Insomnia is common in people with chronic heart failure (HF), affecting up to 75% of patients and often resulting in excessive daytime sleepiness, depression and anxiety, fatigue, and exacerbation of heart failure symptoms. Research has explored possible interventions to help combat insomnia in this population, but thus far studies haven’t been extensive enough to have a significant impact.
Now, the journal Sleep has published the results of the HeartSleep study by an interdisciplinary team from Yale School of Medicine, and led by Principal Investigator Nancy Redeker from Yale School of Nursing and researchers from the Section of Pulmonary, Critical Care & Sleep Medicine (Yale-PCCSM) and the Yale Centers for Sleep Medicine, a center of excellence. The study was funded by the National Institutes of Health and examined the sustained effects of Cognitive Behavioral Therapy for Insomnia (CBT-I) versus a behavioral self-management program and found that CBT-I was more effective than standard heart failure self-management education in treating insomnia in people with heart failure.
“We are the first to show the sustained effects at one year of CBT-I on insomnia, fatigue, and function,” said Nancy Redeker, RN, MSN, PhD, first author and Principal Investigator of the study. “These are important outcomes to heart failure patients.” Redeker is the Beatrice Renfield Term Professor of Nursing and Professor of Medicine (pulmonary) and director of the Center for Biobehavioral Health Research, Yale School of Nursing.
CBT-I is a behavior-modification approach that alters sleep habits and seeks to change ingrained thoughts, behaviors, and environmental influences on sleep. The control group followed a standard self-care program for people with heart failure that includes eating properly, exercising regularly, and taking their medications appropriately.
“These data support the addition of insomnia screening and treatment in the field of heart failure disease management. Based on what we’ve seen, we are beginning to do this at Yale,” said Daniel Jacoby, MD, associate professor (cardiovascular medicine) and co-author on the study.
Redeker has done research on CBT-I for insomnia in people with HF, but in smaller numbers of people for a shorter time. Other research has largely focused on the sleep-disturbing effects of sleep-disordered breathing, also common in those with heart failure.
“The heart failure patients told us when we interviewed them that they had a lot of problems with their sleep, but they didn't want to take medication because they were afraid of getting addicted,” said Redeker. “Some of the over-the-counter medications make them sleepy and unable to perform during the day. And they really wanted a behavioral approach. They also emphasized the importance of sleep to their daily health and function and suggested the need for health care providers to help them address it.”
The study randomized 175 people with HF to either CBT-I or self-management. Along with measuring insomnia severity and self-reported sleep characteristics and symptoms, the researchers measured the participants’ six-minute walk distance at baseline, within one month of treatment, and at six and 12 months. This test is commonly used in cardiac and pulmonary settings.
“The most notable finding, actually, is the fact that we improved the six-minute walk test distance in these patients [by 100 feet],” said Redeker. “And that's important because that's a real important marker of function. It's not just a self-report, it's an objective measure. We showed that improvement was equivalent to some drug trials and some cardiac device trials where they have improved this.”
Henry Klar Yaggi, MD, MPH, associate professor of medicine, vice chief of research at Yale’s Section of Pulmonary, Critical Care & Sleep Medicine (Yale-PCCSM), director of the Yale Centers for Sleep Medicine, and an investigator at the VA CT Clinical Epidemiology Research Center (CERC), highlights the interdisciplinary nature of sleep medicine, not just in heart failure patients, but in general. Yaggi is second author on the study.
“I've always felt [sleep medicine] was a watershed field in between a lot of different specialties,” Yaggi said. “And in that context sleep affects a number of different domains. It affects cardiovascular health, like heart failure. It affects cognitive function. It affects quality of life. It affects mood.”
The next challenge is to make CBT-I accessible and widely available, said the authors, by training more health care providers in the technique in more settings.
“Sleep is really becoming this third pillar of health,” Yaggi said. “We have diet and exercise, but sleep has been ignored or minimized for so many years, and we're starting to realize it has huge implications for the well-being and health of individuals. And this study I think perfectly exemplifies that. Our study also demonstrates the inherently interdisciplinary nature of sleep.”
Additional authors from the School of Nursing: Stephen Breazeale, Samantha Conley, , Joanne Iennaco, Sarah Linsky, Uzoji Nwanaji-Enwerem, Meghan O’Connell, and Sangchoon Jeon
The Section of Pulmonary, Critical Care and Sleep Medicine is one of the eleven sections within YSM's Department of Internal Medicine. To learn more about Yale-PCCSM, visit PCCSM's website, or follow them on Facebook and Twitter.