An integrated behavioral treatment for improving nocturia and insomnia symptoms in older adults (MINT): study protocol for a multi-site randomized clinical trial

Trials · 2026-02-16

BACKGROUND: Nocturia (i.e., waking to void during the primary sleep period) of two or more times per night affects nearly one-third of older adults and can have a severe impact on sleep, contributing to insomnia symptoms. Current treatment approaches for nocturia often overlook non-lower urinary tract factors that may contribute to nighttime awakenings. Nocturia management, for example, may benefit from more effective integration of cognitive behavioral therapy for insomnia (CBT-I) principles that address other factors underlying insomnia symptoms, and early evidence suggests it also reduces nocturia and the bother it causes. Because nocturia treatment crosses specialties, coordinated delivery of urological and sleep therapies is a treatment barrier. The overall purpose of this trial is to determine whether a promising coordinated, integrated behavioral, non-pharmacological, non-surgical treatment that simultaneously addresses both the urological and insomnia factors contributing to nocturia is efficacious for improving nocturia, sleep, and daytime function. METHODS: This multicenter parallel-group randomized, efficacy trial compares a 5-week integrated behavioral treatment program delivered by a single interventionist (psychologist, nurse practitioner, or physician assistant) to a health education control program in adults aged 60 years or older (proposed n = 192) recruited from sites in Atlanta and Los Angeles, who report typically getting up to urinate two or more times per night (International Consultation on Incontinence Questionnaire-Overactive bladder [ICIQ-OAB] nocturia item) and insomnia symptoms (Insomnia Severity Index > 7). The integrated program includes components of CBT-I and pelvic floor muscle exercise-based behavioral therapy for nocturia. The primary outcome is ICIQ-OAB-measured nocturia frequency 4 months after randomization. Secondary outcomes are sleep diary-measured wake after sleep onset (mean minutes) and Insomnia Severity Index total score. DISCUSSION: The interdisciplinary trial team has developed a program aimed at improving nocturia symptoms and overall sleep of older adults in an efficient and safe manner. The integrated behavioral program has the potential to address nocturia, which is a challenging symptom because it has many etiologies that cross multiple specialties. Findings will provide rigorous evidence of the efficacy of the integrated behavioral treatment program to reduce nocturia frequency as well as sleep disturbance in older adults. TRIAL REGISTRATION: Clinicaltrials.gov NCT06110091, registered 10/25/2023.

Experiential Avoidance is Associated with Insomnia Symptoms and Related Consequences Among Veterans with Posttraumatic Stress Disorder

Behavioral Sleep Medicine · 2026-04-15

OBJECTIVES: Experiential avoidance is the unwillingness to come into contact with aversive internal experiences. Trauma exposure is associated with greater experiential avoidance and insomnia symptoms. Experiential avoidance may perpetuate insomnia symptoms in patients with posttraumatic stress disorder (PTSD). We examined the relationship between experiential avoidance and insomnia symptoms among veterans with PTSD (based on the Clinician-Administered PTSD Scale for DSM-5). METHOD: = 54.7 years; 86.0% male) who attributed their sleep disturbance onset to experiences of trauma on the CAPS-5. Experiential avoidance, insomnia, sleep disturbance, daytime sleepiness, and daytime consequences were measured with the Brief Experiential Avoidance Questionnaire (BEAQ), Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and International Classification of Sleep Disorders (ICSD) items. We conducted multiple linear regressions with age, sex, and BEAQ as the independent variables and sleep variables as the dependent variables. RESULTS: There were significant positive associations between the BEAQ and the ISI, PSQI daily disturbance factor, ESS, and ICSD daytime consequences. CONCLUSIONS: Greater experiential avoidance was associated with worse insomnia symptoms and consequences, particularly daytime dysfunction. Experiential avoidance may be an overlooked, but relevant treatment target for patients with comorbid insomnia and PTSD.

