Insomnia in older adults: Behavioral interventions by Edgar Salgado García

INSOMNIA IN OLDER ADULTS: BEHAVIORAL INTERVENTIONS

by Edgar Salgado-Garcia B.S., Psychology Licenciado en Psicologia

A Research Paper Submitted in Partial Fulfillment of the Requirements for the Master of Science Degree

Department of Behavior Analysis and Therapy in the Graduate School Southern Illinois University at Carbondale April 1999

AN ABSTRACT OF THE RESEARCH PAPER OF EDGAR SALGADO-GARCIA, for the Master of Science degree in BEHAVIOR ANALYSIS AND THERAPY, presented on MARCH 30, 1999, at Southern Illinois University at Carbondale. TITLE: Insomnia in Older Adults: Behavioral Interventions. MAJOR PROFESSOR: Roger Poppen, Ph.D. Insomnia is a very common condition among the elderly. The major insomnia complaints of older adults are difficulty maintaining sleep and early morning awakening. A number of factors are related to insomnia in older adults, such as medical conditions, depression, behavioral and cognitive factors, prolonged use of sleep medication, poor sleep hygiene, and changes in sleep-wake rhythms. Changes in sleep patterns often occur as a function of aging. These include a decrease of slow-wave sleep (i.e., deep sleep), and an increase of sleep stages during which the individual is more easily awakened. The distribution of sleep during the day changes, as the individual tends to sleep less during the night and to take more naps during the day. Insomnia can be assessed by a number of subjective (e.g., interviews, questionnaires, sleep diaries) and objective (e.g., polysomnography, direct observation) techniques. Behavioral interventions have been proven effective in treating insomnia in elderly individuals. The major techniques are stimulus control instructions, sleep restriction therapy, relaxation training, cognitive therapy, and multicomponent approaches. The increased interest of behavioral therapists in applying these techniques to the elderly population has resulted in effective interventions that will continue to be researched and validated in the future.

Acknowledgments

I would like to express my appreciation and thankfulness to Dr. Roger Poppen. He was the one who brought me to the B.A.T. program, and the one who helped me graduate successfully at last. My graduate studies would not have been possible without the support and the love for studying that were given to me by my parents, Vera Garcia and Edgar Salgado. I dedicate this paper to my wife Carmen and my daughter Priscila, who stood by me all this time away from our home. We finally did it! Thanks you for your love and support.

Table of Contents

CHAPTER I: Introduction………………………………………..……………………….1 CHAPTER II: Insomnia in Older Adults: Concepts and Causes……………….…………6 Clinical Characteristics of Insomnia………………………………………………6 Insomnia Complaints in Older Adults…………………………………………….7 Causes of Insomnia in Older Adults………………………………………………8 Medical conditions……………………………………………………..….9 Depression………………………………………………………………..12 Behavioral and cognitive factors…………………………………….…..13 Medication and other substances………………………………………...15 Poor sleep hygiene and environmental factors…………………………..17 Inactivity and changes in sleep-wake rhythms………………………..…18 Conclusion………………………………………………………………………19 CHAPTER III: Changes in Sleep Patterns as a Function of Aging………………….…..20 The Stages of Sleep…………………………………………………………….21 Changes in Sleep Architecture as a Function of Aging………………………..22 Changes in Circadian Rhythms………………………………………………..24 CHAPTER IV: Assessment of Insomnia in the Elderly………………..………………..27 Interviews……………………………………………………………………..29 Current status…………………………………………………….……29 Historical factors……………………………………………….……..29 Current and contributing factors…………………………...…………30 iii

Physical Examination………………………...………………………………...30 Questionnaires and Inventories…………………………………………………31 Sleep Diaries……………………………………………………………………32 Direct Observation………………….……...…………………………..………33 Polysomnography………………….……...………………..………………….35 Assessment of Next-Day Effects………………………………..……………..37 CHAPTER V: Behavioral Interventions for Insomnia in Older Adults…………………38 Stimulus Control……………….………………………………………………40 Countercontrol…………………..……………………………………………..42 Sleep Restriction……………….………………………………………………43 Sleep Compression…………….………………………………………………45 Sleep Hygiene Instructions…….………………………………………………46 Relaxation Training……………………………………………………………48 Self-Help Treatments….……………………………………………………….51 Educational Interventions: Information and Support…………….……………52 Cognitive Therapy……………….…………………………………………….53 Multicomponent Approaches…….……………………………………………56 CHAPTER VI: Treatment Effectiveness………………………………………...………57 Studies Evaluating Single Techniques………………………………………..57 Stimulus control………………………………………………………57 Countercontrol………………………………………………………..59 Self-help treatments…………………………………………………..60 Sleep compression………………….……………………………...…61 iv

Relaxation training…………………………………………………...62 Cognitive-Behavioral Therapy……………………………………………….62 Studies Comparing Different Techniques……………………………………64 Discussion……………………………………………………………………67 CHAPTER VII: Summary and Conclusions………………………………….………..69 References………………...……………………………………………………………72 Vita…...………………………………………………………………………………...84

CHAPTER I Introduction

By the turn of the century, there will be approximately 30 million elderly individuals (age 65 and older) in the United States, accounting for 15% of the population (Vitiello & Prinz, 1988). By the year 2040, the elderly are expected to comprise 25% of all North Americans (Rosenthal & Carstensen, 1988). This change in the age composition of the population is directly related to many factors that have increased the life expectancy during the twentieth century, such as sanitation, control of infectious diseases, improved nutrition, and reduction in infant mortality (Miles & Dement, 1980). The increase in the elderly population poses a challenge to the helping professions. Understanding the social and biological changes related to aging becomes imperative in order to provide adequate services to the older adult. The medical and social sciences have turned their attention to the special needs of the aging population. As an example in the field of behavior analysis and therapy, Cautela and Mansfield (1977) and Hussian (1981) called for a behavioral approach to geriatrics. In 1986, the first conference on behavioral gerontology was held at the University of Chicago (Carstensen, 1988). Aging is usually associated with deterioration of physiologic and psychological functioning. Many stereotypes exist, such as attributing disease and disability to a "normal" course of aging. The view that aging consists of inevitable physical and psychological failing has been challenged during the last decades (Williams, 1989;

Williams, 1991). Rowe and Kahn (1987) proposed the notion of "successful aging", referring to the possibility of aging without inevitable disease. Changes in physical, cognitive, and behavioral functioning that are more prevalent among the elderly are not necessarily irreversible. In fact, the success of behavioral interventions with elderly populations has challenged the notion of irreversibility of decline in old age (Carstensen, 1988). Socially accepted signs of aging include, among others, reduced ability to cope with stress or environmental change, reduced strength, loss of flexibility and mobility of joints and tendons, sensory and reflex decrements, infertility, graying of hair, and impaired memory (Miles & Dement, 1980). Yet individual differences make it difficult to conclude that these are essentially true of all "older" people. Some individuals appear old at age 50, while others remain vigorous and youthful at age 80. Many chronic diseases, however, are considered to be age-related, in the sense that they have a distinct window of opportunity for developing as one ages. Heart disease, stroke, certain forms of cancer, and arthritis are some diseases considered to be age-related. Most sleep disorders are also age-related, such as sleep apnea, periodic leg movements, and phase advance of the sleep-wake cycle, which results in insomnia complaints (Bliwise, 1997). Epidemiological surveys have found that approximately 10% to 15% of adults complain of chronic insomnia (Morin, Culbert, & Schwartz, 1994). Among older adults (65 years of age and older), the prevalence of insomnia has been found to be between 40% to 50% (Ancoli-Israel, 1997). This may be due to a number of factors, such as changes in neurological function and biological rhythms associated with "normal" aging,

changes in daily schedules, physical and psychiatric illnesses, and others (Bootzin & Engle-Friedman, 1987). The most common sleep-related complaint of older persons is difficulty maintaining sleep. They report frequent awakenings, and difficulty in going back to sleep once awakened. Studies indicate that as many as 65% of the individuals over age 60 experience at least mild trouble with this symptom (Bliwise, 1997). Sleep disturbance in the elderly can be a strong predictor of nursing home placement and perhaps increased risk of mortality (Pollack, Perlick, Linsner, Wenston, & Hsieh, 1990). Although the elderly currently comprise about 12% of the population of the United States, they receive about 35% to 40% of the sleep medication (Moran, Thompson, & Nies, 1988). Pharmacotherapy continues to be the most commonly used method for the treatment of insomnia. Many individuals use sleep medication for long periods of time. The elderly have a tendency for long-term intake (Englert & Linden, 1998). More than 10% of benzodiazepine (one of the most common sleeping pills) users report having used the medication for more than a year (Mellinger, Balter, & Uhlenhuth, 1985). Chronic use of hypnotics (sleep-inducing medication) is not clinically indicated, as it results in alteration of sleep stages, tolerance, dependence, and rebound insomnia (Morin et al., 1994). Englert and Linden (1998) found that elderly persons (age 70 and older) who took sleep medication for chronic insomnia reported more sleep-related symptoms (e.g., difficulty in initiating sleep and going back to sleep when awakened), than those with insomnia who did not take sleep medication.

The shortcomings in the use of hypnotics led to an increased interest in nonpharmacologic treatments for sleep disorders. Alternatives to pharmacologic treatments for insomnia have been developed by behavior therapists over the years. Behavioral treatments for insomnia appeared as early as the 1960s, and included techniques such as progressive relaxation training, systematic desensitization, and classical conditioning (Montgomery, Perkin, & Wise, 1975). Other, more sophisticated techniques, have been developed during the last decades, such as paradoxical intention, stimulus control training, restriction of time in bed, self-management, and cognitive approaches (Borkovec, 1982; Lacks & Morin, 1992; Lichstein & Riedel, 1994; Morin, Kowatch, Barry, & Walton, 1993). Initially, behavioral interventions for insomnia were aimed at the younger adult population. One of the reasons for the lack of interest in applying these techniques to the elderly was the view that dysfunctional sleep was a normal, irreversible aspect of aging. Elderly subjects were excluded from samples in studies of sleep disorders (Storandt, 1983). However, during the 1980s many of the interventions were tested with the elderly population (Morin & Azrin, 1988; Morin & Rapp, 1987). Researchers and clinicians began to tailor behavioral interventions to the specific sleep complaints of older adults, especially the difficulty in maintaining sleep (Davies, Lacks, Storandt, & Bertelson, 1986; Edinger, Hoelscher, Marsh, Lipper, & Ionescu-Pioggia, 1992; Hoelscher & Edinger, 1988; Lacks, Bertelson, Sugerman, & Kunkel, 1983; Morin & Azrin, 1987; Schoicket, Bertelson, & Lacks, 1988). Examples of specific procedures used in these interventions include the application of stimulus control principles (by instructing the person to use the bedroom

strictly for sleeping), countercontrol (by instructing the person to engage in nonarousing activities upon awakenings), and restriction of time in bed (by reducing the time available for sleep, followed by an extension of time in bed contingent upon increased sleep efficiency). Some of these techniques are often combined in treatment packages (Morin, Kowatch, et al., 1993). Research is still being conducted, and although there are effectiveness studies of behavioral interventions for insomnia in the general adult population (e.g., Morin, Stone, McDonald, & Jones, 1994; Murtagh & Greenwood, 1995), more research is still needed with the elderly population. An increase in the number of studies is to be expected in the following years, as behavior therapists continue to defy aging with research-based, systematic interventions. The purpose of this research paper is to present an overview of the nature and causes of insomnia in the older adult and the major behavioral and cognitive interventions that have been developed for its treatment. The second and third chapters will focus on the major variables associated with insomnia complaints in the elderly, and the changes in sleep patterns associated with aging. The fourth chapter will focus on the assessment of insomnia in the elderly. The sixth and seventh chapters will review the major behavioral and cognitive interventions for geriatric insomnia, with discussions of selected studies and comparisons among the various techniques in terms of treatment effectiveness.

