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Nocturia and chronic insomnia disorder are common conditions that frequently coexist in older adults. Existing medication treatments for each condition have risks, particularly in older adults. While treatment guidelines recommend starting with behavioural therapy for each condition, no existing program simultaneously addresses nocturia and insomnia. Existing behavioural interventions for nocturia or insomnia contain concordant and discordant components. An expert panel (including geriatricians with sleep or nocturia research expertise, sleep psychologists and a behavioural psychologist) was convened to combine and reconcile elements of behavioural treatment for each condition. Concordant treatment recommendations involve using situational self-management strategies such as urge suppression or techniques to influence homeostatic drive for sleep. Fluid modification such as avoiding alcohol and evening caffeine and regular self-monitoring through a daily diary is also appropriate for both conditions. The expert panel resolved discordant recommendations by eliminating overnight completion of voiding diaries (which can interfere with sleep) and discouraging routine overnight voiding (a stimulus control strategy). The final product is an integrated cognitive behavioural treatment that is delivered by advanced practice providers weekly over 5 weeks. This integrated program addresses the common scenario of coexisting nocturia and chronic insomnia disorder.

Introduction In our recent national survey study, 13% of women Veterans reported a diagnosis of Sleep Disordered Breathing (SDB), of whom 65% used positive airway pressure (PAP) treatment. We also found many women Veterans at high risk for SDB were undiagnosed (43%). The current study builds upon this survey research to identify rates of evaluation, diagnosis, treatment, and treatment adherence among women Veterans with risk factors for SDB. Methods We analyzed telephone screening data from an ongoing SDB treatment adherence intervention study for women Veterans in Los Angeles county. A total of 173 women Veterans, identified by retrospective chart review as having at least one risk factor for SDB (i.e. high blood pressure, diabetes, obesity, depression, or > 50 years old), completed the screener. Screening questions included 1) previous diagnostic testing for SDB, 2) SDB diagnosis 3) SDB treatment type, and 4) past week SDB treatment use. Descriptive statistics regarding evaluation and treatment of SDB are reported. Results In total, 31% of respondents endorsed having previously completed diagnostic testing, of whom, 54% reported an SDB diagnosis. Of those with diagnosed SDB, 82.8% were prescribed treatment (PAP [72.4%], oral appliance [6.9%], surgery [3.5%]), and 17.2% did not report being prescribed any SDB treatment. Of the 21 (72.4%) women Veterans diagnosed with SDB that were prescribed PAP, only 33% reported using treatment in the past week. Of the 2 women Veterans (6.9%) prescribed an oral appliance, 0% reported past week use. Conclusion Less than 1/3 of women Veterans with at least one risk factor for SDB had previously been evaluated for SDB; however, over 1/2 of women Veterans who were evaluated tested positive for SDB. Additionally, most women Veterans had not used PAP or oral appliance therapy in the past week. Greater clinical attention is needed to identify, evaluate, and diagnose SDB in women Veterans. Moreover, further research is needed to evaluate and inform interventions to address SDB treatment adherence barriers in women Veterans. Support (if any) VA HSR&D IIR 16–244 and RCS 20–191; NIH/NHLBI K24 HL143055, VAGLAHS GRECC and VA Office of Academic Affiliations.

Introduction Women are at higher risk for cognitive impairment and dementia compared to men. Identifying potentially treatable risk factors such as insomnia is an important clinical goal. In a trial comparing two behavioral treatments for insomnia in women veterans, we hypothesized that 1) worse baseline insomnia severity would be associated with poorer cognitive function, and 2) improvement in insomnia severity with treatment would be associated with improvement in cognitive functioning. Methods 347 women veterans with insomnia disorder [mean age 48.3 (12.9) years] completed baseline testing. Of these, 149 women were randomized to receive cognitive behavioral therapy for insomnia (CBT-I) or acceptance and commitment (ACT) based insomnia treatment (both treatments included sleep restriction, stimulus control, and sleep hygiene). Insomnia Severity Index (ISI) was assessed at baseline, post-treatment, and 3-month follow-up. Cognitive functioning was measured with Symbol Digit Coding (SDC) and Trail Making Test A and B (TMTA and TMTB). Pearson correlations were used to examine associations between insomnia severity and cognitive functioning at baseline and changes in both insomnia severity and cognitive functioning from before to after treatment. Results At baseline (N=347), mean ISI was 14.1 (5.3). Worse baseline ISI was associated with worse baseline cognitive functioning on TMTA (r=-.15, p Conclusion More severe insomnia is associated with worse cognitive functioning in women veterans. The magnitude of improvement in insomnia symptoms may be associated with improvement in cognition. Support NIH/NIA K23AG049955 (PI: Dzierzewski); VA/HSR&D IIR-HX002300 (PI: Martin), NIH/NHLBI K24HL143055 (PI: Martin).

