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1.  Sleep Disorders in the Older Adult – A Mini-Review 
Gerontology  2009;56(2):181-189.
Approximately 50% of older adults complain of difficulty sleeping. Poor sleep results in increased risk of significant morbidity and mortality. The decrements seen in the sleep of the older adult are often due to a decrease in the ability to get needed sleep. However, the decreased ability is less a function of age and more a function of other factors that accompany aging, such as medical and psychiatric illness, increased medication use, advances in the endogenous circadian clock and a higher prevalence of specific sleep disorders. Given the large number of older adults with sleep complaints and sleep disorders, there is a need for health care professionals to have an increased awareness of these sleep disturbances to better enable them to assess and treat these patients. A thorough sleep history (preferably in the presence of their bed partner) is required for a proper diagnosis, and when appropriate, an overnight sleep recording should be done. Treatment of primary sleep problems can improve the quality of life and daytime functioning of older adults. This paper reviews the diagnoses and characteristics of sleep disorders generally found in the older adult. While aimed at the practicing geriatrician, this paper is also of importance for any gerontologist interested in sleep.
doi:10.1159/000236900
PMCID: PMC2842167  PMID: 19738366
Sleep disorders; Circadian rhythms; Insomnia
2.  Prevalence and correlates of sleep disturbance in systemic sclerosis—results from the UCLA scleroderma quality of life study 
Rheumatology (Oxford, England)  2011;50(7):1280-1287.
Objective. Rheumatologic disorders are associated with sleep disturbances. This study examines sleep disturbance correlates in patients with SSc.
Methods. Participants are 180 SSc patients in an observational study. At baseline, patients completed the Medical Outcomes Study Sleep measure (MOS-Sleep scale). In addition, patients were administered other patient-reported outcome (PRO) measures including the 36-item short form (SF-36), HAQ disability index (HAQ-DI), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue), Center for Epidemiologic Studies Depression (CESD) scale and a University of California at Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract Questionnaire (UCLA SCTC GIT 2.0). Descriptive statistics were assessed for six scales of MOS-Sleep and the 9-item sleep problem index (SLP-9; a composite index). We computed Spearman’s rank-order correlations between the MOS-Sleep scales and the HAQ-DI, FACIT-Fatigue, CESD, SSc-SCTC GIT 2.0 and SF-36 scales. In addition, we developed a regression model to assess predictors of SLP-9 scores. Covariates included demographics, physician variables of disease severity and patient-reported variables of worsening symptoms and the PRO measures.
Results. SSc patients reported a mean (s.d.) of 7.1 (1.73) h of sleep a night. Patients reported worse scores on four of six scales (except for snoring and sleep quantity) compared with the US general population (P < 0.001). SLP-9 was correlated with worsening pain and dyspnoea over the past 1 month, reflux scale of the UCLA SCTC GIT 2.0, CESD and FACIT-Fatigue (ρ 0.26–0.56). In the stepwise multivariate regression model, the CESD, worsening dyspnoea and reflux scale were significantly associated with SLP-9 index.
Conclusion. Sleep disturbances are common in SSc and are associated with worsening dyspnoea, depressed mood and severity of reflux symptoms.
doi:10.1093/rheumatology/ker020
PMCID: PMC3116211  PMID: 21324979
Systemic sclerosis; Scleroderma; Sleep; Depression; Gastroesophageal reflux; Quality of life; SF-36; HAQ disability index (HAQ-DI); Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue); Center for Epidemiologic Studies Depression (CESD) scale; University of California at Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract Questionnaire (UCLA SCTC GIT 2.0)
3.  Circadian rhythm sleep disorders in patients with multiple sclerosis and its association with fatigue: A case-control study 
Background:
Circadian rhythm sleep disorders are a presentation of sleep disorders in patients with multiple sclerosis (MS). This study aims to compare this problem in MS patients with healthy people and to determine its association with chronic fatigue in MS patients.
