Publications by authors named "Cathy Alessi"

96 Publications

Environmental Noise in New York City Long-Term Care Facilities: A Window into the COVID-19 Pandemic.

J Am Med Dir Assoc 2021 Feb 16. Epub 2021 Feb 16.

Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, New York, NY, USA; VA New York Harbor Health Care System, New York, NY, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jamda.2021.02.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885630PMC
February 2021

Insomnia Precipitating Events among Women Veterans: The Impact of Traumatic and Nontraumatic Events on Sleep and Mental Health Symptoms.

Behav Sleep Med 2020 Nov 30:1-17. Epub 2020 Nov 30.

Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System , Los Angeles, California.

: The current study describes insomnia precipitating events reported by women Veterans and examines differences in sleep and psychological distress variables in those who endorsed traumatic, nontraumatic, or no insomnia precipitating events. : Baseline data were collected from 347 women Veterans enrolled in a behavioral sleep intervention study (NCT02076165). : Participants completed self-report measures of insomnia symptoms, sleep quality, sleep efficiency (SE), nightmare frequency, and depression and posttraumatic stress disorder (PTSD) symptoms; SE was also assessed by wrist actigraphy. Participants responded to 2 open-ended questions assessing stressful life events and health changes that coincided with insomnia symptom onset. Responses were coded as traumatic, nontraumatic, and no events. Analyses of covariance examined the effect of insomnia precipitating event type on sleep and psychological symptom variables after controlling for sociodemographic factors. : Overall, 25.80% of participants endorsed traumatic events, 65.80% endorsed only nontraumatic events, and 8.41% endorsed no events. Participants who endorsed traumatic events reported more severe insomnia ( = .003), PTSD ( = .001), and depression symptoms ( = .012), and poorer quality of sleep ( = .042) than participants who endorsed no events. Participants who endorsed traumatic events reported more severe PTSD symptoms ( = .004), a longer duration of sleep problems ( = .001), and poorer quality of sleep ( = .039) than participants who endorsed nontraumatic events. Participants who endorsed nontraumatic events reported more severe insomnia ( = .029) and PTSD ( = .049) symptoms than participants who endorsed no events. : Trauma as a precipitant for insomnia may be related to higher symptom severity in women Veterans. Implications for treatment engagement and effectiveness remain unstudied.
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http://dx.doi.org/10.1080/15402002.2020.1846537DOI Listing
November 2020

Randomized controlled trial of an integrated approach to treating insomnia and improving the use of positive airway pressure therapy in veterans with comorbid insomnia disorder and obstructive sleep apnea.

Sleep 2021 Apr;44(4)

Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA.

Study Objectives: Cognitive behavioral therapy for insomnia (CBTI) for comorbid insomnia and obstructive sleep apnea (OSA) has had mixed results. We integrated CBTI with a positive airway pressure (PAP) adherence program and tested effects on sleep and PAP use.

Methods: 125 veterans (mean age 63.2, 96% men, 39% non-Hispanic white, 26% black/African American, 18% Hispanic/Latino) with comorbid insomnia and newly-diagnosed OSA (apnea-hypopnea index ≥ 15) were randomized to 5-weekly sessions integrating CBTI with a PAP adherence program provided by a "sleep coach" (with behavioral sleep medicine supervision), or 5-weekly sleep education control sessions. Participants and assessment staff were blinded to group assignment. Outcomes (baseline, 3 and 6 months) included Pittsburgh Sleep Quality Index (PSQI), 7-day sleep diary (sleep onset latency [SOL-D], wake after sleep onset [WASO-D], sleep efficiency [SE-D]), 7-day actigraphy (SE-A), and objective PAP use (hours/night and nights ≥ 4 h). Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10) were also collected.

Results: Compared to controls, intervention participants showed greater improvement (baseline to 3 and 6 months, respectively) in PSQI (-3.2 and -1.7), SOL-D (-16.2 and -15.5 minutes), SE-D (10.5% and 8.5%), SE-A (4.4% and 2.6%) and more 90-day PAP use (1.3 and 0.9 more hours/night, 17.4 and 11.3 more nights PAP ≥ 4 h). 90-day PAP use at 3 months was 3.2 and 1.9 h/night in intervention versus controls. Intervention participants also had greater improvements in ISI, ESS, and FOSQ-10 (all p < 0.05).

Conclusions: An intervention integrating CBTI with a PAP adherence program delivered by a supervised sleep coach improved sleep and PAP use in adults with comorbid insomnia and OSA.

Trial Registration: ClinicalTrials.govStudy name: Novel Treatment of Comorbid Insomnia and Sleep Apnea in Older VeteransURL: https://clinicaltrials.gov/ct2/results?cond=&term=NCT02027558&cntry=&state=&city=&dist=Registration: NCT02027558.
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http://dx.doi.org/10.1093/sleep/zsaa235DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8033453PMC
April 2021

Sleep apnea in women veterans: results of a national survey of VA health care users.

J Clin Sleep Med 2021 Mar;17(3):555-565

Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California.

Study Objectives: The goals of this study were to estimate rates of undiagnosed, diagnosed, and treated sleep apnea in women veterans and to identify factors associated with diagnosis and treatment of sleep apnea in this population.

Methods: A large nationwide postal survey was sent to a random sample of 4,000 women veterans who had received health care at a Veterans Health Administration (VA) facility in the previous 6 months. A total of 1,498 surveys were completed. Survey items used for the current analyses included: demographics; sleep apnea risk, diagnostic status, and treatment; symptoms of other sleep disorders (eg, insomnia); mental health symptoms; and comorbidities.

Results: Among responders, 13% of women reported a prior sleep apnea diagnosis. Among women who reported a diagnosis of sleep apnea, 65% reported using positive airway pressure therapy. A sleep apnea diagnosis was associated with older age, higher BMI, non-Hispanic African American/Black racial/ethnic identity, being unemployed, other sleep disorder symptoms (eg, insomnia), depression and post-traumatic stress disorder symptoms, and multimorbidity. Among women without a sleep apnea diagnosis, 43% scored as "high risk" on the STOP (snoring, tiredness, observed apneas, blood pressure) questionnaire. High risk scores were associated with older age, higher BMI, African American/Black identity, other sleep disorder symptoms (eg, insomnia), mental health symptoms, and multimorbidity. Only BMI differed between women using vs not using positive airway pressure therapy.

