No abstract

OBJECTIVES To assess whether older persons with osteoarthritis (OA) pain and insomnia receiving cognitive–behavioral therapy for pain and insomnia (CBT-PI), a cognitive–behavioral pain coping skills intervention (CBT-P), and an education-only control (EOC) differed in sleep and pain outcomes. DESIGN Double-blind, cluster-randomized controlled trial with 9-month follow-up. SETTING Group Health and University of Washington, 2009 to 2011. PARTICIPANTS Three hundred sixty-seven older adults with OA pain and insomnia. INTERVENTIONS Six weekly group sessions of CBT-PI, CBT-P, or EOC delivered in participants’ primary care clinics. MEASUREMENTS Primary outcomes were insomnia severity and pain severity. Secondary outcomes were actigraphically measured sleep efficiency and arthritis symptoms. RESULTS CBT-PI reduced insomnia severity (score range 0–28) more than EOC (adjusted mean difference = −1.89, 95% confidence interval = −2.83 to −0.96; P < .001) and CBT-P (adjusted mean difference = −2.03, 95% CI = −3.01 to −1.04; P < .001) and improved sleep efficiency (score range 0−100) more than EOC (adjusted mean difference = 2.64, 95% CI = 0.44−4.84; P = .02). CBT-P did not improve insomnia severity more than EOC, but improved sleep efficiency (adjusted mean difference = 2.91, 95% CI = 0.85−4.97; P = .006). Pain severity and arthritis symptoms did not differ between the three arms. A planned analysis in participants with severe baseline pain revealed similar results. CONCLUSION Over 9 months, CBT of insomnia was effective for older adults with OA pain and insomnia. The addition of CBT for insomnia to CBT for pain alone improved outcomes. J Am Geriatr Soc 2013.

Cognitive-behavioral therapy (CBT) is believed to improve chronic pain problems by decreasing patient catastrophizing and increasing patient self-efficacy for managing pain. Mindfulness-based stress reduction (MBSR) is believed to benefit chronic pain patients by increasing mindfulness and pain acceptance. However, little is known about how these therapeutic mechanism variables relate to each other or whether they are differentially impacted by MBSR versus CBT. In a randomized controlled trial comparing MBSR, CBT, and usual care (UC) for adults aged 20-70 years with chronic low back pain (CLBP) (N = 342), we examined (1) baseline relationships among measures of catastrophizing, self-efficacy, acceptance, and mindfulness; and (2) changes on these measures in the 3 treatment groups. At baseline, catastrophizing was associated negatively with self-efficacy, acceptance, and 3 aspects of mindfulness (non-reactivity, non-judging, and acting with awareness; all P-values <0.01). Acceptance was associated positively with self-efficacy (P < 0.01) and mindfulness (P-values < 0.05) measures. Catastrophizing decreased slightly more post-treatment with MBSR than with CBT or UC (omnibus P = 0.002). Both treatments were effective compared with UC in decreasing catastrophizing at 52 weeks (omnibus P = 0.001). In both the entire randomized sample and the sub-sample of participants who attended ≥6 of the 8 MBSR or CBT sessions, differences between MBSR and CBT at up to 52 weeks were few, small in size, and of questionable clinical meaningfulness. The results indicate overlap across measures of catastrophizing, self-efficacy, acceptance, and mindfulness, and similar effects of MBSR and CBT on these measures among individuals with CLBP.

National Clinical Trial Number NCT02286141.

The population of persons living with HIV (PLWH) is growing older and more prone to developing other chronic health conditions. Disease progression has been shown to be related to quality of life. However, descriptions of chronic comorbid illnesses and the unique quality of life challenges of older adults living with HIV are not well understood and have not been examined in multiple geographic locations. 452 PLWH aged 50 years or older were recruited from AIDS Service Organizations in 9 states. Participants completed a telephone survey that included measures of other chronic health conditions, perceived stress, depression and health related quality of life. 94% of the sample reported a chronic health condition in addition to HIV (mode = 2). The highest reported conditions were hypertension, chronic pain, hepatitis, and arthritis. Despite relatively high rates of depression, overall quality of life was moderately high for the sample. Physical functioning was most impacted by the addition of other chronic health problems. Social functioning, mental health functioning, stress and depression were also strongly associated with chronic disease burden. Additional chronic health problems are the norm for PLWH aged 50 years and older. Quality of life is significantly related to the addition of chronic health problems. As increasing numbers of PLWH reach older age, this raises challenges for providing comprehensive healthcare to older PLWH with multiple chronic conditions.