CHAPTER II Insomnia in Older Adults: Concepts and Causes

Clinical Characteristics of Insomnia Insomnia refers to a variety of problems related to disturbance in the sleep process. Disturbance of sleep may occur in different ways, such as difficulty in falling asleep (sleep-onset insomnia), frequent or prolonged awakenings (sleep-maintenance insomnia), early awakening in the morning with an inability to return to sleep (terminal insomnia), or the subjective report of an unsatisfactory quantity or quality of sleep (Bootzin, Engle-Friedman, & Hazelwood, 1983). People who suffer from insomnia may present one or any combination of these symptoms (Van Brunt, Riedel, & Lichstein, 1996). Insomnia complaints may involve not only nocturnal, but also daytime symptoms, such as changes in mood, performance, and alertness (Bootzin et al., 1983; Bliwise, 1997). It should be noted that disturbed sleep patterns according to objective laboratory assessments (i.e., polysomnography) do not always coincide with self-reported symptoms of disturbed sleep (Englert & Linden, 1998; Vitiello, 1997). Therefore, it is important to consider subjective complaints in their own right, as they may motivate sufferers to seek medical treatment or to use sleep medication (Morgan, Healey, & Healey, 1989). The International Classification of Sleep Disorders (American Sleep Disorders Association, 1990) provides a list of types of insomnia based on the presumed causes of each. The first type, psychophysiological insomnia, is due to anxiety or somatic tension. This is the most common diagnosis for most patients presenting with insomnia (Van

Brunt et al., 1996). It is what people usually mean when they use the term "insomnia" referring to difficulty sleeping. Sleep state misperception consists of the complaint of insomnia in the absence of abnormalities shown by an objective sleep assessment (polysomnography). Idiopathic insomnia is a type of insomnia presumably caused by neurological dysfunction. Inadequate sleep hygiene and environmental sleep disorder are associated with poor daytime habits (e.g., use of caffeine, napping), and a disrupted physical environment (e.g., excessive noise, an uncomfortable bed.), respectively. Altitude insomnia involves a thinned oxygen supply occurring at high altitudes which disrupts sleep. Adjustment sleep disorder results from temporary stressors that affect sleep in individuals who usually have no sleep complaints. Finally, there are three categories for sleep disorders resulting from the dependence on hypnotic medication, stimulants, and alcohol, respectively (American Sleep Disorders Association, 1990).

Insomnia Complaints in Older Adults Several survey studies have shown that the complaint of insomnia is the most prevalent sleep disorder, and is particularly frequent among the elderly (Bixler, Kales, Soldatos, Kales, & Healey, 1979; Karacan, Thornby, Anch, Holzer, Warheit, Schwab, & Williams, 1976). Karacan et al. (1976), reported that 23% of the respondents over 60 years of age experienced sleep disturbance "often" or "all the time", as compared to only 13% of the general population. In a 1979 nationally representative survey of adults 18 to 79 years of age in the United States, Mellinger et al. (1985) found that insomnia, defined as difficulty initiating and maintaining sleep, afflicted 35% of all adults during the course of a year. Approximately half of these adults (17% of the sample) reported having

serious sleep disturbance. The most severe complaints were reported by older adults, especially women. Monjan (1990) reported that approximately 50% of Americans over 65 years of age complain about sleep disruptions. Common symptoms reported by the elderly are related to getting less sleep, waking up frequently during the night, waking up too early in the morning, and daytime sleepiness (Ancoli-Israel, 1997). The most typical sleep-related symptom reported by the elderly consists of increased frequency and duration of nocturnal awakenings (Bootzin & Engle-Friedman, 1987). Studies have found that as many as 65% of the population over 60 years of age experiences at least a mild difficulty in maintaining sleep, whereas 25% to 35% experience problems in falling asleep (Bliwise, 1997). Nocturnal awakenings may be a better predictor of subjective dissatisfaction with sleep than the total amount of sleep reported per night (Moran et al., 1988). Data suggest that younger adults are more likely to suffer from sleep-onset insomnia (i.e., difficulty falling asleep), whereas older adults are more likely to experience sleep-maintenance insomnia (Lichstein & Riedel, 1994). Even though older males have been found to have consistently more disturbed sleep than their female counterparts as measured in a sleep laboratory, women tend to report more sleep-related symptoms (e.g., sleep-maintenance insomnia) than men (Bliwise, 1997; Van Brunt et al., 1996).

Causes of Insomnia in Older Adults The causes of insomnia are multifactorial (Bliwise, 1997; Espie, 1991; Monane, 1992; Trilling, 1992). Insomnia cannot be conceptualized as a simple disorder. Rather,

there are different ways in which insomnia manifests itself (e.g., sleep-onset, sleep maintenance, early morning awakening, etc.), and many factors that may cause the disorder.

Insomnia may be associated with medical conditions (e.g., pain from arthritis,

coronary heart disease, stroke, sleep apnea), and psychiatric conditions (e.g., depression). Psychosocial factors such as loneliness, changes in daily routines and work schedules, and extended travel can also influence the quality of sleep and result in complaints of insomnia (Monane, 1992). Bootzin and Perlis (1992) also mention as causes of insomnia in the elderly the use of substances (e.g., caffeine, nicotine, alcohol, hypnotics, illicit drugs), circadian rhythm alterations (e.g., advanced sleep phase syndrome), poor sleep environment (e.g., noise, temperature, light, sleeping surface, bed partner), and poor sleep habits (e.g., extended time in bed, naps, irregular schedule, bed as a cue for arousal). It should be noted that older adults use sleep medication at about four times the rate of middle-aged persons (Lichstein & Johnson, 1993). Moran et al. (1988) reported that the elderly were prescribed about 35% to 40% of the sedative-hypnotic medications in the United States. Prolonged use of hypnotic medication may be a cause of increased insomnia complaints over time (Bootzin & Perlis, 1992). Insomnia is a complex disorder, and it is important to understand its causes in order to implement effective treatment strategies. Following is a brief discussion of some of the major causes of insomnia in the elderly population. Medical conditions. The most common medical condition that affects sleep is sleep-disordered breathing, especially sleep apnea (Bootzin & Engle-Friedman, 1987). Sleep apnea is a cessation of airflow for 10 seconds or longer. When apnea occurs more than five times per hour, it is considered abnormal. Sleep apnea causes insomnia,

daytime sleepiness, and loud snoring (Karacan & Williams, 1983). Sleep apnea has been found to occur in 39% of older adults seen in sleep disorder clinics (Coleman, Miles, Guilleminault, Zarcone, van den Hoed, & Dement, 1981). Bliwise (1993) points out that numerous studies have definitively concluded that respiratory disturbance in sleep increases with age. Some studies have found that a minimal degree of sleep-disordered breathing occurs in 24% of healthy older adults, and in more than 40% of chronically ill, institutionalized populations (Bundlie, 1998). Arousal must occur for the respiratory pause or apnea to be terminated. This may account for the increasing nocturnal awakenings reported by older persons (Bootzin & Engle-Friedman, 1987). Sleep apnea is almost always related to a complaint of daytime sleepiness, and this is one of the key symptoms for its diagnosis (Vitiello & Prinz, 1988). Nocturnal myoclonus and restless legs are two other muscular disorders that impair sleep. In nocturnal myoclonus leg twitches occur frequently throughout the night; in restless legs, the person experiences severe itching in the legs and the need to move them in order to stop this sensation (Bootzin & Engle-Friedman, 1987). Periodic limb movements in sleep (PLMS) is common in all populations, but its occurrence increases with age (Vitiello & Prinz, 1988). It has been reported in up to 45% of healthy older persons with no sleep complaints (Bundlie, 1998). Although some individuals with nocturnal myoclonus do not report sleep disturbance, its frequency and intensity are associated with the severity of the sleep complaints (Vitiello & Prinz, 1988). Common complaints include difficulty falling asleep and maintaining sleep as a result of frequent arousals. Leg movements are followed by brief arousal (Ancoli-Israel, 1997).

Additional medical conditions that may affect sleep in older individuals are arthritic and other pain syndromes, respiratory disease, cardiac disease, and diabetes mellitus (Prinz & Raskind, 1978; Vitiello & Prinz, 1988). Other medical disorders experienced by older adults can also impair sleep. Back pain, gastric pain from ulcer, and cardiac pain usually affect the quality and quantity of sleep (Bootzin & Engle-Friedman, 1987). Sleep disturbance associated with arthritic pain is a very common complaint of older persons (Prinz & Raskind, 1978). In general, almost any medical condition that produces pain, discomfort, irritation, or itch may negatively affect sleep (Moran & Stoudemire, 1992). Of special relevance to the elderly population is the sleep disturbance caused by neurologic disease, mainly Parkinson's and Alzheimer's disease. Increased sleep onset, increased waking, and other sleep abnormalities have been observed in Parkinson's disease (Moran & Stoudemire, 1992). Alzheimer's disease is associated with deterioration in sleep quality, fragmentation, shallow sleep, and disturbance of normal diurnal rhythms (Bliwise, 1993). Patients with Alzheimer's disease experience increased duration and frequency of awakenings, decreased slow-wave and REM sleep, and in advanced stages, daytime napping (Prinz, Vitiello, Raskind, & Thorpy, 1990). The sleep patterns observed in organic brain syndrome (a severe form of degenerative disease) include a decrease in total sleep time, and an increase in wakefulness. A phenomenon called â&#x20AC;&#x153;sundown syndromeâ&#x20AC;? is common in older persons with degenerative brain disorders (Bundlie, 1998). Its symptoms occur after dark, and include delirium, hallucinations, delusions, bizarre ideation, disorientation, and confused wandering during sleep (Karacan & Williams, 1983).

Depression. Depression can be a factor influencing sleep in older persons. Depression in the elderly may occur as an emotional reaction to severe or chronic medical illnesses (Prinz et al., 1990). It has been estimated that 2% of communitydwelling elderly meet the diagnostic criteria for major depressive disorder (Blazer, Hughes, & George, 1987). Among the hospitalized elderly, the prevalence of major depression may range between 10% and 20% (Koenig, Meador, Cohen, & Blazer, 1988). Disturbed sleep is one of the major symptoms of depression in the elderly (Prinz & Raskind, 1978). In addition to insomnia, depressed elderly persons also experience pessimism, loss of interest, decreased energy, impaired sexual function, social withdrawal, decreased appetite, and weight loss (Vitiello & Prinz, 1988). They may also show increased somatic complaints (e.g., back ache, abdominal pain, headache). Depression as a possible cause of sleep disturbance in the elderly is sometimes dismissed, as the above mentioned symptoms are often considered "normal" signs of aging (Prinz & Raskind, 1978). The major effects of depression on sleep include frequent awakenings, early morning wakefulness, and disturbed EEG patterns during sleep (Karacan & Williams, 1983). Again, these patterns are also associated with the normal changes in sleep and aging. Grief and mourning may also be a cause of sleep disturbance in the elderly. Feelings of loss may be associated with chronic illness or the death of a family member. Grief may last for several months, during which sleep may be disturbed. During acute grief situations, sleep complaints are often present (Moran et al., 1988). Bereavement as

a result of the death of a spouse has been found to be associated with major depression in up to 20% of elderly individuals (Bliwise, 1997). Behavioral and cognitive factors. For many individuals with chronic insomnia, the bed is not just a cue for sleeping. Instead, it becomes a cue for physiological arousal, as they engage in bedtime activities incompatible with falling asleep (Bootzin & EngleFriedman, 1987). While in the bedroom, the individual may engage in reading, talking on the telephone, watching television, eating, listening to music, and other sleepincompatible behaviors (Bootzin & Nicassio, 1978). Stressors that cause transient insomnia (less than one month duration) in older individuals, such as lifestyle changes, may also result in chronic insomnia as the person associates going to bed with insomnia rather than sleep (Van Brunt et al., 1996). Therefore, the bedroom, the bed itself, and activities prior to sleep become conditioned stimuli that continue to elicit insomnia even after the original stressor has disappeared. The individual may also experience anxiety and fear related to not being able to fall asleep. A vicious cycle may develop, in which the person's attempts to fall asleep serve to maintain sleep difficulties (Van Brunt et al., 1996). Clinical evidence suggests that faulty beliefs, attributions, and expectations about sleep are involved in increasing emotional arousal, thus exacerbating sleep disturbances (Morin, 1993). Cognitions or intrusive thoughts have been found to play a significant role in insomnia. Intrusive cognitions include problem solving, planning future activities, ruminating about the day's events, or other arousing thoughts that are incompatible with sleep (Espie, Brooks, & Lindsay, 1989). Research findings suggest that it is not the frequency of intrusive cognitions, but rather their affective valence (i.e., whether they are

negative or positive) that may act as a mediating factor in insomnia (Morin, Stone, Trinkle, Mercer, & Remsberg, 1993). For example, cognitions that are sleep-related and negative (e.g., fear of the consequences of sleep loss) have been found to be associated with sleep difficulties (Van Egeren, Haynes, Franzen, & Hamilton, 1983). The study by Morin, Stone, et al. (1993) found that older adults with insomnia reported stronger negative beliefs and attitudes about sleep than good sleepers. The most frequent negative cognitions were related to the perceived consequences of insomnia, the fear of losing control, and the unpredictability of sleep. Unrealistic expectations may be related to sleep complaints. For example, older persons may strive to sleep as well as they did when younger, leading to frustration and dissatisfaction (Lichstein, 1988). The expectation that a certain number of hours is needed to function normally during the day can also lead to performance anxiety (Morin & Gramling, 1989). Morin (1993) stated that for many individuals chronic insomnia has a self-fulfilling nature, as negative expectations and other thoughts often result in an inability to sleep well through the night. Finally, Youkilis and Bootzin (1981) proposed that insomnia may be maintained by family members or friends sympathetically responding to the complaints of the sufferer. Sleep complaints can be socially reinforced by other people's giving attention or being more tolerant when the individual appears fatigued, groggy, and irritable as a result of sleep disturbance (Bootzin & Engle-Friedman, 1987). The elderly may be particularly vulnerable to the effects of social reinforcement, due to their increasing immobility and loneliness (Lichstein & Riedel, 1994).

