Efficacy of Cognitive Behavioral Therapy for Insomnia in Geriatric Primary Care Patients

Gregory A. Hinrichsen PhD; Rosanne M. Leipzig MD, PhD


J Am Geriatr Soc. 2021;69(10):2993-2995. 

In This Article


Patient Population

Subjects were patients of the Icahn School of Medicine at Mount Sinai geriatric primary care practice who, during the years 2015–2018, were referred by their geriatrician to GAH, a clinical geropsychologist, for assessment of insomnia and treatment with CBT-I. The practice has 4500 patients whose median age was 85 years. Thirty-four referred patients were judged appropriate for CBT-I because they met the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for insomnia, did not have other sleep disorders (including apnea), were cognitively intact, and were interested in taking part in the treatment. Of the 34 patients, 29 (85%) who began CBT-I completed it.


CBT-I was guided by the treatment manual, Cognitive Behavioral Treatment of Insomnia: A Session-by-Session Guide.[6] Participants had an initial evaluation and then 1–2 weeks of baseline sleep diary data were completed and reviewed. After this, the mean number of CBT-I sessions was 6.1 (SD = 3.3, median = 5). Typically, treatment was ended when the patient evidenced 2 weeks of sustained improvement based on sleep diaries. Some patients had lengthier treatment because they did not evidence sustained improvement, were not satisfied with the degree of improvement, and/or a plateau was reached. This pre- and post-treatment study of clinical records was approved by the Icahn School of Medicine at Mount Sinai IRB.


Demographic and medical date were gleaned from the electronic medical record (EMR). Four validated instruments, the Patient Health Questionnaire (PHQ-9),[7] a 9-item depression screen, the Generalized Anxiety Disorder 7-item scale (GAD-7),[8] an anxiety screen, the Insomnia Severity Index (ISI),[9] a commonly used patient report of insomnia severity, and the Epworth Sleepiness Scale (ESS),[10] a patient report measure of daytime sleepiness, were administered to each patient at the initial interview and completion of CBT-I. Sleep diaries yielded continuous data on sleep onset latency (SOL; minutes to fall asleep), wake after sleep onset (WASO; minutes awake after falling asleep), early morning awakening (EMA; minutes awake earlier than intended), total sleep time (TST), and sleep efficiency (the percentage of intended sleep time actually slept).

Data Analysis

Only those 29 patients who completed a full course of CBT-I were included in pre–post analyses where sleep parameters, PHQ-9 (without the sleep item, hence renamed PHQ-8), GAD-7, ISI, and ESS differences, were compared using paired t tests. The magnitude of the effect size of these outcomes was estimated using Cohen's d (Table 1).