Perceived Pain Following Hypnotic Deprescribing in Older Adults

Journal of the American Geriatrics Society · 2026-01-10

BACKGROUND: Older adults with chronic insomnia often use benzodiazepine receptor agonists (BZRAs) despite known associated risks and non-pharmacological alternatives such as cognitive behavioral therapy for insomnia (CBTI). CBTI reduces insomnia severity and could potentially improve other outcomes such as the impact of pain on daily activities, even when BZRAs are deprescribed. Yet concerns that deprescribing may worsen pain (which is often comorbid with insomnia) can be a barrier to engagement in BZRA deprescribing. This study examined changes in pain outcomes associated with deprescribing BZRAs in the context of concurrent CBTI. METHODS: Secondary data analysis was conducted using data from a randomized clinical trial that successfully decreased BZRA use in older adults. Participants (n = 188), who were largely older (68% ≥ 65 years, 55 ≤ range ≤ 91) and male (65%), completed CBTI concurrently with a deprescribing intervention (blinded encapsulated BZRA taper or open pill cutter taper). Participants completed the Brief Pain Inventory (BPI) at baseline, one week posttreatment (1 WK), and at a six-month (6 M) follow-up. Analyses included mixed effects models among all participants and a subset aged 65+ as well as comparison of model results to minimal clinically important difference (MCID) thresholds. RESULTS: Mixed effects models demonstrated that pain severity did not change significantly over time, broadly or in participants aged ≥ 65 years. Significant reductions in pain interference in day-to-day living at 1 WK were observed broadly, although these reductions did not meet the MCID threshold and were no longer significant at 6 M follow-up. CONCLUSIONS: Combined BZRA deprescribing and CBTI did not meaningfully worsen pain in older adults. These results highlight the opportunity for using a combination of CBTI and deprescribing methods in patients with insomnia and comorbid pain, as well as a need for additional interventions to specifically address pain in older adults with chronic insomnia.

0746 Values Expressed by Women Veterans Initiating Treatment for Sleep Apnea

SLEEP · 2025-05-01

Abstract Introduction Women with sleep apnea report poorer sleep and have lower positive airway pressure (PAP) adherence rates than men. Within the Veterans Health Administration, there is a movement toward a Whole Health approach to care, shifting the focus from “what’s the matter with the patient” to “what matters to the patient.” We asked women veterans initiating sleep apnea treatment to describe their personal values and the impact of sleep apnea on these values. Methods Within a larger randomized controlled trial (NCT03377452), 44 women veterans (mean age = 53.7 years; 65.9% White, 34.1% married, 47.7% employed) diagnosed with sleep apnea were randomly assigned to a behavioral treatment for sleep apnea called “Acceptance and the Behavioral Changes to Treat Sleep Apnea” (ABC-SA; compared to an education control condition). In the first ABC-SA session, participants were asked to “list three of the things you most care about in your life” (i.e., values) and “the ways having sleep apnea impacts what you care about most” (i.e., impacts). Value and impact responses were coded into five categories with 100% agreement among three raters after independent coding and adjudication: work/education, relationships, personal care/health, leisure, and pets. Values were further coded into 14 subcategories based on the Valued Living Questionnaire. Results The frequencies of value and impact categories were: relationships (value n = 40; impact n = 25), personal care/health (value n = 39; impact n = 43), work/education (value n = 22; impact n = 11), leisure (value n = 13; impact n = 12), and pets (value n = 7; impact n = 2). The most frequently endorsed value subcategories were physical health (n = 32), family (other than marriage/parenting; n = 30), and friends/social life (n = 20). Conclusion Health and relationships are highly important to women veterans with sleep apnea. Research has focused on the health benefits of PAP, but fewer studies have explored interpersonal factors. The perceived impacts of PAP on relationships may serve as a barrier and/or motivator of PAP use. Support (if any) VA HSR IIR 16-244, VA RCS-20-191, NIH/NHLBI K24 HL143055 (Martin); VA CDA 20-227 (Carlson); NIH/NHLBI K23HL157754 (Kelly); VAGLAHS GRECC CSHIIP