Medication and other substances. The elderly consume a disproportionately large amount of sleep medication as compared to younger populations. A study by James (1985) found that 34% of independently living elderly and 34% of those in skilled nursing facilities used sleep medication regularly. Persons 60 years of age and older receive about 66% more hypnotic prescriptions than persons 40 to 59, with elderly women being 1.7 times more likely to consume hypnotics than elderly men (Vitiello, 1997). Prolonged use of sleep medication has been found to be ineffective in treating insomnia and can produce drug-dependent insomnia, respiratory problems, impaired motor and intellectual functioning, and daytime sleepiness (Bootzin & Engle-Friedman, 1987). Impaired cognition and slowed psychomotor functioning may increase the likelihood of injuries in the elderly resulting from falls (Vitiello, 1997). Also, discontinuation of benzodiazepines, the most frequently used type of sleep medication, can produce "rebound insomnia", which is often more severe than the original insomnia for which the medication was prescribed (Kales, Soldatos, Bixler, & Kales, 1983). Sometimes sleep apnea may be exacerbated as a result of the continued use of sleep medication (Vitiello, 1997). Interestingly, an epidemiological study conducted by Ohayon and Caulet (1995) found that patients with insomnia who use sleep medication reported comparable satisfaction with their sleep quality compared to patients with insomnia not using medication. A study conducted in Germany, called the Berlin Aging Study (Englert & Linden, 1998), revealed that elderly persons (age 70 and older) who used sleep medication had in fact a higher rate of sleep-related complaints than those who did not

use medication. The inability to fall asleep and to go back to sleep after awakening, rather than the frequency of awakenings itself, were the most important variables that discriminated users from nonusers. Current consensus about the prescription of sleep medication is that it should be used only for temporary, situational, or intermittent conditions, for extremely limited periods of time, and at the smallest effective dose (National Institute on Aging, 1990). Further, it is recommended that doses be gradually decreased, and that close monitoring for rebound insomnia be conducted (Kupfer & Reynolds, 1997). Due to the reduced metabolic functioning with aging, potential danger exists in the chronic, unsupervised use of sleep medication in older adults (Lamm, 1993; Morin et al., 1994). The use of other prescription and non-prescription medication for various medical conditions is also associated with sleep disturbance in the elderly. As the likelihood of medical illness increases with age, so does the consumption of multiple medications for their treatment (Vitiello & Prinz, 1988). Some of the drugs used in the management of disease in older patients, such as antiparkinsonian, antihypertensive, and antiseizure medications can increase nighttime wakefulness (Karacan & Williams, 1983). Insomnia has also been found to be associated with the use of alcohol, nicotine, caffeine, and also illegal drugs, such as cocaine (Van Brunt et al., 1996). Frequent use of alcohol causes fragmented sleep, with frequent awakenings during the night (Bootzin & Engle-Friedman, 1987). Caffeine has been found to significantly decrease total sleep time, and to increase sleep latency (i.e., the time elapsing from the moment the person goes to bed to the time he or she falls asleep) and awakenings (Bonnet & Arand, 1992).

Nicotine, like caffeine, is also a central nervous system stimulant that causes lighter and more fragmented sleep (Bonnet, Webb, & Barnard, 1979). Poor sleep hygiene and environmental factors. Sleep hygiene includes a number of behaviors and environmental variables that promote sleep (Lichstein & Riedel, 1994). Typically, sleep hygiene guidelines include decreasing the use of caffeine, alcohol and nicotine before bedtime, eliminating heavy meals close to bedtime, eliminating naps during the day, rising and going to bed at regular times, and exercising regularly in the late afternoon. Napping is very common among older individuals. In some cases, napping may be a consequence of boredom due to decreased activity (Williams & Karacan, 1978). However, napping can also be associated with excessive daytime somnolence (EDS), which may be the result of frequent awakenings and reduced nighttime sleep. EDS increases with age (Schmitt, Phillips, Cook, Berry, & Wekstein, 1996). Older individuals may take naps to compensate for sleep loss during the night. This suggests that older people do not need less sleep as it is sometimes believed (Ancoli-Israel, 1997). There are controversial data regarding the negative effects of napping on insomnia in older adults. Longer late-afternoon naps have been found to have more negative effects on night sleep than earlier naps (Lichstein & Riedel, 1994). But some studies have found that limited naps (less than one hour) may not have a great impact on sleep (Aber & Webb, 1986). As for the physical environment, excessive lighting, noise, as well as extreme temperatures may impair sleep. Excessive noise has the effect of decreasing the amount of sleep, and increasing the frequency of awakenings (Bootzin & Engle-Friedman, 1987).

Elderly persons are more easily awakened (Zepelin, McDonald, & Zammit, 1984), and have more difficulty falling back to sleep once awakened (Webb & Campbell, 1980). Other characteristics of the sleep environment, such as the firmness of the mattress, and whether the bed is shared or not, may also contribute to insomnia (Bootzin & EngleFriedman, 1987). Environmental factors become important when people develop strong preferences to the point where sleep is impaired if the sleep environment differs from the one to which the person is accustomed. An unfamiliar setting and the absence of personal belongings in the bedroom may produce disrupted sleep (Bootzin & Engle-Friedman, 1987). Inactivity and changes in sleep-wake rhythms. The normal activity-rest cycle can be disrupted if the person stays in bed longer, naps during the day, or awakens earlier than usual. Retirement may bring about changes in daily schedules that negatively affect this cycle, and can cause disruptions in sleep (Vitiello & Prinz, 1988). Boredom, loneliness, and decreased structured activities in elderly persons often have a negative impact on their circadian rhythms (to be discussed later). The human circadian rhythm is a biological clock, based on a 24-hour period, that controls the sleepwake cycle (Bundlie, 1997). It relies on external signals, called zeitgebers (Monk, Reynolds, Machen, & Kupfer, 1992). These time cues may be physical (e.g., light), or social (e.g., daily routines and activities that usually involve other people). A regular social rhythm ensures appropriate exposure to the physical cues that maintain the circadian rhythm.

The study by Monk et al. (1992) conducted with a group of healthy 71 to 91 year olds found that they had more regularity in their routines than a younger group, and as many social activities as the young. However, the older persons took more naps than the younger, and subjectively reported getting less sleep than they would have wished during the night. The authors hypothesized also that older people may have less ability to perceive time cues than their younger counterparts. As people get older, the circadian clock advances, resulting in a phenomenon called advanced phase syndrome (Ancoli-Israel, 1997). The habitual bedtimes and awakening times in older adults tend to occur earlier (Bundlie, 1997).

Conclusion Healthy, active, noninstitutionalized elderly persons subjectively report more sleep difficulties than younger adults (Monk et al., 1992). Their sleep patterns are also impaired as measured by objective polysomnographic studies, thus suggesting that sleep disturbance may be a normal consequence of aging. Sleep disturbance, therefore, would be expected to be more severe among the ill, and inactive elderly. It is difficult to discriminate between changes in sleep patterns that are the result of normal aging from those which are associated with some type of disorder unrelated to the aging process. The next chapter will discuss the changes in sleep patterns observed in the elderly population, with a focus on their relationship to the common sleep complaints of the older adult.

CHAPTER III Changes in Sleep Patterns as a Function of Aging

Normal humans of all ages alternate between sleep and wakefulness in a 24-hour period. This constitutes a fundamental biological rhythm, which shows variations across the lifespan (Karacan & Williams, 1983). Measurements of sleep and wakefulness patterns are conducted in a sleep laboratory using instruments that simultaneously record the electrical signals generated by the brain (electroencephalogram, or EEG), muscle activity (electromyogram, or EMG), and eye movement activities (electrooculogram, or EOG). Other physiological activities, such as heart function, respiration, temperature, and airflow may also be monitored in the sleep laboratory depending on the nature of the research or clinical assessments being made (Vitiello & Prinz, 1988). All-night sleep recordings are termed polysomnography (i.e., the recording of multiple physiological functions during sleep). Polysomnography is the measure of sleep that has been generally accepted as most reliable and valid (Bootzin & Engle-Friedman, 1987). The most common variables measured by polysomnography include sleep latency, total sleep time, frequency and duration of spontaneous arousals, duration and sequence of sleep stages, and body movement (Karacan & Williams, 1983). Objective electrophysiologic measures are required to determine sleep stages and to measure some types of sleep disorders (Lichstein & Riedel, 1994). Polysomnographic studies have shown that people with insomnia show greater time to sleep onset, greater

time awake after initial sleep, and more frequent awakenings during the night than people without insomnia (Borkovec, 1982).

The Stages of Sleep The sequence or pattern of sleep stages throughout the night is termed sleep architecture (Bundlie, 1997). Sleep consists of two different neurological states, based on EEG, EOG, and EMG measurements: Rapid eye movement (REM) sleep, and non rapid eye movement (NREM) sleep (Karacan & Williams, 1983). During NREM sleep, eye movements are relatively infrequent, and there is a decrease in muscle tone as compared with waking levels (Prinz et al., 1990). NREM sleep consists of four stages. Stage 1 is considered the lightest stage of sleep, since the person can be easily aroused. As sleep progresses from stage 1 to stage 4, the waves of the EEG become slower and increase in amplitude (Orr, Altshuler, & Stahl, 1982). Stages 3 and 4 of NREM sleep are called slow-wave sleep. The amplitude of the slower brain waves of stages 3 and 4 decreases with age (Moran et al., 1988). Sleep begins with the succession of NREM stages 1 to 4. The first REM period occurs about 90 to 100 minutes after the person falls asleep (Orr et al., 1982). REM sleep is characterized by a significant decrease in muscle tone, and low-amplitude, fastfrequency EEG waves. The experience of dreaming is associated with REM sleep (Dement, 1976). This pattern of brain activity is similar to that observed in wakefulness; therefore, REM sleep is also called paradoxical sleep (Prinz et al., 1990). After the first REM period, REM and NREM periods alternate about three to four times during the night, approximately every 90 minutes. The time from the beginning of

one REM period to the beginning of the next is termed the REM cycle, and it shows significant changes as a function of aging (Orr et al., 1982).