Materials and Methods:
A case-control study was performed on 120 MS patients and 60 healthy subjects matched for age and sex, in 2009 in MS Clinic Alzahra Hospital. Sleep quality, rhythm and fatigue severity were assessed using PSQI (Pittsburgh sleep quality index) and FSS (Fatigue severity Scale) questionnaires, respectively. Its reliability and validity has been confirmed in several studies (Cronbach's alpha = 0.83). This index has seven sections including patient's assessment of his/her sleep, sleep duration, efficacy of routine sleep, sleep disorders, use of hypnotic medication, and dysfunction in daily activities.
Results:
Circadian rhythm sleep disorder was more frequent in MS patients relative to healthy subjects (P: 0.002). It was higher in MS patients with severe fatigue relative to MS patients with mild fatigue (P: 0.05). Fatigue severity was 49.9 ± 8.2 and 22.5 ± 7.4 in the first and second group, respectively. PSQI index was 7.9 ± 4.5 in patients with severe fatigue and 5.9 ± 4.5 in patients with mild fatigue and 4.5 ± 2.4 in the control group (P: 0.0001).
Conclusion:
Circadian rhythm sleep disorders are more frequent in MS patients and those with fatigue. Recognition and management of circadian rhythm sleep disorders in MS patients, especially those with fatigue may be helpful in improving care of these patients.
PMCID: PMC3743326  PMID: 23961292
Chronic fatigue; circadian rhythm sleep disorder; fatigue severity scale; multiple sclerosis; Pittsburg sleep quality index
4.  SLEEP DISTURBANCES IN LONG-TERM CARE 
Clinics in geriatric medicine  2008;24(1):39-vi.
SYNOPSIS
Nighttime sleep disruption is characteristic of long-term care residents, is typically accompanied by daytime sleepiness and may be caused by a multitude of factors. Causal factors include medical and psychiatric illness, medications, circadian rhythm abnormalities, sleep disordered breathing and other primary sleep disorders, environmental factors and lifestyle habits. There is some suggestion that these factors are amenable to treatment; however, further research on the implementation of treatments within the long-term care setting is needed. Additional work is also needed to understand the administrative and policy factors that might lead to systemic changes in how sleep is viewed and sleep problems are addressed in long-term care settings.
A growing number of older adults reside in long-term care facilities. In this setting, residents commonly suffer from nighttime sleep disruption, which is often accompanied by daytime sleepiness and may be caused by a multitude of factors. Importantly, sleep disturbance is associated with negative health outcomes, including risk for falling, and elevated mortality risk among long-term care residents. A number of factors contribute to sleep disturbance in the long-term care setting including medical and psychiatric illness, medications, circadian rhythm abnormalities, sleep disordered breathing and other primary sleep disorders, environmental conditions (e.g., noise and light) and lifestyle habits. Based on research with older adults in the community and work conducted within long-term care settings, there is some suggestion that these factors are amenable to nonpharmacological treatments. Further research on the broad implementation of treatments for sleep problems within the long-term care setting is still needed. Additional work is also needed to understand the administrative and policy factors that might lead to systemic changes in how sleep is viewed and sleep problems are addressed in long-term care settings.
doi:10.1016/j.cger.2007.08.001
PMCID: PMC2215778  PMID: 18035230
long; term care; dementia; circadian rhythms; sleep disorders
5.  Sleep Disturbances Associated with Parkinson's Disease 
Parkinson's Disease  2011;2011:219056.
Sleep disturbances are common problems affecting the quality life of Parkinson's disease (PD) patients and are often underestimated. The causes of sleep disturbances are multifactorial and include nocturnal motor disturbances, nocturia, depressive symptoms, and medication use. Comorbidity of PD with sleep apnea syndrome, restless legs syndrome, rapid eye movement sleep behavior disorder, or circadian cycle disruption also results in impaired sleep. In addition, the involvement of serotoninergic, noradrenergic, and cholinergic neurons in the brainstem as a disease-related change contributes to impaired sleep structures. Excessive daytime sleepiness is not only secondary to nocturnal disturbances or dopaminergic medication but may also be due to independent mechanisms related to impairments in ascending arousal system and the orexin system. Notably, several recent lines of evidence suggest a strong link between rapid eye movement sleep behavior disorder and the risk of neurodegenerative diseases such as PD. In the present paper, we review the current literature concerning sleep disorders in PD.