Introduction Sleep apnea (SA) is the most commonly diagnosed sleep disorder among patients in the US Veterans Administration (VA). The dramatic rise in women receiving VA care makes it essential to understand the presentation and treatment of SA in women Veterans. We performed a nationwide survey about sleep among US women Veterans and compared characteristics of respondents with and without a self-reported history of SA diagnosis and treatment. Methods A survey was mailed to a random sample of 4000 women VA healthcare users. The survey included demographics, Insomnia Severity Index (ISI), Patient Health Questionnaire-4 (PHQ-4 depression/anxiety), Primary Care-Post-Traumatic Stress Disorder (PC-PTSD), RLS symptom presence, SA symptoms (snore loudly, observed breathing pauses), diagnosis of SA, and use of PAP therapy (APAP, BPAP, CPAP). We compared women with and without SA, and (among those with SA) women who did and did not use PAP, using Chi-square and t-tests. Results 1,498 completed surveys were returned (mean age 51.6 years, range 18-105 years, 62% non-Hispanic White). 200 respondents (13.4%) reported diagnosed SA. Women with SA were older (p Conclusion One in 7 women who receive VA care report diagnosed SA. Women with SA had more mental health symptoms and comorbid sleep problems. Most reported using PAP therapy, although the amount of use is unknown. Those with SA symptoms were more likely to use PAP. Future work is needed to understand barriers to diagnosis and treatment of SA among women Veterans. Support Funding: VA Quality Enhancement Research Initiative RRP12-189 (Martin); NIH/NHLBI K24 HL143055 (Martin).

Introduction Nocturia is common among patients with both insomnia disorder and obstructive sleep apnea (OSA) and adversely affects quality of life. Within a randomized controlled trial testing an integrated behavioral therapy for positive airway pressure (PAP) adherence and insomnia for patients with coexisting OSA and insomnia disorder, we examined the impact of the integrated therapy on nocturia frequency. Methods Patients aged > 50 years with untreated OSA (apnea hypopnea index > 15) and chronic insomnia disorder were recruited from a VA medical center and randomized to 5 weekly individual integrated behavioral treatment sessions versus control (general sleep education). Nocturia frequency (self-reported average number of nocturia events per night) was assessed at baseline, 3 months, and 6 months. Linear regression models were used to examine relationships between objective PAP adherence (# nights used > 4hrs over the last 30 days) and Insomnia Severity Index (ISI) score (0 [none] - 28 [severe]) and nocturia frequency (0 - 5+/night), and change in nocturia frequency associated with integrated therapy. Results Nocturia data were available for 112 participants (treatment=56, control=56; mean age 63 [SD 7], 95% male). Mean nocturia frequency (episodes/night) was 2.1 (SD 1.3; baseline), 1.6 (SD 1.1; 3 months), and 1.7 (SD 1.2; 6 months). Overall, higher PAP adherence (B=.029, p=.008) and ISI score improvement (B=0.05, p=.004) were associated with decreased nocturia frequency at 3-month follow-up. No differences were observed in nocturia frequency between treatment and control participants at baseline (p=.429). Integrated therapy reduced nocturia frequency at 3 months (B=-0.56, p=.020) but not at 6 months follow-up (B=-0.4, p=.081) compared to control. Conclusion Nocturia frequency improved with integrated behavioral therapy for PAP adherence and insomnia in veterans (primarily male) with co-existing OSA and insomnia. Additional studies are needed to examine the mechanisms underlying the relationship between the behavioral therapy for PAP adherence and insomnia and nocturia. Support VA HSR&D; NIA; VA GRECC