Changes in Sleep Architecture as a Function of Aging There is considerable evidence supporting the existence of changes in sleep architecture with aging. An extensive discussion of the literature was presented by Miles and Dement (1980), and Bliwise (1993). These authors reviewed hundreds of studies about the neurobiological, age-related changes in sleep. These changes are measured in terms of sleep parameters (i.e., variables derived from all-night polysomnographic recordings). Some important sleep parameters are: Total sleep time (TST), sleep period time (SPT), sleep latency (SL), wake after sleep onset (WASO), time in bed (TIB), and sleep efficiency (TST divided by TIB). Total times for each of the four NREM stages are also calculated, as well as total NREM and REM times (Miles & Dement, 1980). In general, TIB (nocturnal time in bed, from lights-out to morning awakening) increases as a function of aging (Williams, Karacan, & Hursch, 1974). Older individuals spend more time in bed, although not necessarily asleep during the entire period of time. Therefore, sleep efficiency decreases with age, as more time is spent in bed, but a lower proportion of that time is spent sleeping (Wauquier, 1993). WASO changes significantly as a function of aging, as elderly persons experience an increase in the number and total duration of awakenings throughout the night (Miles & Dement, 1980). Sleep latency (the time it takes the person to fall asleep once in bed) increases moderately with age,

although many elderly persons do not show significant changes as compared to younger adults. Slow-wave sleep (NREM stages 3 and 4) decreases with age, especially stage 4. Slow-wave sleep occupies only a small fraction of total sleep in the elderly (Bliwise, 1997). For example, by age 70, men have almost no stage 4 sleep, and spend only about 1% of sleep time in stage 3 (Williams & Karacan, 1983). As a comparison, at age 20, slow-wave sleep accounts for 15% to 20% of total sleep time (Orr et al., 1982). Reduction in slow-wave or deep sleep are important because they are considered the deepest and soundest stages of sleep, during which the person is not easily awakened by external stimuli. Also, stage 1, associated with light sleep and increased vulnerability to awakening, dramatically increases with age (Williams & Karacan, 1983). Therefore, the increase in NREM stage 1, in addition to the decrease in stages 3 and 4, may account for the lowered awakening threshold experienced by older adults (Prinz et al., 1990). Decreased slow-wave sleep and increased wakefulness have also been associated with psychopathology, such as depression and anxiety, and also with poor health. However, studies conducted with healthy elderly individuals have found the alterations in sleep architecture mentioned above, suggesting that they reflect the effects of an agedependent alteration in the nervous system (Prinz & Raskind, 1978; Vitiello & Prinz, 1988). There is a small reduction in REM sleep and in total sleep time with aging. This slight decrease is associated with a reduction in nocturnal sleep time, but the relative percentage of REM sleep is usually maintained until advanced age (Orr et al., 1982). Reduction in REM sleep, although not significant among healthy older adults, may be

dramatic in cases of Alzheimer's and Parkinson's disease (Bliwise, 1997). In younger adults, the duration of each REM period increases with each successive cycle. However, in older persons, the duration of successive REM periods remains constant, and REM sleep is often interrupted by stage 2 NREM sleep (Prinz & Raskind, 1978; Williams & Karacan, 1983). Elderly persons are less able to maintain a sleep stage; stage shifts occur more frequently in addition to the frequent awakenings (Wauquier, 1993). Gender differences have been observed in sleep-related brain activity disruption. The sleep of elderly men is generally more fragmented than that of elderly women. This may seem contradictory, as elderly women self-report more sleep disturbances than men (Bliwise, 1997). The complexities of sleep are not yet fully understood, and the discrepancy between subjective and objective measures of sleep is clearly an area in need of more research.

Changes in Circadian Rhythms Studies of sleep patterns in aging support the notion that the elderly do not need less sleep; rather, their sleep patterns show less regularity than those of younger adults (Ancoli-Israel, 1997; Bliwise, 1993; Bliwise, 1997). Elderly persons sleep less during the night as compared with younger individuals. However, the elderly take more naps during the day, which appear to compensate for the decrease in nocturnal sleep. Frequent napping may occur because older adults may be chronically sleep-deprived (Miles & Dement, 1980). Therefore, what seems to be different among the elderly is the distribution of sleep during the 24-hour cycle, and not a reduced need for sleep (Bootzin et al., 1983; Moran et al., 1988).

In general, older subjects (60 years old and older) have a TST (total sleep time, including naps) about the same of adults 40 or younger. However, older adults, even those who remain active and have regular work schedules, sleep less during the night and take more daytime naps (Aber & Webb, 1986; Miles & Dement, 1980). Although it is not unusual for elderly persons to not report napping, 24-hour EEG monitoring has shown that there are short periods of sleep during the day (intrusion of sleep EEG during wakefulness), often referred to as "microsleep" (Orr et al., 1982). The circadian rhythms of older adults are usually "advanced". For example, the person begins to feel sleepy earlier in the evening (around 8 p.m.), and arises earlier in the morning (Moran et al., 1988). This phenomenon is usually referred to as sleep phase advancing, and may be the result of a shortening or speeding up of the circadian pacemaker in aging individuals (Bundlie, 1997). When the person tries to remain awake until their customary bedtime time (10 or 11 p.m.), they still wake up at 4 or 5 a.m. (Ancoli-Israel, 1997). The sleep-wake rhythm is a pacemaker for other physiologic variables, such as temperature and hormone secretions. Body temperature decreases as a function of sleep, but rises upon awakening (Orr et al., 1982). In older individuals, temperature rises occur earlier in the morning, thus possibly accounting for the early-morning awakenings experienced by the elderly (Williams & Karacan, 1983). In general, elderly persons have an increased nocturnal body temperature during sleep. The same is true of individuals with major depression and insomnia (Prinz et al., 1990). Circadian rhythm disturbances may be even more severe among the institutionalized elderly (Karacan & Williams, 1983). Nursing homes and hospitals tend

to be noisy, and this can lead to difficulty in initiating and maintaining sleep. Also, a person's sleep-wake cycle may not correspond with the institution's schedule. Patients are often awakened for meals or medications, or told to go to bed at inappropriate times for his or her biological rhythm. In addition, prolonged bed rest and inactivity are major causes of circadian rhythm alterations (Miles & Dement, 1980).

CHAPTER IV Assessment of Insomnia in the Elderly

The assessment of insomnia in older adults is a complex task, and includes behavioral, physiologic, psychiatric, psychological, and medical aspects (Bootzin et al., 1983). Insomnia complaints, as discussed previously, are often associated with physical illness, psychopathology, stress, and other primary factors. Some conditions, such as sleep apnea and PLMS can be diagnosed accurately only by polysomnography. Other factors that may be contributing to sleep disturbance are revealed through the use of assessment procedures such as interviews, psychological inventories, and sleep diaries. From a behavioral standpoint, it is useful to conceptualize sleep as a behavior consisting of different modalities. Poppen (1998) proposed four modalities of behavior: motoric, visceral, observational, and verbal. Assessment of insomnia focuses on these aspects of sleep behavior in several ways. Motoric behavior involves factors such as the personâ&#x20AC;&#x2122;s activities before going to bed, posture and body movements during sleep (e.g., moving the legs or other body parts while asleep, sleepwalking). Visceral aspects are often assessed with all-night polysomnography, which measures physiologic activity during sleep. Observational factors include the person's attending to environmental or internal stimuli that may interfere with sleep behavior. These are usually assessed with sleep diaries, inventories, and interviews. Verbal behavior can also be measured with these instruments, and they include possible dysfunctional throughts, beliefs, and expectations about sleep in the form of self-statements.

Insomnia complaints are in themselves subjective or private events, as they are sometimes independent of objective measures of sleep. Each of the four modalities of behavior have a public or overt component, as well as a private, or covert component. Thus, for example, observational behavior may be focused on external stimuli (e.g., noise, light, temperature), or internal stimuli (e.g., pain). Visceral behavior can be covert, such as brain activity (which can only be measured with special instruments), and also overt, such as snoring. Covert verbal behavior may consist of self-statements about the inability to sleep. An example of overt verbal behavior is the complaint of insomnia made to a family member or a physician. A number of special considerations must be made in the assessment of sleep disturbance in the elderly. Even though sleep difficulties may be associated with physiologic changes related to aging, they may also result from a variety of other factors, and these must be evaluated in order to target the intervention strategy appropriately (Kupfer & Reynolds, 1997). The assessment of insomnia is not restricted to an initial evaluation period. Rather, assessment is an ongoing process during the course of treatment. This is essential for making treatment adjustments, evaluating progress, and determining when treatment is completed. Ongoing assessment may include repeating the initial assessment in an abbreviated form, with periodic sleep diaries and a review of daytime habits, daytime functioning, and attitudes about sleep (Lichstein & Riedel, 1994). The major assessment procedures are discussed below. They are logically ordered, following an ABC (antecedents, behavior, and consequences) analysis. Interviews, physical examination, and questionnaires and inventories are part of the

assessment of antecedents or contributing factors. The next three procedures (sleep diaries, direct observation, and polysomnography), are measures of the sleep behavior itself. Finally, the assessment of next-day effects is a measure of the consequences of insomnia.

Interviews Espie (1991), Morin (1993), and Spielman (1986) developed strategies for interviewing clients with insomnia. Their recommendations were summarized by Lichstein and Riedel (1994), and include the following areas: Current status. The interviewer must obtain a quantitative description of the current sleep problem, including the frequency, severity, and chronicity, as well as the personâ&#x20AC;&#x2122;s subjective rating of the quality of his or her sleep. Also, the person should be asked about whether he or she has experienced symptoms associated with sleep apnea, narcolepsy, and other sleep disorders. Finally, the interviewer should ask the person what he or she thinks is causing the insomnia, and what goals he or she expects to attain through treatment. Historical factors. The clinician should obtain from the patient a history of possible psychiatric (e.g., depression, anxiety) and physical illness that may be associated with the sleep disturbance. The patient should be encouraged to describe his or her sleep prior to the current difficulties, and the circumstances that led to these. It is possible that, if the insomnia is sporadic, some factors are associated with the recurrence of the problem. These are to be explored during the interview. Also, the clinician should ask

about past treatment attempts, treatment response, and compliance with treatment procedures. Current and contributing factors. It is important to inquire about the use of sleep medication and also medication for other medical conditions. Alcohol consumption, smoking, caffeine consumption, and use of other drugs should also be considered. The patient should also be questioned about the quality of life impact of insomnia, including daytime sleepiness, fatigue, performance deficits, and mood changes. A relevant area for discussion is the patient's emotional and behavioral reactions to a bad night's sleep (e.g., irrational fears associated with not being able to sleep, activities in which the patient engages when unable to sleep). Finally, sleep hygiene habits should be considered, such as regularity of sleep schedule, exercise, and napping.

Physical Examination A thorough physical examination is essential during the initial assessment of insomnia. As discussed previously, medical conditions and medications are often associated with sleep disturbance. Physical sleep disorders, such as PLMS, sleep apnea, and narcolepsy should be ruled out (Bootzin et al., 1983). A detailed medical history should be obtained from the client. Structured questionnaires or medical interviews can be used to complete the medical history. The client's physician should also evaluate the extent to which existing medical conditions or medications could be contributing to the sleep disorder.

Questionnaires and Inventories Sleep questionnaires are self-report measures used to assess the person's view about the severity of his or her sleep problem. Sleep questionnaires are retrospective. For example, the person is asked to estimate a sleep variable, such as average number of awakenings, from anywhere over the past few days to an unspecified time period (Bootzin & Engle-Friedman, 1981). Other self-report instruments measure arousal, dysfunctional sleep cognitions, and knowledge and practice of sleep hygiene principles (e.g., Lacks & Rotert, 1986). Even though sleep questionnaires usually do not correlate significantly with sleep diaries and objective measures of sleep, they are often used as a screening instrument because they provide information about the person's subjective experience of his or her insomnia. It should be noted that it is the person's subjective experience what motivates him or her to seek treatment (Bootzin et al., 1983). Psychological inventories are often administered as part of the initial evaluation period. Since insomnia may be associated with depression and anxiety, it is important to evaluate these before planning the appropriate treatment. There are numerous psychological inventories that may be used to assess depression, anxiety, and other forms of psychopathology. Some examples of common psychological instruments are anxiety scales (e.g., Manifest Anxiety Scale), the Beck Depression Inventory (BDI), and inventories of life stress that help to identify recent stressful life changes (Bootzin et al., 1983).

Sleep Diaries There are many examples of sleep diaries (also called sleep logs) that have been used in the assessment of insomnia (Hauri & Linde, 1990; Morin, 1993, Riedel & Lichstein, 1994). This is the most common assessment device used in clinical practice. A sleep diary consists of a questionnaire completed in the morning by the person to describe his or her sleep the night before. Sleep diaries should be completed by the person for at least one week, and ideally for two weeks (Kupfer & Reynolds, 1997). A typical sleep diary includes entries for the time entering and leaving bed, latency to sleep, number and duration of awakenings during the night, time of final awakening, nap taking, subjective sleep ratings (e.g., quality of sleep, satisfaction), daytime sleepiness, and use of medication, alcohol, or other substances (Bootzin et al., 1983; Lichstein & Riedel, 1994). Sleep diaries are a form of self-monitoring. Therefore, the issues of reactivity, reliability, and validity that affect self-monitoring are also involved in this method (Bootzin et al., 1983). However, since subjective sleep complaints are central to insomnia, sleep diaries continue to be used and provide useful information about the symptoms experienced by the patient (Bootzin & Engle-Friedman, 1981). Some studies have found that insomnia clients usually overestimate the time it takes them to fall asleep and underestimate the amount of time that they sleep during the night (Lacks & Morin, 1992). Despite the possible inaccuracies in the self-monitoring of sleep behavior, studies have shown that sleep diary entries completed by persons with insomnia correlate highly with polysomnographic measures (Van Brunt et al., 1996).

Self-monitoring with sleep logs has many advantages over objective (e.g., polysomnographic) assessment procedures. The method is inexpensive, nonintrusive, and easy to use. As Bootzin and Engle-Friedman (1981) point out, "the ultimate test of an effective treatment is how well the insomniac does at home in his or her own bed" (p.111).