doi:10.4061/2011/219056
PMCID: PMC3159123  PMID: 21876839
6.  A Review on Genetics of Sleep Disorders 
One-third of population deal with sleep disorders which might be due to social, economic or medical problems. Studies on twins have indicated the role of genetic factors in these disorders. Monozygotic twins have a very similar hypnogram. A higher prevalence of some sleep disorders is reported in relatives of the patients with these disorders. Genes also affect sleep disorders as well as some other disorders at the same time. Sleep disorders can also influence the level of the personal and social functioning. Recent genetic advances have clarified the role of different genes in sleep disorders. The purpose of this article is to present a brief review about the role of genetic factors in some of the sleep disorders.
PMCID: PMC3939950  PMID: 24644464
Gene; Genetic study; Sleep disorders
7.  Prevalence of sleep deprivation in patients with chronic neck and back pain: a retrospective evaluation of 1016 patients 
Background
Chronic low back pain (CLBP) and chronic neck pain (CNP) have become a serious medical and socioeconomic problem in recent decades. Patients suffering from chronic pain seem to have a higher prevalence of sleep disorders.
Purpose
To calculate the prevalence of sleep deprivation in patients with CLBP and CNP and to evaluate the factors that may contribute to sleep impairment.
Methods
This study was a retrospective evaluation of 1016 patients with CNP and CLBP who consulted an orthopedic department at a university hospital. Factors assessed were gender, age, diagnosis, grade of sleep deprivation, pain intensity, chronification grade, and migrational background. Pearson’s chi-squared test was performed to calculate the relationship between these factors and the grade of sleep deprivation. Regression analysis was performed to explore the correlation between the grade of sleep deprivation and age, pain intensity, and chronification grade.
Results
A high prevalence of sleep deprivation (42.22%) was calculated in patients with CNP and CLBP, even when analgesics had been taken. About 19.88% of the patients reported serious sleep impairments (ie, <4 hours of sleep per night). The grade of sleep deprivation did not correlate with the gender or age distribution. A significant relationship was found between the grade of sleep deprivation and pain intensity, failed back surgery syndrome, and patients with a migrational background. There was a moderate relationship with intervertebral disc disease and no relationship with spinal stenosis.
Conclusion
Sleep disturbance should be assessed when treating patients with CNP or CLBP, especially in patients with higher pain intensity, failed back surgery syndrome, and a migrational background. Further research is needed to explore the complex relationship of sleep disturbance and chronic pain.
doi:10.2147/JPR.S36386
PMCID: PMC3536352  PMID: 23300350
sleep disturbance; impairment; chronic low back pain; failed back surgery; disc disease; spinal stenosis; spondylolisthesis; migrational background; prevalence
8.  Current Treatments for Sleep Disturbances in Individuals With Dementia 
Current psychiatry reports  2009;11(1):20-26.
Sleep disturbances are widespread among older adults. Degenerative neurologic disorders that cause dementia, such as Alzheimer's disease and Parkinson's disease, exacerbate age-related changes in sleep, as do many common comorbid medical and psychiatric conditions. Medications used to treat chronic illness and insomnia have many side effects that can further disrupt sleep and place patients at risk for injury. This article reviews the neurophysiology of sleep in normal aging and sleep changes associated with common dementia subtypes and comorbid conditions. Current pharmacologic and nonpharmacologic evidence-based treatment options are discussed, including the use of light therapy, increased physical and social activity, and multicomponent cognitive-behavioral interventions for improving sleep in institutionalized and community-dwelling adults with dementia.
