Telehealth‐delivered CBT‐I programme enhanced by acceptance and commitment therapy for insomnia and hypnotic dependence: A pilot randomized controlled trial

Cognitive behavioural therapy for insomnia is the recommended treatment for chronic insomnia. However, up to a quarter of patients dropout from cognitive behavioural therapy for insomnia programmes. Acceptance, mindfulness and values‐based actions may constitute complementary therapeutic tools to cognitive behavioural therapy for insomnia. The current study sought to evaluate the efficacy of a remotely delivered programme combining the main components of cognitive behavioural therapy for insomnia (sleep restriction and stimulus control) with the third‐wave cognitive behavioural therapy acceptance and commitment therapy in adults with chronic insomnia and hypnotic dependence on insomnia symptoms and quality of life. Thirty‐two participants were enrolled in a pilot randomized controlled trial: half of them were assigned to a 3‐month waiting list before receiving the four “acceptance and commitment therapy‐enhanced cognitive behavioural therapy for insomnia” treatment sessions using videoconference. The primary outcome was sleep quality as measured by the Insomnia Severity Index and the Pittsburgh Sleep Quality Index. All participants also filled out questionnaires about quality of life, use of hypnotics, depression and anxiety, acceptance, mindfulness, thought suppression, as well as a sleep diary at baseline, post‐treatment and 6‐month follow‐up. A large effect size was found for Insomnia Severity Index and Pittsburgh Sleep Quality Index, but also daytime improvements, with increased quality of life and acceptance at post‐treatment endpoint in acceptance and commitment therapy‐enhanced cognitive behavioural therapy for insomnia participants. Improvement in Insomnia Severity Index and Pittsburgh Sleep Quality Index was maintained at the 6‐month follow‐up. Wait‐list participants increased their use of hypnotics, whereas acceptance and commitment therapy‐enhanced cognitive behavioural therapy for insomnia participants evidenced reduced use of them. This pilot study suggests that web‐based cognitive behavioural therapy for insomnia incorporating acceptance and commitment therapy processes may be an efficient option to treat chronic insomnia and hypnotic dependence.     

Effects of insomnia symptoms and objective short sleep duration on memory performance in youths

Sleep quantity and quality are both important for optimal development and functioning during youth. Yet few studies have examined the effects of insomnia symptoms and objective short sleep duration on memory performance among adolescents and young adults. One‐hundred and ninety participants (female: 61.6%) aged from 12 to 24 years completed this study. All participants underwent a clinical interview, a 7‐day actigraphic assessment, a battery of self‐report questionnaires and cognitive tests to assess working memory and episodic memory. Insomnia symptoms were defined as a score ≥ 9 on the Insomnia Severity Index, and objective short sleep duration was defined as average total sleep time less than 7 hr for those aged 12–17 years, and 6 hr for those aged 18 years and above as assessed by actigraphy. Insomnia symptoms were significantly associated with worse self‐perceived memory (p < .05) and poorer performance on the digit span task (p < .01), but not the dual N‐back task and verbal learning task. There was no significant difference in any of the memory measures between participants with objective short sleep duration and their counterparts. No interaction effect was found between insomnia and short sleep duration on any of the objective memory outcomes. Insomnia symptoms, but not objective short sleep duration, were associated with poorer subjective memory and objective working memory performance in youths. Further studies are needed to investigate the underlying mechanisms linking insomnia and memory impairments, and to delineate the long‐term impacts of insomnia on other aspects of neurocognitive functioning in youth.     