Introduction Sleep disordered breathing (SDB) is underdiagnosed in older women, despite a significant increase in SDB prevalence post-menopause. Few studies have assessed the diagnostic accuracy of SDB screening questionnaires in older women, particularly older Women Veterans (WV). WV have higher rates of SDB compared to non-Veteran women and are particularly vulnerable to sleep disorders in general. We examined the diagnostic accuracy of the STOP questionnaire compared to home sleep apnea testing (HSAT) that includes sleep time estimation (i.e., WatchPAT) in older WV. Methods Cross-sectional baseline data obtained from chart review were combined from two behavioral sleep intervention studies targeting WV with sleep difficulties (i.e., insomnia symptoms) or SDB risk factors (e.g., hypertension, obesity). A total of 136 older WV (50-91y; age=60.0±7.8y) completed the STOP questionnaire (yes/no: snoring, tiredness, observed breathing pauses, and high blood pressure [BP]) and had an apnea-hypopnea index (AHI) available from their baseline HSAT (WatchPAT). Sensitivity, specificity, and positive and negative likelihood ratios (+LR/-LR) were calculated to characterize the diagnostic accuracy of STOP≥2 for AHI≥5 (mild SDB) or AHI≥15 (moderate SDB). Results 70.6% (n=96) of participants endorsed a STOP≥2, 83.8% (n=114) demonstrated an AHI≥5 and 46.3% (n=63) demonstrated an AHI≥15. For AHI≥5, sensitivity was 73.7% (95% CI=64.6,81.5%), specificity was 45.5% (95% CI=24.4,67.8%), +LR was 1.35 (95% CI=0.91, 2.01), and -LR was 0.58 (95% CI=0.33,1.00). For AHI≥15, sensitivity was 76.2% (95% CI=63.8,86%), specificity was 34.2% (95% CI=23.5,46.3%), +LR was 1.16 (95% CI=0.93,1.44), and -LR was 0.70 (95% CI=0.30,1.20). Conclusion The likelihood ratios for STOP≥2 limited the utility of the STOP vs. an HSAT system with sleep scoring in determining AHI. While the STOP correctly identified 3/4 of older WV with SDB on WatchPAT, it correctly identified Support (if any) VA HSR&D IIR-13–058, IIR 16–244 and RCS 20–191; NIH/NHLBI K24 HL143055, VAGLAHS GRECC, VA Office of Academic Affiliations, and AASM Foundation.

Introduction Cognitive behavioral therapy for insomnia (CBT-I) is recommended as first-line treatment for chronic insomnia disorder for all adults. Older adults are often prescribed sedative-hypnotics (e.g., benzodiazepine receptor agonists, BRAs) for insomnia, despite observational studies showing these medications increase risk of falls, fractures, and cognitive decline. In an ongoing randomized controlled trial, we are testing “Sleep EducatioN Information Sent Directly to Patients (SEND),” a novel program combining direct-to-patient mailing with information about access to an online CBT-I resource, compared to a similarly structured control condition. In the current study, we surveyed participants in both groups to examine their self-reported use of intervention or control materials. Methods In the larger trial, 1,672 Veteran participants (aged >=65 years, receiving care from a Colorado VA facility, and prescribed a BRA) were randomized to receive the SEND intervention brochure with information on how to access a free, anonymous online CBT-I resource (n=836) or control condition brochure with information about general sleep education (n=836). Six months after the initial brochure mailing, all participants were mailed a blinded survey querying participants’ recollection and use of the mailed materials. We used chi-squared tests to compare survey responses for SEND versus control groups. Results 354 surveys were returned by study participants (overall response rate: 21%; SEND: 172 [20%], control: 182 [22%]). Respondents were 94% male with mean age 71.7 years (no difference between groups). In the SEND group, 97 (56%) reported receiving the brochure, 18 (10%) visited the website, and 14 (8%) discussed the brochure with their provider. No significant differences between groups were observed in the number of participants who reported receiving the brochure (chi2=2.96, p=.085); visiting the website (chi2=0.0253, p=.874); or discussing the brochure with their provider (chi2=1.91, p=.167). Conclusion At 6-months follow-up, over half of participants recalled receiving a mailing about sedative-hypnotics. A modest number reported visiting the online CBT-I program and a similar number discussed the materials with their healthcare provider. Similar results between groups suggest successful blinding of the intervention and control participants. If successful, the SEND intervention may provide a low-touch, low-cost approach to address BRA over-use in some older adults. Support (if any)