Conclusions: Women veterans with diagnosed sleep apnea were commonly treated with positive airway pressure therapy, which is standard first-line treatment; however, many undiagnosed women were at high risk. Efforts to increase screening, diagnosis, and treatment of sleep apnea in women with comorbid mental and physical health conditions are needed.
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http://dx.doi.org/10.5664/jcsm.8956DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7927345PMC
March 2021

Efficacy of a patient decision aid for improving person-centered decision-making by older adults with obstructive sleep apnea.

J Clin Sleep Med 2021 Feb;17(2):121-128

Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California.

Study Objectives: Person-centered obstructive sleep apnea (OSA) care is a collaborative approach that is respectful of an individual's health priorities. Informed decision-making is essential to person-centered care, especially as patients age. In a feasibility study, we evaluated the effects of a new decision aid (Decide2Rest) on OSA treatment decision-making in older adults.

Methods: Patients (aged ≥ 60 years) with newly diagnosed OSA were recruited from two health care systems and randomized either to Decide2Rest or to a control program. Postintervention outcomes included 1) Decisional Conflict Scale (0-100, where 0 = low and 100 = high conflict), which measures perceptions of uncertainty, whether decisions reflect what matters most to patients, and whether patients feel supported in decision-making; 2) Preparation for Decision-Making scale (0-100, where 0 = least and 100 most prepared); and 3) OSA knowledge (0-100, where 0 = poor and 100 = outstanding). Multivariable linear regression models examined relationships between Decide2Rest and outcomes (Decisional Conflict Scale, Preparation for Decision-Making, OSA knowledge).

Results: Seventy-three patients were randomized to Decide2Rest (n = 36; mean age, 69 years; 72% male) vs control (n = 37; mean age, 69 years; 70% male). Results from the regressions, controlling for study site, indicate that the Decide2Rest program resulted in less decisional conflict (20.5 vs 32.7 on the Decisional Conflict Scale; P = .014), more preparedness for decision-making (87.8 vs 66.2 on the Preparation for Decision-Making scale; P < .001), and greater OSA knowledge (75.1 vs 65.3 OSA knowledge score; P = .04) scores than in the control group.

Conclusions: The Decide2Rest program promotes person-centered OSA decision-making for older patients with newly diagnosed OSA. Future studies are needed to optimize implementation of the program.

Clinical Trial Registration: Registry: ClinicalTrials.gov, Name: Improving Older Adults' Decision-Making for OSAT (eDecide2Rest); URL: https://clinicaltrials.gov/ct2/show/NCT03138993; Identifier: NCT03138993.
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http://dx.doi.org/10.5664/jcsm.8798DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853212PMC
February 2021

Sleep Disruption Due to Stress in Women Veterans: A Comparison between Caregivers and Noncaregivers.

Behav Sleep Med 2021 Mar-Apr;19(2):243-254. Epub 2020 Feb 29.

Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System , North Hills, California.

: Sleep problems are common in women and caregiving for an adult is a common role among women. However, the effects of caregiving on sleep and related daytime impairment are poorly understood among women veterans. This study compared stress-related sleep disturbances, insomnia symptoms, and sleep-related daytime impairment between women veterans who were caregivers and those who did not have a caregiving role. : Of 12,225 women veterans who received care in one Veterans Administration Healthcare System, 1,457 completed data on a postal survey (mean age = 51.7 ± 15.9 years). Two hundred forty three (17%) respondents (mean age 53.8 ± 12.7 years) were caregivers for an adult, predominantly for a parent, providing transportation. : The survey included items that addressed insomnia symptoms, total sleep time, sleep-related daytime impairments, caregiving characteristics, self-rated health, pain, stress, body mass index, and demographic information. : In adjusted analyses, caregiver status did not directly predict sleep complaints alone. However, in multiple regression analyses, being a caregiver (odds ratio 1.7, = .001) significantly predicted stress-related sleep disturbance, even after adjusting for age, pain, self-rated health, and other characteristics. Furthermore, being a caregiver (β = 3.9, = .031) significantly predicted more symptoms of sleep-related daytime impairment after adjusting for age, pain, self-rated health, and other factors. : Compared to noncaregivers, women veterans who were caregivers for an adult were more likely to report stress causing poor sleep, and more daytime impairment due to poor sleep. These findings suggest the need to target stress and other factors when addressing sleep disturbance among women veterans who are caregivers.
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http://dx.doi.org/10.1080/15402002.2020.1732981DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483161PMC
February 2020

Hypnotic Discontinuation Using a Blinded (Masked) Tapering Approach: A Case Series.

Front Psychiatry 2019 24;10:717. Epub 2019 Oct 24.

Northwest Sleep and Behavior, Lake Oswego, OR, United States.

Chronic use of hypnotic medications such as benzodiazepines is associated with adverse consequences including increased risk of falls. Efforts to help patients discontinue these medications have had varying levels of success. We developed a blinded (masked) tapering protocol to help patients taper off hypnotics. In this blinded protocol, patients consented to a drug taper but agreed to forego knowledge about the specific tapering schedule or the actual dose each night until the end of the taper. Blinded tapering aims to reduce negative expectancies for withdrawal effects that may impair a patient's successful discontinuation of hypnotics. In preparation for a randomized trial, we tested the feasibility of adding a blinded tapering component to current best evidence practice [supervised hypnotic taper combined with cognitive behavioral therapy for insomnia (CBTI)] in 5 adult patients recruited from an outpatient mental health practice in Oregon. A compounding pharmacy prepared the blinded capsules for each patient. During the gradual blinded taper, each participant completed CBTI. Measures collected included feasibility/process (e.g., recruitment barriers), hypnotic use, the Dysfunctional Beliefs and Attitudes about Sleep Scale, Insomnia Severity Index, Epworth Sleepiness Scale, and Patient Health Questionnaire-9 (depressive symptoms). The intervention was feasible, and participants reported high satisfaction with the protocol and willingness to follow the same treatment again. All five participants successfully discontinued their hypnotic medication use post-treatment. Dysfunctional beliefs/attitudes about sleep and insomnia severity improved. Blinded tapering is a promising new method for improving hypnotic discontinuation among patients treated with a combination of hypnotic tapering plus CBTI.
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http://dx.doi.org/10.3389/fpsyt.2019.00717DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6822133PMC
October 2019

Development of a dyadic sleep intervention for Alzheimer's disease patients and their caregivers.

