Treating Sleep Problems in VA Adult Day Health Care

描述(由申请人提供)： 1999年《退伍军人千年保健和福利法》授权退伍军人事务部(退伍军人事务部)向退伍军人提供非机构长期护理。成人日间保健(ADHC)是一系列长期护理服务中一个重要组成部分，在白天以集体形式提供保健、康复服务和社交服务。以前的研究已经证明，睡眠障碍与老年人的功能结果不佳有关。虽然我们发现ADHC患者中睡眠障碍的发生率很高，但在常规临床护理中没有解决这个问题，治疗通常仅限于药物治疗。非药物干预已被证明在改善睡眠方面有效，并与老年人情绪、生活质量和健康的改善有关。这项拟议研究的目的是评估在成人日间保健(ADHC)的背景下提供的非药理学睡眠干预计划(SIP)是否会导致自我报告和客观测量(通过手腕活动记录仪)睡眠质量的显著改善，并评估与治疗相关的改善是否在6个月的随访中保持。共有70名60岁以上的退伍军人参加退伍军人管理局ADHC计划至少一个月。以下个人将被排除在外：1)有证据表明有严重的未经治疗的睡眠呼吸障碍，需要立即转诊治疗(基于在家过夜的呼吸监测，每小时记录30次呼吸事件)，2)不符合失眠障碍的诊断标准，或3)具有Mini-State检查分数&lt；20，表明中度至严重的认知障碍，这将限制对干预措施的理解。这项干预将包括针对失眠的4个疗程的手动认知行为疗法(CBT-I)，外加每天的户外时间，以增加对明亮光线的暴露。通过对70名退伍军人(每组35名)进行随机对照试验，将这一SIP与仅提供信息的对照条件进行比较。所有参与者将完成基线、治疗后和6个月的跟踪评估，对自我报告(问卷)和客观测量(手腕活动)睡眠进行评估。研究假设将用2(组)x3(时间)混合模型的方差分析进行检验。据我们所知，这项研究将是第一次解决ADHC患者睡眠问题的非药物治疗的未得到满足的需求。干预设计(例如，使用可由非心理学家提供的手动治疗)将有助于将其转化为常规护理并应用于其他类似的VA计划。 公共卫生相关性： 项目简介拟议的工作与退伍军人管理局对老年退伍军人的高质量非机构长期护理的关注直接相关。成人日间保健(ADHC)是退伍军人管理局提供的非机构长期护理服务中的一个关键组成部分。这项研究将在VA ADHC的背景下解决一个关键的健康问题，即睡眠质量差。由于睡眠障碍一再被证明会导致不良的健康结果，而且药物治疗可能会增加摔倒和其他不良后果的风险，因此评估在其他环境中被证明有效的非药物干预措施具有很大的前景。这项研究的发现可以为正在进行的退伍军人管理局长期护理服务的重组提供参考，并提高退伍军人管理局ADHC计划的质量和结果。

DESCRIPTION (provided by applicant): ABSTRACT The Veterans Millennium Health Care and Benefits Act (Millennium Act) of 1999 mandated the Department of Veterans Affairs (VA) to provide non-institutional long-term care to veterans. Adult Day Health Care (ADHC) is a key component of that spectrum of long-term care services, providing health maintenance, rehabilitation services and socialization in a group setting during daytime hours. Previous studies have demonstrated that sleep disruption is associated with poor functional outcomes among older adults. While we have found high rates of sleep disturbance among ADHC patients, it is not addressed within routine clinical care, and treatment is typically limited to medications. Nonpharmacological interventions have been shown to be effective in improving sleep and are associated with improvements in mood, quality of life and health among older adults. The aims of the proposed study are to evaluate whether a non-pharmacological Sleep Intervention Program (SIP), delivered in the context of adult day health care (ADHC), will lead to significant improvements in self-reported and objectively-measured (by wrist actigraphy) sleep quality and to evaluate whether treatment-related improvements are maintained at 6-months follow-up. A total of 70 veterans over age 60 who have been participating in a VA ADHC program for at least one month will be included. Individuals will be excluded if they: 1) show evidence of severe untreated sleep disordered breathing necessitating immediate referral for treatment (>30 respiratory events per hour of recording, based on at-home overnight respiratory monitoring), 2) do not meet diagnostic criteria for an insomnia disorder, or 3) have a Mini-Mental State Examination score <20 suggesting moderate-to-severe cognitive impairment that would limit comprehension of the intervention. The intervention will involve a 4-session manualized cognitive-behavioral therapy for insomnia (CBT-I), plus daily time outdoors to increase exposure to bright light. This SIP will be compared to an information-only control condition using a randomized, controlled trial with 70 veterans (35 per group). All participants will complete baseline, post-treatment and 6-month follow-up assessments of self-reported (questionnaire) and objectively-measured (wrist actigraphy) sleep. Study hypotheses will be tested with 2 (group) x3 (time) mixed model Analysis of Variance. To our knowledge, this study would be the first to address the unmet need for non-pharmacological treatment of sleep problems among ADHC patients. The intervention design (e.g., use of a manualized treatment that can be provided by non-psychologists) will facilitate translation into routine care and application in other similar VA programs. PUBLIC HEALTH RELEVANCE: PROJECT NARRATIVE The proposed work is directly relevant to the VA's focus on high-quality non-institutional long-term care for older veterans. Adult Day Health Care (ADHC) is a key component within the spectrum of non-institutional long-term care services offered by VA. This study will address a key health concern, poor sleep quality, in the context of VA ADHC. Since sleep disturbance has repeatedly been shown to contribute to poor health outcomes, and pharmacological treatments may increase risk of falls and other adverse consequences, evaluating nonpharmacological interventions shown to be effective in other settings has great promise. Findings from this study can inform ongoing re-organization of VA long-term care services, and enhance the quality and outcomes of VA ADHC programs.