RESEARCH FINDINGS USING GUIDED
IMAGERY FOR
GERIATRIC
INSOMNIA
August, 2006
What
is Insomnia?
Insomnia is defined as taking
more than 30 minutes to get to sleep, waking for a period
of more than 30 minutes, or waking earlier than desired,
with feelings of fatigue and drowsiness during the day,
recurring over at least a 30 day period (Lacks, 1987).
Dimensions
of the Problem
Insomnia is a very common
problem in the elderly. People over age 65 experience
sleeping problems more and are more sensitive to sleeping
aids than other groups (Aging and Drugs, undated). The
National Commission on Sleep Disorders Research reported
$15.9 billion as direct cost of sleep disorders and sleep
deprivation, with an estimated $50 to $100 billion in
indirect costs, mostly from accidents (Overview of the
Findings, 1998). In European studies, drowsiness
has been found to be a greater traffic hazard than alcohol
consumption (Haraldsson and Akerstedt, 2001).
The cost to Americans for
products and services to treat insomnia is $14 billion
annually, with $10 billion of that being spent on nursing
home patients; Americans spend $2 billion annually on sleep
products (Walsh and
Engelhardt, 1999), with seniors or their insurance
carriers paying a substantial percentage of that amount,
since older people are prescribed sleep medicines twice as
much as younger people (Folks and Burke, 1998).
Causes of Chronic Insomnia
Although
a number of medical conditions can cause insomnia, chronic
insomnia is most commonly a behavioral or mind-body problem
(Lacks, 1987). In the geriatric population, other
conditions must also be considered, since their symptoms
(e.g., chronic pain) can contribute to insomnia.
Temporary sleeplessness during stressful times can lead
people to form a link between bed and worrying. Insomniacs
tend to have higher than normal levels of anxiety and
depression, low self-efficacy, and expect too much of
themselves -- all of which can either cause or effect
sleeplessness. Hormonal changes and drug use, including
prescription drugs, cigarettes, and alcohol, can also cause
insomnia (Lacks).
Medical Treatment
Until recently, sleeping pills
have had as many risks as benefits. With older pills,
people can build up a tolerance to them in about two weeks
With the newer ones, it can take about four weeks. In
elderly patients, sleep medications can cause falls or
breathing complications, and are associated with a high
incidence of hip fracture (Ray, Griffin, et al, 1987; Ray,
Griffin, et al, 1989; Ray, Griffin, and Malcom, 1991).
Sleep aids can interact with other medications or alcohol,
and can disrupt natural sleep/awake cycles circadian
rhythms. There is a rebound effect after people stop taking
them. The
next day, the after-effects of sleep medications can make
people feel as bad as not sleeping does (Lacks,
1987).
Nonpharmacologic
Treatment Including Guided Imagery
"CBT
[cognitive behavioral therapy] has emerged as 'the
treatment of choice'" for managing the sleep/wake aspects
of primary insomnia, according to one research team
(Edinger & Means, 2005.) Behavioral therapy has been
repeatedly demonstrated the most effective long-term
approach to chronic insomnia, in both general and specific
populations (Backhaus, Hohagen, et al, 2001; Dashevsky
& Kramer, 1998; Jansson & Linton, 2005; McClusky,
Milby, et al, 1991; Morin, Colecchi, et al, 1999; Morin,
Mimeault, 1999; Pallesen, Nordhus, et al, 2003). The main
categories of behavior therapy for insomnia are stimulus
control – using bed only for sleep – a sleep hygiene
program, keeping a sleep log, cognitive control, and
progressive relaxation. These methods are often combined.
Cognitive distraction – a major
component of guided imagery, hypnosis, and similar
techniques, can be instrumental in avoiding worry and
anxiety that often contributes to insomnia (Harvey &
Payne, 2002; Ree, Harvey, et al, 2005).
Relaxation is effective, with
or without stimulus control measures, in reducing
sleep-onset insomnia (Cannici, Malcolm & Peek, 1983).
Effects are better when the two techniques are combined
(Jacobs, Rosenberg, et al, 1993). In one well-designed clinical
trial, seniors using Cognitive Behavioral Therapy (CBT) and
relaxation therapy were able to fall asleep 54% faster and
16% faster respectively (Edinger, Wohlgemuth, et al, 2001).
Similar results were reported in a 2002 study of older
patients: 54% of patients who received classroom CBT, and
35% of patients who used home-based audio relaxation
treatment achieved significant changes (Rybarczyk, Lopez,
et al, 2002).
Authors of a 2006 review of the literature reported that
seniors (age 55+) using CBT had “robust improvements in
sleep quality, sleep latency, and wakening after sleep
onset” (Irwin, Cole
& Nicassio, 2006).
Since CBT and relaxation (including audio tapes) are both
effective, evidence suggests that combining the two would
yield greater benefits. This seems to be borne out by the
Engle-Friedman study of older adults. It demonstrated that
progressive relaxation and learning new sleep habits helped
patients become less depressed, and achieve a better sense
of control, fell asleep faster, and slept better, even two
years later (Engle-Friedman, Bootzin, et al, 1992).
Authors of three reviews of the literature of mind-body
techniques (including techniques such as relaxation,
meditation, biofeedback) concluded that there is,
respectively, either “considerable,” “sufficient,” or
“moderate” evidence of their effectiveness in insomnia
(Astin, Shapiro, et al, 2003; Barrows & Jacobs, 2002;
Mamtani & Cimino, 2002). A 2003 study found that at-home
use of relaxation tapes was just as effective as massage in
improving subjects’ sleep (Hanley, Stirling & Brown,
2003).
Conclusion
Guided imagery can help senior
patients cope with chronic insomnia, and may save resources
spent on prescription sleep medications. Effects will be
stronger if included behavioral recommendations are
followed.
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