NUR 7633 Module 5 Insomnia in Later Life Case: ISI Scoring, CBT for Insomnia and Sedative Risks Example

Awake From 2 to 5: Measuring Insomnia and Choosing CBT Over a Sleeping Pill for a 69-Year-Old Retired Postal Carrier

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7633: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Geriatric Population, Part A

Mentor Name

Month Day, Year

Awake From 2 to 5: Measuring Insomnia and Choosing CBT Over a Sleeping Pill for a 69-Year-Old Retired Postal Carrier

The Request

Harold, an invented patient, is 69 and carried mail in Atlantic City for thirty-four years. Since retiring three years ago he has had trouble sleeping. He goes to bed at 9:30 p.m. because there is nothing else to do, falls asleep within half an hour, is wide awake by two and stays that way until five, glancing at the clock. He naps for an hour after lunch and dozes in front of the evening news. He feels foggy and irritable most days and has stopped his morning walks. A friend gave him a few zolpidem tablets, which worked, and he asks for a prescription.

He has hypertension, mild benign prostatic enlargement that wakes him once a night to urinate and osteoarthritis in his knees. Coffee is limited to two mugs before ten, and he has one beer with supper. He does not snore loudly, and his wife has not seen him stop breathing in his sleep. He has no sadness or worry beyond the sleep itself, and his PHQ-9 is 4.

His retirement is part of the story. For three decades he rose at 5:30 a.m., walked twelve miles a day and was asleep by 10. Now he has no reason to get up, spends most of the day indoors watching television and gets little daylight. The paper treats this loss of routine, activity and light as a cause of his insomnia, not a side note.

Measuring the Insomnia

Bastien et al. (2001) tested the Insomnia Severity Index, a seven-item questionnaire about difficulty falling asleep, staying asleep and waking too early, satisfaction with sleep, its effect on daytime function, how noticeable the problem is to others and how worried the person is about it. In 145 patients at a sleep clinic, the scale showed adequate internal consistency, and in 78 older adults in a treatment trial, its scores changed in line with sleep diaries and sleep studies. Versions completed by patients, partners and clinicians agreed closely.

Harold scores 19, in the range of moderate clinical insomnia. A two-week sleep diary shows he spends about eight and a half hours in bed and sleeps about six, a sleep efficiency of roughly 70 percent. His symptoms have lasted more than three months, occur most nights and harm his daytime life, meeting criteria for chronic insomnia disorder. His wife's report and the absence of loud snoring make sleep apnea less likely, though a screening questionnaire is completed and is low risk.

Why Not a Sleeping Pill

Glass et al. (2005) combined 24 randomized trials with 2,417 people aged 60 or older with insomnia to weigh the benefits and risks of sedative hypnotics, including benzodiazepines and newer drugs such as zolpidem. Sedatives improved sleep quality slightly, added about 25 minutes of sleep a night and reduced night awakenings. But adverse cognitive events were 4.78 times as common and adverse psychomotor events 2.61 times as common with sedatives as with placebo. The authors concluded that for people over 60 the benefits may not justify the risks, especially for those at risk of falls or cognitive problems.

For Harold, who walks to the bathroom every night, the extra 25 minutes would come with a real risk of falling or of being unsteady when he drives in the morning. The paper explains this in plain terms and offers a treatment that works longer.

Choosing CBT for Insomnia

Sivertsen et al. (2006) randomly assigned 46 adults with a mean age of about 61 and chronic primary insomnia at a Norwegian university clinic to six weeks of cognitive behavioral therapy, zopiclone each night or placebo. The therapy combined sleep hygiene, sleep restriction, stimulus control, cognitive therapy and relaxation. Those who received therapy raised their sleep efficiency from 81.4 percent before treatment to 90.1 percent six months later, while the zopiclone group fell slightly, from 82.3 to 81.9 percent. Zopiclone did not differ from placebo on most measures, and the therapy group spent more time in deep sleep and less time awake at night. The trial was small, a limit the paper notes.

The Six Sessions

Harold's therapy is delivered in six weekly sessions. In the first, his sleep diary sets a time in bed close to the six hours he actually sleeps: bed at 12:30 a.m. and up at 6:30 a.m. every day, with no naps. Under stimulus control the bed is kept for sleep alone; after roughly twenty wakeful minutes he moves to the living room under a dim lamp and goes back only once drowsy. The clock is turned away. As his sleep efficiency rises above 85 percent, his time in bed is extended by fifteen minutes each week.

Cognitive work addresses his belief that he needs eight hours to function and that a poor night ruins the next day. Relaxation exercises are practiced before bed. Sleep hygiene steps include moving his beer earlier, keeping coffee to the morning and returning to his morning walk on the boardwalk, which adds daylight at the right time. His prostate symptoms are referred to his primary care clinician, since fewer bathroom trips would help.

Expecting the Hard Weeks

Harold is warned that the first two weeks of sleep restriction often bring more daytime tiredness before sleep improves, and that he should not drive when drowsy during that time. His wife agrees to help him stay up until his set bedtime. The nurse practitioner calls after the first week to troubleshoot.

Conclusion

Harold has chronic insomnia disorder, with an Insomnia Severity Index of 19 and a sleep efficiency near 70 percent, driven by long time in bed, naps, worry about sleep and less daylight since retiring. A sedative is declined because pooled trials show small benefit and higher risks of confusion and unsteadiness after 60. CBT for insomnia, which outperformed zopiclone in older adults, is delivered over six sessions with a precise schedule. His index score and sleep diary will be repeated at the end of treatment and three months later.

References

Bastien, C. H., Vallières, A., & Morin, C. M. (2001). Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Medicine, 2(4), 297-307. https://doi.org/10.1016/S1389-9457(00)00065-4

Glass, J., Lanctôt, K. L., Herrmann, N., Sproule, B. A., & Busto, U. E. (2005). Sedative hypnotics in older people with insomnia: Meta-analysis of risks and benefits. BMJ, 331(7526), 1169. https://doi.org/10.1136/bmj.38623.768588.47

Sivertsen, B., Omvik, S., Pallesen, S., Bjorvatn, B., Havik, O. E., Kvale, G., Nielsen, G. H., & Nordhus, I. H. (2006). Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: A randomized controlled trial. JAMA, 295(24), 2851-2858. https://doi.org/10.1001/jama.295.24.2851