Table 2: Insomnia: Theoretical and Pragmatic
Underpinnings of Algorithm Recommendations

Table 2.   Insomnia: Theoretical and Pragmatic
Underpinnings of Algorithm Recommendations

Algorithm component	Comments	References
Evaluate for comorbid disorders that may require treatment and evaluate for potential sleep disturbing medications	Before considering a sleep disorder in the older adult with chronic pain, it is important to evaluate and potentially manage comorbidities and/or medications prior to addressing the sleep disorder. Dependent on comorbidity, the sleep problem may be able to be addressed prior to, or concurrently with, the management of a comorbidity or medication.	[4,25,26, 43–45]
Sleep Disorders Brief Screening Questionnaire	This questionnaire (a compilation of elements of DSM-5) assesses for key diagnostic criteria for noninsomnia sleep-wake disorders. If any question is positive, further evaluation by a sleep specialist may be necessary.	[4]
STOP-BANG	The STOP-BANG is a brief screening measure to detect risks for obstructive sleep apnea (e.g., snoring, neck size, hypertension). A score ≥3 indicates intermediate to high risk of obstructive sleep apnea (OSA). In patients with mild, moderate, and severe OSA, this cut-off had sensitivity of 84.1%, 68.4%, and 94.8%, respectively, and specificity of 40.3%, 10.8%, and 27.6%, respectively. 0–2, low risk 3–4, intermediate risk 5–8, high risk	[36]
Insomnia Severity Index	Insomnia Severity Index (ISI)—a brief screening and outcome measure of insomnia severity. Insomnia causes nighttime sleep disturbance and clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important area of functioning. ISI score ≥11 indicates further assessment and/or treatment is needed. In a clinical sample, this cut-off had 97% sensitivity, 100% specificity, and a 97.9% correct classification rate. Categorical Scoring: 0–7, no clinical insomnia 8–14, subthreshold insomnia 15–21, clinical insomnia, moderate 22–28, clinical insomnia, severe	[37,38]
Treatment
Nonpharmacological treatment of insomnia	Brief Behavioral Treatment for Insomnia (BBTI) and Cognitive Behavioral Therapy for Insomnia (CBTI) are the recommended first-line treatments for insomnia.	[28,55]
BBTI	BBTI emphasizes the behavioral components: stimulus control and sleep restriction. Stimulus Control, an American Academy of Sleep Medicine (AASM) Standard Recommendation, helps patients to re-associate the bed/bedroom with sleep and re-establish a consistent sleep-wake schedule. Sleep restriction, an AASM Guideline Recommendation, helps patients to re-associate the bed/bedroom with sleep and re-establish a consistent sleep-wake schedule.	[28,39,56]
CBTI	CBTI is a multicomponent therapy that includes stimulus control and sleep restriction plus cognitive therapy and relaxation training, both AASM Standard Recommendations. Cognitive therapy can further benefit treatment outcomes when combined with stimulus control and sleep restriction; cognitive therapy seeks to change maladaptive and/or dysfunctional beliefs about insomnia and perceived daytime impact. Relaxation training helps reduce somatic tension or intrusive thoughts using active (e.g., progressive muscle relaxation) or passive (e.g., autogenic training) methods.	[28,39,56,57]
Pharmacological treatment of insomnia	Pharmacological management of insomnia is recommended to be initiated after a nonresponse or suboptimal response to BBTI/CBTI if the patient is not a good candidate for, or refuses, nonpharmacological treatments. For all sedative hypnotic and/or prescription sleep medication, it is recommended that the lowest effective dose be used to avoid chronic use (>90 days). There is potential for habituation and tolerance for nonbenzodiazepine receptor agonists (BZRA). Activities that require concentration, such as driving, should be avoided; sedative hypnotics may cause sleep-related behaviors like sleep-walking, sleep-driving, making phone calls while sleeping, and eating while asleep. See Table 3 for more information about specific sedative-hypnotic medications.	[39,56,58]
Note: Standard Recommendation: a generally accepted patient care strategy with a high-degree of clinical certainty; Guideline Recommendation: a patient care strategy with a moderate degree of clinical certainty; SOL = sleep onset latency TAU = treatment as usual TIB = time in bed TST = total sleep time TWT = total wake time WASO = wake after sleep onset.