Efficacy of Scalable CBT for Insomnia in Older Adults with Osteoarthritis Pain

25%的老年人患有严重的骨关节炎（OA）相关共病 睡眠障碍冲动与对功能，情绪， 医疗资源利用。失眠的认知行为疗法（CBT-I）是证据- 并已被证明是有效的人群与各种共病 包括OA相关的慢性疼痛。然而，面对面的CBT干预是不可能的。 可以广泛应用于医疗系统。电话投递的优点是 患者从家中获得个性化的，有效的CBT-I干预措施， 普及性，以及向少数民族、农村和其他得不到充分服务的人口的推广。先前 电话CBT-I的小型试验报告了积极的失眠结果，但没有大规模的 随机试验已经评估了其长期疗效，对原发性高血压相关结局的影响， 护理患者群体或成本效益。这项建议建立在我们成功的基础上。 完成两项老年人失眠症CBT随机试验：生活方式，一项关于 在患有OA相关失眠和疼痛的老年人中进行的CBT组，以及MsFLASH 04，一项 电话CBT-I治疗合并血管痉挛症状绝经期妇女失眠症老年 (60将对华盛顿州的20名（+岁）初级保健患者进行重度持续性 OA相关的失眠和疼痛。270例患者将随机分配至 CBT-I或仅教育注意力控制（EOC）。每次治疗将包括6个20-30 在八周的时间里进行了几分钟的电话会议。预处理、后处理（2 9个月和18个月的评估将包括睡眠，疼痛，疲劳，情绪， 和生活质量。还将对干预措施进行成本效益评价。我们 假设：1）CBT-I将在以下方面产生显著更大的初始和长期改善： 睡眠结果相对于EOC; 2）CBT-I将产生显着更大的初始和长期 与EOC相比，疼痛、疲劳和情绪改善; 3）CBT-I将产生长期的 与平等机会委员会相比，卫生保健利用率和成本降低。我们还将探讨 失眠严重程度的变化解释了CBT-I对次要结局的观察效果 （中介分析），以及CBT-I对失眠的影响是否因基线失眠、疼痛或 抑郁症状严重程度（调节剂分析）。这项研究将确定， 电话CBT-I改善了OA失眠和全州初级保健的相关结果 老年人，并为广泛传播 电话CBT-I在这个和相关的患者人群。

Twenty-five percent of older adults experience significant osteoarthritis (OA)-related comorbid sleep disturbance. Insomnia is associated with substantial negative effects on function, mood, and medical resource utilization. Cognitive behavioral therapy for insomnia (CBT-I) is evidence- based and has been shown to be efficacious in populations with a variety of comorbid conditions including OA-related chronic pain. However, in-person CBT interventions are unlikely to be widely deployable in healthcare systems. Telephone delivery has the advantage of giving patients access to personalized, efficacious CBT-I interventions from home, increasing generalizability, and outreach to minority, rural, and other underserved populations. Previous small trials of telephone CBT-I have reported positive insomnia outcomes, but no large randomized trials have assessed its long-term efficacy, impact on related outcomes in a primary care patient population, or cost-effectiveness. This proposal builds upon our successful completion of two randomized trials of CBT for insomnia with older adults: Lifestyles, a trial of group CBT in older adults with OA-related insomnia and pain, and MsFLASH04, a trial of telephone CBT-I for insomnia in menopausal women with comorbid vasomotor symptoms. Older (60+ yrs) primary care patients across Washington State will be screened for severe persistent OA-related insomnia and pain. Two hundred and seventy patients will be randomized to either CBT-I or an education only attention control (EOC). Each treatment will consist of six 20-30 minute telephone-based sessions over an eight week period. Pre-treatment, post-treatment (2 months), and 9 and 18 month assessments will include measures of sleep, pain, fatigue, mood, and quality of life. A cost effectiveness evaluation of the intervention will also be conducted. We hypothesize: 1) CBT-I will produce significantly greater initial and long-term improvements in sleep outcomes relative to EOC; 2) CBT-I will produce significantly greater initial and long-term improvements in pain, fatigue and mood relative to EOC; and 3) CBT-I will produce long-term reductions in health care utilization and costs relative to EOC. We will also explore whether changes in insomnia severity explain observed effects of CBT-I on secondary outcomes (mediator analysis), and whether CBT-I effects on insomnia differ by baseline insomnia, pain, or depression symptom severity (moderator analysis). The proposed research will determine if telephone CBT-I improves OA insomnia and associated outcomes in a state-wide primary care population of older adults, and inform policy decisions about widespread dissemination of telephone CBT-I in this and related patient populations.