Online COgnitive Behavioural Therapy for Sleep and Mental Health for Older Adults With Insomnia and Subjective Cognitive Complaints

Study Overview
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Brief Summary
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The goal of this randomized controlled clinical trial is to assess a novel cognitive-behavioral program for sleep and mental health using a multidomain web platform (eCBTi+) in participants with insomnia and subjective memory decline. The main questions it aims to answer are: Whether the eCBTi+ intervention improves sleep (subjective: Insomnia severity index [ISI], objective: EEG-based sleep efficiency) sleep and mental health (Geriatric Anxiety Index [GAI] and Geriatric Depression Scale [GDS]) compared to the control intervention Whether the eCBTi+ intervention improves cognitive abilities (subjective: Everyday Cognition [ECog], objective: CANTAB executive functions composite score) compared to the control intervention

Detailed Description
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Participants with insomnia disorder will complete: A phone interview Two video conferences (assessment of eligibility and tutorial to set up sleep monitoring devices) 9 nights of at-home polysomnography with an EEG headband (3 times x 3 nights) 42 sleep diaries (3 times x 14 days) 42 days wearing an actigraphy device (3 times x 14 days) Online questionnaires 3 cognitive testing sessions 10 modules of online information on health, over the course of 10 weeks In MRI subgroup: 2 in-person testing Good sleeper participants will complete: A phone interview Two video conferences (assessment of eligibility and tutorial to set up sleep monitoring devices) 3 nights of at-home polysomnography with an EEG headband 14 sleep diaries 14 days wearing an actigraphy device Online questionnaires 1 cognitive testing session 1 in person session for MRI. In addition, researchers will compare outcomes from participants with insomnia and subjective memory decline to a group of good sleepers to have normative values for imaging data.

Official Title
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Improving Sleep to Protect Brain Health in Older Adults: Assessing a Novel Cognitive-behavioral Program for Insomnia Using a Multidomain Web Platform

Conditions
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Insomnia

Intervention / Treatment
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* Behavioral: cognitive behavioral therapy for sleep, anxiety, and depression
* Behavioral: education about healthy nutrition habits and communication in older age


Participation Criteria
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Eligibility Criteria
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Inclusion age 60 years or older at the time of enrolment DSM-5 criteria for insomnia disorder (Sleep Condition Indicator, SCI ≤ 16) subjective memory decline ability to read and understand French or English ability to use a smartphone or tablet, and access to home internet connection If on hypnotic or psychotropic medication, being on stable dosage for at least 2 months prior to study entry Exclusion located outside of Québec or Ontario current hospitalization or planned major surgery uncorrected severe hearing or vision impairment reported diagnosis of major neurocognitive disorder or mild cognitive impairment (MCI) performance suggestive of major neurocognitive disorder or MCI on T-MoCA < 17 reported diagnosis of schizophrenia or bipolar disorder reported diagnosis or positive screen on the MINI for psychotic or bipolar disorders high suicidal risk, as assessed by the modified Columbia-Suicide Severity Rating Scale reported diagnosis or positive screening for another untreated sleep disorder (e.g., sleep disordered breathing (OSA), REM sleep behavior disorder (RBD), restless legs syndrome (RLS); individuals with treated and controlled OSA or RLS will not be excluded) apnea-hypopnea index >10 on a level 3 home sleep apnea test or residual AHI >10 for individuals on CPAP current shift work currently receiving CBT frequent alcohol consumption (>10 glasses/week or 3times/week), or use of alcohol 3x/week for sleep, or use of cannabis (more than once a week) or illicit drugs (more than once a month) smoking more than 10 cigarettes/day Additional exclusion criteria for neuroimaging psychotropic (including hypnotic) medication in the past 2 weeks contraindications for MRI (e.g., pacemaker, metallic implant, claustrophobia) unable or unwilling to come to one of the participating MRI centers (Montreal, Ottawa) medical conditions likely to affect sleep; in particular: current neurological disorder (e.g., epilepsy with any seizure in the past year, concussion in the past 3 months, multiple sclerosis, Parkinson's disease) past history of brain lesion (e.g., brain hemorrhage, brain tumor, any condition having required brain surgery) major surgery (i.e., requiring general anesthesia) in the past 3 months untreated thyroid disorder chronic pain syndrome self-reported as interfering with sleep (e.g., migraine, fibromyalgia, rheumatoid arthritis) recent and severe infection in the past 3 months (e.g., pneumonia, kidney infection) active cancer or treated cancer with post-cancer treatment for less than 2 years Inclusion/exclusion criteria for good sleepers Twenty-five good sleepers without cognitive complaint will be recruited as controls for the MRI session following the same criteria described above, except that SCI ≥ 17, not meeting the diagnostic criteria for chronic insomnia as assessed by the insomnia module of the SCID and no subjective memory decline.