Disabil Rehabil 2019 Oct 26:1-11. Epub 2019 Oct 26.

Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System , North Hills , CA , USA.

This study aimed to refine a behavioral sleep intervention program targeting patients with Alzheimer's disease and their caregivers. In this case series, key components of the sleep program were built upon previous intervention studies of patients with cognitive impairment/dementia. The intervention consisted of five weekly sessions covering sleep hygiene, sleep compression, stimulus control, daily walking/light exposure, relaxation/mindfulness, and caregiver training to manage patients' behavioral problems. The materials and structure were iteratively refined based on feedback from caregivers and sleep educators. Sleep diaries were used to evaluate sleep outcomes. Five out of six enrolled dyads completed the sessions. Several revisions were made during testing: the last session was changed from telephone to in-person; some components (e.g., sleep scheduling, mindfulness) were rearranged within or across sessions; sleep educator guidelines for sleep scheduling, light exposure, and walking were revised. After the fifth dyad, no additional issues were identified by the caregiver or the sleep educator. Four patients and three caregivers had improved sleep at the last session. The iterative refinement process was successful in finalizing the intervention program, with evidence of sleep improvements. Formal pilot testing of the program will provide further information on feasibility and effectiveness. IMPLICATIONS FOR REHABILITATION Our dyadic behavioral sleep program can be tailored to various types of sleep problems among patients with Alzheimer's disease and their family caregivers, with the goal of improving daytime function by reducing sleep disturbances at night. Caregiver training and participation of both members of the dyad in sleep management may benefit the patients' sleep and other health outcomes, reduce caregiver stress and burden, and ultimately delay or prevent institutionalization of Alzheimer's disease patients.
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http://dx.doi.org/10.1080/09638288.2019.1680748DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7183441PMC
October 2019

Use of alcohol as a sleep aid, unhealthy drinking behaviors, and sleeping pill use among women veterans.

Sleep Health 2019 10 12;5(5):495-500. Epub 2019 Aug 12.

David Geffen School of Medicine, University of California, Los Angeles; Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System. Electronic address:

Objectives: Sleep complaints, such as insomnia and sleep disturbances caused by posttraumatic stress disorder (PTSD), are more common among women veterans than nonveteran women. Alcohol use among some women may be partially motivated by the desire to improve sleep. This study evaluated rates of alcohol use as a sleep aid among women veterans and explored the relationship between alcohol use to aid sleep and drinking frequency and sleeping pill use.

Design And Setting: National cross-sectional population-based residential mail survey on sleep and other symptoms.

Participants: Random sample of women veteran VA users who completed a postal survey (N = 1533).

Interventions: None.

Measurements: The survey included demographics, Insomnia Severity Index, Primary Care PTSD screen, and items on alcohol use frequency (days/week), use of prescription or over-the-counter sleep medications, and use of alcohol as a sleep aid (yes/no for each item) over the past month.

Results: A total of 14.3% of respondents endorsed using alcohol to aid sleep. Logistic regression models showed more severe insomnia (odds ratio [OR] = 1.03; 95% confidence interval [CI]: 1.01-1.06) and PTSD (OR = 2.11; 95% CI: 1.49-2.97) were associated with increased odds of using alcohol to aid sleep. Alcohol use to aid sleep was associated with increased odds of daily drinking (OR = 8.46; 95% CI: 4.00-17.87) and prescription (OR = 1.79; 95% CI: 1.34-2.38) and over-the-counter sleep aid use (OR = 1.54; 95% CI: 1.12-2.11).

Conclusions: Insomnia and PTSD may increase risk for using alcohol as a sleep aid, which may increase risk for unhealthy drinking and for mixing alcohol with sleep medications. Findings highlight the need for alcohol use screening in the context of insomnia and for delivery of cognitive-behavioral therapy for insomnia to women veterans with insomnia.
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http://dx.doi.org/10.1016/j.sleh.2019.06.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6801087PMC
October 2019

Insomnia Disorder Among Older Veterans: Results of a Postal Survey.

J Clin Sleep Med 2019 04 15;15(4):543-551. Epub 2019 Apr 15.

David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California.

Study Objectives: To estimate the prevalence of insomnia disorder among older veterans and to study relationships among age and self-rated health, with insomnia disorder, self-reported sleep duration and sleep efficiency.

Methods: A cross-sectional postal survey of community-dwelling older veterans (older than 60 years) seen at one VA Healthcare System in the prior 18 months was performed, which was constructed to align with the general diagnostic criteria for insomnia disorder (International Classification of Sleep Disorders, Second Edition [ICSD-2]). The survey also queried self-reported sleep duration, bedtime, and wake time, which were used to calculate sleep efficiency. The survey also asked about race/ethnicity and self-rated health (using the general health item from the Short Form-36).

Results: A completed survey was returned by 4,717 individuals (51.9% response rate; mean age 74.1 years). Of those, 2,249 (47.7%) met ICSD-2 diagnostic criteria for insomnia disorder. In logistic regression analyses, insomnia disorder was more likely among younger age categories (odds ratios [OR] 1.4-2.5) and in those with worse self-rated health (OR 2.1-14.4). Both total nocturnal sleep time and time in bed increased with older age (all < .001), whereas sleep efficiency did not differ. Worse self-rated health was associated with shorter total nocturnal sleep time, more time in bed, and lower (worse) sleep efficiency.

Conclusions: Results of the postal survey suggest that almost half of community-dwelling older veterans have insomnia disorder, which was more common in young-old and among those with worse self-rated health. Additional work is needed to address the high burden of insomnia among older adults, including those with poor health.
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http://dx.doi.org/10.5664/jcsm.7710DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6457506PMC
April 2019

CBT for late-life insomnia and the accuracy of sleep and wake perceptions: Results from a randomized-controlled trial.

J Sleep Res 2019 08 4;28(4):e12809. Epub 2019 Jan 4.

David Geffen School of Medicine, University of California, Los Angeles, California, USA.

