-state misperception, which is the tendency to misperceive one’s sleep.

70    dillon, wetzler, and lichstein

 Specifically, Ms. Insomnia perceives that she is sleeping far less than she is
actually sleeping, which results in inaccurate estimates of TST. The educational
material and cognitive therapy techniques used with Ms. Insomnia in Session
6 are also aimed at recognizing and reducing possible sleep-state misperception.

Session 7: Introduction to Mindfulness

The rationale for including mindfulness was based on the patient’s his-
tory of anxiety and her current depression. In a way, we conceptualized her
case as an anxiety-based depression. We thought being introduced to the
Copyright American Psychological Association. Not for further distribution.

concept of mindfulness might instill a perspective that would insulate her

from future episodes of worry and anxiety. Mindfulness is also a nice way to
integrate the relaxation therapies and cognitive therapies. Mindfulness has
been found in some studies to prevent relapse of depression. Perhaps it can
do the same for insomnia. (See Kabat-Zinn, 1990, and Ong & Sholtes, 2010,
for more information on mindfulness.)

Sleep Log Data From Session 7:

Sleep-onset latency = 8 minutes
Wake time after sleep onset = 8 minutes
Nightly awakenings = 0.9
Estimated total sleep time = 7.7 hours
Sleep efficiency (%) = 89
Daytime stress rating = 0.25
Daytime sadness rating = 0.10

Review of Ms. Insomnia’s most recent sleep log (from Session 7, above)
shows no changes in sleep-onset latency or wake time after sleep onset but
notable increases in TST and sleep efficiency. Following the cognitive ther-
apy session (Session 6), Ms. Insomnia began resolving her tendency toward
misperceiving her sleep. The jump in sleep efficiency in Session 7 likely
reflects her more-accurate estimate of TST.

Session 8: 1-Month Follow-Up Visit

At her 1-month follow-up visit, Ms. Insomnia’s sleep logs showed con-
tinued improvement in her sleep. She also reported that her mood and stress
levels were more stable than before treatment. We briefly reviewed her prog-
ress and encouraged her to continue following all treatment recommenda-
tions. The rest of the session was spent discussing applications of mindfulness

insomnia in older adults    71

 to everyday life circumstances. She was encouraged to contact our office
should she experience relapse of symptoms.

Sleep Log Data From Session 8:

Sleep-onset latency = 6 minutes
Wake time after sleep onset = 6 minutes
Nightly awakenings = 0.4
Copyright American Psychological Association. Not for further distribution.

Estimated total sleep time = 7.6 hours

Sleep efficiency (%) = 94
Daytime stress rating = 0.10
Daytime sadness rating = 0.25

Overall Outcomes

In summary, Ms. Insomnia experienced significant improvement in her

sleep and also experienced significant improvements in self-reported levels of
daily anxiety and depression. Her sleep log data are presented in Table 3.2.

Table 3.2
Ms. Insomnia’s Sleep Log Data

Wake time Estimated

Sleep-onset after sleep total Sleep
latency onset (in sleep time efficiency
CBT treatment outcomes (in minutes) minutes) (hours/night) (%)
Pretreatment 274 80 2.6 21
Posttreatment   8 8 7.7 89
1-month follow-up   6 6 7.6 94
Note. CBT = cognitive behavioral therapy.

72    dillon, wetzler, and lichstein

 APPENDIX 3.1: Sleep Diary

Please answer the following questionnaire WHEN YOU AWAKE IN

THE MORNING. Enter yesterday’s day and date and provide the informa-
tion to describe your sleep the night before. Definitions explaining each line
of the questionnaire are given below.

Item Definitions
Copyright American Psychological Association. Not for further distribution.

1. If you napped yesterday, enter total time napping in minutes.

2. What time did you enter bed for the purpose of going to sleep
(not for reading or other activities)?
3. Counting from the time you wished to fall asleep, how many
minutes did it take you to fall asleep?
4. How many times did you awaken during the night?
5. What is the total time (# minutes) you were awake during the
middle of the night? This does not include time to fall asleep at
the beginning of the night. It also does not include awake time
in bed before the final morning arising.
6. What time did you wake up for the last time this morning?
7. What time did you actually get out of bed this morning?
8. Pick one number below to indicate your overall QUALITY
RATING or satisfaction with your sleep.
1 = very poor 2 = poor 3 = fair 4 = good 5 = excellent
9. List any sleep medication or alcohol taken at or near bedtime,
and give the amount and time taken.

insomnia in older adults    73

 Copyright American Psychological Association. Not for further distribution.