Direct Observation Direct observation of sleep behavior has been used to assess sleep onset, total sleep time, sleep maintenance, and sleep quality (Bootzin & Engle-Friedman, 1981). Observers are instructed to pay attention to the client's respiration, movements, and reaction when called by name or when a light is shone. This procedure, however, is often difficult to implement, since spouses or other family members usually fall asleep before the person with insomnia does. Bootzin and Engle-Friedman (1981) described some criteria that have been used to determine sleep onset. These include: (a) eyes closed, (b) no voluntary movements for at least 10 minutes, (c) rate of respiration less than normal, and (d) the subject does not respond to the question "Are you asleep?". Although there are high correlations between observations based on these criteria and the subject's estimate of sleep latency in good sleepers, poor correlations have been found in persons with insomnia. Observation by a bed partner can be a useful method for obtaining information about the client's sleep patterns. The bed partner can be asked whether the person snores loudly, behaves abnormally during sleep (e.g., has episodes of confusion), or is excessively sleepy during the day (Kupfer & Reynolds, 1997). This approach is often

used as part of the initial assessment, and relies more on casual observation and retrospective estimations than on systematic observation. However, this method provides vital information for the clinician, as it may confirm or disconfirm the client's self-report, and also reveal new, important information. Family members or other people can also be instructed to observe the client's behavior more systematically (using a checklist or data sheet) throughout the intervention phase. An example would be to have another person periodically check the client for daytime sleepiness at different times of day, or to keep track of the nights in which he or she was awakened by the client's snoring. In general, observation by bed partners is used primarily as a supplementary source of information in addition to sleep diaries. Some clinicians have also used this type of observation method to evaluate general improvement after treatment (Bootzin et al., 1983). Direct observation has been used in institutional settings, such as nursing homes. Staff members (typically nurses) are trained to observe the sleep behavior of the clients. Many studies that have used this method have not reported reliability data and a number of difficulties have arisen. For example, staff may not always be available to conduct ratings, as they usually have other duties to complete. Observer drift has also been a problem (Bootzin & Engle-Friedman, 1981). A potential (yet expensive and not always feasible) solution would be to videotape the client during sleep, and then have trained observers rate the client's all-night sleep behavior.

Polysomnography According to Hoelscher and Edinger (1988), a polysomnographic evaluation is clinically indicated for complaints of excessive daytime sleepiness, insomnia with symptoms of sleep apnea (e.g., snoring, respiratory pauses) or PLMS, unresponsiveness to treatment, and severe sleep maintenance insomnia in older adults. As the presence of sleep apnea and PLMS increase with aging, it is important to refer the client to a sleep disorders clinic where he or she can be diagnosed with the use of polysomnography. Serious sleep maintenance insomnia in older adults, for example, may be the result of sleep apnea or PLMS, both of which cause frequent nocturnal awakenings. Even though polysomnography is considered the "gold standard" for sleep measurement (Lacks & Morin, 1992), some of its disadvantages include elevated costs, obtrusiveness, and reactivity to the laboratory setting. The value of polysomnography for assessing insomnia is controversial (Lacks & Morin, 1992). As insomnia may be setting-specific, it is argued that polysomnography (which is carried out in a clinic or laboratory) may not be reflective of the actual sleep disturbance that the person experiences at home. If the client's disrupted sleep behavior is under strong stimulus control, he or she may be unable to sleep at home, but may sleep normally in a new setting (Bootzin et al., 1983). Also, a single polysomnography session may not detect chronic insomnia, which does not necessarily occur every night (Lichstein & Riedel, 1994). Insomnia complaints are not always correlated with EEG abnormalities. Persons who had insomnia complaints but were not found to have EEG disturbances were once called "pseudoinsomniacs". An alternative explanation might be that EEG recordings are

not sensitive to the sleep disturbance of these individuals (Bootzin et al., 1983). It is important to note that the stages of sleep measured by the EEG are arbitrary operational definitions of sleep (Bootzin & Engle-Friedman, 1981). Sleep parameters are inferred constructs that involve different cognitive, behavioral, and physiologic components (Bootzin & Nicassio, 1978). As an example, there is no agreed-upon measure of sleep onset, and in some individuals (e.g., brain damaged) there is no relationship between EEG patterns and the behavioral component of sleep. Some individuals with brain injury may show EEG deep sleep when awake and responding (Bootzin et al., 1983). There is considerable variability in self-reports of the depth of sleep during different EEG stages. Some individuals report being awake during stages in which they would be assumed to be asleep, and vice-versa (Bootzin et al., 1983). Another example of discrepancies between subjective and objective measures of sleep is that elderly women often present more insomnia complaints than men. However, as it was discussed earlier, older women show less fragmented EEG patterns than men. As Lacks and Morin (1992) point out: The discrepancies between subjective, behavioral, and physiological measures of sleep, a problem observed with other clinical dysfunctions as well (e.g., anxiety), remain a difficult issue facing clinicians and researchers. Ideally, multiple outcome measures from various sources (e.g., self, significant others, clinicians, and objective devices) tapping not only sleep but other parameters covarying with sleep (e.g., mood, performance, quality of life) should be integrated in the overall assessment process (p.588).

Again, insomnia is a complex phenomenon, and modern assessment strategies address the different modalities (i.e., physiologic, motoric, observational, and verbal) of sleep. Polysomnography remains the most widely accepted objective measure of sleep. However, it measures only a physiologic aspect of sleep. Both objective and subjective assessment procedures complement each other and provide useful information about insomnia, as they consider all modalities of sleep behavior.

Assessment of Next-Day Effects Elderly persons with insomnia often report feeling sleepy and fatigued during the day (Bootzin et al., 1983). Poor performance, changes in mood, and sleepiness are assessed using rating scales or checklists. Nicassio and Bootzin (1974) used ratings on a 5-point scale as part of a sleep diary. The subjects were asked to rate fatigue, ability to function during the day on a task or on the job, and irritability or grouchiness. Bootzin et al. (1983) used a brief four-item rating scale that the subjects completed each evening before going to sleep. The scale included ratings on feelings upon awakening in the morning, fatigue during the day, sleepiness during the day, and ability to function at work or at daily chores. Each item was rated on a 5-point scale. Assessment of daytime functioning is important not only in determining the extent to which the sleep disturbances affect the individual's daily activities, but also in the subsequent evaluation of treatment effectiveness.

CHAPTER V Behavioral Interventions for Insomnia in Older Adults

Applications of behavior therapy for insomnia were initially developed during the 1960s, being among the first psychological treatments for traditionally medical disorders, predating the emergence of behavioral medicine (Lichstein & Riedel, 1994; Montgomery et al., 1975). There are currently five major behavioral approaches in the treatment for insomnia. These are stimulus control therapy, relaxation training, cognitive therapy, sleep hygiene instructions, and sleep restriction (Hauri, 1997). Lichstein and Riedel (1994) point out that only stimulus control, relaxation training, and cognitive therapy emerged from the field of behavior therapy itself, while sleep hygiene and sleep restriction were derived from empirical sleep research. As was discussed in the introduction, these techniques were applied initially to younger adults, as many researchers purposefully excluded elderly subjects from their studies. However, the last two decades have witnessed an increasing interest in studying the effectiveness of behavioral interventions for late-life insomnia (e.g., Engle-Friedman, Bootzin, Hazelwood, & Tsao, 1992; Davies et al., 1986; Morin & Azrin, 1988; Morin, Kowatch, et al., 1993). The assumption that disturbed sleep is an inevitable (and irreversible) consequence of aging still remains (Lacks & Morin, 1992), and insomnia complaints in the elderly are often overlooked and untreated (Engle-Friedman et al., 1992; Morin & Gramling, 1989).

When sleep disturbance is acknowledged, prescription of sleep medication continues to be the most frequent treatment approach. Clinical research has shown, however, that geriatric insomnia is a legitimate complaint and a treatable condition with nonpharmacologic (i.e., behavioral) interventions (Friedman, Bliwise, Yesavage, & Salom, 1991; Lacks & Morin, 1992). Stevenson and Winston (1991) described five necessary conditions for adequate sleep: (a) a positive association between the bed and bedroom and sleep, (b) an ability to relax and reduce cognitive and somatic arousal, (c) a regular sleep-wake circadian rhythm, (d) sleepiness at bedtime, and (e) minimizing internal and external disturbances. Research has shown that older adults often have trouble with stimulus control, cognitive intrusions, fragmented schedules, and increased vulnerability to the effects of disturbing stimuli (Bootzin & Engle-Friedman, 1987). Behavioral and cognitive interventions are aimed at establishing regular schedules, reducing arousal, managing the effects of external stimuli, and establishing stimulus control. The task is to set the conditions for sleep to occur. The remaining part of this chapter will describe the major behavioral and cognitive interventions for insomnia in older adults. Interventions were included because: (a) there were published reports of their applicability to the elderly population, (b) there is evidence of their effectiveness, and (c) they are currently being used in clinical and/or research settings with the elderly. The interventions described in this chapter are: stimulus control, countercontrol, sleep restriction, sleep compression, sleep hygiene, relaxation training, self-help

treatments, educational interventions, cognitive therapy, and treatment packages or multicomponent approaches.

Stimulus Control Stimulus control is a basic principle of behavior analysis. It refers to the influence of an antecedent stimulus (i.e., a stimulus that precedes a response) on the probability of occurrence of a response (Sulzer-Azaroff & Mayer, 1991). For example, if a person goes to bed but stays awake for a long time without being able to fall asleep, the bedroom, the bed, and even the bedtime routine could become cues for sleeplessness and anxiety (Van Brunt et al., 1996). Stimulus control was introduced as a behavioral treatment for insomnia by Bootzin (1972). This technique is based on the premise that, for individuals with insomnia, the bedroom has become a poor discriminative stimulus for sleep (Lichstein & Riedel, 1994). Stimulus control techniques are thus aimed at establishing the bedroom as a discriminative stimulus for falling asleep (Bootzin, 1972). This is accomplished by instructing the individual with insomnia to follow a set of instructions. Bootzin, Epstein, and Wood (1991) presented the following stimulus control instructions: (1) Go to bed only when sleepy. (2) Do not use your bed or bedroom for anything but sleep (or sex). Examples of activities that patients may have to avoid include eating, watching television, and working in the bedroom. (3) If you do not fall asleep within about 10 minutes, leave the bed and do something in another room. Go back to bed only when you feel sleepy again. Clock-

watching with regard to the 10 minute rule is not recommended, as this may create tension. (4) If you do not fall asleep quickly upon returning to bed, repeat instruction 3 as many times as is necessary. Also, if you do not fall asleep rapidly after an awakening, follow rule 3 again. (5) Use your alarm to leave bed at the same time every morning regardless of the amount of sleep obtained. (6) Do not nap. In some cases, depending on the client's response, the 10 minute limit on awake time in bed may be extended to 15 or even 20 minutes (Lichstein & Riedel, 1994). Hoelscher and Edinger (1988) have used a modified stimulus control procedure with older adults, in which the time limit was extended to 20-30 minutes. If napping is unavoidable, it is preferable to take morning naps than afternoon naps (Morin & Rapp, 1987). Stimulus control instructions are especially important for the elderly, since a number of them have unstructured daily routines and sleep schedules (Morin & Rapp, 1987). Adherence to these instructions can help the person not only to establish a connection between the bedroom and sleep, but also to achieve a more structured sleepwake rhythm, by raising at the same time each morning regardless of the amount of sleep that they obtained on the previous night. Treatment compliance, however, has been an issue in this and other treatment modalities. Clients may have difficulty in understanding and remembering the instructions (Lichstein & Riedel, 1994). It can be helpful to give a rationale for each

instruction, and to provide the client with concrete examples about how to follow them. Also, written materials can serve as cues for compliance. Another suggestion is to offer a behavioral contract in which the client agrees to comply for a period of time (e.g., two weeks). Clinical improvement often occurs within this time frame, and this may motivate the client to further adhere to the treatment (Morin & Rapp, 1987). Although stimulus control was initially used mainly for treating sleep-onset insomnia, research showed that it could also be used for alleviating sleep-maintenance insomnia. Lacks et al. (1983) considered that stimulus control could help the person's return to sleep after arousal, since many of the same sleep-interfering behaviors that prevent sleep-onset are also present during nocturnal awakenings.

Countercontrol A modification of the stimulus control technique, termed countercontrol treatment, was developed by Zwart and Lisman (1979). This technique is designed to disrupt sleep-incompatible activities. In contrast to stimulus control, the clients are not instructed to leave the bed. Rather, they are asked to deliberately engage in a nonarousing activity (e.g., dull reading) in bed whenever they find themselves unable to sleep. Borkovec (1982), in a review of stimulus control procedures, suggested that their effectiveness is due to a disruption of sleep-incompatible behaviors, such as cognitive activity or restless tossing. Therefore, if the above were the essential component to stimulus control rather than establishing the bed as a discriminative stimulus, then the requirement to leave the bed and bedroom would be unnecessary. Based on this

hypothesis, Davies et al. (1986) designed a study to test countercontrol treatment. They argued that removing the out-of-bed requirement would add to the effectiveness and feasibility of the treatment for the elderly, as some have ambulatory difficulties. The results of this study will be discussed later.