Subjective and objective estimates of sleep are often discordant among individuals with insomnia who typically under-report sleep time and over-report wake time at night. This study examined the impact and durability of cognitive-behavioural therapy for insomnia on improving the accuracy of sleep and wake perceptions in older adults, and tested whether changes in sleep quality were related to changes in the accuracy of sleep/wake perceptions. One-hundred and fifty-nine older veterans (97% male, mean age 72.2 years) who met diagnostic criteria for insomnia disorder were randomized to: (1) cognitive-behavioural therapy for insomnia (n = 106); or (2) attention control (n = 53). Assessments were conducted at baseline, post-treatment, 6-months and 12-months follow-up. Sleep measures included objective (via wrist actigraphy) and subjective (via self-report diary) total sleep time and total wake time, along with Pittsburgh Sleep Quality Index score. Discrepancy was computed as the difference between objective and subjective estimates of wake and sleep. Minutes of discrepancy were compared between groups across time, as were the relationships between Pittsburgh Sleep Quality Index scores and subsequent changes in discrepancy. Compared with controls, participants randomized to cognitive-behavioural therapy for insomnia became more accurate (i.e. minutes discrepancy was reduced) in their perceptions of sleep/wake at post-treatment, 6-months and 12-months follow-up (p < .05). Improved Pittsburgh Sleep Quality Index scores at each study assessment preceded and predicted reduced discrepancy at the next study assessment (p < .05). Cognitive-behavioural therapy for insomnia reduces sleep/wake discrepancy among older adults with insomnia. The reductions may be driven by improvements in sleep quality. Improving sleep quality appears to be a viable path to improving sleep perception and may contribute to the underlying effectiveness of cognitive-behavioural therapy for insomnia.
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http://dx.doi.org/10.1111/jsr.12809DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6609514PMC
August 2019

Sleep Outcomes With Cognitive Behavioral Therapy for Insomnia Are Similar Between Older Adults With Low vs. High Self-Reported Physical Activity.

Front Aging Neurosci 2018 13;10:274. Epub 2018 Sep 13.

Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, North Hills, CA, United States.

We examined whether baseline self-reported physical activity is associated with the efficacy of cognitive behavioral therapy for insomnia (CBT-I) in older veterans. Community-dwelling veterans aged 60 years and older with insomnia received CBT-I in a randomized controlled trial. Participants who received active treatment were divided into low and high physical activity based on self-report. Sleep outcomes were measured by sleep diary, questionnaire and wrist actigraphy; collected at baseline, post-treatment, 6-month and 12-month follow-up. Mixed-effects models compared differences between physical activity groups in change in sleep outcome from baseline to each follow-up, and equivalence tests examined if physical activity groups were clinically equal. There were no significant differences in sleep outcomes between physical activity groups. Equivalence tests suggested possible equality in physical activity groups for five of seven sleep outcomes. Efficacy of CBT-I in older veterans was not associated with self-reported physical activity at baseline. Older adults with insomnia who report low levels of physical activity can benefit from CBT-I.
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http://dx.doi.org/10.3389/fnagi.2018.00274DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6146107PMC
September 2018

Sleep in Older Adults: Challenges and Opportunities.

Sleep Med Clin 2018 03;13(1):xv-xviii

Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA 91343, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jsmc.2017.12.002DOI Listing
March 2018

Measuring Sleep in Vulnerable Older Adults: A Comparison of Subjective and Objective Sleep Measures.

Clin Gerontol 2018 Mar-Apr;41(2):145-157. Epub 2017 Dec 28.

b Geriatric Research, Education, and Clinical Center , VA Greater Los Angeles Healthcare System , Los Angeles , California , USA.

Objectives: This study compared subjective (questionnaire) and objective (actigraphy) sleep assessments, and examined agreement between these methods, in vulnerable older adults participating in a Veterans Administration Adult Day Health Care (ADHC) program.

Methods: 59 ADHC participants (95% male, mean age = 78 years) completed sleep questionnaires and 72 continuous hours of wrist actigraphy. Linear regression was used to examine agreement between methods and explore discrepancies in subjective/objective measures.

Results: Disturbed sleep was common, yet there was no agreement between subjective and objective sleep assessment methods. Compared with objective measures, one-half of participants reported worse sleep efficiency (SE) on questionnaires while one-quarter over-estimated SE. Participants reporting worse pain had a greater discrepancy between subjective and objective SE.

Conclusions: Vulnerable older adults demonstrated unique patterns of reporting sleep quality when comparing subjective and objective methods. Additional research is needed to better understand how vulnerable older adults evaluate sleep problems.

Clinical Implications: Objective and subjective sleep measures may represent unique and equally important constructs in this population. Clinicians should consider utilizing both objective and subjective sleep measures to identify individuals who may benefit from behavioral sleep treatments, and future research is needed to develop and validate appropriate sleep assessments for vulnerable older adults.
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http://dx.doi.org/10.1080/07317115.2017.1408734DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5809246PMC
July 2019

Changes in Caregiving Status and Intensity and Sleep Characteristics Among High and Low Stressed Older Women.

J Clin Sleep Med 2017 12 15;13(12):1403-1410. Epub 2017 Dec 15.

Department of Epidemiology, Boston University, Boston, Massachusetts.

Study Objectives: To examine whether change in caregiving status and intensity among community-dwelling older women was associated with sleep characteristics at follow-up, and whether perceived stress modified these associations.

Methods: The sample included 800 women aged 65 years or older who completed baseline and second follow-up interviews in the Caregiver-Study of Osteoporotic Fractures (Caregiver-SOF). Respondents were categorized into four groups based on change in caregiving status and intensity between the two time points: continuous noncaregivers, ceased caregivers, low-intensity caregivers (continuous caregivers with low/decreased intensity), and high-intensity caregivers (continuous caregivers with high/increased intensity or new caregivers). Perceived Stress Scale scores at the second follow-up were dichotomized into high versus low stress. Sleep outcomes at SOF Visit 8 (which overlapped with Caregiver-SOF second follow-up) included the Pittsburgh Sleep Quality Index total score; and actigraphy-measured total sleep time, sleep efficiency, wake after sleep onset, and sleep latency.

Results: Multivariate-adjusted sleep characteristics did not differ significantly across caregiving groups. Among high-intensity caregivers, however, those with high stress levels had significantly longer wake after sleep onset (mean 82.3 minutes, 95% confidence interval = 70.9-93.7) than those with low stress levels (mean 65.4 minutes, 95% confidence interval = 55.2-75.7). No other sleep outcomes were modified by stress levels. Further, higher stress was significantly associated with worse Pittsburgh Sleep Quality Index scores, regardless of the caregiving group.