Yesterday’s day ⇒ Tuesday Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Yesterday’s date ⇒ 10/14/97

74   
Example

1. NAP (yesterday) 70 min

2. BEDTIME (last night) 10:55 p.m.

3. TIME TO FALL ASLEEP 65 min

4. # OF AWAKENINGS 4

5. WAKE TIME in middle of night 110 min

(# of minutes)

dillon, wetzler, and lichstein

6. FINAL WAKE-UP 6:05 a.m.

7. OUT OF BED 7:10 a.m.

8. QUALITY RATING 2

9. BEDTIME MEDICATIONS Ambien

(include amount & time) 10 mg
10:40 p.m.
 APPENDIX 3.2: Sleep Hygiene Instructions

Sleep hygiene identifies everyday behaviors that may help or hurt sleep.
Following the instructions below increases the likelihood that you will sleep
well. Failing to follow any of these instructions may lead to sleep disruption.
1. Avoid caffeine after noon: Caffeine is a stimulant that can lead
to increased arousal and difficulty falling and staying asleep.
Some people are very sensitive to the effects of caffeine, and
Copyright American Psychological Association. Not for further distribution.

use of caffeine after noon may disrupt sleep.

2. Avoid exercise within 2 hours of bedtime: Exercising too
close to bedtime may put your body in an aroused state when
you need to be relaxing. However, participation in regular
exercise that occurs earlier in the day is healthy and may even
improve sleep.
3. Avoid nicotine within 2 hours of bedtime: Nicotine, like caf-
feine, is a stimulant that can make falling and staying asleep
difficult.
4. Avoid alcohol within 2 hours of bedtime: Although you may
initially feel sleepy after drinking alcohol, alcohol use near bed-
time usually leads to more awake time during the night.
5. Avoid heavy meals within 2 hours of bedtime: Heavy meals
close to bedtime put a strain on your digestive system while
you are trying to sleep. Heavy meals may produce physical dis-
comfort or metabolic changes that interfere with sleep.
6. Avoid napping: Napping during the day may disrupt sleep or
make it harder to fall asleep at night. If you must nap, keep it short
(less than half an hour) and do it early in the day (before 3 p.m.).

insomnia in older adults    75

 APPENDIX 3.3: Stimulus Control Instructions

A person’s body should automatically associate getting into bed with

going to sleep. Sometimes people develop habits that may make the bedroom
a nonsleep promoting environment. Using the bed or bedroom for other
activities (e.g., reading or watching TV, planning what needs to be done
the next day), may cause a person’s body to associate getting into bed with
being awake; this may interfere with sleep. Stimulus control helps break this
association and reestablish the bed and bedroom as a sleep-promoting place.
Copyright American Psychological Association. Not for further distribution.

Follow all six instructions to increase the likelihood that you will sleep well.
1. Don’t use your bed or bedroom for anything (any time of the
day) but sleep (or sex). Doing other things in bed is “misusing”
the bed. There is an appropriate time and place for everything.
Doing other things reinforces the notion that a variety of
actions are appropriate in that setting (e.g., if you often watch
television in bed, going to bed will become a cue to begin think-
ing about things related to what you have seen on television). If
the bed is reserved for sleep alone, then climbing into bed will
be a strong cue for you to fall asleep.
2. Lie down in bed intending to go to sleep only when you are
very sleepy. Don’t let the clock dictate when you go to bed.
By staying up until you have a strong urge to sleep, you will
be more likely to fall asleep quickly, reinforcing the association
between bed and sleep. If you go to bed when you are not sleepy,
you might toss and turn, begin to think and get mentally and
physically aroused. That would only reinforce the old habit pat-
terns we are trying to eliminate. By establishing a fixed time for
getting up and allowing your bedtime to vary, your body can
determine how much sleep you need to function well. Your body
will let you know this by getting sleepy when it is time for you
to go to bed.
3. Get out of bed if you do not initially fall asleep within 15–
20 minutes, and go to another room to do a relaxing activity
(e.g., reading or watching TV in a dimly lit room). Go back to
bed only when you feel extremely sleepy again. If you do not
fall asleep within 20 minutes upon returning to bed, repeat
this instruction as many times as needed. Although the idea of
getting out of bed to promote better sleep might seem counter-
intuitive or strange, the reason for doing this is to strengthen the
association of the bed and bedroom with sleep. By getting out of
bed when you have not fallen asleep after 15–20 minutes, you

76    dillon, wetzler, and lichstein

 can promote this association. (Clock watching for this rule is not
recommended. Get out of bed when you feel it has been about 15
to 20 minutes.)
4. If you wake up during the night and do not fall back to sleep
within 15–20 minutes, follow rule # 3 again. New habits come
only with repeated practice. When first beginning this treat-
ment, it is common to have to get up many times each night
before falling asleep.
5. Use your alarm to leave bed at the same time every morning
Copyright American Psychological Association. Not for further distribution.

regardless of the amount of sleep obtained. This will help your

body acquire a constant sleep rhythm. By varying the time you
get up you are shifting your rhythm each day so that it is not in
stable harmony with clock time.
6. Avoid napping. Naps meet some of your sleep need and make
it less likely that you will fall asleep quickly. By not napping,
you also help to ensure that any sleep deprivation you feel from
last night will increase your likelihood of falling asleep quickly
tonight. If you must nap, do not nap past 3 p.m. Napping throws
your body rhythm off schedule and makes it more difficult for
you to sleep at night.