Sleep‐related eye symptoms and their potential for identifying driver sleepiness

The majority of individuals appear to have insight into their own sleepiness, but there is some evidence that this does not hold true for all, for example treated patients with obstructive sleep apnoea. Identification of sleep‐related symptoms may help drivers determine their sleepiness, eye symptoms in particular show promise. Sixteen participants completed four motorway drives on two separate occasions. Drives were completed during daytime and night‐time in both a driving simulator and on the real road. Ten eye symptoms were rated at the end of each drive, and compared with driving performance and subjective and objective sleep metrics recorded during driving. ‘Eye strain’, ‘difficulty focusing’, ‘heavy eyelids’ and ‘difficulty keeping the eyes open’ were identified as the four key sleep‐related eye symptoms. Drives resulting in these eye symptoms were more likely to have high subjective sleepiness and more line crossings than drives where similar eye discomfort was not reported. Furthermore, drivers having unintentional line crossings were likely to have ‘heavy eyelids’ and ‘difficulty keeping the eyes open’. Results suggest that drivers struggling to identify sleepiness could be assisted with the advice ‘stop driving if you feel sleepy and/or have heavy eyelids or difficulty keeping your eyes open’.     

Reduced dynamic functional connectivity between salience and executive brain networks in insomnia disorder

Research into insomnia disorder has pointed to large‐scale brain network dysfunctions. Dynamic functional connectivity is instrumental to cognitive functions but has not been investigated in insomnia disorder. This study assessed between‐network functional connectivity strength and variability in patients with insomnia disorder as compared with matched controls without sleep complaints. Twelve‐minute resting‐state functional magnetic resonance images and T1‐weighed images were acquired in 65 people diagnosed with insomnia disorder (21–69 years, 48 female) and 65 matched controls without sleep complaints (22–70 years, 42 female). Pairwise correlations between the activity time series of 14 resting‐state networks and temporal variability of the correlations were compared between cases and controls. After false discovery rate correction for multiple comparisons, people with insomnia disorder and controls did not differ significantly in terms of mean between‐network functional connectivity strength; people with insomnia disorder did, however, show less functional connectivity variability between the anterior salience network and the left executive‐control network. The finding suggests less flexible interactions between the networks during the resting state in people with insomnia disorder.     

Prevalence and management of chronic insomnia in Swiss primary care: Cross‐sectional data from the “Sentinella” practice‐based research network

We investigated the prevalence and treatment of patients with chronic insomnia presenting to Swiss primary care physicians (PCPs) part of “Sentinella”, a nationwide practice‐based research network. Each PCP consecutively asked 40 patients if they had sleep complaints, documented frequency, duration, comorbidities, and reported ongoing treatment. We analysed data of 63% (83/132) of the PCPs invited. The PCPs asked 76% (2,432/3,216) of included patients about their sleep (51% female); 31% (761/2,432) of these had had insomnia symptoms; 36% (875/2,432) had current insomnia symptoms; 11% (269/2,432) met the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM‐5) criteria for chronic insomnia (61% female). In all, 75% (201/269) of patients with chronic insomnia had comorbidities, with 49% (99/201) reporting depression. Chronic insomnia was treated in 78% (209/269); 70% (188/268) took medication, 38% (102/268) benzodiazepines or benzodiazepine receptor agonists, 32% (86/268) took antidepressants. Only 1% (three of 268) had been treated with cognitive behavioural therapy for insomnia (CBT‐I). A third of patients presenting for a non‐urgent visit in Swiss primary care reported insomnia symptoms and 11% met the DSM‐5 criteria for chronic insomnia. Hypnotics were the most common treatment, but almost no patients received first‐line CBT‐I. Reducing the burden of insomnia depends on disseminating knowledge about and access to CBT‐I, and encouraging PCPs to discuss it with and offer it as a first‐line treatment to patients with chronic insomnia.     