Introduction Insomnia among informal caregivers (providing care to family/friends) is common and associated with worse mental and physical health outcomes. Traditional cognitive behavioral therapy for insomnia may be challenging for caregivers whose beliefs about sleep may relate to beliefs and behaviors that are intertwined with their unique situation of caregiving. We examined whether an insomnia treatment using an acceptance and commitment (ACT) approach (i.e. committing to values-based actions toward goals vs. experiential avoidance of distressing emotions/thoughts) plus sleep restriction, stimulus control and sleep hygiene improves sleep, mental health, and daytime symptoms among caregivers. Methods We analyzed data from women veterans with insomnia who were informal caregivers (mean age=44 years [range 25–57]; N=6) and were participating in a clinical trial of an ACT-focused treatment (termed ABC-I). We measured: Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Patient Health Questionnaire (PHQ-9), General Anxiety Disorder (GAD-7), 11 items assessing symptoms of daytime impairment due to poor sleep derived from the International Classification of Sleep Disorders-Third Edition, and the Acceptance and Action Questionnaire (AAQ). Student t-tests were used to compare outcomes between pre- and post-ABC-I. Results Caregivers showed significant improvements between pre- and post-ABC-I (all p-values Conclusion We found that caregivers with insomnia may benefit from ACT-based treatment in improving perceived sleep quality and insomnia, depression, anxiety, sleep-related daytime impairment and reduced experiential avoidance. This approach may increase motivation by linking the sleep program to core values, and acceptance and tolerance of emotions or thoughts may benefit caregivers with insomnia. Further studies using an ACT-based insomnia program are needed to test its effect in a larger sample of caregivers and evaluate benefits in terms of reduced stress and improved health. Support (if any) VA HSR&D (Martin IIR 13-058-2 and RCS-20–191), NIA (K23AG055668, Song), NHLBI (K23HL143055, Martin) of the NIH, VAGLAHS GRECC, and VA Office of Academic Affiliations (Kelly; Carlson).

Introduction We present a case of paradoxically worsened hypoxia during wake phase of polysomnography while undergoing a CPAP titration study. Nighttime hypoxemia is a common feature in obstructive sleep apnea, due to obstructive events that manifest while sleeping. Excluding OSA, there remains an extensive differential for disease processes that cause hypoxemia while asleep; however, none of these processes can explain waking hypoxemia that improves upon sleeping. Report of case(s) A 70 year old male with severe OSA diagnosed by home sleep test (REI 46.5, nadir O2=76%) underwent polysomnography with PAP titration and demonstrated several hours of interrupted sleep without hypoxia and minimal obstructive events on CPAP 9–13 cmH2O. During the study, while awake at CPAP of 14 cmH2O, he developed hypoxia to mid-high 80s and supplemental oxygen bleed in was added starting at 3L and increased to 5L during a prolonged period of wakefulness. On CPAP 15 cmmH2O with 5L bleed-in, the patient fell asleep and oxygen saturation again increased to low 90s. He underwent an extensive workup for other cardiopulmonary causes of hypoxemia, with pulmonary function testing showing moderate obstructive ventilatory defect and mild DLCO impairment. An echocardiogram with saline contrast bubble study was relatively unremarkable, without evidence of right to left shunting. He underwent a chest CTA which was negative for pulmonary embolism, though it did reveal an enlarged pulmonary artery consistent with pulmonary hypertension. His chronic hypoxemia was treated with 2L supplemental oxygen during the day and bleed-in with CPAP at night. Conclusion Though nocturnal hypoxemia is common with OSA, polysomnography with paradoxical hypoxemia during wake phase has not been reported. Notably, the patient was without prolonged hypoxia during his sleep phase while on CPAP treatment with minimal apneic/hypopneic events. Pulmonary hypertension can also present as nocturnal hypoxemia, but it should worsen with sleep, rather than improve. There are case reports of right to left shunting worsened by PAP, though his hypoxemia persisted despite PAP. His paradoxical worsening hypoxemia with wakefulness is still unexplained. Support (if any)

