Objectives. Disclosure. APNA 26th Annual Conference Session 2017: November 8, Kurtz 1. The speaker has no conflicts of interest to disclose

Transcription

1 Christine Kurtz, DNP, PMHCNS BC Valparaiso University Disclosure The speaker has no conflicts of interest to disclose Objectives The learner will Describe the rationale for and five therapies of CBT I and patients for whom it is appropriate Explain the process and outcomes of an EBP project involving CBT I in an outpatient sleep center Describe implications for practice, education, and research related to CBT I and potential opportunities for psychiatric nurses Kurtz 1

2 Significance of Problem Definition Chronic insomnia affects 10% of population Usual treatment is hypnotic medication Cognitive behavioral therapy for insomnia (CBT I) targets perpetuating factors of insomnia (Schutte Rodin et al., 2008) Evolution of Insomnia Predisposing factors Precipitating factors Perpetuating factors (Perlis, M. L. et al., 2005) Cognitive Therapy Change distorted thoughts related to sleep Thought record Goal: decrease anxiety related to sleep problems Kurtz 2

3 Sleep Restriction Therapy Decrease amount of time in bed to match total sleep time Prescribed wake time and bedtime Goal: Decrease time awake in bed and improve sleep drive Most powerful component of CBT I Stimulus Control Therapy Develop positive association between sleep and bed Go to bed only when sleepy Get out of bed if unable to sleep for 30 minutes Distraction and decreased frustration Relaxation Therapy Arousal theory of primary insomnia Learn to induce relaxation response Practice during the day, then before bed Kurtz 3

4 Sleep Hygiene Sleep in cool, dark, quiet place Avoid caffeine after 3pm & alcohol before bed Regular bedtime routine Regular exercise and sunlight Who is appropriate for CBT I? Difficulty initiating or maintaining sleep Problem not due to circadian rhythm disorder No unstable medical or psychiatric illness Exhibit behavioral or psychological factors (Smith, & Perlis, 2006) Patient Assessment Sleep history Medical, psychiatric, & substance abuse history Development of sleep problem including perpetuating behaviors Sleep diary (Edinger, J& Carney, 2008) Kurtz 4

5 EBP Project Purpose Answer clinical question Assess patient satisfaction Review of literature High level evidence supporting efficacy Implementation Sleep center Participants N = 14 9 women, 5 men Age: M = 55 yrs (range = 42 66) Duration: M = 14.8 yrs 86.7% using hypnotic medications M = 5.7 doses per week Duration of usage: 5.9 years 93% had at least one comorbidity Outcome Measures Sleep Diary Sleep Onset Latency Wake After Sleep Onset Total Sleep Time Sleep Efficiency Medication Usage Insomnia Severity Index Patient Satisfaction Survey Kurtz 5

6 Weekly Sleep Diary Instructions: Keep this at your bedside and complete each morning upon awakening. Bring to each program session. Day of the week Calendar date Yesterday, I napped for: (add total naps, eg., 15 mins, ½, 1, 2 hrs, etc) Yesterday, I drank cups of (caffeine) at (time). Last night I took mg of or of alcohol as a sleep aid. (Include prescription, herbal, and overthe-counter sleep aids). Last night I went to bed at: Last night I turned out the lights to go to sleep at: It took about minutes to fall asleep. Last night I woke up times. I was awake minutes (total time of all awakenings). I woke up at this morning. I got out of bed for the day at this morning. I would rate the quality of my sleep: Very poor Fair Excellent How well rested did you feel upon rising today? Not at all Somewhat Well Rested Insomnia Severity Index Please refer to the Insomnia Severity Index located at Fs/InsomniaSeverityIndex.pdf Statistical Tests Paired sample t tests One way repeated measures ANOVAs Cohen s d Frequencies of responses on PSS Kurtz 6

7 Kurtz 7

8 Clinical Significance & Patient Satisfaction Effect sizes using Cohen s d WASO (d =.71) ISI score (d = 1.01) Medication reduction (d = 1.05) 91% rated all criteria as great or good Implications Lack of awareness Lack of CBT I practitioners Nurses are ideal providers of CBT I Training opportunities are needed Billing and reimbursement issues Research needed Provision Patient satisfaction Children and adolescents (Perlis, & Smith, 2008) Questions? Kurtz 8

9 References Edinger, J. D., & Carney, C. E. (2008). Overcoming insomnia: A cognitivebehavioral approach: Therapist guide. New York: Oxford University Press, Inc. Perlis, M. L., & Smith, M. T. (2008). How can we make CBT I and other BSM services more widely available? Journal of Clinical Sleep Medicine, 4(1), Perlis, M. L., Jungquist, C., Smith, M. T., & Posner, D. (2005). Cognitive behavioral treatment of insomnia: A session by session guide. New York: Springer Science+Business Media, LLC. Perlis, M. L., & Smith, M. T. (2008). How can we make CBT I and other BSM services more widely available? Journal of Clinical Sleep Medicine, 4(1), Smith, M. T., & Perlis, M. L. (2006). Who is a good candidate for cognitivebehavioral therapy for insomnia? Health Psychology, 25(1), Schutte Rodin, S., Broch, L., Buysse, D., Dorsey, C., & Sateia, M. (2008). Clinical guideline for the evaluation and management of chronic insomnia in adults. Journal of Clinical Sleep Medicine, 4, Kurtz 9