Subjective–objective sleep discrepancy among older adults: associations with insomnia diagnosis and insomnia treatment

Discrepancy between subjective and objective measures of sleep is associated with insomnia and increasing age. Cognitive behavioural therapy for insomnia improves sleep quality and decreases subjective–objective sleep discrepancy. This study describes differences between older adults with insomnia and controls in sleep discrepancy, and tests the hypothesis that reduced sleep discrepancy following cognitive behavioural therapy for insomnia correlates with the magnitude of symptom improvement reported by older adults with insomnia. Participants were 63 adults >60 years of age with insomnia, and 51 controls. At baseline, participants completed sleep diaries for 7 days while wearing wrist actigraphs. After receiving cognitive behavioural therapy for insomnia, insomnia patients repeated this sleep assessment. Sleep discrepancy variables were calculated by subtracting actigraphic sleep onset latency and wake after sleep onset from respective self‐reported estimates, pre‐ and post‐treatment. Mean level and night‐to‐night variability in sleep discrepancy were investigated. Baseline sleep discrepancies were compared between groups. Pre–post‐treatment changes in Insomnia Severity Index score and sleep discrepancy variables were investigated within older adults with insomnia. Sleep discrepancy was significantly greater and more variable across nights in older adults with insomnia than controls, P ≤ 0.001 for all. Treatment with cognitive behavioural therapy for insomnia was associated with significant reduction in the Insomnia Severity Index score that correlated with changes in mean level and night‐to‐night variability in wake after sleep onset discrepancy, P < 0.001 for all. Study of sleep discrepancy patterns may guide more targeted treatments for late‐life insomnia.     

The relationship between a night's sleep and subsequent daytime functioning in older poor and good sleepers

Those suffering insomnia symptoms generally report daytime impairments. However, research has not assessed whether this relationship holds on a nightly basis, despite the strongly held belief that a night of poor sleep impairs mood and functioning the following day. The objective of this study was to test this relationship in a group of older poor sleepers with insomnia symptoms compared with good sleepers. This study utilized a within‐subjects design to investigate day‐to‐day subjective daytime functioning and its relation to the previous night's sleep. Seventeen older individuals (mean age: 67.5 years) were identified with a retrospective questionnaire and 2 weeks of sleep–wake diary to have poor sleep consistent with insomnia. Seventeen good sleepers (mean age: 67.8 years) were selected using the same measures. Participants reported their beliefs about sleep and daytime functioning on the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS‐16). One week later they commenced a 14‐day period of sleep–wake diaries and concurrent responses to a modified Daytime Insomnia Symptom Scale (DISS). Results showed significant night‐to‐day covariation between sleep efficiency and daytime functioning for individuals with poor sleep (r = 0.34), but not for good sleepers (r = 0.08). Those poor sleepers who held this covariation belief most strongly were those who subsequently showed this night‐to‐day relationship the most strongly (r = 0.56). This was not true for good sleepers. For those suffering insomnia, these findings demonstrate their belief that a poor sleep is followed by an impaired daytime, consistent with their experience.     

Case-control study of subjective and objective differences in sleep patterns in older adults with insomnia symptoms

Older adults have high prevalence rates of insomnia symptoms, yet it is unclear if these insomnia symptoms are associated with objective impairments in sleep. We hypothesized that insomnia complaints in older adults would be associated with objective differences in sleep compared with those without insomnia complaints. To test this hypothesis, we conducted a cross‐sectional study in which older adults with insomnia complaints (cases, n = 100) were compared with older adults without insomnia complaints (controls, n = 100) using dual‐night in‐lab nocturnal polysomnography, study questionnaires and 7 days of at‐home actigraphy and sleep diaries. Cases were noted to have reduced objective total sleep time compared with controls (25.8 ± 8.56 min, P = 0.003). This was largely due to increased wakefulness after sleep onset, and not increased sleep latency. When participants with sleep‐related breathing disorder or periodic limb movement disorder were excluded, the polysomnography total sleep time difference became even larger. Cases also had reduced slow‐wave sleep (5.10 ± 1.38 min versus 10.57 ± 2.29 min, effect size −0.29, P = 0.04). When comparing self‐reported sleep latency and sleep efficiency with objective polysomnographic findings, cases demonstrated low, but statistically significant correlations, while no such correlations were observed in controls. Cases tended to underestimate their sleep efficiency by 1.6% (±18.4%), while controls overestimated their sleep efficiency by 12.4% (±14.5%). In conclusion, we noted that older adults with insomnia complaints have significant differences in several objective sleep findings relative to controls, suggesting that insomnia complaints in older adults are associated with objective impairments in sleep.     