Conclusions: Overall, sleep characteristics did not differ among noncaregivers, ceased caregivers, or those with high-/low-intensity caregiving among older women. However, subgroups of caregivers may be vulnerable to developing sleep problems, particularly those with high stress levels.
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http://dx.doi.org/10.5664/jcsm.6834DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5695986PMC
December 2017

Sleep and Caregiving Experiences among Caregivers of Veterans in an Adult Day Health Care Program: A Pilot Study.

Clin Gerontol 2018 Mar-Apr;41(2):167-171. Epub 2017 Oct 9.

a Geriatric Research, Education and Clinical Center , VA Greater Los Angeles Healthcare System , Los Angeles , California , USA.

Objectives: This pilot study explored caregivers' attitudes toward core elements of a behavioral sleep intervention for managing sleep problems of older veteran care recipients and the caregivers, as an initial step for developing a dyadic sleep intervention program.

Methods: Five caregivers (all women; age range, 66-75 years) participated in a focus group discussion. Data were collected at one Veterans Affairs, adult day health care program.

Results: Caregivers' poor sleep was not necessarily explained by their caregiving responsibility. Caregivers felt that behavioral recommendations regarding sleep compression scheduling, increased indoor physical activity, and outdoor light exposure would be acceptable sleep interventions for themselves and the care recipients. Some challenges to the sleep recommendation were identified and they included limiting naptime of care recipients and change of their current sleep schedule.

Conclusions: Caregivers are receptive to some key components of behavioral approaches to improving sleep. Tailored sleep recommendation strategy is needed to address potential challenges.

Clinical Implications: If available within clinical care settings or delivered at the patient's home, caregivers of older veterans are likely to engage in behavioral sleep intervention programs.
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http://dx.doi.org/10.1080/07317115.2017.1365795DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5847391PMC
July 2019

Cognitive Expectancies for Hypnotic Use among Older Adult Veterans with Chronic Insomnia.

Clin Gerontol 2018 Mar-Apr;41(2):130-135. Epub 2017 Sep 29.

a Geriatric Research, Education and Clinical Center , VA Greater Los Angeles Healthcare System , Los Angeles , California , USA.

Objectives: To examine relationships between cognitive expectancies about sleep and hypnotics and use of medications commonly used for insomnia (hypnotics).

Methods: We analyzed baseline data from older veterans who met diagnostic criteria for insomnia and were enrolled in a trial comparing CBTI delivered by a supervised, sleep educator to an attention control condition (N = 159; 97% male, mean age 72 years). We classified individuals as hypnotic users (N = 23) vs. non-users (N = 135) based upon medication diaries. Associations between hypnotic status and Dysfunctional Beliefs and Attitudes about Sleep-16 (DBAS) total score (0-10, higher = worse) and two DBAS medication item scores (Item 1: "…better off taking a sleeping pill rather than having a poor night's sleep;" Item 2: "Medication… probably the only solution to sleeplessness"; 0-10, higher = worse) were examined in logistic regression models.

Results: Higher scores on the DBAS medication items (both odds ratios = 1.3; p-values < .001) were significantly associated with hypnotic use. DBAS-16 total score was not associated with hypnotic use.

Conclusion: Cognitive expectancy (dysfunctional beliefs) about hypnotics was associated with hypnotic use in older adults with chronic insomnia disorder.

Clinical Implications: Strategies that specifically target dysfunctional beliefs about hypnotics are needed and may impact hypnotic use in older adults.
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http://dx.doi.org/10.1080/07317115.2017.1356895DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5775935PMC
July 2019

Nocturia is Associated with Poor Sleep Quality Among Older Women in the Study of Osteoporotic Fractures.

J Am Geriatr Soc 2017 Nov 15;65(11):2502-2509. Epub 2017 Sep 15.

California Pacific Medical Center, San Francisco, California.

Objectives: (1) To examine relationships between frequency of nocturia and self-reported sleep quality and objective sleep measures in older women, and (2) to estimate the amount of variation in sleep measures that is specifically attributable to frequency of nocturia.

Design And Setting: Secondary, cross sectional analysis of the multicenter prospective cohort Study of Osteoporotic Fractures (SOF).

Participants: Community-dwelling women aged ≥80 years.

Measurements: Frequency of nocturia in the previous 12 months, Pittsburgh Sleep Quality Index sleep quality subscale, and actigraphy-measured wake after sleep onset (WASO) and total sleep time (TST).

Results: Of 1,520 participants, 25% (n = 392) reported their nocturia frequency was 3-4 times/night and an additional 60% (n = 917) reported their nocturia frequency was 1-2 times/night. More frequent nocturia was associated with poor sleep quality (3-4/night: 26.8% reported fairly bad or very bad sleep quality; 1-2/night: 14.7%; 0/night: 7.7%; P < .001) and longer WASO (3-4/night: 89.8 minutes; 1-2/night: 70.6; 0/night: 55.5; P < .001). In nested regression models, a nocturia frequency of 3-4/night quadrupled the odds of poor sleep quality (odds ratio: 4.26 [95% CI 1.65, 11.01]; P = .003) and was associated with a 37-minute worsening in WASO (95% CI 26.0, 49.0; P < .001). Frequency of nocturia explained an additional 6% variation in WASO, above and beyond demographic, medical/psychiatric conditions, and medication factors (∆R = 0.06).

Conclusions: Nocturia is common among octogenarian and nonagenarian women and is independently associated with poor sleep quality and longer wake time at night. Interventions that improve nocturia may be useful in improving sleep quality and wake time at night.
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http://dx.doi.org/10.1111/jgs.15027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5681421PMC
November 2017

A Four-Session Sleep Intervention Program Improves Sleep for Older Adult Day Health Care Participants: Results of a Randomized Controlled Trial.

Sleep 2017 08;40(8)

Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, North Hills, CA.

Study Objective: To test the effectiveness of a 4-week behavioral Sleep Intervention Program (SIP: sleep compression, modified stimulus control, and sleep hygiene) compared to a 4-week information-only control (IC) among older adults attending a VA Adult Day Health Care (ADHC) program in a double-blind, randomized, clinical trial.

Methods: Forty-two individuals (mean age: 77 years, 93% male) enrolled in a VA ADHC program were randomized to receive SIP or IC. All completed in-person sleep and health assessments at baseline, post-treatment and 4-months follow-up that included 3 days/nights of wrist actigraphy, the Pittsburgh Sleep Quality Index (PSQI), and the Insomnia Severity Index (ISI). Mixed repeated measures analysis was used to compare sleep outcomes at post-treatment and 4-months follow-up, with baseline values as covariates.

