Treating Sleep Problems in VA Adult Day Health Care

描述（由申请人提供）： 1999年的《退伍军人千年保健和福利法案》（《千年法案》）授权退伍军人事务部（VA）为退伍军人提供非机构性的长期护理。成人日间保健是这一系列长期保健服务的一个关键组成部分，在日间提供健康维护、康复服务和群体社会化。以前的研究表明，睡眠中断与老年人的不良功能结果有关。虽然我们发现ADHC患者的睡眠障碍发生率很高，但在常规临床护理中并没有得到解决，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，并与老年人的情绪、生活质量和健康状况的改善有关。 这项拟议研究的目的是评估在成人日间医疗保健（ADHC）背景下实施的非药物性睡眠干预计划（SIP）是否会显著改善自我报告和客观测量（通过腕动计）的睡眠质量，并评估治疗相关改善是否在6个月随访时得以维持。总共有70名60岁以上的退伍军人参加了至少一个月的VA ADHC计划。个人将被排除，如果他们：1）显示严重未经治疗的睡眠呼吸障碍的证据，需要立即转诊治疗（基于在家过夜呼吸监测，每小时记录>30次呼吸事件），2）不符合失眠症的诊断标准，或3）简易精神状态检查评分<20，提示中度至重度认知障碍，这将限制对干预措施的理解。干预将涉及4次治疗失眠的手动认知行为疗法（CBT-I），加上每天户外时间以增加暴露于强光下。该SIP将使用随机对照试验与70名退伍军人（每组35名）的仅信息对照条件进行比较。所有参与者将完成基线、治疗后和6个月的自我报告（问卷）和客观测量（腕动记录）睡眠的随访评估。将采用2（组）× 3（时间）混合模型方差分析检验研究假设。 据我们所知，这项研究将是第一个解决ADHC患者睡眠问题非药物治疗需求未得到满足的研究。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： 项目叙述拟议的工作是直接相关的退伍军人事务部的重点是高质量的非机构长期照顾老年退伍军人。成人日间保健（ADHC）是VA提供的非机构长期护理服务范围内的一个关键组成部分。这项研究将解决一个关键的健康问题，睡眠质量差，在VA ADHC的背景下。由于睡眠障碍已多次被证明有助于不良的健康结果，药物治疗可能会增加福尔斯和其他不良后果的风险，评价非药物干预措施在其他环境中显示出有效性，有很大的希望。这项研究的结果可以为正在进行的VA长期护理服务的重组提供信息，并提高VA 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.