Although it is commonly supposed that older people need less sleep than youngsters, insomnia is a particularly common complaint as we age. Some reports say that between 12% and 25% of healthy seniors have chronic insomnia, and, of course, it's even commoner in those with medical or psychiatric illnesses. It can involve difficulty in falling asleep, frequent or prolonged periods awake during the night, or early wakening with inability to go to sleep again. Chronic insomnia has been reported to cause depression and it may hasten admission to a nursing home, so that it makes sense to seek treatment.

While sedative drugs clearly work, at least while they are being taken, less is known about what is called cognitive-behavioral treatment. A recent study has examined the effectiveness of behavioral treatment, drug treatment, and both sorts of treatments combined, compared with no treatment at all.¹

Participants in the study were recruited by newspaper advertisements or through their family physicians. They had to have had chronic insomnia for least six months, and to be 55 or over. After careful evaluation, they were randomly allocated to receive one of four treatments: behavioral therapy, drug therapy, combined behavioral and drug therapy, or "placebo". A total of 78 subjects were enrolled. Their average age was 65, and two-thirds of them were women. Most had tried sleep medications, and had suffered from insomnia for over 16 years.

Subjects were asked to keep a daily sleep diary for two weeks before treatment, and during the eight-week treatment period. In the diary they noted their bedtime, getting-up time, time taken to fall asleep, and how long they were awake after falling asleep. They spent three nights in the sleep laboratory before and at the end of treatment; this involved sleeping with head electrodes and cameras to record their stages of sleep and limb movements. Subjects also completed a questionnaire to accompany the sleep diary information. This allowed them to score the severity of their insomnia as well as it's interference with daytime functioning.

The cognitive behavior treatment addressed three areas: sleep restriction, stimulus control and education. For "sleep restriction", the time allowed in bed was shortened to equal the actual sleep time. If someone reported an average of six hours sleep a night out of eight hours spent in bed, they were given a maximum period of six hours to spend in bed for the first week; this "sleep window" was altered each week, according to their sleep achieved, based on their sleep diary.

"Stimulus control" was used to persuade one to associate bed with sleep, rather than sleeplessness. Participants were not to go to bed unless they were sleepy, use the bed only for sleep and sex, and to get up and go to another room if they were unable to fall asleep within 15 minutes; moving from the bedroom was repeated as often as necessary. They were to get up at the same time each morning, regardless of the amount of sleep they had had. Short daytime naps were allowed, up to 3 p.m.

"Sleep education" consisted of correcting unrealistic expectations about the need for sleep, fears about the effects of insomnia, and mistaken ideas on how to promote sleep. Also covered were the effects on sleep of diet, exercise, beverages (coffee, tea and alcohol), and environmental factors in the bedroom (temperature, light, windows open, etc).

The drug used was temazepam taken one hour before bedtime (7.5 mg, increased to 30 mg if necessary). The placebo group took plain gelatin capsules.

To see how the benefits produced by treatment were sustained, everyone was contacted 3, 12 and 24 months after completing the treatment, and asked to complete two-week sleep diaries.

The results showed that all three active treatments (behavioral therapy, drug treatment, and both combined) were more effective than placebo capsules. For example, the average time awake after sleep onset, as shown by sleep diaries, was reduced by 64% in the combined treatment group, 55% with behavioral treatment, 47% with drug treatment, and 17% with placebo. The questionnaires and the sleep laboratory results confirmed these findings.

The follow-up sleep diaries showed that those participants given the behavioral treatment had their improvement sustained over 24 months, while those given drug treatment didn't. Both behavioral and drug treatment showed their best effects immediately at the end of the 8-week treatment period, but afterwards those that given drug treatment gradually returned towards their starting level, almost reaching it by two years. On the other hand, those who got behavioral treatment returned to about 60% of their starting level of insomnia. This was not surprising, as behavioral changes are obviously designed to have long-term effects.

More surprising was the finding that combined treatment (behavioral plus drug treatment) was slightly less effective than behavioral treatment alone. The physicians doing the study think that those people given the drug attributed their improvement to the medication, and were therefore more likely to relapse when it was discontinued. (Or perhaps they paid less attention at the behavioral therapy sessions due to a sedative effect of the medication?) At all events, the study shows that insomnia in the elderly is a treatable problem, and relatively simple non-drug approaches can be surprisingly effective and long lasting.