0527 Differences in Subjective and Objective Measures of Sleep by Marital Status in a Sample of US Veterans

SLEEP · 2025-05-01

Abstract Introduction Marriage confers a degree of benefit for a range of health factors, including sleep behaviors and outcomes. Veterans are more likely to report sleep difficulties (e.g., insomnia) and have less social support than the general population. As such, it is important to examine associations between marital status and the occurrence of sleep issues among veterans. Methods This study utilizes baseline visit data from veterans in Los Angeles reporting sleep concerns who were enrolled across four structured cognitive behavioral therapy for insomnia intervention trials. Measures included the Pittsburgh Sleep Quality Index (PSQI) total and factor scores, Insomnia Severity Index (ISI), sleep efficiency (measured with actigraphy), and the Patient Health Questionnaire (PHQ-9). Overall, 1,411 veterans had available data (74.1% male; mean age: 63.4 years; 43.3% married/living as married, 21.9% separated, 17.0% single/never married, 10.5% divorced, 7.2% widowed). Multilevel models were constructed to evaluate associations between marital status and sleep measures after controlling for sex, age, and depressive symptoms. Individuals were nested within the four different sleep trials and “married” served as the reference group. Results Multilevel modeling showed that separated individuals had scores indicative of worse sleep compared to married individuals (PSQI total score: β = 0.18, p <.01, N = 1,181; PSQI Sleep Efficiency factor score: β = 0.18, p =.017, N = 1,188; sleep efficiency per actigraphy: β = -0.23, p = 0.014, N = 845). Differences by marital status were not found for the PSQI Perceived Sleep Quality factor, PSQI Daily Disturbances factor, or ISI. Divorced, widowed, and single/never married compared to married did not show differences for any of the sleep measure outcomes. Conclusion Using cross-sectional data, we found that veterans who are separated have more severe sleep concerns compared to veterans who are married/living as married. Given this difference, separated veterans may represent a group that are particularly at-risk for sleep difficulties and they may benefit from evaluation of sleep concerns and management of sleep disorders. Findings align with past work showing that marital status can impact measures of health. Support (if any) VA OAA (Gold); VA SWI 24-001, VA OAA (Erickson), RCS-20-191, NIH K24 HL143055 (Martin); VAGLAHS CSHIIP and GRECC

Insomnia Symptom Improvement as a Mediator for Mental Health Symptom Reduction Following Behavioral Insomnia Treatment Among Women Veterans

Behavior Therapy · 2025-02-20

Feasibility of cognitive testing and ecological momentary assessments using smartphones in middle aged and older adults with insomnia

BMC Digital Health · 2025-06-30 · 3 citations

Background: Older adults with insomnia who use benzodiazepine receptor agonists (BZAs) may be at increased risk of cognitive impairment. Cognitive testing outside of clinical settings may yield results that are more reflective of individuals' cognition in their natural environment, where they experience fluctuations in mental state (e.g. drowsiness). We assessed the feasibility of self-administered cognitive testing via smartphone apps for collecting in-moment, in-context data about a person's current state (ecological momentary assessment, EMA). Methods: = 20; median age 66 years; 14 females, 18 white) aged ≥ 55 years who were recruited from a BZA deprescribing trial were invited to complete (over a 28 day period) daily drowsiness assessments on an EMA app (cued by smartwatch alerts) and weekly self-administered digit span (DGS) forward/backward (2 [minimum] - 9 [maximum]), verbal paired associates (VPA; 0 [best]-24 [worst] total errors), and cued delayed recall of VPA (VPA-DR; 0 [best] - 8 [worst] errors) tests on a cognitive app. We assessed the completion of EMA (0-28 days) and cognitive sessions (# of participants per # sessions completed). We performed thematic analysis of the participant interviews. Results: The median number of days that EMA was completed was 24.5. Twelve (60%) individuals participated in 4 sessions; 2 (10%) individuals participated in 3 sessions; 2 (10%) individuals participated in 2 sessions; and 4 (20%) individuals participated in 1 session. No drowsiness was reported 36% of the time, whereas 38% of the responses reflected feeling "a little bit" drowsy and 26% at least "somewhat" drowsy. Mean cognitive test scores were DGS-Forward = 7 (SD 1.3), DGS-Backward = 5.6 (SD 1.0), VPA total errors = 9.9 (SD 3.7), and VPA-DR = 2.2 (SD 1.9). Three themes emerged from the participant interviews: 1) concern for one's own cognitive abilities, 2) strategies employed for optimizing scores (including strategies that would invalidate results), and 3) ease of use of the applications. Conclusions: Our findings indicate that mobile cognitive tests and EMAs are feasible in this older population. Further work is needed to understand how scores are influenced by the setting, mood, and behaviors. Supplementary Information: The online version contains supplementary material available at 10.1186/s44247-025-00158-4.

