Insomnia is common in the older population, over 50% of older adults have sleep complaints, and 20-40% are reported to have insomnia. In HK, 38% of adults have reported insomnia. Insomnia is associated with increased mortality and morbidity. As the worldwide population continues to age, insomnia in older adults will increasingly cause substantial economic burdens on healthcare systems and society. Cognitive behavioral therapy for insomnia (CBT-I) is currently the first-line clinically recommended non-pharmacological treatment for insomnia in older persons. Our group has been actively studying the health-enhancing effects of tai chi. Tai chi has various health benefits including fall prevention, osteoarthritis management, cardiorespiratory fitness and improvement of sleep. In the present study, the investigators want to validate the clinical effectiveness of tai chi on improving insomnia in older adults. This study aims to exam whether three months of CBT-I or three months of tai chi have similar robust effects in treating insomnia in older adults. The investigators want to validate the clinical effectiveness of tai chi on improving insomnia in older adults. The CBT-I and tai chi classes will be held twice a week with each lasting for 60 mins. The treatment is three months with 12-month follow-up. The primary outcome of this study is the insomnia severity index (ISI) score at post-intervention measure, which examining sleep-onset and sleep maintenance difficulties, satisfaction with current sleep pattern, inference with daily functioning.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
SINGLE
Enrollment
200
Mind-body exercise intervention
First-line clinically recommended non-pharmacological treatment of insomnia
School of Public Health, The University of Hong Kong
Hong Kong, Hong Kong
Insomnia Severity Index (ISI)
ISI will be used to assess the perceived insomnia severity. ISI has seven items examining sleep-onset and sleep maintenance difficulties, satisfaction with the current sleep pattern, interference with daily functioning, noticeable impairment due to sleep problems, degree of distress, and concerns caused by sleep problems. All 160 participants will complete this subjective questionnaire in paper-pencil based manner.
Time frame: 3-month follow-up
Insomnia Severity Index (ISI)
ISI will be used to assess the perceived insomnia severity. ISI has seven items examining sleep-onset and sleep maintenance difficulties, satisfaction with the current sleep pattern, interference with daily functioning, noticeable impairment due to sleep problems, degree of distress, and concerns caused by sleep problems. All 160 participants will complete this subjective questionnaire in paper-pencil based manner.
Time frame: 15-month follow-up
Remission of Chronic Insomnia-Semi-Structured Interview
The DSM-5 criteria for chronic insomnia will be used to assess the remission of chronic insomnia. All 160 participants will be led by research personnel to complete the brief insomnia questionnaire in a semi-structured interview.
Time frame: 3-month follow-up and 15-month follow-up
Treatment Response-Insomnia Severity Index (ISI)
Treatment response is defined as a decrease in the Insomnia Severity Index (ISI) by at least 8 points, which indicates marked improvement or nearly complete or complete remission of insomnia symptoms.
Time frame: 3-month follow-up and 15-month follow-up
7-day Actigraphy
A wrist actigraph (wGT3X-BT, Actigraph; a 3-axis accelerometer waterproof watch-like device) that detects movement or lack of movement correlating with wakefulness and sleep, respectively, will be used to objectively estimate sleep. All 160 participants will be instructed to wear an actigraph on the non-dominant wrist for 24 hours per day for 7 days. Actigraphic data will be analyzed by the ActiLifeV6.11.7 software to determine the sleep efficiency.
Time frame: 3-month follow-up and 15-month follow-up
7-day Sleep Diary
All 160 participants will be instructed to record their sleep pattern each morning for 7 days using the provided log sheet that records information on bedtime, sleep rising time, total time in bed (TIB), sleep-onset latency (SOL), wake time after sleep onset (WASO), and total sleep time (TST). Sleep efficiency (SE) is estimated as TST/TIB x 100%.
Time frame: 3-month follow-up and 15-month follow-up
Pittsburgh Sleep Quality Index (PSQI)
PSQI is a standardized instrument to estimate sleep quantity and quality. There are 19 items that subjectively assess sleep quantity, perceived restfulness, and disturbance of sleep by gathering information on usual bedtime, wake time, time to fall asleep, time of actual sleep, and quality of sleep. All 160 participants will be asked to complete this questionnaire in paper-pencil based manner.
Time frame: 3-month follow-up and 15-month follow-up
Sleep Medication Record
The use of sleep aid medications such as narcotics, antihistamines (diphenhydramine), benzodiazepines (e.g., flurazepam, etc), non-benzodiazepine, and benzodiazepine receptor agonists (e.g., zolpidem, etc) with detailed usage information (e.g., drug name, type, dose, and weekly frequency) will be recorded. All 160 participants will be asked to provide the dose and frequency of any sleep medications used by responding to a checklist of all available sleep medications. Data on medication dose and weekly frequency will be presented as the total number of lowest recommended dose (LRD) in 7 days.
Time frame: 3-month follow-up and 15-month follow-up
Quality of Life by Standard SF-12 Health Survey (SF12v2)
The Chinese version SF-12, derived from the SF-36, will be used to measure health-related quality of life. There are 12 items assessing physical functioning, emotional and mental health, bodily pain, general health, vitality, and social functioning, with higher overall scores indicating a better quality of life. The Chinese version SF- 12 has been validated in the Hong Kong Chinese population. All 160 participants will be asked to complete this questionnaire in paper-pencil based manner.
Time frame: 3-month follow-up and 15-month follow-up
Mental Health by Hospital Anxiety and Depression Scale (HADS)
Hospital Anxiety and Depression Scale (HADS) will be used to evaluate the severity of depression and anxiety. This 7-item questionnaire has an overall score ranging from 0 to 21 (with subscales for both anxiety and depression), with a higher score indicating more severe symptoms. All 160 participants will be asked to complete this questionnaire in paper-pencil based manner.
Time frame: 3-month follow-up and 15-month follow-up
Balance and Lower Extremity Function by Short Physical Performance Battery (SPPB)
SPPB will be used to assess balance and lower extremity function. SPPB includes repeated timed chair stands, timed standing balance (with feet in parallel, semi-tandem, and tandem positions), and a 4-meter walk to measure the usual gait speed. These outcomes will objectively validate the receipt of the tai chi intervention based on the known benefits of tai chi on balance and lower extremity performance. The investigators will assess the balance and lower extremity function during the baseline measurement.
Time frame: 3-month follow-up and 15-month follow-up
Adverse Events
Adverse events (such as injuries related to interventions or not) will be closely monitored and recorded through regular surveys by instructors and research personnel, and by voluntary reports from the subjects. Subjects with sustained serious adverse events that affect their daily function will terminate the study, but their data will be included in our ITT analyses.
Time frame: 3-month follow-up and 15-month follow-up
Habitual Physical Activity
Potential confounding factors including changes in habitual physical activity will be monitored. The habitual physical activity will be assessed by the international physical activity questionnaire and 7-day actigraph.
Time frame: 3-month follow-up and 15-month follow-up
Dietary Intake
The diet will be assessed by a 3-day food diary. The research personnel will explain how to fill a 3-day food diary and all 160 participants will be asked to complete these 3 measurements
Time frame: 3-month follow-up and 15-month follow-up
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