Practical Integration of Actigraphy with Cognitive Behavioral Therapy for Insomnia

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Practical Integration of Actigraphy with
Cognitive Behavioral Therapy for Insomnia
Dr. Derek Loewy, Ph.D.
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Overview

• Background information
• Cognitive behavioral therapy for insomnia (CBTI)
• Sleep diaries
• Actigraphy
• How actigraphy can enhance CBTI
• Sample actograms
• Program content overview
• Fitting actigraphy into the CBTI session
• Actigraphy/CBTI reimbursement update

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CBTI Basics

• Clinically effective, behaviorally-based approach
  to improve sleep for patients with
  insomnia
• Delivered individually or in groups
• Helps optimize the potential for good sleep,
  improve sleep quality, and improve daytime
  alertness through education and practice
• Multi-component incorporates behavioral and
  cognitive techniques delivered over weekly
  sessions (typically four-eight)
• Effectiveness of CBTI is highly dependent on
  patient compliance

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CBTI program from Philips Respironics

• Brief, four-session, CBTI program incorporating
  conventional interventions
• sleep hygiene
• sleep restriction
• stimulus control
• Integration of actigraphy as a central
  therapeutic assessment tool

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Sleep diary use in CBTI

• Useful and important component of the therapy
• Completed and tracked through therapy using paper
  and pen
• Patients perspective on sleep/wake pattern
• Informative for the patient and the therapist
  regarding sleep perceptions
• Input on progress, compliance, and therapeutic
  adjustments
• Limitations
• Entirely subjective
• Retrospective completion and recall errors
• Contradictory data
• Requires time-consuming, manual computation of
  sleep/wake data

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Actiwatch
Adds valuable quantitative and qualitative
elements to help compensate for sleep diary
limitations.

• Wrist-worn recording device
• Activity (accelerometer)
• Ambient light
• Event marking
• Designed to be worn 24/7
• Multiple-week recording time

Automated creation of a clinicians report with
objective information about the rest/activity
patterns to evaluate along with diary input and
self-report.
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Using Actiwatch to enhance a CBTI program

• Statistics rapid, automated, computation of key
  sleep variables (TST, WASO, SOL, sleep
  efficiency, etc.) presented in concise tabular
  format
• Objective data that can be compared with diaries
• Weekly and change from baseline data
• Automation reduces time to make sleep scheduling
  calculations
• Data contradictions reduced when compared with
  diaries

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Using Actiwatch to enhance a CBTI program (Cont.)

• Actogram a continuous, longitudinal picture
  of in vivo rest and activity behavior
• Visual, qualitative depiction of sleep/wake
  activity
• Weekly feedback to the patient
• Therapist and patient can collectively identify
  critical aspects of sleep/wake behavior
  (circadian rhythmicity, sleep consolidation,
  sleep schedule regularity, and napping)

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Example actogram 1
Rhythmicity?
Consolidation?
Regularity?
Napping?
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Example actogram 2
Rhythmicity?
Consolidation?
Regularity?
Napping?
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Integrating Actiwatch into the CBTI program

• Preparation for program
• Provide to the patient at least one week
  before Session 1 along with a sleep diary
• Before each session
• Retrieve data (one-two minutes)
• Generate clinicians report and review data
  (three-five minutes)

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Integrating Actiwatch into the CBTI program
(Cont.)

• During each session
• Review previous weeks sleep diary and actigraphy
  data
• Patient feedback rhythmicity, consolidation,
  regularity and napping
• Compliance review adjust/troubleshoot as needed
• Review/modify sleep restriction plan
• Preparation for the next session
• Reconfigure (one-two minutes)
• Recharge (if needed during the session)
• Return device to the patient

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Reimbursement

• Insurance coverage for actigraphy and CBTI are
  variable
• 95803 code for actigraphy
• EM codes for office visits, etc.
• Individual or group psychotherapy codes
• Health and behavior (HB) codes for assessment
  and treatment
• Roughly 30 of patients have coverage for CBTI
• Nationwide clarification of reimbursement rates
  for actigraphy July 2009
• Out-of-pocket approach may be the most cost
  effective
• Group therapy will be appealing from a cost
  perspective
• 500-1200 for CBTI depending upon the number of
  sessions and time

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