Patients with primary insomnia in the sleep laboratory: do they present with typical nights of sleep?

The validity of sleep laboratory investigations in patients with insomnia is important for researchers and clinicians. The objective of this study was to examine the first‐night effect and the reverse first‐night effect in patients with chronic primary insomnia compared with good sleeper controls. A retrospective comparison of a well‐characterised sample of 50 patients with primary insomnia and 50 good sleeper controls was conducted with respect to 2 nights of polysomnography, and subjective sleep parameters in the sleep laboratory and the home setting. When comparing the first and second sleep laboratory night, a significant first‐night effect was observed across both groups in the great majority of the investigated polysomnographic and subjective variables. However, patients with primary insomnia and good sleeper controls did not differ with respect to this effect. Regarding the comparison between the sleep laboratory nights and the home setting, unlike good sleeper controls, patients with primary insomnia reported an increased subjective sleep efficiency on both nights (in part due to a reduced bed time) and an increased subjective total sleep time on the second night. These results suggest that even the second sleep laboratory night does not necessarily provide clinicians and researchers with a representative insight into the sleep perception of patients with primary insomnia. Future studies should investigate whether these findings also hold for other patient populations.     

The exploratory power of sleep effort,dysfunctional beliefs and arousal for insomnia severity and polysomnography‐determined sleep

Differences between subjective sleep perception and sleep determined by polysomnography (PSG) are prevalent, particularly in patients with primary insomnia, indicating that the two measures are partially independent. To identify individualized treatment strategies, it is important to understand the potentially different mechanisms influencing subjective and PSG‐determined sleep. The aim of this study was to investigate to what extent three major components of insomnia models, i.e. sleep effort, dysfunctional beliefs and attitudes about sleep, and presleep arousal, are associated with subjective insomnia severity and PSG‐ determined sleep. A sample of 47 patients with primary insomnia according to DSM‐IV criteria and 52 good sleeper controls underwent 2 nights of PSG and completed the Glasgow Sleep Effort Scale, the Dysfunctional Beliefs and Attitudes about Sleep Scale, the Pre‐Sleep Arousal Scale and the Insomnia Severity Index. Regression analyses were conducted to investigate the impact of the three predictors on subjective insomnia severity and PSG‐ determined total sleep time. All analyses were adjusted for age, gender, depressive symptoms and group status. The results showed that subjective insomnia severity was associated positively with sleep effort. PSG‐determined total sleep time was associated negatively with somatic presleep arousal and dysfunctional beliefs and attitudes about sleep. This pattern of results provides testable hypotheses for prospective studies on the impact of distinct cognitive and somatic variables on subjective insomnia severity and PSG‐determined total sleep time.     

Public health and insomnia: economic impact

There seems to be a lack of understanding between practitioners and patients on the topic of insomnia. One adult out of four complains of insomnia; however only one insomniac out of four has ever complained about it to their practitioner during a visit made for another problem and only one out of twenty has come to discuss specifically the problem of his or her insomnia. Only a few patients with insomnia take a treatment for it. This gap between the patient's feeling and the practitioner's answer has to be better understood if we want to know why insomnia seems to be so prevalent and what impact it has on society. One aspect may be a question of definition. Insomnia may be considered an ordinary complaint (after one poor night) or as a chronic disease. Practitioners have poor knowledge about sleep disorders and may be embarrassed about coping with an impairment they never specifically learned to manage. The second aspect concerns the impact of insomnia on daytime alertness and performance. While patients usually complain of an impaired daytime functioning with a feeling of fatigue, sleepiness, and risk of mistakes, many studies of insomniacs do not reveal any increased sleepiness or decrease of performance (measured by objective tests) the day following a poor night. Practitioners may therefore find it difficult to understand the real impact of insomnia on daytime functioning. The third aspect is related to the large co-morbidity between insomnia and psychiatric diseases, especially depression and anxiety. It does make it harder for practitioners to define whether the sleep impairment suffered by their patient is the cause for other symptoms or the consequence of an underlying disease. Thus, it makes it all the more difficult for the practitioner to determine which treatment is the most appropriate. These aspects have to be clarified if one wants to estimate the real impact of insomnia on society. It could be useful to both practitioners and patients to have a better understanding on the relationship between poor sleep and daily lives.     

