Clinical Question

Can brief behavior therapy improve sleep in older adults with insomnia?

Bottom Line

Although based on only a few studies, it appears that a brief four-week behavior therapy program will improve sleep quality in older adults with chronic insomnia. The findings underscore guidelines from the American College of Physicians and others to avoid drugs and use nonpharmacologic approaches for the initial management of insomnia.

This POEM aligns with the Canadian Geriatrics Society's Choosing Wisely Canada recommendation: do not use benzodiazepines or other sedative-hypnotics in older adults as first-choice therapy for insomnia, agitation, or delirium. Choosing Wisely Canada's hospital and primary care toolkits provide tools to reduce inappropriate use of benzodiazepines. (Level of Evidence = 2a)

Synopsis

The authors searched multiple databases and registries to identify randomized trials, systematic reviews, and meta-analyses that evaluated the effectiveness of brief behavior interventions in community-dwelling adults at least 60 years of age with chronic insomnia. They identified only four trials with 190 participants. Overall, the risk of bias was medium to low. In these studies, a four-week behavior intervention program had a large effect size on sleep quality based on the Pittsburgh Sleep Quality Index and the Insomnia Severity Index (standardized mean difference = −1.07; 95% CI, −1.43 to −0.71) and improved total sleep time by 25.7 minutes. The brief interventions improved several other measures of sleep efficiency. The authors found no heterogeneity among the data and did not report any data on daytime sleepiness, quality of life, or cognition.