Sleep Restriction Although often called sleep restriction therapy (SRT), this technique was initially termed restriction of time in bed (Spielman, Saskin, & Thorpy, 1987). It is the person's time in bed, not sleep time itself, what is restricted in this approach. By restricting time in bed, SRT induces a mild sleep deprivation that is assumed to promote rapid sleep onset, consolidated sleep, and less internight variability (Lacks & Morin, 1992). The increases in TIB contingent on sleep efficiency are designed to gradually establish a normal sleep schedule for the client. The basic assumption of SRT is that excessive time in bed tends to perpetuate insomnia. Spielman et al. (1987) argued that individuals with insomnia often spend too much time in bed in a failing attempt to acquire more sleep. However, frustration and anxiety produced by excess time in bed only serve to perpetuate the insomnia. SRT was designed to achieve two main effects: (a) eliminating excess preoccupation about falling asleep, and (b) creating an initial state of sleep deprivation, which itself produces consolidated, satisfying sleep. A likely side-effect of SRT is daytime fatigue during the first days of treatment. However, this is usually corrected later on by determining an appropriate degree of

restriction for the client. Spielman et al. (1987) described the following procedures for implementing SRT: (1) Clients complete a sleep diary for two weeks, and the therapist uses these to calculate an average of total subjective sleep time (TST). (2) The amount of time that the clients are allowed to spend in bed is initially restricted to this average TST. Regardless of the baseline TST, no client is prescribed less than 4.5 hours of time in bed (TIB). Napping or lying down during periods outside of the prescribed time limits is prohibited throughout treatment. (3) Clients choose a fixed time to enter and leave the bed. For example, a client prescribed six hours in bed may choose an 11:00 p.m. to 5:00 a.m. schedule, or alternatively, a 1:00 a.m. to 7:00 a.m. schedule. (4) Over the course of treatment, clients call the therapist daily to report retiring time, out-of-bed time in the morning, and their estimate of total sleep time. If sleep efficiency (i.e., TST divided by TIB, multiplied by 100) exceeds 90% for five consecutive days, then the client's TIB is increased by allowing him or her to enter bed 15 minutes earlier. Five days of unaltered sleep schedule always follow any increase in TIB. (5) If sleep efficiency drops below an average of 85% for five consecutive days, TIB is reduced to the mean TST for those five days. Reductions in TIB are not made for at least 10 days from the start of treatment or for 10 days following a sleep schedule change. (6) If mean sleep efficiency falls between 85% and 90% during a five day period, the client's sleep schedule is not altered. Glovinsky and Spielman (1991) revised the above guidelines, and suggested that for elderly clients, the sleep efficiency criteria be lowered by 5%. Also, after setting the

TIB, subsequent reductions are rarely made, since clients' compliance has been a problem. For some clients who have difficulty estimating their sleep time (e.g., they consistently report little or no sleep at all), increasing sleep efficiency may not be an appropriate goal (Glovinsky & Spielman, 1991). Therefore, these clients are started at the minimum TIB and then weekly TIB increments are made until TIB reaches seven hours. SRT has been the most frequently used intervention for insomnia in the elderly, yielding excellent results according to Lichstein and Riedel (1994).

Sleep Compression Lichstein (1988) designed a procedure called sleep compression, which is very similar to SRT, for the treatment of what he called an "insomnoid state". An insomnoid (also called pseudoinsomniac) is an individual who complaints of insomnia symptoms, although objective sleep measurements show no physiologic disruption. This condition is currently diagnosed as sleep state misperception, according to the guidelines of the American Sleep Disorders Association (1990). The rationale for using sleep compression is that increasing time in bed to compensate for fragmented sleep may be unnecessary (Riedel, Lichstein, & Dwyer, 1995), since it could be normal for older adults to sleep less during the night. A major contributing factor to an elderly person's report of insomnia is presumed to be the unrealistic expectations about the sleep changes associated with aging. In a published case study, Lichstein (1988) reported the procedures of sleep compression. The technique involves advancing the time of entering bed in the evening

and setting a fixed time to awaken in the morning. Restriction of time in bed is applied gradually, rather than immediately. Riedel, Lichstein, and Dwyer (1995) have also used a three-week compression schedule, in which excess time in bed is estimated from comparing total time in bed to actual time slept during baseline. Then, time permitted in bed is reduced by one half of this excess time the first treatment week and by one fourth in each of the two subsequent weeks. Sleep compression has been clinically tested along with educational interventions directed at older adults' unrealistic expectations about their sleep needs.

Sleep Hygiene Instructions Sleep hygiene refers to lifestyle behaviors and environmental factors that influence sleep (Van Brunt et al., 1996). Some examples are exercise, diet, napping, and sleep schedules. These instructions are often included with other intervention strategies. Research has shown that sleep hygiene factors account only for part of the sleep problem (Lichstein & Riedel, 1994). Lacks & Rotert (1986) found that individuals with insomnia have more sleep hygiene knowledge than those without insomnia. However, the former practice sleep hygiene less consistently. These researchers also found that knowledge and practice of sleep hygiene were relatively high for both insomniacs and noninsomniacs, and concluded that poor sleep hygiene is not likely to be a primary cause of insomnia. Despite these findings, lifestyle and environmental factors should be addressed in treatment, since they have a potential for perpetuating poor sleep (Lichstein & Riedel, 1994; Van Brunt et al., 1996). Hauri and Linde (1990) suggested that all interventions

for insomnia should start by reducing or eliminating caffeine, alcohol, and smoking. Regular exercise completed 3 to 4 hours before bedtime, reducing or eliminating napping, and establishing a consistent sleep schedule (i.e., going to bed and rising at about the same times every day) are also included as part of standard sleep hygiene instructions. Following are the sleep hygiene instructions used by Lichstein and Riedel (1994) in their clinical work: (1) Caffeine. This stimulant drug is found mainly in coffee, and in smaller quantities in tea, soft drinks, and chocolate. Many over-the-counter medications, such as Anacin, also contain caffeine. Individuals' sensitivity to caffeine varies greatly, and some people's sleep will suffer greatly from even small quantities of caffeine. Avoid all caffeine after lunch. (2) Naps. Many people exhibit the tendency to fall into a deep sleep during daytime napping. This may rob nighttime sleep of its deep sleep quota. Daytime napping may result in nighttime sleep being light, restless, and subject to multiple awakenings. Do not nap. (3) Exercise. If your physical health permits, regular exercise may aid sleep in a number of ways. Sleep onset may come sooner and the quality of sleep may be improved. Some caution should be taken to avoid strenuous exercise within a few hours of sleep. Vigorous exercise taken daily or every other day may improve sleep. (4) Consistent sleep schedule. Some individuals will greatly vary the time they go to bed and the time they arise in the morning due to varying work schedules and recreational activities. Such variation may be an obstacle to attaining sound, continuous sleep in persons prone to insomnia. Establish a regular sleep schedule, and in particular,

arise at a fixed time every morning. Resist altering your sleep schedule even on the weekends. Consistency in sleep schedule may improve sleep. In addition to these, other authors, such as Morin and Rapp (1987) suggest avoiding spicy, high-protein foods before going to bed, as they increase activation of the digestive system, which may interfere with sleep. They also recommend that the elderly increase their involvement with other persons and their participation in pleasant activities during the day. Another very important consideration with the elderly population is limiting the intake of fluids before going to bed. Research has found that nocturia (i.e., urinating during the night) is very common among the elderly (Bliwise, 1997). Likewise, Libman, Creti, Amsel, Brender, and Fichten (1997) found that urges to go to the toilet account for many of the nocturnal awakenings experienced by the elderly.

Relaxation Training Jacobson (1938) was the first to report the use of muscle relaxation in the treatment of insomnia. Different relaxation techniques have been used in the treatment of insomnia, such as progressive, hypnotic, autogenic, and meditational (Borkovec, 1982). Progressive relaxation, the method developed by Jacobson (1938), has been the most widely researched behavioral intervention for insomnia. It consists of sequentially tensing and relaxing the body's major muscle groups while focusing on and contrasting somatic sensations of tension and relaxation (Lichstein & Riedel, 1994). Approximately 16 muscle groups are progressively tensed and released. The individual is asked to tense the muscles groups one at a time for only about seven seconds, and then to relax them for

about 45 seconds (Van Brunt et al., 1996). A common problem with elderly clients is that muscle tension may induce arthritic pain (Bootzin et al., 1983). In these cases, the person is instructed not to tense the muscle group that produces pain, but to just release already existing tension in that particular muscle group. The goal of progressive relaxation is to achieve low levels of general muscle tension at will, which is presumed to be associated with low physiologic arousal (Montgomery et al., 1975). Relaxation is presumed to help the individual with insomnia by providing a means for inducing sleep, and also by providing them with a general coping skill to be used to deal more effectively with stress (Bootzin & Engle-Friedman, 1987). Progressive relaxation has been applied mainly to sleep-onset insomnia, but it has also been proven useful in treating sleep-maintenance insomnia (Bootzin & EngleFriedman, 1987). Several studies cited by Borkovec (1982) found that decreased physiologic arousal induced by relaxation was not related to both subjective and objective sleep measures. However, reductions in reported cognitive intrusions at bedtime have been found to be associated with sleep latency improvements. For this reason, Borkovec (1982) suggested that: The site of effect for relaxation treatment of the disorder may be the uncontrollable cognitive activity that seems to characterize the insomniac. From this point of view, learning to focus one's attention on relatively pleasant, monotonous, internal sensations, especially those generated by attention-getting, discrete tension release of muscle groups, may be incompatible with worrisome

thoughts and images that prevent sleep onset and/or may create a monotonous stimulation paradigm known to be actively soporific (p.890). Lichstein and Riedel (1994), based on a review of empirical studies, suggested that even though progressive relaxation has been found effective for insomnia in young adults, this technique is increasingly ineffective with advancing age. These authors recommended a relaxation technique that is not so physically demanding and procedurally complex for older adults. Lichstein and Johnson (1993) developed a modified relaxation technique especially designed for the elderly. This technique involves concentration on relaxed somatic sensations. The muscle tension-release cycles of progressive relaxation were omitted, and breathing exercises and the repetition of an autogenic phrase were included. The procedure, called by the authors "passive relaxation" (in contrast to the "active" nature of the tension-release exercises of progressive relaxation), was tested with women ranging in age from 60 to 80 years (mean = 66.2). Their results showed that the relaxation technique led to significant sleep improvement for a group not using hypnotic medications, and reduced hypnotic usage without sleep deterioration for a medicated group (Lichstein & Johnson, 1993). Another relaxation technique is guided imagery. It requires the individual to focus his or her attention on an image, such as a pleasant nature scene or a neutral object (Lichstein & Riedel, 1994). In this technique, it is important to retain the person's attention on the image. This may be accomplished by having the person concentrate on particular sensations related to the nature scene or details of a neutral object (Van Brunt

et al., 1996). This form of relaxation is targeted at inhibiting intrusive cognitions that prevent sleep. Lacks and Morin (1992) reviewed studies showing that, as Borkovec (1982) suggested, reduced physiological arousal may not be the mechanism of change in relaxation. This is supported by data suggesting that visual focusing methods are more effective than muscle-tension release (i.e., progressive relaxation) for reducing target insomnia symptoms.

Self-Help Treatments An important issue for delivering behavioral treatments to the elderly is ensuring access to treatment. Many older adults face difficulties in keeping outpatient appointments because of transportation problems or chronic illness. There has been a concern over the last few years about improving the accessibility of psychosocial and medical treatments for the elderly (e.g., Zeiss & Breckenridge, 1997). One alternative to office consultation at a facility is the use of self-administered treatments, such as bibliotherapy (e.g., self-help books), and support from a therapist either by telephone or a brief periodic visit. Zeiss and Breckenridge (1997) reviewed studies in which a self-help intervention was used to treat depression in elderly individuals living in the community. A similar approach has been used in treating geriatric insomnia. Alperson and Biglan (1979) tested the effects of two self-help manuals on sleep-onset insomnia. This study compared the effectiveness of self-help approaches between young adults and older adults (age 55 and over). The manuals contained different combinations of relaxation exercises and stimulus control

instructions. Morawetz (1989) conducted an evaluation of a self-help treatment for insomnia consisting of stimulus control and relaxation techniques on audio tape accompanied by a printed manual. Riedel et al. (1995) applied sleep compression and sleep education for older adults with insomnia, and compared a self-help approach with a therapist-guided approach. The major findings and conclusions of these studies will be discussed later.