Primary insomnia patients’ performances during simulated car following and urban driving in the afternoon

According to epidemiological studies, insomnia is associated with an increase in risk of traffic accidents. Recent investigations revealed that patients with insomnia had driving performance impairment under monotonous conditions. However, it is unclear whether other driving abilities may be impacted by insomnia, especially those needing more attentional resources than those involved in monotonous driving. Other findings revealed that impaired performances are more likely to occur with the increase of cognitive demands. However, such tests did not reflect difficulties in situations of everyday life expressed by patients with insomnia, such as driving in an urban environment with traffic and critical situations. Therefore, behaviour in situations encountered in everyday life has to be explored. The aim of the present study was to assess driving performances of patients with insomnia in daily routine tasks such as urban and car‐following tests. For this purpose, 15 patients with insomnia and 16 good sleepers performed an urban test of driving with original risk scenarios and a car‐following test during the middle afternoon. No significant behavioural difference between patients with insomnia and good sleepers has been found in both the urban test and the car‐following test, showing that patients with insomnia have no impairment in behaviour implicated in daily contexts driving tasks of short period of time performed in the late afternoon. Although our results provide a first step towards knowledge of behavioural performance during daily routine driving tasks in patients with insomnia, future studies are needed using on‐the‐road driving tests and/or different population of patients with insomnia before generalisation.     

Dynamic daily associations between insomnia symptoms and alcohol use in adults with chronic pain

Individuals with chronic pain are at risk for sleep disruption and heavy alcohol use, yet the daily associations between these behaviours are not well characterized. This study aimed to determine the extent to which alcohol use affects insomnia symptoms and vice versa in adults reporting symptoms of chronic pain. Participants were 73 individuals (93% women) reporting alcohol use in addition to symptoms of insomnia and chronic pain. They completed daily diaries assessing insomnia symptoms and alcohol use for 14 days. Multilevel modelling was used to evaluate the bidirectional associations between alcohol use and insomnia symptoms at the daily level. Consistent with laboratory‐based research, alcohol use was associated with decreased sleep‐onset latency the same night but increased sleep‐onset latency 2 nights later. Specifically, for every alcoholic drink consumed, time to sleep onset decreased by 5.0 min in the same night but increased by 4.3 min 2 nights later. Alcohol use was not significantly associated with subsequent wake after sleep onset or total sleep time, and insomnia symptoms were not significantly associated with subsequent alcohol use. To our knowledge, these data provide the first evidence that alcohol use negatively affects insomnia symptoms up to 2 days post‐consumption in patients reporting symptoms of insomnia and chronic pain. Findings suggest that one drink will have minimal impact on sleep, but heavier drinking (e.g. four–five drinks) may have a clinically significant impact (16–25‐min increase in sleep‐onset latency). Future studies may assess alcohol use as a point of intervention within this population.     

The role of vulnerability in stress‐related insomnia,social support and coping styles on incidence and persistence of insomnia