0733 Insomnia Severity Predicts Increased PAP Side Effects and Use in Women Veterans with Newly Diagnosed Apnea

SLEEP · 2025-05-01

Abstract Introduction Despite positive airway pressure (PAP) being the gold-standard treatment for sleep disordered breathing (SDB), treatment adherence remains a challenge for providers and patients. Women with SDB are understudied, and understanding the difficulties associated with PAP use in this population is crucial to promoting treatment adherence. We aimed to assess the role of demographics and insomnia symptoms in PAP side effects and PAP use for women veterans. Methods We analyzed data from a randomized controlled trial of an Acceptance and Commitment Therapy-based intervention to promote PAP adherence vs. a sleep education control condition for women veterans newly diagnosed with SDB (NCT03377452). Data included demographics (age; body mass index, BMI; race/ethnicity), baseline assessment Insomnia Severity Index (ISI), PAP use data (days used, hours used at 30-, 60- and 90-days post-PAP initiation), and the PAP side effects subscale of the Calgary Sleep Apnea Quality of Life Index (SAQLI). Analyses included Pearson correlations and t-tests. Results Of the 90 participants (Mean age = 53.2±12.8), 83 (92.2%) attempted to use PAP and completed the questionnaires. The most common PAP side effects included: upper respiratory symptoms (stuffed/congested nose = 60.2%, excessive dryness of nose/throat = 55.4%, soreness = 39.8%), mask-related issues (discomfort = 56.6%, air leak =47.0%) and insomnia-like symptoms (waking frequently = 36.6%, difficulty returning to sleep = 31.3%). There was no relationship between age, BMI, or race/ethnicity and number of PAP-related side effects, nor was there a correlation between number of PAP side effects and PAP use variables. Elevated ISI prior to initiating PAP was associated with greater number of PAP side effects, F(1, 81)=5.29, p=0.02. Worse ISI was associated with fewer days of PAP use at 90 days post-PAP initiation, F(1, 88)=4.55, p=0.04. Conclusion Insomnia symptom severity prior to initiating PAP treatment for SDB is a significant contributing factor to increased endorsement of PAP-related side effects. Pre-existing insomnia symptoms prior to PAP initiation may play a role in fewer days of PAP use in the long term. Future research should explore the impact of insomnia treatment in PAP side effects and use in women. Support (if any) VA/HSR IIR-16-244; VA/HSR RCS20-191; NIH/NHLBI K24HL143055; NIH/NHLBI K23HL157754; VA/HSR CDA 20-227

Is a good night’s sleep one of the keys to successful aging?

SLEEP · 2025-03-23

0959 Association Between Inflammatory Markers and Sleep Quality in Family Caregivers of People Living with Dementia

SLEEP · 2025-05-01

Abstract Introduction Family caregivers of adults with dementia often report poor sleep quality due to the demands of caregiving. Poor sleep, due to shorter sleep duration and/or disturbed sleep, has been linked to inflammatory processes. Previous research has identified elevated levels of C-reactive protein (CRP), tumor necrosis factor alpha (TNF-□), and interleukin-6 (IL-6) as significant markers of poor sleep. Additionally, interleukin-10 (IL-10) and interferon-gamma (IFN-□) are involved in inflammatory processes that may impact sleep but have not been evaluated in caregivers. This pilot study aimed to examine the relationship between sleep quality and inflammatory markers in family caregivers of people living with dementia (PLWD). Methods Data were collected from 18 caregivers enrolled in a dyadic behavioral sleep study involving PLWD and their family caregivers (NCT05102565). Plasma samples from caregivers were analyzed for inflammatory markers, including CRP, IL-6, IL-10, TNF-□, and IFN-□. The Pittsburgh Sleep Quality Index (PSQI) global score was used to assess sleep quality. Spearman correlations coefficients (□) were calculated, with a significance threshold of p < 0.20, given the pilot nature of the study. Results Among the 18 caregivers, the mean PSQI score was 6.6□ 3.6. IL-6 showed a slight positive correlation with the PSQI score (□ □ =0.18, p=0.025). Both IL-10 and IFN-□ were significantly associated with PSQI global scores (□ □ =0.28, p=0.03 for IL-10 and □ □ =0.27, p=0.001 for IFN-□). CRP levels showed a minimum positive correlation with the PSQI score (□=0.07, p=0.19). A slight negative correlation was observed between PSQI scores and TNF-□ □ levels (□=-0.10, p< 0.01). Conclusion In this pilot study, higher PSQI scores were associated with elevated levels of IL-6, IL-10, IFN-□, and CRP levels, suggesting a link between poor sleep quality and increased immune and inflammatory marker levers in caregivers. The negative correlation observed between PSQI and TNF-□ is contrary to what is noted in literature reviews; however, this is due to the small sample size. Larger studies are needed to confirm these findings and further explore the health implications of poor sleep among caregivers of PLWD. Support (if any) This study was supported by National Institute on Aging (K23AG055668, Song) and VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center.