Critique of Article #1 The title of the article, “Psychological treatment of insomnia in hypnotic-dependent older adults”, by Soeffing et al. (2008), gives an accurate portrayal of the research topic, as the wording is very understandable. The title clearly identifies the intended population of older adults, as well as reveals the key independent variable of cognitive behavioral therapy that is suggested to affect the dependent variable of insomnia. The title encompasses the idea that the population of older adults who take hypnotics for insomnia will be exposed to some sort of psychological treatment. The abstract is well organized and summarizes the main sections of the study. It contains the most relevant and extensively used terms and ideas from the article. The problem statement of this study is clearly presented and identifies that insomnia is a condition that can have detrimental effects on many older adults, and therefore, Soeffing et al. (2008) found the importance in developing new interventions to improve insomnia in older adults who are habitual users of sleep medications. The purpose of this study seeks to evaluate whether the psychological treatment of cognitive behavioral therapy (CBT) will have an effect on older adults that suffer from insomnia and chronically use hypnotics. Many of these older adults are comfortable with their sleep medication regimen; however, introducing CBT as a second line of treatment could lead to further improvement of their sleeping patterns. Being that the prevalence of insomnia is higher among older adults than younger adults and is more serious, this study can only serve as beneficial if the hypothesis is proven to be true. The specific research hypothesis about the insomniac older adult benefiting from CBT is stated in the Introduction section. Appropriate wording is used to clearly specify the dependent variable of sleep and the independent variable of cognitive behavioral therapy; however, the investigators failed to identify their theoretical framework. Improving the sleeping patterns of older adults can not only improve daytime fatigue and reduce health care spending, but it can also improve quality of life. From a nursing perspective, improving a patient’s quality of life is an important aspect of caring for the whole patient. The review of literature performed by the investigators provided a background for understanding current knowledge on CBT and insomnia in older adults. Previous studies that were reviewed were predominantly primary sources, however, a systematic review from 2002 was also looked upon for this study. The primary sources that were reviewed were published between the years of 1993-2004, which indicates that some of the information examined is based upon dated sources. A lack of existing research regarding cognitive behavioral therapy effectiveness on older adults who chronically use hypnotics are clearly articulated in the introduction section and clarifies the significance for this research study. This research study used an experimental design in which older adults were randomly assigned to control and treatment group conditions. Because there was a masking of the outcome assessment, due to participants’ unawareness to which group they were in, the internal validity of the study is strengthened. The design of the study was appropriate for the hypothesis as knowledge was enhanced. A pre-test/post-test design was implemented, in which baseline data was gathered from all participants prior to the implementation of the CBT treatment to the experimental group. The intervention to the treatment group was adequately described and occurred during eight individual sessions, spaced about a week a part and consisted of three elements: relaxation, stimulus control, and sleep hygiene. The control group received a placebo-biofeedback treatment in which they believed their brain waves were being positively affected in regards to their sleeping patterns. Post-treatment assessments were measured by evaluating the dependent measures of the sleep variables after the CBT interventions had concluded. This study design serves as reliable for revealing the effects of the CBT intervention, which is the intention of the study. Intervention fidelity was demonstrated as the researchers followed an explicit decision making model to ensure that treatment was given appropriately. The therapists, who were advanced doctoral student in clinical psychology, conducted the treatment following a specific manual, as well as attended mock training sessions to ensure the integrity of the study. The sample was randomized, including forty-seven participants that were made known of the study by a newspaper announcement. Within the sample, 30 were women and 17 were men. The population for the study was clearly defined as “50 years or older, with chronic insomnia, and regularly using prescription sleep medication” (Soeffing et al., 2008). There was also a four-stage screening process, including a 20-minute phone screen, an in-person interview, a two-week sleep diary, and a polysomnographic assessment, that participants had to undergo to ensure that they would be appropriate for the study. The sampling design for this study appears to be well planned in how participants are to be selected, but is limited in how many to include. Unfortunately, the sample size was relatively small (n=47) and a larger amount of participants would have improved the study’s ability to take a closer look at specific