Effects of Non-pharmacological Interventions on Primary Insomnia in Adults Aged 55 and Above: A Meta-analysis

Ji Hyun Kim; Pok Ja Oh

doi:10.7469/kjan.2016.28.1.13

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Kim and Oh: Effects of Non-pharmacological Interventions on Primary Insomnia in Adults Aged 55 and Above: A Meta-analysis

Original Article

Korean J Adult Nurs 2016;28(1):13-29.

Published online: February 2016

DOI: https://doi.org/10.7469/kjan.2016.28.1.13

Effects of Non-pharmacological Interventions on Primary Insomnia in Adults Aged 55 and Above: A Meta-analysis

Ji Hyun Kim¹, Pok Ja Oh^2,

^¹Graduate School, College of Nursing, Korea University, Seoul

^²Department of Nursing, Sahmyook University, Seoul, Korea

Corresponding author: Oh, Pok-Ja Department of Nursing, Sahmyook University, 815 Kongnung-dong, Hwarang-ro, Nowon-gu. Seoul 01795, Korea. Tel: +82-2-3399-1589, Fax: +82-2-3399-1594, E-mail: ohpj@syu.ac.kr

Received 1 October 201525 January 2016 Accepted 12 February 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

This study was performed to evaluate the effects of non-pharmacological interventions on sleep disturbance amongst adults aged 55 and above.

Methods

PubMed, Cochrane Library, EMBASE, CINAHL and several Korean databases were searched. The main search strategy combined terms including non-pharmacological interventions and presence of insomnia. Non-pharmacological interventions included cognitive behavioral therapy, auricular acupuncture, aromatherapy, and emotional freedom techniques. Methodological quality was assessed using Cochrane's Risk of Bias for randomized studies and Risk of Bias Assessment tool for non randomized studies. Data were analyzed by the RevMan 5.3 program of Cochrane Library.

Results

Sixteen clinical trials met the inclusion criteria with a total of 962 participants. Non-pharmacological interventions was conducted for a mean of 5.5 weeks, 7.7 sessions, and an average of 70 minutes per session. The effects of non-pharmacological interventions on sleep quality (ES=-1.18), sleep efficiency (ES=-1.14), sleep onset latency (ES=-0.88), awakening time after sleep onset (ES=-0.87), and sleep belief (ES=-0.71) were significant, and their effect sizes were ranged from moderate to large. However, the effects on total sleep time and insomnia severity were not significant.

Conclusion

The findings of the current study suggest that non-pharmacological interventions have a positive impact on attitudes and beliefs about sleep, sleep quality, sleep duration, and sleep efficiency. Therefore, the findings of the study provide an evidence to incorporate various non-pharmacological interventions into nursing practice to improve both sleep quality and quantity in patients with insomnia.

Keywords: Sleep initiation and maintenance disorders, Intervention studies, Aged, Meta-analysis

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Figure 1.

Flow of studies included from database search.

Figure 2.

Forest plot of effect size and 95% CI by non-pharmacological interventions on sleep onset latency, wake after sleep onset (WASO), and sleep efficiency.

Figure 3.

Forest plot of effect size and 95% CI by non-pharmacological interventions on sleep quality and sleep belief.

Table 1.

Descriptive Summary of the Included Studies (N=16)