Results: SIP participants (n = 21) showed significant improvement on actigraphy sleep efficiency (p = .007), number of nighttime awakenings (p = .016), and minutes awake at night (p = .001) at post-treatment, compared to IC participants (n = 21). Benefits were slightly attenuated but remained significant at 4-month follow-up (all p's < .05). There were no differences in total sleep time between groups. There was significant improvement on PSQI factor 3 (daily disturbances) at 4-month follow-up (p = .016), but no differences were observed between SIP and IC on other PSQI components or ISI scores at post-treatment or 4-month follow-up.

Conclusions: A short behavioral sleep intervention may have important benefits in improving objectively measured sleep in older adults participating in ADHC. Future studies are needed to study implementation of this intervention into routine clinical care within ADHC.
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http://dx.doi.org/10.1093/sleep/zsx079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5804980PMC
August 2017

Patient-Reported Usability of Positive Airway Pressure Equipment Is Associated With Adherence in Older Adults.

Sleep 2017 Mar;40(3)

Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California.

Study Objectives: To examine the usability of positive airway pressure (PAP) devices and its association with PAP adherence among older adults with sleep-disordered breathing.

Methods: We mailed questionnaires to patients aged ≥65 years prescribed PAP therapy during the prior 36 months from two large healthcare systems. Survey participants completed the Usability of Sleep Apnea Equipment-Positive Airway Pressure (USE-PAP) questionnaire, which assessed the usability of their PAP device. Other questionnaire items included demographics and self-rated health. We also abstracted adherence data (mean nightly hours of PAP use available from one site) and interface type from the electronic health record.

Results: Five hundred sixty-four patients completed the survey (response rate = 33%). The mean USE-PAP score (0 = best to 100 = worst) was 20 (SD ± 20). Mean duration of PAP use (available in 189 respondents) was 5.2 hours per night (SD ± 2.0). In a nested regression model predicting nightly hours of PAP use, a 10-point (0.5 SD) increase in USE-PAP score corresponded to a 0.37 hour/night reduction in PAP use. The model including the USE-PAP score explained a significant proportion (R2 = 15%) of the variation in nightly hours of PAP use above and beyond demographics, self-reported health, and interface type (∆R2 = 12%).

Conclusions: Our results demonstrate that PAP usability varies among older patients and is associated with PAP adherence, above and beyond other predictors of adherence. These results support measuring and improving PAP usability to further improve PAP adherence for older patients.
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http://dx.doi.org/10.1093/sleep/zsx007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5806579PMC
March 2017

Acceptability of Medication and Nonmedication Treatment for Insomnia Among Female Veterans: Effects of Age, Insomnia Severity, and Psychiatric Symptoms.

Clin Ther 2016 Nov 27;38(11):2373-2385. Epub 2016 Oct 27.

Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System; David Geffen School of Medicine, University of California, Los Angeles, California.

Purpose: Female veterans are at high risk for sleep problems, and there is a need to provide effective treatment for this population who experience insomnia. This study's primary goal was to compare the acceptability of medication versus nonmedication treatments for insomnia among female veterans. In addition, we examined the role of patient age, severity of sleep disturbance, and psychiatric symptoms on acceptability of each treatment approach and on the differences in acceptability between these approaches.

Methods: A large nationwide postal survey was sent to a random sample of 4000 female veterans who had received health care at a Veterans Administration (VA) facility in the previous 6 months (May 29, 2012-November 28, 2012). A total of 1559 completed surveys were returned. Survey items used for the current analyses included: demographic characteristics, sleep quality, psychiatric symptoms, military service experience, and acceptability of medication and nonmedication treatments for insomnia. For analysis, only ratings of "very acceptable" were used to indicate an interest in the treatment approach (vs ratings of "not at all acceptable," "a little acceptable," "somewhat acceptable," and "no opinion/don׳t know").

Findings: In the final sample of 1538 women with complete data, 57.7% rated nonmedication treatment as very acceptable while only 33.5% rated medication treatment as very acceptable. This difference was statistically significant for the group as a whole and when examining subgroups of patients based on age, sleep quality, psychiatric symptoms, and military experience. The percentage of respondents rating medication treatment as very acceptable was higher for women who were younger, had more severe sleep disturbances, had more psychiatric symptoms, who were not combat exposed, and who had experienced military sexual trauma. By contrast, the percentage of respondents rating nonmedication treatment as very acceptable differed only by age (younger women were more likely to find nonmedication treatment acceptable) and difficulty falling asleep.

Implications: Female veterans are more likely to find nonmedication insomnia treatment acceptable compared with medication treatment. Thus, it is important to match these patients with effective behavioral interventions such as cognitive behavioral therapy for insomnia. Efforts to educate providers about these preferences and about the efficacy of cognitive behavioral therapy for insomnia may serve to connect female veterans who have insomnia to the treatment they prefer. These findings also suggest that older female veterans may be less likely to find either approach as acceptable as their younger counterparts.
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http://dx.doi.org/10.1016/j.clinthera.2016.09.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5769480PMC
November 2016

Estimated Prevalence of Insomnia among Women Veterans: Results of a Postal Survey.

Womens Health Issues 2017 May - Jun;27(3):366-373. Epub 2017 Jan 17.

VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, Los Angeles, California; David Geffen School of Medicine at the University of California, Los Angeles, California.

Objectives: Insomnia is a significant public health concern known to particularly impact women and the veteran population; however, rates of insomnia disorder among women veterans are not known.

Method: Women veterans who had received health care at VA Greater Los Angeles Healthcare System between 2008 and 2010 and resided within 25 miles of the facility were sent a postal survey assessing sleep, demographics, and other related patient characteristics.

Results: A total of 660 women (43.1% of potential responders) returned the postal survey and provided sufficient information for insomnia diagnosis. On average, women reported 6.2 hours of sleep per night. The prevalence of insomnia, determined according to diagnostic criteria from the International Classification of Sleep Disorders-2, was 52.3%. Women with insomnia reported more severely disturbed sleep, and more pain, menopausal symptoms, stress/worries, and nightmares compared with women without insomnia. There was a quadratic relationship between age and insomnia with women in their mid-40s, most likely to have insomnia.