Introduction Sleep disordered breathing (SDB) is common among individuals with spinal cord injuries or diseases (SCI/D), many of whom are military Veterans, and physical limitations make use of positive airway pressure (PAP) therapy challenging. This study sought to test the effects of an educational and behavioral intervention to improve PAP adherence among Veterans with SCI/D over the first 3 months of use. Methods 63 Veterans (mean age=60.7(10.2) years; 92% male) with SCI/D (33 SCI, 30 SCD; 25 cervical involvement; 38 thoracic and below) and SDB (23 with AHI 5-15; 40 with AHI≥15) who received PAP treatment (CPAP or BPAP) were randomly assigned to receive a comprehensive 3-month intervention (INT) or an equal attention control (EAC). INT and EAC both included 1 face-to-face session (week 1) and 5 additional telephone sessions (weeks 2, 3, 4, 8 and 12). Main outcome measures were PAP use over the first 3 months: nights of use, nights of use ≥4 hours, and mean hours of use per night. Repeated measures ANCOVA models were used to test the differences between INT and EAC over the first 3 months of treatment. Results Number of nights with ≥4 hours of use in months 1-3 was 9, 7, and 6 nights in the INT and 8, 5 and 4 nights in the EAC (p’s≥.37), respectively. There were no significant differences between INT and EAC for number of nights with any use (p’s≥.24), or mean hours of use per night (p’s≥.30). All 3 PAP use variables declined over time in both groups. Conclusion Sustained use of PAP therapy was difficult to achieve among those with SCI/D, and a 6-session behavioral intervention did not lead to significant improvements in use. Even when relatively high levels of initial use are achieved, this is difficult to sustain over time. Future studies should explore whether SCI/D patients experience significant symptom relief with PAP, and if so, whether home-based interventions or more intensive face-to-face PAP adherence programs will be effective. Support VA Rehabilitation Research and Development Service, Merit Review (1RX002116; PI: Badr); NIH/NHLBI K24 HL143055 (Martin).

Introduction The long-term impact of addressing sleep-related cognitions, which is an important component of cognitive behavioral therapy for insomnia (CBTI), has not been established, particularly in older adults. We examined whether specific changes in sleep-related cognitions predicted long-term changes in sleep and other outcomes following CBTI in older adults. Methods We analyzed data from a randomized controlled trial testing CBTI in older veterans with insomnia (N=159, mean age 72 years). Sleep-related cognitions were assessed with the Dysfunctional Beliefs and Attitudes about Sleep scale (DBAS, subscales: Consequences, Worry/Helplessness, Sleep Expectations, Medication). Outcome measures included the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), sleep diary variables, Flinders Fatigue Scale (FFS), and Short Form-12 health-related quality of life (QOL). Analyses completed slope of change in DBAS subscales (baseline to post-treatment: T1) between CBTI and control with respect to slope of change in sleep and other outcomes from post-treatment to 6-months (T2). Results Compared to controls, the CBTI group had significantly stronger associations between improvement (T1) in DBAS-Consequences and subsequent (T2) improvement in PSQI (difference in slopes [DIS]=0.9, 95%CI=[.29, 1.43], p=0.004), ISI (DIS=1.1, 95%CI=[.18, 2.0], p=0.019), ESS (DIS=0.6, 95%CI=[.10, 1.18], p=0.020), and FFS (DIS=1.9, 95%CI=[.76, 3.09], p=0.001). The CBTI group also had significantly stronger associations between improvement in DBAS-Worry/Helplessness and subsequent improvements in PSQI, ISI, and FFS; improvement in DBAS-Medication and PSQI and ISI; and improvement in DBAS-Sleep Expectations and improved FFS. Slopes were not different between groups for sleep diary variables or QOL. Conclusion Significant improvements in sleep-related cognitions with CBTI across DBAS subscales in older adults predicted improvement in several outcomes of nighttime sleep and daytime consequences. These findings suggest the importance of addressing dysfunctional sleep-related cognitions for sustained improvement with CBTI in older adults Support The study was supported by VA Health Services, Research and Development (Alessi, IIR 08-295), National Institute on Aging (K23AG055668, Song), National Heart, Lung, and Blood Institute (K24HL 143055, Martin) of the National Institutes of Health and VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center.