PMCID: PMC2649672  PMID: 19187704
9.  Clinical diagnosis and misdiagnosis of sleep disorders 
Sleep disorders are common in all sections of the population and are either the main clinical complaint or a frequent complication of many conditions for which patients are seen in primary care or specialist services. However, the subject is poorly covered in medical education. A major consequence is that the manifestations of the many sleep disorders now identified are likely to be misinterpreted as other clinical conditions of a physical or psychological nature, especially neurological or psychiatric disorders. To illustrate this problem, examples are provided of the various possible causes of sleep loss, poor quality sleep, excessive daytime sleepiness and episodes of disturbed behaviour at night (parasomnias). All of these sleep disorders can adversely affect mental state and behaviour, daytime performance or physical health, the true cause of which needs to be recognised by clinicians to ensure that appropriate treatment is provided. As conventional history taking in neurology and psychiatry pays little attention to sleep and its possible disorders, suggestions are made concerning the enquiries that could be included in history taking schedules to increase the likelihood that sleep disorders will be correctly identified.
doi:10.1136/jnnp.2006.111179
PMCID: PMC2095611  PMID: 18024690
10.  Sleep and Culture in Children with Medical Conditions 
Journal of Pediatric Psychology  2010;35(9):915-926.
Objectives To provide an integrative review of the existing literature on the interrelationships among sleep, culture, and medical conditions in children. Methods A comprehensive literature search was conducted using PubMed, Medline, and PsychINFO computerized databases and bibliographies of relevant articles. Results Children with chronic illnesses experience more sleep problems than healthy children. Cultural beliefs and practices are likely to impact the sleep of children with chronic illnesses. Few studies have examined cultural factors affecting the relationship between sleep and illness, but existing evidence suggests the relationship between sleep and illness is exacerbated for diverse groups. Conclusions Sleep is of critical importance to children with chronic illnesses. Cultural factors can predispose children both to sleep problems and to certain medical conditions. Additional research is needed to address the limitations of the existing literature, and to develop culturally sensitive interventions to treat sleep problems in children with chronic illnesses.
doi:10.1093/jpepsy/jsq016
PMCID: PMC3708537  PMID: 20332222
children; chronic illness; culture; ethnicity; sleep
11.  Effect of lisdexamfetamine dimesylate on sleep in adults with attention-deficit/hyperactivity disorder 
Background
Sleep problems are common in adults with attention-deficit/hyperactivity disorder (ADHD). This analysis aimed to evaluate the impact of lisdexamfetamine dimesylate (LDX) on sleep quality in adults with ADHD.
Methods
This 4-week, phase 3, double-blind, forced-dose escalation study of adults aged 18 to 55 years with ADHD randomized participants to receive placebo (n = 62), or 30 (n = 119), 50 (n = 117), or 70 (n = 122) mg/d LDX, taken once a day in the morning. The self-rated Pittsburgh Sleep Quality Index (PSQI) was administered at baseline and at week 4 to assess sleep quality. The PSQI global score assesses 7 sleep components (subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction) each scored from 0 (no difficulty) to 3 (severe difficulty).
Results
The mean baseline PSQI global score was 5.8 for LDX and 6.3 for placebo (P = .19) indicating poor overall sleep quality. At endpoint, least squares (LS) mean change from baseline was -0.8 for LDX vs -0.5 for placebo (P = .33). The daytime functioning component showed significant improvement in LS mean change at endpoint for LDX compared with placebo (LDX -0.4 vs placebo 0.0, P = .0001). LS mean changes for the other 6 PSQI components did not significantly differ from placebo. Sleep-related treatment-emergent adverse events with an incidence ≥2% in the active treatment and placebo groups, respectively, were insomnia (19.3% and 4.8%), initial insomnia (5.0% and 3.2%), middle insomnia (3.6% and 0%), sleep disorder (0.6% and 3.2%), somnolence (0.3% and 3.2%), and fatigue (4.7% and 4.8%), and were generally mild or moderate in severity.
Conclusion
For most subjects, LDX was not associated with an overall worsening of sleep quality and significantly improved daytime functioning in adults with ADHD.