Conclusions: This survey study found that insomnia symptoms were endorsed by more than one-half of the women veterans in this sample of VA users, highlighting the critical need for enhanced clinical identification and intervention. Further research is needed to establish national rates of insomnia among women veterans and to improve access to evidence-based treatment of insomnia disorder.
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http://dx.doi.org/10.1016/j.whi.2016.12.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5435535PMC
January 2018

Report and Research Agenda of the American Geriatrics Society and National Institute on Aging Bedside-to-Bench Conference on Sleep, Circadian Rhythms, and Aging: New Avenues for Improving Brain Health, Physical Health, and Functioning.

J Am Geriatr Soc 2016 12 14;64(12):e238-e247. Epub 2016 Nov 14.

Center on Aging, University of Connecticut Health Center, Farmington, Connecticut.

The American Geriatrics Society, with support from the National Institute on Aging and other funders, held its eighth Bedside-to-Bench research conference, entitled "Sleep, Circadian Rhythms, and Aging: New Avenues for Improving Brain Health, Physical Health and Functioning," October 4 to 6, 2015, in Bethesda, Maryland. Part of a conference series addressing three common geriatric syndromes-delirium, sleep and circadian rhythm (SCR) disturbance, and voiding dysfunction-the series highlighted relationships and pertinent clinical and pathophysiological commonalities between these three geriatric syndromes. The conference provided a forum for discussing current sleep, circadian rhythm, and aging research; identifying gaps in knowledge; and developing a research agenda to inform future investigative efforts. The conference also promoted networking among developing researchers, leaders in the field of SCR and aging, and National Institutes of Health program personnel.
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http://dx.doi.org/10.1111/jgs.14493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5173456PMC
December 2016

Perceived Effectiveness, Self-efficacy, and Social Support for Oral Appliance Therapy Among Older Veterans With Obstructive Sleep Apnea.

Clin Ther 2016 Nov 15;38(11):2407-2415. Epub 2016 Oct 15.

Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; Department of Medicine, University of California, Los Angeles, California; David Geffen School of Medicine, University of California, Los Angeles.

Purpose: Obstructive sleep apnea is a prevalent sleep disorder among older adults. Oral appliances are increasingly prescribed as therapy for obstructive sleep apnea. Adherence to oral appliance therapy is highly variable. Based on value-expectancy theory and other social-psychological theories, adherence to oral appliance therapy may be influenced by patients' perceived effectiveness of the therapy, self-efficacy, and availability of social support. We examined these perceptions among older adults with obstructive sleep apnea who were prescribed oral appliance therapy.

Methods: We mailed surveys to all patients aged ≥65 years who had been prescribed oral appliance therapy for obstructive sleep apnea over the prior 36 months at a Veterans Affairs medical center. We examined frequencies of responses to items that assessed perceived effectiveness, self-efficacy, and social support for nightly use of oral appliances from friends, family, or health care staff.

Findings: Thirty-nine individuals responded (response rate, 30%; mean [SD] age 71.4 [SD 6.3] years; 97% male). Thirty-six percent of the respondents perceived regular use of oral appliance therapy to be effective in managing obstructive sleep apnea; 39% agreed that they felt confident about using oral appliances regularly; 41% felt supported by people in their life in using oral appliance therapy; and 38% agreed that health care staff would help them to use their oral appliance regularly. These rates represented less than half of respondents despite the finding that 65% of patients believed that they would use their oral appliance regularly.

Implications: Although oral appliance therapy is increasingly prescribed for obstructive sleep apnea, only about one third of older adults prescribed it perceived it to be an effective treatment, were confident about oral appliance use, and/or believed that they would receive needed support. Future research is needed to better understand older adults' perceptions so that interventions can be designed to improve the effectiveness of oral appliances, their self-efficacy for using oral appliances, and their social support for this therapy, which may, in turn, improve oral appliance therapy adherence.
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http://dx.doi.org/10.1016/j.clinthera.2016.09.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5110379PMC
November 2016

Caregiving-Related Sleep Problems and Their Relationship to Mental Health and Daytime Function in Female Veterans.

Behav Sleep Med 2018 Jul-Aug;16(4):371-379. Epub 2016 Oct 3.

a Geriatric Research , Education and Clinical Center, VA Greater Los Angeles Healthcare System , Los Angeles , California.

Objective/background: To identify caregiving-related sleep problems and their relationship to mental health and daytime function in female Veterans.

Participants: Female Veterans (N = 1,477) from cross-sectional, nationwide, postal survey data.

Methods: The survey respondent characteristics included demographics, comorbidity, physical activity, health, use of sleep medications, and history of sleep apnea. They self-identified caregiving- related sleep problems (i.e., those who had trouble sleeping because of caring for a sick adult, an infant/child, or other respondents). Patient Health Questionnaire (PHQ-4) was used to assess mental health, and daytime function was measured using 11 items of International Classification of Sleep Disorders-2 (ICSD-2).

Results: Female Veterans with self-identified sleep problems due to caring for a sick adult (n = 59) experienced significantly more symptoms of depression and anxiety (p < 0.001) and impairment in daytime function (e.g., fatigue, daytime sleepiness, loss of concentration, p < 0.001) than those with self-identified sleep problems due to caring for an infant or child (n = 95) or all other respondents (n = 1,323) after controlling for the respondent characteristics.

Conclusions: Healthcare providers should pay attention to assessing sleep characteristics of female Veterans with caregiving responsibilities, particularly those caregiving for a sick adult.
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http://dx.doi.org/10.1080/15402002.2016.1228640DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5378653PMC
November 2018

Cognitive Behavioral Therapy for Insomnia in Older Veterans Using Nonclinician Sleep Coaches: Randomized Controlled Trial.

J Am Geriatr Soc 2016 09 22;64(9):1830-8. Epub 2016 Aug 22.

Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.

Objectives: To test a new cognitive behavioral therapy for insomnia (CBT-I) program designed for use by nonclinicians.

Design: Randomized controlled trial.

Setting: Department of Veterans Affairs healthcare system.

Participants: Community-dwelling veterans aged 60 and older who met diagnostic criteria for insomnia of 3 months duration or longer (N = 159).