pii: zsw007 http://dx.doi.org/10.1093/sleep/zsx007 ORIGINAL ARTICLE Patient-Reported Usability of Positive Airway Pressure Equipment Is Associated With Adherence in Older Adults Constance H. Fung, MD, MS 1,2 ; Jennifer L. Martin, PhD 1,2 ; Ron D. Hays, PhD 2 ; Emily S. Patterson, PhD 3 ; Ravi Aysola, MD 2 ; Nananda Col, MD, MPP, MPH 4 ; Michael N. Mitchell, PhD 1 ; Cindy Truong, BS 1 ; Joseph M. Dzierzewski, PhD 1,5 ; Stella Jouldjian, MSW, MPH 1 ; Yeonsu Song, PhD, RN 1,2 ; Juan Carlos Rodriguez, MD, MPH 2,6 ; Karen Josephson, MPH 1 ; Cathy Alessi, MD 1,2 Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California; 2 Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; 3 School of Health and Rehabilitation Sciences, Ohio State University, Columbus, Ohio; 4 University of New England, Biddeford, Maine; Department of Psychology, Virginia Commonwealth University, Richmond, Virginia; 6 Pontificia Universidad Catolica de Chile, Santiago, Chile Study objectives: To examine the usability of positive airway pressure (PAP) devices and its association with PAP adherence among older adults with sleep-disordered breathing. Methods: We mailed questionnaires to patients aged ≥65 years prescribed PAP therapy during the prior 36 months from two large healthcare systems. Survey participants completed the Usability of Sleep Apnea Equipment-Positive Airway Pressure (USE-PAP) questionnaire, which assessed the usability of their PAP device. Other questionnaire items included demographics and self-rated health. We also abstracted adherence data (mean nightly hours of PAP use available from one site) and interface type from the electronic health record. Results: Five hundred sixty-four patients completed the survey (response rate = 33%). The mean USE-PAP score (0 = best to 100 = worst) was 20 (SD ± 20). Mean duration of PAP use (available in 189 respondents) was 5.2 hours per night (SD ± 2.0). In a nested regression model predicting nightly hours of PAP use, a 10-point (0.5 SD) increase in USE-PAP score corresponded to a 0.37 hour/night reduction in PAP use. The model including the USE-PAP score explained a signifi- cant proportion (R 2 = 15%) of the variation in nightly hours of PAP use above and beyond demographics, self-reported health, and interface type (∆R 2 = 12%). Conclusions: Our results demonstrate that PAP usability varies among older patients and is associated with PAP adherence, above and beyond other predic- tors of adherence. These results support measuring and improving PAP usability to further improve PAP adherence for older patients. Keywords: sleep apnea, adherence, usability, predictive modeling. Statement of Significance We conducted a survey to collect data on patient-reported usability of positive airway pressure (PAP) equipment among older patients, who may be more susceptible to user-device interaction design issues. We found variations in usability issues and showed that usability is significantly associated with PAP adherence. Patient-reported usability is not generally assessed in clinical practice. Because device usability may be a modifiable risk-factor for interventions aimed at improving PAP adherence, we recommend assessing patients’ beliefs about and experiences with PAP usability. INTRODUCTION Positive airway pressure (PAP) therapy is the most commonly prescribed treatment for sleep-disordered breathing (SDB). 1 Although PAP is an efficacious therapy for reducing the apnea-hypopnea index (AHI), many patients are non-adherent to PAP therapy, with estimates of non-adherence ranging from 28% to 60%. 2,3 Research on PAP non-adherence has focused on psychosocial factors (e.g., outcome expectancies, self-effi- cacy beliefs, socioeconomic characteristics), disease charac- teristics (e.g., AHI, sleepiness), technical aspects of devices such as interface type (i.e., nasal pillows versus nasal mask ver- sus full face mask), device modality/titration procedure (e.g., auto-titrating, continuous versus bi-level), and side effects (e.g., claustrophobia, irritation). 3 One category of barriers that has received little attention is the usability of PAP devices. 4–6 Device usability refers to design factors that impact inter- actions between individuals and devices. 7 The International Organization for Standardization defines usability as “the effec- tiveness, efficiency and satisfaction with which specified users achieve specified goals in particular environments.” 8 Usability may impact the accuracy and completeness with which patients achieve PAP therapy goals such as putting on a PAP mask, the resources expended to achieve these goals, the ease of learning how to use the PAP device, the ease of remembering how to use the device, and the degree to which the user finds the device acceptable and pleasant. 9 Beneficial outcomes of optimizing usability characteristics of medical devices include minimizing SLEEP, Vol. 40, No. 3, 2017 risk of error and ensuring device safety (i.e., promoting use of the device in a manner that does not result in harm to the patient or environment). 9 Usability test results are submitted to the Food and Drug Administration (FDA) during the pre-market device approval process. 9 In addition to impacting device safety, usability has the poten- tial to impact PAP adherence, which in turn may contribute to the overall impact that PAP has on health outcomes. 10,11 Making PAP easier to set up, use, and clean may positively affect adher- ence to therapy. Large-scale surveys of the usability of PAP devices are lacking, even though interviews with patients about their experiences with these devices suggest variability in PAP usability across patients. 5 Older adults may be more likely to experience usability problems due to the higher prevalence of physical and sensory impairments that occur with advanced age. In this study, we sought to measure PAP usability and to eval- uate the associations between PAP usability and PAP adherence among older adult patients prescribed PAP therapy for SDB. We hypothesized there would be a considerable range of PAP usability scores and that usability scores would be associated with adherence to PAP. METHODS Conceptual Model The FDA’s model for medical device usability, 9 which is based upon the International Organization for Standardization Patient-Reported PAP Usability and Adherence—Fung et al.