Individuals who are more prone to experience situational insomnia under stressful conditions may also be at greater risk to develop subsequent insomnia. While cross‐sectional data exist on the link between sleep reactivity (heightened vulnerability to stress‐related insomnia) and insomnia, limited data exist on its predictive value. The aim of the study was to evaluate prospectively whether sleep reactivity was associated with increased risk of incident and persistent insomnia in a population‐based sample of good sleepers. Social support and coping styles were also investigated as potential moderators. Participants were 1449 adults (M_age = 47.4 years, standard deviation = 15.1; 41.2% male) without insomnia at baseline and evaluated four times over 3 years. Sleep reactivity was measured using the Ford Insomnia Response to Stress Test (FIRST). Additional measures included depressive symptoms, the frequency and perceived impact of stressful life events, social support and coping styles. After controlling for prior sleep history, depressive symptoms, arousal predisposition, stressful life events and perceived impact, individuals with higher sleep reactivity had an odds ratio (OR) of 1.56 [95% confidence interval (CI): 1.13–2.16], 1.41 (95% CI: 0.87–2.30) and 2.02 (95% CI: 1.30–3.15) of developing insomnia symptoms, syndrome and persistent insomnia, respectively. Social support and coping styles did not moderate these associations. Results suggest that heightened vulnerability to insomnia is associated with an increased risk of developing new‐onset subsyndromal and persistent insomnia in good sleepers. Knowledge of premorbid differences is important to identify at‐risk individuals, as this may help to develop more targeted prevention and intervention strategies for insomnia.     

Trends in self‐reported sleep problems,tiredness and related school performance among Finnish adolescents from 1984 to 2011

The aim of this study was to investigate long‐term trends in insomnia symptoms, tiredness and school performance among Finnish adolescents. A time–series from 1984 to 2011 was analysed from two large‐scale survey studies, the Finnish School Health Promotion Study and the Health Behavior in School‐Aged Children study. A total of 1 136 583 adolescents aged 11–18 years answered a standardized questionnaire assessing frequency of insomnia symptoms, tiredness and school performance. A clear approximately twofold increasing trend in insomnia symptoms and tiredness was found from the mid‐1990s to the end of the 2000s. The increase was evident in all participating age groups and in both genders. After 2008, the increase seems to have stopped. Insomnia symptoms and tiredness were associated with lower school performance and they were more prevalent among girls (11.9 and 18.4%) compared to boys (6.9 and 9.0%, respectively). Unexpectedly, we also observed an increasingly widening gap in school performance between normally vigilant and chronically tired pupils. The underlying causes of these phenomena are unknown, but may concern changes in the broader society. The observed recent increasing trend in adolescents’ sleep problems is worrisome: poor sleep quality has also been suggested to associate with clinical or subclinical mood or anxiety disorders and behavioural problems and predispose to sleep and psychiatric disorders later in life. Our results justify further studies and call for serious attention to be paid to adolescent's sleep in the Finnish educational system and society at large.     

Fatigue, sleepiness, and performance in simulated versus real driving conditions

STUDY OBJECTIVES: To determine whether real-life driving would produce different effects from those obtained in a driving simulator on fatigue, performances and sleepiness. DESIGN: Cross-over study involving real driving (1200 km) or simulated driving after controlled habitual sleep (8 hours) or restricted sleep (2 hours). SETTING: Sleep laboratory and open French Highway. PARTICIPANTS: Twelve healthy men (mean age +/- SD = 21.1 +/- 1.6 years, range 19-24 years, mean yearly driving distance +/- SD = 6563 +/- 1950 miles) free of sleep disorders. MEASUREMENTS: Self-rated fatigue and sleepiness, simple reaction time before and after each session, number of inappropriate line crossings from the driving simulator and from video-recordings of real driving. RESULTS: Line crossings were more frequent in the driving simulator than in real driving (P < .001) and were increased by sleep deprivation in both conditions. Reaction times (10% slowest) were slower during simulated driving (P = .004) and sleep deprivation (P = .004). Subjects had higher sleepiness scores in the driving simulator (P = .016) and in the sleep restricted condition (P = .001). Fatigue increased over time (P = .011) and with sleep deprivation (P = .000) but was similar in both driving conditions. CONCLUSIONS: Fatigue can be equally studied in real and simulated environments but reaction time and self-evaluation of sleepiness are more affected in a simulated environment. Real driving and driving simulators are comparable for measuring line crossings but the effects are of higher amplitude in the simulated condition. Driving simulator may need to be calibrated against real driving in various condition.     