Trial Registration
clinicaltrials.gov Identifier: NCT00334880
doi:10.1186/1744-9081-5-34
PMCID: PMC2732626  PMID: 19650932
12.  Sleep and aging: 1. Sleep disorders commonly found in older people 
Aging is associated with several well-described changes in patterns of sleep. Typically, there is a phase advance in the normal circadian sleep cycle: older people tend to go to sleep earlier in the evening but also to wake earlier. They may also wake more frequently during the night and experience fragmented sleep. The prevalence of many sleep disorders increases with age. Insomnia, whether primary or secondary to coexistant illness or medication use, is very common among elderly people. Rapid eye movement (REM) sleep behaviour disorder and narcolepsy, although less common, are frequently not considered for this population. Periodic leg-movement disorder, a frequent cause of interrupted sleep, can be easily diagnosed with electromyography during nocturnal polysomnography. Restless legs syndrome, however, is diagnosed clinically. Snoring is a common sleep-related respiratory disorder; so is obstructive sleep apnea, which is increasingly seen among older people and is significantly associated with cardio-and cerebrovascular disease as well as cognitive impairment.
doi:10.1503/cmaj.060792
PMCID: PMC1852874  PMID: 17452665
13.  Prevalence of sleep problems in individuals with multiple sclerosis 
Background
Sleep disturbance in multiple sclerosis has received little research attention despite the potential influence it may have on disease impact.
Objective
To estimate the prevalence of sleep disorders in a large community sample of individuals with multiple sclerosis.
Methods
A cross-sectional self-report survey of 1063 persons with multiple sclerosis. Sleep was assessed using the Women’s Health Initiative Insomnia Rating Scale and Medical Outcomes Study Sleep measure.
Results
The prevalence of sleep problems in multiple sclerosis is significantly higher than in the general population or other chronic diseases and may affect women with multiple sclerosis more than men.
Conclusion
Sleep disturbance should routinely be evaluated in patients with multiple sclerosis and new interventions developed.
doi:10.1177/1352458508092807
PMCID: PMC2845464  PMID: 18632776
insomnia; medical outcomes study sleep measure; multiple sclerosis; sleep adequacy; sleep disturbance; women’s health initiative insomnia rating scale
14.  Sleep Deprivation in Critical Illness: Its Role in Physical and Psychological Recovery 
Critically ill patients frequently experience poor sleep, characterized by frequent disruptions, loss of circadian rhythms, and a paucity of time spent in restorative sleep stages. Factors that are associated with sleep disruption in the intensive care unit (ICU) include patient-ventilator dysynchrony, medications, patient care interactions, and environmental noise and light. As the field of critical care increasingly focuses on patients' physical and psychological outcomes following critical illness, understanding the potential contribution of ICU-related sleep disruption on patient recovery is an important area of investigation. This review article summarizes the literature regarding sleep architecture and measurement in the critically ill, causes of ICU sleep fragmentation, and potential implications of ICU-related sleep disruption on patients' recovery from critical illness. With this background information, strategies to optimize sleep in the ICU are also discussed.
doi:10.1177/0885066610394322
PMCID: PMC3299928  PMID: 21220271
sleep; sleep deprivation; intensive care unit; mental health; outcomes
15.  Sleep fragmentation elevates behavioral, electrographic and neurochemical measures of sleepiness 
Neuroscience  2007;146(4):1462-1473.