Educational Interventions: Information and Support An important component of cognitive-behavioral interventions for geriatric insomnia consists of education about the sleep changes observed in aging. As mentioned earlier, older adults may not have a reduced overall need for sleep. However, the elderly do sleep less at night compared to younger adults (Vitiello, 1997). This may or may not lead to insomnia complaints. A number of factors may account for whether or not an elderly person complains about disrupted sleep. The frequency and duration of awakenings, and the intensity of sleep-related conditions, such as sleep apnea and PLMS may be directly related to the severity of the insomnia complaints. However, beliefs and expectations may also play an important role. For example, some elderly individuals may expect to sleep for the same amount of time as they did when younger (Morin & Rapp, 1987). Others may have a negative appraisal of the sleep disturbance, worrying about their inability to sleep (Bootzin & Engle-Friedman, 1987). Bootzin et al. (1983) used information and support as a component of different interventions for geriatric insomnia. They informed the clients about sleep stages and the

developmental changes associated with age. They stressed that sleep needs vary among individuals (e.g., some people function well with very little sleep, while others may feel extremely fatigued after a bad night's sleep). Also, they attempted to modify the belief that sleep loss is a calamity. They pointed out that sleep deprivation does not necessarily lead to decreased performance or sleepiness. Morin and Rapp (1987) recommended the use of written materials containing information about changes in sleep and how to cope with them. They also recommended self-monitoring of amount of sleep and daytime energy and activity levels. In this way, each individual can learn how much sleep he or she needs in order to function comfortably during the day. Education about the negative effects of long-term sleep medication intake is often necessary among the elderly. Educational interventions may be delivered through self-help books, manuals, pamphlets, or in an office setting with the therapist's guidance and support. Sleep hygiene instructions are often combined with the kind of educational approach discussed above. As Morin and Rapp (1987) concluded: Education whether through seminars, bibliotherapy, or self-monitoring accompanied by clinician's support can help modify the patient's cognitive appraisal of the problem and alleviate his distress over not getting enough sleep (p.18).

Cognitive Therapy Cognitive interventions are based on research showing that sleep is negatively affected by cognitive intrusions (Borkovec, 1982). Research has shown that negative

cognitions (e.g., worries, unrealistic expectations, negative attitudes and beliefs) lead to sleep disturbance, as individuals with insomnia spend a great deal of time in bed ruminating over a variety of thoughts (Lichstein & Fanning, 1990). Educational interventions attempt to modify dysfunctional cognitions, and in this sense they include a heavy cognitive component. The role of unrealistic expectations about sleep needs among the elderly was discussed above, and is one of the major targets of cognitive restructuring interventions. Morin, Stone, et al. (1993) studied the beliefs and attitudes about sleep among 145 elderly subjects using self-report measures. They were either chronic insomniacs or selfdefined good sleepers. The authors found that the individuals with insomnia held stronger beliefs about the negative consequences of insomnia, and expressed more hopelessness (e.g., fear of losing control of their sleep) and helplessness about its predictability. Libman et al. (1997) reviewed a variety of studies showing that cognitive arousal (i.e., intrusive, uncontrollable cognitive activity in the form of negative and worrying thoughts) plays a major role in perpetuating insomnia. Cognitive intrusions may have different specific contents, such as attempting to problem-solve, thinking about the day's events, and worrying about the consequences of not getting enough sleep. These cognitions occur not only before going to sleep, but also during wakefulness periods through the night. Cognitive restructuring is accomplished by verbal interaction between the therapist and the client. The major feature of this approach consists of challenging the client's cognitions, and attempting to provide alternative views to replace the client's

dysfunctional (i.e., negative) cognitions. Negative cognitions are challenged by reality testing (i.e., confronting the client's self-report against past or present events that contradict his or her beliefs). Most cognitive restructuring methods are based on the works of Aaron Beck, Albert Ellis, and Donald Meichenbaum (Morin, 1993). Morin, Kowatch, et al. (1993) described cognitive restructuring as an important component of treatments for geriatric insomnia. They followed a three-step process, consisting of: (a) identification of patientspecific dysfunctional thoughts, (b) confrontation and challenging of those thoughts, and (c) implementation of methods for revising and altering these thoughts with more rationale substitutes. Cognitive activity is inferred from overt verbal behavior or assessed with self-report questionnaires or inventories (Libman et al., 1997). From a behavioral standpoint, cognitions are considered verbal self-statements, in the form of rules (e.g., "if I don't get eight hours of sleep tonight, I will feel terrible tomorrow"). Some forms of relaxation, such as imagery training and meditation, are also regarded as cognitive interventions by some authors (e.g., Morin & Azrin, 1988), as they are targeted at reducing cognitive arousal. Cognitive interventions are often a component of treatment packages (e.g., Edinger et al., 1992; Hoelscher & Edinger, 1988; Morin & Azrin, 1988), and have been incorporated with behavioral techniques into what is now called cognitive-behavioral therapy.

Multicomponent Approaches Recent applications of behavioral technology to insomnia in older adults have used multicomponent approaches (Lacks & Morin, 1992). These consist of treatment packages incorporating two or more of the interventions discussed above. A cognitive-behavioral therapy (CBT) for geriatric insomnia was developed by Hoelscher and Edinger (1988). This approach includes cognitive restructuring for addressing dysfunctional cognitions that contribute to individuals' spending excessive time in bed. It also involves stimulus control instructions and sleep restriction techniques. CBT is especially designed for treating the sleep-maintenance complaints of older adults, and it has been tested by different researchers (e.g., Edinger et al., 1992; Morin, Kowatch, et al., 1993). Behavioral interventions for geriatric insomnia often include sleep hygiene instructions and some kind of education and support (Engle-Friedman et al., 1992). In addition to these, SRT and stimulus control are often used, as they have proven successful in treating both sleep-onset and sleep-maintenance insomnia in older adults.

CHAPTER VI Treatment Effectiveness

This chapter describes the major features and results of selected research evaluating treatment effectiveness in the elderly population. Some studies have used a single technique while others have used multicomponent approaches. Other studies have used group designs and single-subject designs in order to compare the effectiveness of various techniques. Following is a review of some of the major studies that have evaluated the behavioral and cognitive interventions described in the previous chapter.

Studies Evaluating Single Techniques Stimulus control. Stimulus control techniques for geriatric insomnia were evaluated by Puder, Lacks, Bertelson, and Storandt (1983). These authors used a shortterm stimulus control treatment with 16 older adults reporting sleep-onset difficulties. Nine subjects were provided immediate treatment, and 7 were provided delayed treatment. Data were collected through a sleep diary and other self-report measures (questionnaires). Ten of the 16 subjects decreased sleep-onset latency by 50% at the end of treatment, which had a duration of 4 weeks. The effectiveness of the intervention was maintained at 6-week follow-up. The authors concluded that stimulus control worked well for geriatric patients. This study was important because it was one of the first to evaluate this intervention with older adults, who had been excluded of most of the previous behavioral interventions for insomnia.

Another study by Lacks et al. (1983) applied stimulus control to sleepmaintenance insomnia. The subjects in this study were not older adults (range= 31-59 years; mean age= 43 years). However, this study is important because it was instrumental in fostering research in the application of this technique to sleepmaintenance insomnia. The researchers also used a desensitization "credible placebo" group. Results showed significant improvements in number and frequency of awakenings for both groups. A possible reason for this is that the desensitization technique may not have been a true placebo condition, as subjects could use the procedure on their own to interfere with sleep-incompatible thoughts and behaviors. Also, treatment duration was short (4 weeks), and the authors speculated that perhaps more significant effects would have been achieved by the stimulus control subjects with a more prolonged treatment. Other studies using stimulus control techniques are reviewed later as part of the discussion on studies comparing different techniques. Riedel, Lichstein, Peterson, Epperson, Means, and Aguillard (1998) used a 2 (stimulus control vs. control condition) X 2 (medicated vs. nonmedicated subjects) factorial design to compare the response of medicated and nonmedicated subjects to stimulus control treatment. Forty-one subjects participated in the study (aged 19 to 80 years). A medication withdrawal program was established for the medicated subjects before initiating stimulus control treatment. Medicated subjects in the control condition participated in the medication withdrawal program, but did not receive the stimulus control treatment. Sleep diaries were used to collect data. Dependent measures included total sleep-time, latency to sleep-onset, WASO, sleep efficiency, and sleep quality rating on a 5-point scale.

Results showed that medicated subjects were able to reduce medication consumption with the gradual withdrawal program. When the stimulus control treatment was introduced, the subjects were able to experience improved sleep even when not taking medication. These gains were maintained at 8-week follow-up. Stimulus control subjects showed improvements in all sleep measures, whereas control subjects did not improve significantly as compared to baseline levels. Nonmedicated subjects showed significantly more treatment gains than medicated subjects with the stimulus control treatment, and also responded faster to treatment than medicated subjects. This is a relevant study because it addressed the possibility of combining a behavioral intervention for insomnia with a medication withdrawal program. The authors did not report differences in response to treatment between older and younger participants. More research is needed in this area, due to the current interest in finding alternatives to pharmacologic therapy. Countercontrol. Davies et al. (1986) evaluated countercontrol in the treatment of sleep-maintenance insomnia. Thirty-four individuals with insomnia (ranging in age from 35 to 78 years) participated in the study. Individuals taking sleep medication were excluded from the study. Twenty-two subjects received immediate treatment, and 12 received delayed treatment. Sleep diaries were used to collect data. The major dependent variable was WASO. Total number of arousals and number of arousals exceeding 10 minutes were also monitored. The authors found that countercontrol therapy reduced WASO for the total group by approximately 30% at the end of treatment, with gradual improvement continuing through a 4-week follow-up. An important finding is that WASO was correlated with

age (i.e., the older the individual, the longer he or she stays awake during the night) but response to treatment was not. This means that older adults can profit from behavioral interventions for insomnia as well as younger adults. Another important feature of this study is that a 1-year follow-up was obtained for 16 of the 22 subjects. Statistical analyses indicated that treatment gains were still maintained at that time. Total number of awakenings per night, WASO, and number of awakenings longer than 10 minutes did not differ significantly from the data obtained at 1-month follow-up. Self-help treatments. In their study of self-administered treatments for insomnia, Alperson and Biglan (1979) found that subjects over 55 years improved significantly less than the younger subjects on measures of sleep-onset latency. It was unclear why this was the case. The authors concluded that, "relaxation and stimulus control procedures are not as effective with older persons as they are with younger persons" (p.355). However, these interventions were delivered in a self-administered format, and it is possible that these procedures would work if delivered in a different manner (e.g., with therapist's support). A study by Morawetz (1979), although not conducted with elderly subjects, was important because he found that a self-help treatment (consisting of stimulus control and relaxation on audio tape and printed instructions) was not as effective for the subjects who took sleep medication as it was for the subjects who did not. This study measured not only sleep-onset latency, but also sleep parameters related to sleep-maintenance insomnia.

A study by Riedel et al. (1995) evaluated a treatment package consisting of sleep compression and sleep education in individuals over 60 years of age (mean age= 67.4). They also evaluated the effects of delivering the treatment package in a self-help format (a videotape) versus a therapist-guidance format. Although subjects improved in measures of WASO, sleep latency, and sleep satisfaction with the self-help treatment only, the addition of a therapist-guided treatment appeared to improve treatment outcomes. The researchers concluded that, "a treatment package that combines the video with therapist guidance appears to produce significantly greater sleep improvement than no treatment" (p.62). Sleep compression. Lichstein (1988) reported a case study with a 59-year-old male with chronic insomnia. He had taken sleep medication for 30 years, but at the time of the intervention he had stopped intake for the past 2 years. Sleep compression (consisting of sleep education and a gradual restriction of time in bed) was used after a relaxation technique and stimulus control had failed. Sleep compression was administered over 8 months. Although nocturnal sleep-time remained very low (about 3 hours of sleep per night), variables such as sleep-onset latency, WASO, and sleep efficiency were improved. The individual's self-rating of his quality of sleep increased. The author discussed the vulnerability of older adults' becoming "insomnoids" due to their perceived sleep difficulties. He commented that some individuals are "short-sleepers" and do not need as much sleep as others do. Sleep education, therefore, should play a major role in behavioral interventions.