Background: Older US veterans and their caregivers often report significant sleep disruption, but little is known about caregivers’ attitudes towards sleep therapies. This study explored caregivers’ attitudes toward therapies for managing veterans’ sleep problems and their own sleep issues, and collected pilot data about caregivers’ sleep and daytime function.

Background: Cognitive behavioral therapy for insomnia (CBTI) is recommended for older adults, but availability of behavioral sleep medicine (BSM) specialists to provide CBTI is limited. We recently reported improved sleep (e.g., Pittsburgh Sleep Quality Index [PSQI] and Insomnia Severity Index [ISI] total scores) in a 4-year randomized controlled trial testing CBTI provided by nonclinician sleep coaches among older outpatients with insomnia at one US Veterans Administration healthcare system. As secondary analyses, we explored intervention effects on participants’ beliefs and attitudes about sleep, specific aspects of self-reported sleep quality and symptoms of insomnia.

Background: Nocturia is common in older women with chronic insomnia disorder. Few studies have examined nocturia symptoms and treatments in older women veterans. This study assessed changes in nocturia frequency associated with behavioral interventions for insomnia in older women veterans. Methods: In the context of an ongoing comparative effectiveness trial of two behavioral interventions for insomnia conducted at a VA medical center among women veterans, data from baseline, post-intervention, and 3-month follow up for participants aged ≥ 55 years were analyzed. Measures included self-reported nocturia frequency in the past month (0–5+/night) and degree of bother from nocturia (4-point scale; 0=not at all, 3= a lot). Nocturia frequency responses were categorized as nocturia (≥ 2 times/night) versus no nocturia (< 2 times/night). Differences in the proportion of participants with nocturia and degree of bother (post-intervention vs. baseline; 3-month follow-up vs. baseline) were examined with two-sample test of proportions and t-tests, respectively. Results: 36 participants (mean age 63, range 55–91 years) completed all or part of their assigned intervention. At baseline, 23 (64%) participants had nocturia. Nocturia decreased post-intervention (11 [33%], p=.011) and at 3-month follow-up (7 [25%], p=. 002 vs. baseline). Degree of bother mean scores decreased from baseline to post-intervention (1.43 vs. 0.75, p=.014) and 3-month follow-up (1.56 vs. 0.89, p=.031). Conclusions: Nocturia frequency and degree of bother improve with behavioral interventions for insomnia. These results suggest that a sleep-focused, non-pharmacological strategy for treating nocturia may be effective and indicate a need for a trial examining such a strategy.

Background: Current treatment for insomnia does not address the complex comorbidity associated with insomnia in older adults. The purpose of this study was to identify comorbid conditions and symptoms among older US Veterans with insomnia.