Sleep fragmentation, a feature of sleep apnea as well as other sleep and medical/psychiatric disorders, is thought to lead to excessive daytime sleepiness. A rodent model of sleep fragmentation was developed (termed sleep interruption, SI), where rats were awakened every 2 min by the movement of an automated treadmill for either 6 or 24 h of exposure. The sleep pattern of rats exposed to 24h of SI resembled sleep of the apneic patient in the following ways: sleep was fragmented (up to 30 awakening/h), total REM sleep time was greatly reduced, NREM sleep episode duration was reduced (from 2 min, 5 s baseline to 58 s during SI), whereas the total amount of NREM sleep time per 24h approached basal levels. Both 6 and 24 h of SI made rats more sleepy, as indicated by a reduced latency to fall asleep upon SI termination. Electrographic measures in the recovery sleep period following either 6 or 24 h of SI also indicated an elevation of homeostatic sleep drive; specifically, the average NREM episode duration increased (e.g., for 24 h SI, from 2 min, 5 s baseline to 3 min, 19 s following SI), as did the NREM delta power during recovery sleep. Basal forebrain (BF) levels of extracellular adenosine (AD) were also measured with microdialysis sample collection and HPLC detection, as previous work suggests that increasing concentrations of BF AD are related to sleepiness. BF AD levels were significantly elevated during SI, peaking at 220% of baseline during 30 h of SI exposure. These combined findings imply an elevation of the homeostatic sleep drive following either 6 or 24 h of SI, and BF AD levels appear to correlate more with sleepiness than with the cumulative amount of prior wakefulness, since total NREM sleep time declined only slightly. SI may be partially responsible for the symptom of daytime sleepiness observed in a number of clinical disorders, and this may be mediated by mechanisms involving BF AD.
doi:10.1016/j.neuroscience.2007.03.009
PMCID: PMC2156190  PMID: 17442498
adenosine; sleep; EEG (electroencephalogram); rat; microdialysis; forebrain; homeostasis; apnea; delta; sleep latency
16.  Beyond fatigue: Assessing variables associated with sleep problems and use of sleep medications in multiple sclerosis 
Clinical Epidemiology  2010;2:99-106.
Background:
Recent research indicates that sleep disturbances are common in persons with multiple sclerosis (MS), though research to date has primarily focused on the relationship between fatigue and sleep. In order to improve treatment of sleep disorders in MS, a better understanding of other factors that contribute to MS sleep disturbance and use of sleep medications in this population is needed.
Methods:
Individuals with MS (N = 473) involved in an ongoing self-report survey study were asked to report on use of over-the-counter and prescription sleep medications. Participants completed the Medical Outcomes Study Sleep (MOSS) scale and other common self-report symptom measures. Multiple regression was used to evaluate factors associated with sleep problems and descriptive statistics were generated to examine use of sleep medications.
Results:
The mean score on the MOSS scale was 35.9 (standard deviation, 20.2) and 46.8% of the sample had moderate or severe sleep problems. The majority of participants did not use over-the-counter (78%) or prescription (70%) sleep medications. In a regression model variables statistically significantly associated with sleep problems included depression, nighttime leg cramps, younger age, pain, female sex, fatigue, shorter duration of MS, and nocturia. The model explained 45% of the variance in sleep problems. Of the variance explained, depression accounted for the majority of variance in sleep problems (33%), with other variables explaining significantly less variance.
Conclusions:
Regression results indicate that fatigue may play a minor role in sleep disturbance in MS and that clinicians should consider the interrelationship between depression and sleep problems when treating either symptom in this population. More research is needed to explore the possibility of under-treatment of sleep disorders in MS and examine the potential effectiveness of nonpharmaceutical treatment options.
PMCID: PMC2936768  PMID: 20838467
multiple sclerosis; sleep; depression; fatigue; nonpharmaceutical treatments; self-medication
17.  Beyond fatigue: Assessing variables associated with sleep problems and use of sleep medications in multiple sclerosis 
Clinical epidemiology  2010;2010(2):99-106.
Background
Recent research indicates that sleep disturbances are common in persons with multiple sclerosis (MS), though research to date has primarily focused on the relationship between fatigue and sleep. In order to improve treatment of sleep disorders in MS, a better understanding of other factors that contribute to MS sleep disturbance and use of sleep medications in this population is needed.
Methods
Individuals with MS (N = 473) involved in an ongoing self-report survey study were asked to report on use of over-the-counter and prescription sleep medications. Participants completed the Medical Outcomes Study Sleep (MOSS) scale and other common self-report symptom measures. Multiple regression was used to evaluate factors associated with sleep problems and descriptive statistics were generated to examine use of sleep medications.