Study	Country	Patient	Design	Mean age	Sample size	Intervention					Control group	Outcomes (Scale)
Study	Country	Patient	Design	Mean age	Sample size	Name	Format (setting)	Provider	Duration/ No. of session	Min/ session	Control group	Outcomes (Scale)
1. Buysse et al (2011)	USA	Chronic insomnia and comorn comorbidities	RCT	Exp. (72.5) Cont. (70.8)	Exp. (39) Cont. (40)	BBTI (brief behavioral treatment for insomnia)	Individual (unclear)	Nurse clinician	2 wks/ 2+2 telephone calls	45~60+ 20-minute telephone calls later and after 1, 3 wks	Information control (read publication s and 10-minute telephone calls)	1) Neuropsychiatric status
												- Depression (Hamilton Rating Scale for Depression)
												- Anxiety (Hamilton Anxiety Rating Scale)
												2) Subjective sleep quality (PSQI / ESS)
												3) Health related quality of life (SF-36)
												4) sleep (The pittsburgh sleep diary)
												5) Wrist actigraphy data
												6) PSG
2. Haimov & Shatil (2013)	USA	Chronic insomnia	RCT	Exp. (73.2) Cont. (69.9)	Exp. (34) Cont. (17)	CogniFit (cognitive training program)	Individual (home)	Computer-based personalized	8 wks/ 24	20~30	Active control (software program, "Word and Paint")	1) Sleep quality
												- SOL, SE, TST, WASO, Actigraphy
												2) Cognitive performance (AM, DA, DS, GC, GM, IN, NM, PL, RT, SH, SP, TE, VM, VP, VS, WM)
3. Hong (2008)	Republic of Korea	Elderly with insomnia	Non-RCT	Exp. (67.9) Cont. (70.7)	Exp. (16) Cont. (16)	Sleep management training (sleep hygiene & progressive muscle relaxation)	Group (unclear)	Researcher & assistants	4 wks/ 4	60+30 Home-work	No treatment	1) Sleep score
												2) Sleep-satisfaction score (VAS)
												3) Partial immune response (T3 (CD3), T4 (CD4), B cell (CD19))
4. Irwin et al (2014)	USA	Chronic and primary insomnia	RCT	Exp. 1 (64.4) Exp. 2 (66.3) Cont. (66.4)	Exp. 1 (50) Exp. 2 (48) Cont. (25)	Exp. 1: CBT Exp. 2: TCC (tai chi chih)	Group (unclear)	Therapist	12 wks/ 12	120	Sleep seminar education control	1) Patient reported outcomes of insomnia symptom severity and sleep quality
												- Sleep Quality, TST, SL, SE, WASO (PSQI/AIS/Sleep Diary/PSG)
												2) Additional behavioral outcomes
												- Fatigue (MDFSI)
												- Sleepiness (ESS)
												- Depressive symptom (IDS-C)
												3) CRP levels
5. Lee & Kwon (2009)	Republic of Korea	Elderly with sleep disorder	on-RCT	Exp. (74.5) Cont. (69.4)	Exp. (23) Cont. (20)	Auriculotherapy	Individual (community senior centers	s) Researcher & assistants	4 wks/ 4	Unclear	No treatment	1) Sleep scale score
5. Lee & Kwon (2009)	Republic of Korea	Elderly with sleep disorder	on-RCT	Exp. (74.5) Cont. (69.4)	Exp. (23) Cont. (20)	Auriculotherapy	Individual (community senior centers	s) Researcher & assistants	4 wks/ 4	Unclear	No treatment	2) Sleep satisfaction
6. Lee (2011)	Republic of Korea	Institutionalize d elderly	Non-RCT	Exp. (74.1) Cont. (73.5)	Exp. (20) Cont. (22)	Aromatherapy hand massage program	Individual (hospital)	Researcher & assistants	2 wks/ 10	10	No treatment	1) Anxiety scale
												2) Depression scale 3) Sleep disturbance scale
												3) Sleep disturbance scale
												4) Fatigue scale
7. Lee (2013)	Republic of Korea	Elderly with insomnia	RCT	Exp. (79.67) Cont. (76.07)	Exp. (15) Cont. (15)	EFT-I (emotional freedom techniques)	Group (hospital)	EFT instructor	4 wks/ 8	60	Sleep hygiene education	1) Korean sleep scale
												2) Sleep quality (PSQI)
												3) Depression (GDS-K)
												4) State-Trait Anxiety (STAI)
												5) life satisfaction scale
8. Lichstein et al (2001)	USA	Late-life insomnia	RCT	Exp. 1 (68.11) Exp. 2 (67.92) Cont. (68.04)	Exp. 1 (27) Exp. 2 (24) Cont. (23)	Exp. 1: Relaxation Exp. 2: Sleep compression	Individual (sleep disorders center)	Therapists	6 wks/ 6	45	Usual care (placebo-quasi desensitization)	(Sleep Diary, PSG)
												1) Sleep latency
												2) Number of awakening
												- 3) WASO
												4) TST
												5) SE
												6) Sleep quality rating
												7) Napping
												8) REM (%)
												9) Fatigue (FSS)
												10) Insomnia impact (IIS)
												11) Epwoth sleep (ESS)
												12) Beliefs and attitude about sleep (BASS)
9. Lovato et al (2014)	Austrailia	Sleep maintanance insomnia	RCT	63.76	Exp. (86) Cont. (32)	CBT-I	Group (flinder university)	Five trainee psychologists	4 wks/ 4	60	Waiting-list	1) Subjective sleep quality
												- WASO, SE, Number of awakenings, SOL, TST, Bedtime, Lights-out time, Sleep onset time, Final wake-up time, Out-of-bed time, Time in bed
												2) Objective sleep quality
												- WASO, TST, SE (Actigraphy)
												3) Reported severity of insomnia/ Daytime functioning/Confidence and beliefs about sleep
												- ISI/FFS, ESS, Daytime feeling and functioning scale/sleep self-efficacy, DBAS, sleep anticipatory anxiety
10. Morgan et al (2012)	UK	Insomnia	RCT	Exp. (67) Cont. (66.3)	Exp. (98) Cont. (95)	Self-help CBT	Individual (home)	Trained advisors	Unclear (6 self-help booklets & low-cost telephone helpline)	Unclear	Treatment as usual	Primary outcome
												1) Sleep Quality (PSQI)
												Secondary outcome measures
												1) Insomnia severity (ISI)
												2) Subjective sleep efficiency (SE)
												3) Fatigue (FSS)
												4) Sleep medication use
11. Morin & Azrin (1988)	Canada	Geriatric insomnia (sleep-mainte nance insomnia)	RCT	Exp. 1 (68.4) Exp. 2 (67.5) Cont. (67.4)	Exp. 1 (9) Exp. 2 (9) Cont. (10)	Behavioral cognitive treatment (Exp. 1: Stimulus control, Exp. 2: Imagery training)	) Group (unclear)	Therapists	5 wks/ 6	60~75	Waiting-list	(Sleep Diary)
												1) Awakening duration
												2) Awakening frequency
												3) Sleep-onset latency
												4) TST
12. Morin et al (1993)	USA	Late-life insomnia	RCT	67.1	Exp. 1 (12) Cont. (12)	CBT	Group (home)	Clinical psychologist	8 wks/ unclear	90	Waiting-list	1) Sleep-onset latency
												2) WASO
												3) Early morning awakening
												4) Total wake time
												5) TST
												6) SE
13. Morin et al (1999)	Canada	Late-life insomnia	RCT	Exp. 1 (64.4)	Exp. 1 (18)	Exp. 1: CBT	Group (hospital-outpatients)	Clinical psychologist or a postdoctoral fellow in clinical psychology	8 wks/ 8	90	Waiting-list	(Sleep diary, PSG)
				Exp. 2 (64.1)	Exp. 2 (17)	Exp. 2: PCT						1) WASO
				Exp. 3 (65.2)	Exp. 3 (19)	Exp. 3: CBT+PCT						2) SE
				Cont. (64.9)	Cont. (18)							3) TST
14. Rybarczyk et al (2002)	USA	Comorbid geriatric insomnia	RCT	Exp. 1 (66.5)	Exp. 1 (11)	Exp. 1: CBT	Group (unclear)	Clinical gero-psychologists	6 wks/ 6	90	Treatment as usual	1) Sleep log measures
				Exp. 2 (65.6)	Exp. 2 (14)	Exp. 2: Home based audio relaxation treatment (HART)						2) Actigraphy
				Cont. (71.4)	Cont. (13)							3) Sleep quality (PSQI)
												4) Dysfunction beliefs and attitude (DBAS)
												5) Geriatric depression scale (GDS)
												6) BAI
												7) Pain (SF-MPQ)
												8) Life Satisfaction Index-Short Form
												9) Quality of life (SF-36)
15. Rybarczyk et al (2005)	USA	Comorbid Insomnia	RCT	Exp. (70.1) Cont. (67.7)	Exp. (46) Cont. (46)	CBT	Group (medical offices and senior centers)	Clinical psychologists	8 wks/ 8	120	Stress manageme nt and wellness	1) Sleep log
												2) Sleep quality (PSQI)
												3) SII
												4) Dysfunction beliefs and attitude (DBAS)
												5) POMS
												6) Geriatric depression scale (GDS)
												(GDS) 7) Quality of life (SF-36)
												8) Sickness impact profile (SIP)
												8) Sickness impact profile (SIP) 9) Pain (SF-MPQ)
												10) TEQ
16. Sok & Kim (2008)	Republic of Korea	a Insomnia of Taeumin in elderly women	Non-RCT	≥65	Exp. (28)	Auricular acupuncture therapy	Individual (home, community welfare center, senior citizen center)	Researcher	2 wks/ 4	Unclear	Usual care (blood pressure)	1) Sleep score
16. Sok & Kim (2008)	Republic of Korea	a Insomnia of Taeumin in elderly women	Non-RCT	≥65	Cont. (28)	Auricular acupuncture therapy		Researcher	2 wks/ 4	Unclear	Usual care (blood pressure)	2) Self-reported satisfaction (Visual Analogue Scale)