Manifestations of Insomnia in Sleep Apnea: Implications for Screening and Treatment

The aims of this study were to examine the presence, type, and severity of insomnia complaints in obstructive sleep apnea (OSA) patients and to assess the utility of the Sleep Symptom Checklist (SSC) for case identification in primary care. Participants were 88 OSA patients, 57 cognitive-behavioral therapy for insomnia (CBT-I) patients, and 14 healthy controls (Ctrl). Each completed a sleep questionnaire as well as the SSC, which includes insomnia, daytime functioning, psychological, and sleep disorder subscales. Results showed that OSA patients could be grouped according to 3 insomnia patterns: no insomnia (OSA), n = 21; insomnia (OSA-I), n = 30, with a subjective complaint and disrupted sleep; and noncomplaining poor sleepers (OSA-I-NC), n = 37. Comparisons among the OSA, CBT-I, and Ctrl groups demonstrate distinct profiles on the SSC subscales, indicating its potential utility for both case identification and treatment planning.     

A randomized controlled trial of bedtime music for insomnia disorder

Music is often used as a self‐help tool to alleviate insomnia. To evaluate the effect of bedtime music listening as a strategy for improving insomnia, we conducted an assessor‐blinded randomized controlled trial. Fifty‐seven persons with insomnia disorder were included and randomized to music intervention (n = 19), audiobook control (n = 19) or a waitlist control group (n = 19). The primary outcome measure was the Insomnia Severity Index. In addition, we used polysomnography and actigraphy to evaluate objective measures of sleep, and assessed sleep quality and quality of life. The results showed no clear effect of music on insomnia symptoms as the group × time interaction only approached significance (effect size = 0.71, p = .06), though there was a significant improvement in insomnia severity within the music group. With regard to the secondary outcomes, we found a significant effect of the music intervention on perceived sleep improvement and quality of life, but no changes in the objective measures of sleep. In conclusion, music listening at bedtime appears to have a positive impact on sleep perception and quality of life, but no clear effect on insomnia severity. Music is safe and easy to administer, but further research is needed to assess the effect of music on different insomnia subtypes, and as an adjunctive or preventive intervention.     

Predictors of insomnia symptoms and nightmares among individuals with post‐traumatic stress disorder: an ecological momentary assessment study

Despite the high levels of comorbidity between post‐traumatic stress disorder (PTSD) and sleep disturbance, little research has examined the predictors of insomnia and nightmares in this population. The current study tested both PTSD‐specific (i.e. PTSD symptoms, comorbid anxiety and depression, nightmares and fear of sleep) and insomnia‐specific (i.e. dysfunctional beliefs about sleep, insomnia‐related safety behaviours and daily stressors) predictors of sleep quality, efficiency and nightmares in a sample of 30 individuals with PTSD. Participants participated in ecological momentary assessment to determine how daily changes in PTSD‐ and insomnia‐related factors lead to changes in sleep. Multi‐level modelling analyses indicated that, after accounting for baseline PTSD symptom severity, PTSD‐specific factors were associated with insomnia symptoms, but insomnia‐specific factors were not. Only daytime PTSD symptoms and fear of sleep predicted nightmares. Both sleep‐ and PTSD‐related factors play a role in maintaining insomnia among those with PTSD, while nightmares seem to be linked more closely with only PTSD‐related factors.     

Optimizing sleep in older adults: Treating insomnia

As the world's population ages, the elevated prevalence of insomnia in older adults is a growing concern. Insomnia is characterized by difficulty falling or remaining asleep, or by non-restorative sleep, and resultant daytime dysfunction. In addition to being at elevated risk for primary insomnia, older adults are at greater risk for comorbid insomnia, which results from, or occurs in conjunction with another medical or psychiatric condition. In this review, we discuss normal changes in sleep that accompany aging, circadian rhythm changes and other factors that can contribute to late-life insomnia, useful tools for the assessment of insomnia and related problems in older people, and both non-pharmacological and pharmacological strategies for the management of insomnia and optimization of sleep in later life.