variables, such as gender, race, ethnicity, and medication type, and how they impact insomnia in older adults. The researchers did not mention the use of a power analysis to help determine the necessary number of subjects needed for the study. This in itself indicates one of the limitations of this study as not every aspect was thought about thoroughly before data was collected. Participants were required to give written informed consent prior to taking part in the study; therefore, ensuring their rights were protected. An appropriate level of detail is given about the data collection procedure and measurements used in the study, including the measurements used during the screening process. There is also good congruency between the conceptual definition of the sleep variables discussed in the introduction of the study and the operational definition of sleep described in the methods section of the report. Demographic variables were also compared in regards to age, educational level, gender, and ethnicity. Participants were required to keep a sleep diary, in which there was a subjective assessment of the following sleep variables: sleep onset latency (SOL), number of awakenings (NWAK), wake time after sleep onset (WASO), total sleep time (TST), and sleep efficiency (SE). Outcome measures also included sleep quality rating index (SQR), five daytime function questionnaires, and the Medical Outcome Study Short Form Health Survey. The data from the sleep diaries, index, questionnaires and the survey were collected at two points during the study: pre- and post-treatment. There is some concern with the validity and reliability of the participants’ self-reports in the sleep diaries because of the subjective nature of the results and potential biases it may contain. It is possible the participants in the treatment group responded as they expected that the researchers would want them to. The data analysis of the study seems to be well thought out. Analysis of covariance (ANCOVA) was used to analyze and evaluate the values of the sleep variables during the baseline assessment and post-treatment assessment for both the experimental and control groups. ANCOVA was also used to analyze the daytime function variables. While a t-test was utilized when comparing the ages of participants, a chi-square test was used to evaluate the significance between genders of the group. With all the statistical tests, used values were reported clearly throughout the study using written context, as well as a single table. The results of the study were clearly presented, as well as consistent with the hypothesis that the intervention of cognitive behavioral therapy would produce improved outcomes to the treatment group of hypnotic older adults with insomnia. However, it was revealed that the control group actually reported lower levels of fatigue rather than the treatment group. The investigators were unclear as to why this result occurred. The table presented in the study was appropriately chosen and well organized. Data trends are illuminated and the results are educational and inclusive. Not only are the conclusions of this study based on the results and relate to the hypothesis, but investigators of the study elaborated on the significance of the findings and how older adults with insomnia that are chronically dependent on sleeping medications can benefit from CBT. It is also important to consider limitations within the study when considering its contributions. Limitations are identified in that the study sample is relatively small. A larger amount of participants would have allowed for further explanation from the effect of other variables of the study, such as gender, ethnicity, and pharmacology type. It is also mentioned that further studies should evaluate the objective measures of the sleeping patterns of the participants, instead of just obtaining subjective data. As stated earlier, primarily subjective data has a risk of potential biases. It would have also been beneficial to evaluate participants in a larger study, who had reduced the amount of hypnotic medications. This would help to evaluate the long-term effects of CBT on insomnia. Because the screening process was so rigorous, it is hard to generalize the intervention of CBT within the scope of the findings to the whole older adult community. The overall presentation and clarity of the article was well done. The quality of the study is sufficient to meet the criterion of scientific merit. The study design meets the core hypothesis, serves as a general resource for future studies, and it is feasible in its methods and results. The investigators are appropriately trained individuals with the experience needed to carry out such a study. Not only does this study have relevance to nursing but also the interventions mentioned are all possible for nurses to apply to their practice for older adult patients with insomnia. Nurses could perform these interventions without significant compromise or problems. Specific training in relaxation techniques should be acquired first by the nurses that will implement the intervention. Because there were no unfavorable experiences connected with any of the interventions and positive results were obtained, the benefits of the study outweigh the risks.

References

Soeffing, J.P., Lichstein, K.L., Nau, S.D., McCraw, C.S., Wilson, N.M., Aguillard, N., Et al. (2008). Psychological treatment of insomnia in hypnotic-dependent older Adults. Sleep Med. 9(2) 165-171.