Ages Eligible for Study
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Minimum Age: 60 Years
Maximum Age: 99 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Participants with insomnia and subjective memory decline are randomized into 2 groups with a 1:1 allocation ratio, after the pre-treatment assessment. Allocation will be stratified based on a composite mental health score. An assessment post-intervention will occur 10 weeks after the start of the intervention and a follow-up assessment 24 weeks after the start of the intervention. One group will receive the online CBT for sleep and mental health after the baseline assessment and the other group will receive the control intervention. The group receiving the control intervention will access the CBT intervention after completion of the study. A good sleepers group, matched on age and gender, will also be recruited and assessed at baseline only to provide a normative reference group. A subgroup of participants and the good sleepers group will undergo MRI and classical neuropsychological testing at baseline and 24 weeks after the start of the intervention.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: online cognitive behavioral therapy for insomnia, anxiety and depression<br>10 self-directed modules of cognitive behavioral therapy for insomnia, anxiety and depression, delivered online, once a week | Behavioral: cognitive behavioral therapy for sleep, anxiety, and depression<br>* This intervention addresses insomnia, anxiety and depression via modules covering all the core CBTi components: psychoeducation about insomnia, relaxation, cognitive restructuring, stimulus control, sleep restriction and stress management; as well as psychoeducation about anxiety and low mood, behavioral activation strategies, and strategies to better manage ruminations. The modules are adapted to older adults and include short texts, pictures, quizzes with feedback, interactive exercises, logbooks, audio and video recordings.<br>* Other names: eCBTi+;|
| Active Comparator: online intervention on nutrition and communication in older age<br>10 self-directed modules on healthy nutrition habits and communication strategies, delivered online, once a week | Behavioral: education about healthy nutrition habits and communication in older age<br>* This intervention addresses healthy nutrition habits as well as communication and aging. The modules are adapted to older adults and include short texts, pictures, quizzes with feedback, interactive exercises, logbooks, audio and video recordings<br>* Other names: active control;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Insomnia severity index | Change in Insomnia Severity Index. ISI range from 0 to 28, higher score means more severe insomnia symptoms. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Subjective cognitive abilities based on the everyday cognition questionnaire | Change in Everyday cognition Questionnaire (ECog) total score as well as number of items with a score ≥ 3. The ECog comprises 39 items and total score corresponds to the sum of all completed items, divided by the number of items completed; thus, total scores range from 1-4. Higher score means more severe cognitive impairment. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Objective cognitive performance based on a composite score for executive functions from the CANTAB | Change in the Cambridge Neuropsychological Test Automated Battery (CANTAB) executive functions composite score (Intra-Extra Dimensional Set Shift [IED] and Stocking of Cambridge [SOC], ranging from 0 to 100 with higher scores reflecting poorer executive functions. | At baseline and at 24 weeks after the start of the intervention | 
| Geriatric anxiety index | Change in Geriatric anxiety index. GAI scores range from 0 to 20 and higher scores mean more severe anxiety symptoms. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Geriatric depression scale | Change in Geriatric depression scale. GDS scores range from 0 to 15, higher scores mean more severe depression symptoms. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Sleep quality based on the Pittsburgh sleep quality index | Change in Pittsburgh sleep quality index. PSQI scores range from 0 to 21, higher scores mean worse sleep quality. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Objective sleep measures based on actigraphy: Sleep Efficiency | Change in Sleep Efficiency (SE) from actigraphs. Sleep efficiency ranges from 0 to 100, values closer to 100 mean greater sleep efficiency. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Objective sleep measures based on actigraphy: Sleep Latency | Change in Sleep Latency (SL) from actigraphs. Sleep latency in minutes, greater values mean longer time to fall asleep. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Objective sleep measures based on actigraphy: Total Sleep Time | Change in Total Sleep Time (TST) from actigraphs. Total Sleep Time in minutes, greater values mean longer time spent asleep. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Objective sleep measures based on actigraphy: Wake After Sleep Onset | Change in Wake After Sleep Onset (WASO) from actigraphs. Wake After Sleep Onset in minutes, greater values mean longer time spent awake. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Objective sleep measures based on EEG: Sleep Efficiency | Change in Sleep Efficiency (SE) from EEG. Sleep efficiency ranges from 0 to 100, values closer to 100 mean greater sleep efficiency. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Objective sleep measures based on EEG: Sleep Latency | Change in Sleep Latency (SL) from EEG. Sleep latency in minutes, greater values mean longer time to fall asleep | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Objective sleep measures based on EEG: Total Sleep Time | Change in Total Sleep Time (TST) from EEG. Total Sleep Time in minutes, greater values mean longer time spent asleep. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Objective sleep measures based on EEG: Wake After Sleep Onset | Change in Wake After Sleep Onset (WASO) from EEG. Wake After Sleep Onset in minutes, greater values mean longer time spent awake. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Objective sleep measures based on EEG: Slow Wave Activity | Change in Slow Wave Activity (SWA) power density from EEG. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Objective sleep measures based on EEG: Slow Wave Sleep | Change in Slow Wave Sleep (SWS) from EEG. Slow Wave Sleep in minutes, greater values mean longer time spent in Slow Wave Sleep. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Subjective sleep measures based on sleep diaries: Sleep Efficiency | Change in Sleep Efficiency (SE) from sleep diaries. Sleep efficiency ranges from 0 to 100, values closer to 100 mean greater sleep efficiency. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Subjective sleep measures based on sleep diaries: Sleep Latency | Change in Sleep Latency (SL) from sleep diaries. Sleep latency in minutes, greater values mean longer time to fall asleep. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Subjective sleep measures based on sleep diaries: Total Sleep Time | Change in Total Sleep Time (TST) from sleep diaries. Total Sleep Time in minutes, greater values mean longer time spent asleep. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Subjective sleep measures based on sleep diaries: Wake After Sleep Onset | Change in Wake After Sleep Onset (WASO) from sleep diaries. Wake After Sleep Onset in minutes, greater values mean longer time spent awake. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Cognitive performances from the CANTAB: Rapid Visual Information Processing (RVP) | Change in Rapid Visual Information Processing RVP - A' (sensitivity to the target sequence) and probability of false alarm (range: 0.00 - 1.00; bad to good)]. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Cognitive performances from the CANTAB: Spatial Span (SSP) | Change in Spatial Span [SSP - Forward/Reverse Span Lengths (range: 2-9; bad to good] | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Cognitive performances from the CANTAB: Spatial Working Memory (SWM) | Change in Spatial Working Memory [SWM - Number of times the subject incorrectly revisits a box in which a token has previously been found (range: 0 - ∞; good to bad)]. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Cognitive performances from the CANTAB: Paired Associates Learning (PAL) | Change in Paired Associates Learning [PAL - Total errors adjusted (range: 0 - 70; good to bad; First attempt memory score (range: 0-20; bad to good)] | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Cognitive performances from the CANTAB: Pattern Recognition Memory (PRM) | Change in Pattern Recognition Memory [PRM - Percent correct immediate/delayed (range: 0-100; bad to good)]. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Cognitive performances from the CANTAB: Intra-Extra Dimensional Set Shift (IED) | Intra-Extra Dimensional Set Shift, IED - number of times that the subject failed to select the stimulus compatible with the current rule on the stage where the extra-dimensional shift occurs (range: 0-50; good to bad); Total errors adjusted (range: 0-402; good to bad) | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Cognitive performances from the CANTAB: Stocking of Cambridge (SOC) | Stocking of Cambridge, SOC - Number of problems successfully completed in the minimum possible number of moves (range: 0 - 12; bad to good); Mean number of moves required to complete problems (range: 5 - 12; good to bad); Initial thinking time median (range: 0 ms to ∞; longer times may indicate better planning efforts | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Negative emotional bias measured on the Cambridge Neuropsychological Test Automated Battery (CANTAB) | Change in Emotional Bias Task (EBT) subscales from the CANTAB [EBT - proportion of trials rated as 'Happy' (range: 0-15, bad to good)]. | At baseline, at 10-12 weeks and at 24 weeks after the start of the intervention | 
| Memory encoding fMRI activations | Change in fMRI activation level (arbitrary units) in the hippocampus, temporal lobe and prefrontal cortex during the memory encoding task. | At baseline, at 24 weeks after the start of the intervention | 
| Cognitive performance (classical neuropsychological tests) | all subscales from classical neuropsychological test battery (Trail Making Test A [TMT-A], Digit Symbol Substitution test (WAIS), Boston Naming Test, Digit Span - forward and backward (WAIS), Rey Auditory Verbal Learning test, Logical Memory I and II (Wechsler Memory Scale), Brief Visuospatial Memory Test Revised (BVMT-R), Trail Making Test B [TMT-B], Verbal Fluency Test (from D-KEFS), Color-Word Interference Test [Stroop test, from D-KEFS]). | At baseline, at 24 weeks after the start of the intervention | 
| Cortical thickness measures | Change in cortical thickness (mm) in the prefrontal cortex and precuneus. | At baseline, at 24 weeks after the start of the intervention | 
| Fractional anisotropy | Change in fractional anisotropy of the superior longitudinal fasciculus and internal capsule. | At baseline, at 24 weeks after the start of the intervention | 
| Resting-state measures | Change in the ratio between segregation and integration within and between the default-mode network and the limbic network during resting-state as measured with functional connectivity. | At baseline, at 24 weeks after the start of the intervention | 
| GABA/glutamate ratio from magnetic resonance spectroscopy | Change in the GABA/glutamate ratio in the anterior cingulate cortex. | At baseline, at 24 weeks after the start of the intervention | 
| Treatment-mediated association between changes in sleep and cognition | Mediation estimate of the extent to which exposure to eCBTi+ explains the association between improved sleep and improved cognition | At 10-12 weeks and at 24 weeks after the start of the intervention | 
| Satisfaction from System Usability Scale | Score on the System Usability Scale, reflecting the degree to which participants were satisfied with the eCBTi+ and the control intervention. Percentage ranging between 0 and 100%. | At 10-12 weeks after the start of the intervention | 
| Technology acceptance | Score on the extended version of the Technology Acceptance Model-2 reflecting th degree to which participants use and intend to use the eCBTi+ (and control intervention) as implemented on e-SPACE. Each process influencing technology acceptance is scored on a 7-point Likert scale. | At 10-12 weeks after the start of the intervention | 
| Adherence to treatment | Number of modules completed as a measure of treatment adherence | At 10-12 weeks after the start of the intervention | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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insomnia, cognition, mental health, subjective memory decline, sleep, online CBT, older adults, anxiety, depression, executive functions, electroencephalography, magnetic resonance imaging