Results
The mean score on the MOSS scale was 35.9 (standard deviation, 20.2) and 46.8% of the sample had moderate or severe sleep problems. The majority of participants did not use over-the-counter (78%) or prescription (70%) sleep medications. In a regression model variables statistically significantly associated with sleep problems included depression, nighttime leg cramps, younger age, pain, female sex, fatigue, shorter duration of MS, and nocturia. The model explained 45% of the variance in sleep problems. Of the variance explained, depression accounted for the majority of variance in sleep problems (33%), with other variables explaining significantly less variance.
Conclusions
Regression results indicate that fatigue may play a minor role in sleep disturbance in MS and that clinicians should consider the interrelationship between depression and sleep problems when treating either symptom in this population. More research is needed to explore the possibility of under-treatment of sleep disorders in MS and examine the potential effectiveness of nonpharmaceutical treatment options.
doi:10.2147/CLEP.S10425
PMCID: PMC2936768  PMID: 20838467
multiple sclerosis; sleep; depression; fatigue; nonpharmaceutical treatments; self-medication
18.  Sleep Disturbances in Parkinson’s Disease 
Sleep disturbances are very common in patients with PD and are associated with a variety of negative outcomes. The evaluation of sleep disturbances in these patients is complex, as sleep may be affected by a host of primary sleep disorders, other primary medical or psychiatric conditions, reactions to medications, aging or the neuropathophysiology of PD itself. In this article we review the evaluation of the common disturbances of sleep seen in PD. This includes the primary sleep disorders, the interaction of depression and insomnia, the impact that medications for PD have on sleep, as well as the role of factors such as nocturia, pain, dystonia, akinesia, difficulty turning in bed and vivid dreaming. The treatment of sleep disturbances in PD is largely unstudied but recommendations based on clinical experience in PD and research studies in other geriatric populations can be made. Important principles include, diagnosis, treating the specific sleep disorder or co-occurring disorder, and control of the motor aspects of PD.
doi:10.1002/mds.22788
PMCID: PMC2840057  PMID: 20187236
19.  Sleep Problems in Children and Adolescents with Common Medical Conditions 
Synopsis
Sleep is critically important to children’s health and well-being. Untreated sleep disturbances and sleep disorders pose significant adverse daytime consequences and place children at considerable risk for poor health outcomes. Sleep disturbances occur at a greater frequency in children with acute and chronic medical conditions compared to otherwise healthy peers. Sleep disturbances in medically ill children can be associated with sleep disorders (e.g., sleep disordered breathing, restless leg syndrome), co-morbid with acute and chronic conditions (e.g., asthma, arthritis, cancer), or secondary to underlying disease-related mechanisms (e.g. airway restriction, inflammation) treatment regimens, or hospitalization. Clinical management should include a multidisciplinary approach with particular emphasis on routine, regular sleep assessments and prevention of daytime consequences and promotion of healthy sleep habits and health outcomes.
doi:10.1016/j.pcl.2011.03.012
PMCID: PMC3100529  PMID: 21600350
Sleep; pediatric; chronic illness
20.  Evaluation and Management of Sleep Disturbance During the Menopause Transition 
Seminars in reproductive medicine  2010;28(5):404-421.
Sleep disturbances in midlife women are common and have been associated with the menopause transition itself, symptoms of hot flashes, anxiety and depressive disorders, aging, primary sleep disorders (i.e., obstructive sleep apnea, periodic limb movement disorder), comorbid medical conditions and medications, as well as with psychosocial and behavioral factors. Because there are several common sources of sleep problems in midlife women, the cause of an individual woman's sleep disturbance may be multifactorial. Effective behavioral and pharmacological therapies are available to treat sleep disturbances of different etiologies. This review provides an overview of different types of sleep disturbance occurring in midlife women and presents data supporting the use of hormone therapy, hypnotic agents, and behavioral strategies to treat sleep problems in this population. The review aims to equip clinicians evaluating menopause-age women with the knowledge and evaluation tools to diagnose, engage sleep experts where appropriate, and treat sleep disturbance in this population. Sleep disorders in midlife women should be treated because substantial improvements in quality of life and health outcomes are achievable.
doi:10.1055/s-0030-1262900
PMCID: PMC3736837  PMID: 20845239
21.  Circadian-Related Sleep Disorders and Sleep Medication Use in the New Zealand Blind Population: An Observational Prevalence Survey 
PLoS ONE  2011;6(7):e22073.
