Web-based CBT for Insomnia in Rural Dementia Caregivers: Examination of Sleep, Arousal, Mood, Cognitive, and Immune Outcomes

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PROJECT SUMMARY Compared to their urban counterparts, rural family dementia caregivers (CGs) face increased vulnerability to insomnia and related health concerns (stress, inflammation, depression, anxiety, cognitive disturbance). Cognitive behavioral treatment for insomnia (CBT-I) holds promise for improving insomnia and these related concerns, but is difficult to access in rural areas. Our team developed brief telehealth CBT-I (tele bCBT-I) tailored for CGs (e.g., includes stress management/problem solving) that improved sleep, arousal, mood, cognition and inflammation (small to large effects). While telehealth improves accessibility, it is still burdensome for CGs due to inflexible scheduling and scarcity of trained therapists. Thus, more research is needed. Web delivery would increase access and web CBT-I is efficacious in non-CG adults, but has not been tested in rural CGs. Using the NIH Stage Model flexible framework and Medical Research Council recommendations, we developed NiteCAPP (web translation of our tele bCBT-I protocol). Stage IA/B validation and testing show high feasibility and acceptability, and improvements in sleep, arousal, mood, burden and cognition in a single arm pilot in rural CGs (n=5). The proposed trial is the next logical step - Stage II testing in an RCT (n=100) to establish efficacy and further evaluate feasibility and acceptability. The Cognitive Activation Theory of Stress provides a framework for our basic premise that CGs experience insomnia, arousal and inflammation that prompt sympathetic activation and hypothalamic-pituitary-adrenal (HPA) disruption that have downstream negative effects on health. The proposed trial tests the novel hypothesis that NiteCAPP will improve CG health, mood, burden and cognition by targeting their shared underlying mechanisms – sleep, arousal and inflammation – thereby, returning sympathetic and HPA functioning to normal. Another novel aspect of the proposed trial is inclusion of behavioral strategies to target the person with dementia’s (PWD) sleep. Outcomes will be assessed at baseline, post-treatment and two follow-ups (6 and 12 months) and include CG sleep, arousal, inflammation, health, mood, burden and cognition, and PWD sleep. The proposed study has four specific aims. Aim 1 focuses on the feasibility and acceptability of NiteCAPP and WebSHE (sleep hygiene education – active web comparator). Aims 2 and 3 examine NiteCAPP’s effects (versus WebSHE) on CG primary/mechanistic (sleep, arousal, inflammation) and secondary outcomes (health, mood, burden, cognition), respectively. Because the PWD’s sleep impacts CG sleep, Aim 4 examines NiteCAPP’s secondary effects on PWD sleep (objectively assessed). An Exploratory Aim examines the relationships between changes in CG primary and secondary outcomes, and their potential mediators/ moderators. Public Health Implications: Demonstration that rural CGs can use NiteCAPP to target sleep, arousal/stress, inflammation and related health concerns has important implications for multiple stakeholders, including rural CGs, rural PWDs, their families, clinicians and policymakers.