Intervention: Nonclinician "sleep coaches" delivered a five-session manual-based CBT-I program including stimulus control, sleep restriction, sleep hygiene, and cognitive therapy (individually or in small groups), with weekly telephone behavioral sleep medicine supervision. Controls received five sessions of general sleep education.

Measurements: Primary outcomes, including self-reported (7-day sleep diary) sleep onset latency (SOL-D), wake after sleep onset (WASO-D), total wake time (TWT-D), and sleep efficiency (SE-D); Pittsburgh Sleep Quality Index (PSQI); and objective sleep efficiency (7-day wrist actigraphy, SE-A) were measured at baseline, at the posttreatment assessment, and at 6- and 12-month follow-up. Additional measures included the Insomnia Severity Index (ISI), depressive symptoms (Patient Health Questionnaire-9 (PHQ-9)), and quality of life (Medical Outcomes Study 12-item Short-form Survey version 2 (SF-12v2)).

Results: Intervention subjects had greater improvement than controls between the baseline and posttreatment assessments, the baseline and 6-month assessments, and the baseline and 12-month assessments in SOL-D (-23.4, -15.8, and -17.3 minutes, respectively), TWT-D (-68.4, -37.0, and -30.9 minutes, respectively), SE-D (10.5%, 6.7%, and 5.4%, respectively), PSQI (-3.4, -2.4, and -2.1 in total score, respectively), and ISI (-4.5, -3.9, and -2.8 in total score, respectively) (all P < .05). There were no significant differences in SE-A, PHQ-9, or SF-12v2.

Conclusion: Manual-based CBT-I delivered by nonclinician sleep coaches improves sleep in older adults with chronic insomnia.
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http://dx.doi.org/10.1111/jgs.14304DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5351772PMC
September 2016

A Brief Report on the Development of The Usability of Sleep Apnea Equipment-Oral Appliance (USE-OA) Questionnaire: A Pilot Study.

J Dent Sleep Med 2015 Jul;2(3):67-70

David Geffen School of Medicine at UCLA, Los Angeles, CA.

Study Objectives: To develop a questionnaire for measuring human factors (usability) associated with oral appliance use and to assess the feasibility of administering the questionnaire to patients with obstructive sleep apnea in a clinic setting.

Methods: We developed the 11-item Usability of Sleep Apnea Equipment-Oral Appliance (USE-OA) Questionnaire by adapting items from a published questionnaire that had been developed to assess human factors associated with positive airway pressure device use. Then we distributed the USE-OA to patients at a university dental clinic between January and July 2014. We evaluated our survey methods qualitatively, calculated the response rate, and assessed completeness and response patterns of the USE-OA.

Results: Our formative evaluation revealed that the questionnaire was easy to distribute and administer in a clinic setting. Our response rate was 23%. A majority of respondents gave favorable usability ratings, and a small number of respondents gave unfavorable usability ratings.

Conclusions: The USE-OA questionnaire can be easily administered in a dental clinic setting. Additional studies conducted in high-volume sleep oral appliance clinics are needed to assess the psychometric properties of the USE-OA and to compare the results of the USE-OA to direct observation of patients getting their oral appliance ready for use and cleaning their oral appliance.
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http://dx.doi.org/10.15331/jdsm.4866DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4957952PMC
July 2015

Patient-Provider Communication With Older Adults About Sleep Apnea Diagnosis and Treatment.

Behav Sleep Med 2017 Nov-Dec;15(6):423-437. Epub 2016 May 4.

a VA Greater Los Angeles Healthcare System , North Hills , California.

Patient-provider communication impacts adherence to therapy. We explored older adults' communication with their providers, preferences for communication, and views on communication attributes and decision aid characteristics, by conducting four focus groups. Several participants reported they had received insufficient information about their sleep apnea diagnosis and treatment options. Most participants felt that it would be helpful to have treatment information tailored to their needs, including information on the negative impact of treatment on comfort and convenience and disclosure about common barriers to adherence. Participants provided desired characteristics for a decision aid, including their preferred delivery method, content, and format. These findings have implications for how to design useful decision aids for older adults with newly diagnosed sleep apnea.
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http://dx.doi.org/10.1080/15402002.2016.1150278DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5429217PMC
October 2017

Efficacy of Cognitive Behavioral Therapy for Insomnia in Older Adults With Occult Sleep-Disordered Breathing.

Psychosom Med 2016 06;78(5):629-39

From the Geriatric Research, Education and Clinical Center (Fung, Martin, Josephson, Dzierzewski, Jouldjian, Rodriguez, Mitchell, Alessi), VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Medicine (Fung, Martin, Dzierzewski, Rodriguez, Alessi), David Geffen School of Medicine at UCLA, Los Angeles, California; School of Medicine (Fiorentino), University of California, San Diego, California; and Department of Medicine (Rodriguez), Pontificia Universidad Catolica de Chile, Santiago, Región Metropolitana, Chile.

Objectives: The aims of the study were to determine whether mild, occult sleep-disordered breathing (SDB) moderates the efficacy of cognitive behavioral therapy for insomnia (CBTI) in older adults and to explore whether CBTI reduces the number of patients eligible for positive airway pressure (PAP) therapy.

Methods: Data were analyzed for 134 adults 60 years or older with insomnia and apnea-hypopnea index (AHI) of less than 15 who were randomized to a larger study of CBTI versus a sleep education control. Sleep outcomes (sleep onset latency, total wake time, wake after sleep onset, sleep efficiency, Pittsburgh Sleep Quality Index) were compared between CBTI and control at 6 months using repeated-measures analysis of variance adjusted for baseline values. AHI of 5 or greater versus less than 5 was included as an interaction term to evaluate changes in sleep outcomes. The number of participants at baseline and 6 months with mild SDB for whom insomnia was their only other indication for PAP was also compared between CBTI and control.

Results: AHI status (AHI ≥ 5 [75.5% of participants] versus AHI < 5) did not moderate improvements in sleep associated with CBTI (all p values ≥ .12). Nine (45.0%) of 20 participants with mild SDB for whom insomnia was their only other indication for PAP therapy at baseline no longer had another indication for PAP at 6 months, with no significant difference between CBTI and control.

Conclusions: CBTI improves sleep in older veterans with insomnia and untreated mild SDB. Larger trials are needed to assess whether CBTI reduces the number of patients with mild SDB eligible for PAP.
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http://dx.doi.org/10.1097/PSY.0000000000000314DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4891271PMC
June 2016