Relaxation training. Lichstein and Johnson (1993) used relaxation therapy with three groups of elderly women (mean age= 66.2 years): one group consisted of medicated subjects with insomnia, another included nonmedicated subjects with insomnia, and the third group consisted of subjects without insomnia. Self-report measures of sleep and medication intake, and a relaxation practice log were used to collect data. The relaxation technique used in this study was designed to avoid possible problems of complexity and physical exertion characterizing progressive relaxation training. It consisted of deep breathing, self-instructions, slowly reviewing the body and focusing on relaxing sensations, and repetition of an autogenic phrase. The nonmedicated subjects with insomnia improved in all sleep measures (sleeponset latency, number of awakenings during the night, WASO, total sleep-time, sleep efficiency, daytime napping, rated difficulty falling asleep, and rated overall quality of sleep). There was a 47% reduction in sleep medication intake among the medicated subjects with insomnia. The authors concluded that the relaxation technique used in this study was effective in treating insomnia in older adults, and attributed this to the features of the relaxation procedure (passive relaxation). However, treatment gains were significant only for nonmedicated subjects, suggesting that relaxation may be effective depending on medication status.

Cognitive-Behavioral Therapy Hoelscher and Edinger (1988) tested their CBT package with four older adults with chronic insomnia (ages 59, 65, 65, and 72), using a multiple baseline design. Sleep

diaries and an objective measure of sleep were used to measure improvement. This study was targeted at sleep-maintenance insomnia, with time awake after sleep onset (WASO) as the main dependent variable. An average reduction of 50% in WASO was observed in all subjects, and results were maintained at follow-ups conducted 2 and 6 months after treatment. Only one subject did not show significant improvement, but further assessments indicated that the subject experienced severe PLMS. Edinger et al. (1992) used relaxation therapy and CBT in a multiple baseline design with seven older adults (aged 55 to 68 years) with chronic insomnia. Sleepmaintenance was also addressed in this study, with WASO and sleep efficiency as the major dependent variables. Sleep diaries and an objective measure of sleep were used to collect data. Progressive muscle relaxation training was introduced sequentially for four weeks, and then CBT was introduced for another four weeks. Relaxation training did not produce significant changes in the dependent variables. However, after the introduction of CBT, subjects showed 63% and 71% reductions in WASO as measured by sleep diaries and the objective measures of sleep, respectively. The effects were maintained at a 3-month follow-up. Morin, Kowatch, et al. (1993) reported a study using CBT with 24 older adults (mean age= 67.1 years) with chronic insomnia. Subjects were randomly assigned to either a CBT or a wait-list control condition. Sleep diaries and polysomnographic measures were used to collect data. CBT consisted of sleep restriction, stimulus control instructions, and cognitive restructuring of dysfunctional beliefs. The results of this study showed that CBT was effective in decreasing sleep-onset latency, WASO, early morning awakenings, and increasing sleep efficiency. Improvements in sleep parameters were

maintained at 3 and 12-month follow-ups. Follow-ups also indicated that none of the subjects treated by CBT were regularly using sleep medication (54% of the subjects did use hypnotics prior to enrollment in the study). Improvements measured by polysomnography were not as high as those measured by sleep diaries, but they were in a positive direction. An important finding in this study was that poor sleep efficiency may be a better predictor of insomnia complaints in older adults that total sleep-time. This was concluded from the data, which showed that total sleep-time among the subjects never exceeded 6.5 hours.

Studies Comparing Different Techniques Morin and Azrin (1987) conducted a group study with 21 subjects (mean age= 57) with chronic sleep-maintenance insomnia. Subjects were randomly assigned to three conditions: stimulus control, imagery training, and a wait-list control condition. Sleep diaries were used to collect data. Frequency and duration of nighttime awakenings were the primary dependent variables. The results of this study indicated that stimulus control was more effective than either imagery training or the control condition. Imagery training, although not significantly effective during treatment, produced significant improvements over baseline level at 3-month and 12-month follow-ups. The authors recommended the combined used of imagery training and stimulus control. Morin and Azrin (1988) used a group design to evaluate changes in sleepmaintenance insomnia (awakening duration and total sleep-time measures) with 27 elderly individuals (mean age= 67). The study admitted subjects with a variety of

medical conditions. Three conditions were compared: stimulus control, imagery training, and a wait-list control. Data were collected by sleep diaries and an objective measure of nighttime awakenings (a switch-activated clock). Stimulus control produced significant improvement in the dependent variables compared to either imagery training or the control condition. Changes were maintained at 3 and 12-month follow-ups. It is important to note that subjective reports (sleep diaries) correlated highly with objective measures of awakenings. Also, the authors reported that the maximum night sleep-time achieved was 6 hours, suggesting that this may be a more realistic expectation for elderly individuals. This is consistent with the findings of Morin, Kowatch, et al. (1993) discussed above. Another important feature of this study is that approximately half the subjects were taking sleep medication. Although the intervention did not target medication intake, there was a significant medication reduction after treatment, and drug-free subjects showed the greatest improvement. Friedman et al. (1991) compared SRT and progressive relaxation training in a sample of community-residing elderly (mean age= 69.7). Subjects with sleep apnea, depression, and severe medical conditions were excluded from the initial sample. Subjects were matched on type of insomnia complaints (e.g., sleep-onset, sleepmaintenance) and assigned to either an SRT group or a relaxation group. In this study, SRT was modified so that the researchers never decreased the allowed time in bed if the subjects did not reach the sleep efficiency criterion. The authors considered that, if not modified in this way, the procedure could have led to noncompliance by the elderly subjects.

Sleep-onset latency and WASO were significantly reduced for both groups. SRT subjects also reported decreased time in bed and increased sleep efficiency. At 3-month follow-up, these changes were still maintained. However, the relaxation group did not maintain their level of change at follow-up. Total sleep-time was increased in both groups at follow-up, but the improvement for the SRT subjects was almost twice that observed in the relaxation group. Engle-Friedman et al. (1992) compared three treatments for geriatric insomnia. These were: sleep hygiene and support alone, progressive relaxation training, and stimulus control instructions. Sleep hygiene and support were used in all treatment conditions. There was also an additional control group, in which subjects completed assessment, took daily sleep measures, and were assessed polysomnographically on the same schedule as the subjects in the active treatment conditions. Sleep diaries were used to collect data. Also, all-night polysomnographic measures were obtained in the subjects' homes at different times throughout the study, using a special device to transmit the data over the telephone to a sleep laboratory. Fifty-three older adults (aged 47 to 76 years) served as participants. They were all asked to refrain from taking sleep medications for 2 weeks prior to and during the course of the study. Frequency and duration of nocturnal awakenings, sleep latency, and total sleep-time were some of the major dependent variables. The results indicated that all groups, including the measurement control, improved their sleep patterns. Polysomnography did not show significant changes over the course of treatment. The authors suggested that insomnia in clinical settings may be best measured by subjective approaches (e.g., sleep diary), since it is the person's

subjective complaint that makes him or her seek treatment. Treatment gains in all conditions may have been associated with the use of self-monitoring (i.e., sleep diaries), which often produces reactivity. Also, all subjects received attention and support from the therapists when reviewing the self-report data. At a 2-year follow-up, stimulus control subjects most frequently used the instructions and showed shorter sleep latencies and highest sleep quality. While all treatments were effective, the authors concluded that stimulus control instructions may be the most effective in improving the sleep quality of elderly individuals.

Discussion Recent literature reviews of behavioral interventions for insomnia suggest that it is effective in treating both sleep-onset and sleep-maintenance insomnia (Lacks & Morin, 1992; Lichstein & Riedel, 1994; Morin, Stone, et al., 1994). Meta-analytic studies have also found significant effects of behavioral interventions on several sleep parameters (Morin, Culbert, et al., 1994; Murtagh & Greenwood, 1995). Although most behavioral interventions initially targeted sleep-onset insomnia, the increasing interest in treating geriatric insomnia made researchers target their interventions at sleep-maintenance insomnia, one of the most frequent sleep complaints of older adults. Almost all of the reviewed studies were targeted at modifying sleep parameters related to sleep-maintenance. Sleep restriction techniques are very promising. Lichstein and Riedel (1994) suggested that, "overall, SRT is by now probably the treatment of choice for geriatric insomnia" (p.671). Stimulus control techniques are also promising for treating insomnia

in the elderly. Sleep hygiene by itself, although it produces treatment gains, is usually not well accepted by clients (Schoicket et al., 1988). Relaxation training is also an effective approach, and new methods continue to be tested with the elderly, consisting of passive relaxation exercises, directed at concentrating on body sensations and using autogenic phrases and self-instructions. Multicomponent packages are a current trend in behavioral interventions, as they address different modalities of behavior. CBT approaches discussed above include techniques for modifying dysfunctional, sleep-incompatible cognitions, as well as SRT and stimulus control procedures. These have also yielded positive results among the elderly with insomnia.

CHAPTER VII Summary and Conclusions

The causes of insomnia in the elderly are multiple and complex, and it is important to gain an understanding of these in order to design effective interventions. A major issue in the study of geriatric insomnia is the distinction between normal and pathological aging. Although sleep-related changes are observed with aging, and possibly they are associated with a normal aging process, a number of other variables (psychological, physiologic, environmental, cognitive, and behavioral) may also be causes of insomnia in the elderly. Based on research results, however, geriatric insomnia seems to be a treatable condition with behavioral and cognitive interventions. Due to the potential negative sideeffects of long-term sleep medication use, these interventions are promising as alternatives to pharmachologic treatments. Recently, a study by Hauri (1997) found that treatment gains obtained by behavioral interventions (sleep hygiene and relaxation) were best maintained at 10-month follow-up by subjects who had learned sleep hygiene and relaxation without the use of hypnotics. Similar results were obtained by Lichstein and Johnson (1993), who found that nonmedicated subjects benefited more from behavioral interventions than medicated subjects. Behavioral interventions have also been proven effective in improving sleep quality after a medication withdrawal program (Riedel et al., 1998). More research will be needed in the future evaluating behavioral interventions at elderly individuals with medical conditions and disabilities. The institutionalized elderly

are in great need of these treatments since their sleep is usually more fragmented than that of the community-residing elderly, to the point of not being able to experience even a single hour of consolidated sleep (Jacobs, Ancoli-Israel, Parker, & Kripke, 1989). Tailoring treatments to the special needs of the elderly is also an important issue. Tailored treatments also need to be formally addressed by researchers. Also, it is important to consider the mechanisms of change for each technique in order to plan symptom-specific interventions (Lacks & Morin, 1992). To date, there is insufficient knowledge about the specific mechanism of change for each behavioral technique. For example, it is not clear whether various techniques are effective due to specific features of each or to a common active ingredient (Espie et al., 1989). This will most likely be a major challenge for researchers in the future. Current research is focusing on possible cognitive and behavioral factors that seem to prevent a good night's sleep in older individuals. It is still not known exactly what determines whether or not an elderly person considers himself or herself an insomniac. A recent study by Riedel and Lichstein (1998) suggested that decreased deep sleep (NREM stages 3 and 4), and increased light sleep (NREM stage 1) were associated with poorer self-reported sleep satisfaction. These polysomnographic measures are known to be directly related to increasing age. Still some of the older adults' complaints of insomnia are unrelated to polysomnographic measures. This is especially true among elderly women. Even though their sleep patterns are less fragmented than those of elderly men, it was noteworthy that the vast majority of the subjects in the reviewed studies were female. Psychosocial variables are possibly involved in these gender differences. These also warrant further

research, as they may produce important information for understanding insomnia complaints in the elderly. Other factors, such as negative beliefs and unrealistic expectations about sleep, may account for older adults' complaints of insomnia (Libman et al., 1997). Spending too much time in bed without sleeping has been proposed either as a cause (Lichstein, 1988) or a perpetuating factor (Spielman et al., 1987) of insomnia. Sleep-incompatible activities, including cognitive activity, can be associated with decreased sleep efficiency. A greater understanding of the complexities involved in geriatric insomnia will undoubtedly lead to better (and probably new) treatment options, in an attempt to improve the quality of life of the elderly, currently the fastest growing segment of the population.

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VITA

Graduate School Southern Illinois University

Edgar Salgado-Garcia

Date of Birth: June 4, 1970

2001 W. Evergreen Terrace Dr., Apt. 6, Carbondale, Illinois 62901 Residencial La Alhambra, Casa 4-H, Sabanilla de Montes de Oca San Jose, Costa Rica

Florida State University Bachelor of Science, Psychology, June 1992 Universidad de Costa Rica Licenciado en Psicologia, December 1994

Research Paper Title: Insomnia in Older Adults: Behavioral Interventions Major Professor: Roger Poppen, Ph.D.