insomnia in older adults    77

 APPENDIX 3.4: Sleep History Questionnaire

Name ________________________________________
Age____________  Race/Ethnicity____________  Date__________
Name of Primary Physician: ______________________________________
Name of Referring Physician (if not your primary physician): _____________

Briefly describe the problem(s) you are experiencing with your sleep or the
Copyright American Psychological Association. Not for further distribution.

reason you were referred to our sleep center. _________________________

_____________________________________________________________
_____________________________________________________________
When did you first notice your sleep problem? What may have contributed
to the onset of your difficulty sleeping (i.e., birth of a child, death of a loved
one, traumatic event)? __________________________________________
_____________________________________________________________
_____________________________________________________________
What do you feel are the major contributors to your sleep problem at this
time? ________________________________________________________
_____________________________________________________________
_____________________________________________________________
What medications and other treatments have you tried for your sleep prob-
lem to date? __________________________________________________
_____________________________________________________________
_____________________________________________________________
What medication(s) are you currently taking for sleep? And how many
times per week? ________________________________________________
_____________________________________________________________
_____________________________________________________________
How long (on average) does it take you to get to sleep? ________________
How many times do you wake up in an average night? _________________
How long on average do you remain awake during these awakenings
(in total)? ______________
How much sleep do you get in total in an average night? _______hours/night
How much sleep do you feel you need each night to feel well rested and
able to function? _______hours/night

78    dillon, wetzler, and lichstein

 Does a poor night’s sleep Does a poor night’s sleep negatively
make you affect your
YES NO YES NO
Depressed M M Ability to concentrate M M
Anxious M M Memory M M
Irritable M M Ability to work M M
Fatigued M M Mood M M
Other (please describe): ______________________________
Copyright American Psychological Association. Not for further distribution.

Sleep Symptoms:
YES NO
Has anyone told you that you snore loudly? . . . . . . . . . . . . . . M M
Has your family told you that you quit breathing
   at night? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M M
Have you ever awakened gasping for breath? . . . . . . . . . . . . .  M M
Have you ever awakened at night with a sour taste in
   your mouth, or a burning sensation in your chest? . . . . . . . M M
Do you have morning headaches? . . . . . . . . . . . . . . . . . . . . . . M M
Are you sleepy even when you increase your sleep time? . . . . M M

YES NO
Do you have trouble getting to sleep at night? . . . . . . . . . . . . M M
Do you have trouble staying asleep at night? . . . . . . . . . . . . . M M
Do you have frequent awakenings and/or restless sleep? . . . . . M M

YES NO
Do you frequently kick and jerk your legs at night while
   trying to fall asleep? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M M
Do you have discomfort in your legs while trying to
   fall asleep? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M M
  If YES to previous question, does moving your legs
   give you relief of discomfort? . . . . . . . . . . . . . . . . . . . . . . M M
Do you have tingling or discomfort in your legs
   during the day? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M M
Do you have discomfort in your legs when sitting
   for long periods? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M M

YES NO
Do you have sudden episodes of sleep during the day? . . . . . . . M M
Have you ever experienced periods in which you
   feel paralyzed while going to sleep, or waking up? . . . . . . . .  M M

insomnia in older adults    79

 Have you ever had visual hallucinations or dream-like
   mental images when falling to sleep? . . . . . . . . . . . . . . . . .  M M
Have you ever experienced sudden physical weakness
  during strong emotions? (such as your mouth dropping
open or legs going limp, during laughter or anger). . . . . . .  M M
Were you excessively sleepy as a teenager or
   young adult? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  M M

YES NO
Copyright American Psychological Association. Not for further distribution.

Do you sleep walk? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M M

Do you talk in your sleep? . . . . . . . . . . . . . . . . . . . . . . . . . . . . M M
Do you have frequent nightmares? . . . . . . . . . . . . . . . . . . . . . M M
Do you ever wake up screaming at night? . . . . . . . . . . . . . . . . M M
Do you eat in the middle of the night? . . . . . . . . . . . . . . . . . . M M
Do you physically act out your dreams at night? . . . . . . . . . . . M M

YES NO
Do you grind your teeth in your sleep? . . . . . . . . . . . . . . . . . . M M
Have you or your dentist noticed your teeth
   being worn down? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M M
Have you noticed that your teeth hurt? . . . . . . . . . . . . . . . . . M M
Do you experience pain in your jaw muscles? . . . . . . . . . . . . . M M
Has anyone told you that you make sounds with
   your teeth or jaw during sleep? . . . . . . . . . . . . . . . . . . . . . . M M

YES NO
Do you have rotating or night shift work? . . . . . . . . . . . . . . . . M M
Have you ever worked shift work or had an
   on-call schedule? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M M
Do you have difficulty getting to sleep at your
   desired time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M M
Do you wake up in the morning prior to your
   desired time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M M
Do you find that your present sleep schedule is
   inconvenient, inappropriate, or unsatisfactory? . . . . . . . . . M M

Sleep Schedule
Weekday Weekend
Time you go to bed __________ __________
Time you get up __________ __________
Average amount of sleep per night __________ __________

80    dillon, wetzler, and lichstein

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