Exp.=experimental group; Cont.=control group; RCT=randomized controlled trials; Non-RCT=non-randomized controlled trial; PSQI=the pittsburgh sleep quality index; ESS=epworth sleepiness scale; SF-36=short form(36) health survey; PSG=polysomnography; SOL=sleep onset latency; SE=sleep efficiency; TST=total sleep time; WASO=wakefulness after sleep onset; NA=number of awakenings; AM=auditory memory; DA=divided attention; DS=avoiding distractions; GC=hand-eye co-ordination; GM=general memory; IN=inhibition; NM=naming; PL=planning; RT=response time; SH=shifting; SP=spatial perception; TE=time estimation; VM=visual working memory; VP=visual perception; VS=visual scanning; WM=working linguistic-auditory memory; VAS=visual analog scale; CBT=cognitive behavioral therapy; SL=sleep latency; AIS=athens insomnia scale; MDFSI=multidimensional fatigue severity index; IDS-C=inventory of depressive symptomatology-clinician rating scale; GDS-K=geriatric depression scale in Korea; STAI=state-trait anxiety inventory; FSS=fatigue severity scale; IIS=insomnia impact scale; BASS=belief and attitudes about sleep scale; ISI=insomnia severity inventory; FFS=flinders fatigue scale; DBAS=dysfunctional beliefs and attitudes about sleep scale; GDS=geriatric depression scale; BAI=beck anxiety inventory; SF-MPQ=short form mcgill pain questionnaire; SII=sleep impairment index; POMS=profile of mood states; SIP=sickness impact profile; ITEQ=insomnia treatment evaluation questionnaire.

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