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)相关疾病 睡眠障碍。失眠与对功能、情绪、 和医疗资源利用。失眠的认知行为疗法(CBT-I)是证据- 以此为基础，并已被证明在患有各种并存疾病的人群中有效 病情包括与骨性关节炎相关的慢性疼痛。然而，面对面的CBT干预是不可能的 可广泛部署在医疗保健系统中。电话递送的好处是 患者可以从家里获得个性化、有效的CBT-I干预，增加 概括性，以及对少数族裔、农村和其他服务不足的人群的推广。上一首 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 随机试验已经评估了它的长期疗效，对初选患者相关结局的影响 护理患者群体，或成本效益。这项建议是建立在我们成功的基础上的 CBT治疗老年人失眠的两项随机试验：生活方式试验 患有骨性关节炎相关失眠和疼痛的老年人的CBT组，以及MsFLASH04，一项关于 CBT-I电话治疗伴有血管舒缩症状的绝经妇女失眠。更老的 (60岁)华盛顿州的初级保健患者将接受严重持续性筛查 与骨性关节炎相关的失眠和疼痛。270名患者将随机分为两组 CBT-I或仅限教育的注意力控制(EOC)。每个疗程由6个20-30人组成 在八周的时间里，通过电话进行分钟的会议。治疗前、治疗后(2 月)，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估。我们 假设：1)CBT-I将在以下方面产生更大的初步和长期改善 睡眠结果相对于EOC；2)CBT-I将产生显著更多的初始和长期 与EOC相比，疼痛、疲劳和情绪的改善；以及3)CBT-I将产生长期的 与EOC相比，降低了医疗保健利用率和成本。我们还将探索是否 失眠严重程度的变化解释了CBT-I对二次结局的观察效果 (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(调节因素分析)。这项拟议的研究将确定 电话CBT-I在全州范围的初级保健中改善OA失眠和相关结果 老年人人口，并为政策决策提供关于广泛传播艾滋病的信息 在该患者及相关患者群体中使用电话CBT-I。

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.