Study Objectives
To determine the prevalence of self-reported circadian-related sleep disorders, sleep medication and melatonin use in the New Zealand blind population.
Design
A telephone survey incorporating 62 questions on sleep habits and medication together with validated questionnaires on sleep quality, chronotype and seasonality.
Participants
Participants were grouped into: (i) 157 with reduced conscious perception of light (RLP); (ii) 156 visually impaired with no reduction in light perception (LP) matched for age, sex and socioeconomic status, and (iii) 156 matched fully-sighted controls (FS).
Sleep Habits and Disturbances
The incidence of sleep disorders, daytime somnolence, insomnia and sleep timing problems was significantly higher in RLP and LP compared to the FS controls (p<0.001). The RLP group had the highest incidence (55%) of sleep timing problems, and 26% showed drifting sleep patterns (vs. 4% FS). Odds ratios for unconventional sleep timing were 2.41 (RLP) and 1.63 (LP) compared to FS controls. For drifting sleep patterns, they were 7.3 (RLP) and 6.0 (LP).
Medication Use
Zopiclone was the most frequently prescribed sleep medication. Melatonin was used by only 4% in the RLP group and 2% in the LP group.
Conclusions
Extrapolations from the current study suggest that 3,000 blind and visually impaired New Zealanders may suffer from circadian-related sleep problems, and that of these, fewer than 15% have been prescribed melatonin. This may represent a therapeutic gap in the treatment of circadian-related sleep disorders in New Zealand, findings that may generalize to other countries.
doi:10.1371/journal.pone.0022073
PMCID: PMC3138759  PMID: 21789214
22.  Sleep Lab Adaptation in Children with Attention-Deficit/Hyperactivity Disorder and Typically Developing Children 
Sleep Disorders  2013;2013:698957.
Objectives. Research has shown inconsistencies across studies examining sleep problems in children with attention-deficit/hyperactivity disorder (ADHD). It is possible that these inconsistencies are due to sleep lab adaptation. The goal of the current study was to investigate the possibility that children with ADHD adapt differently to the sleep lab than do typically developing (TD) children. Patients and Methods. Actigraphy variables were compared between home and the sleep lab. Sleep lab adaptation reports from the parent and child were compared between children with ADHD (n = 25) and TD children (n = 25). Results. Based on actigraphy, both groups had reduced sleep duration and reduced wake after sleep onset in the sleep lab compared to home. The only interaction effect was that TD children had increased sleep efficiency in the sleep lab compared to home. Conclusions. The results of this study do not support the hypothesis that children with ADHD adjust to the sleep lab differently than their typically developing peers. However, both groups of children did sleep differently in the sleep lab compared to home, and this needs to be considered when generalizing research findings from a sleep lab environment to children's sleep in general.
doi:10.1155/2013/698957
PMCID: PMC3666280  PMID: 23766917
23.  Sleep disorders and their determinants in multiple system atrophy 
Methods: Information about sleep disorders was collected using a standardised questionnaire in an unselected group of 57 patients with MSA and in 62 patients with PD matched as a group for age, sex distribution, and disease duration.
Results: Seventy percent of patients with MSA complained of sleep disorders compared with 51% of patients with PD (p=0.03). The most commonly reported sleep disorders were sleep fragmentation (52.5%), vocalisation (60%), REM sleep behaviour disorder (47.5%), and nocturnal stridor (19%). Except for sleep fragmentation, the incidence of these disorders was significantly higher than in PD. Sleep problems tended to be associated with more severe motor symptoms, longer disease duration, depression, and longer duration of levodopa treatment. Half of patients with MSA with sleep disorders complained of daytime somnolence compared with 30% of patients with PD. Daytime somnolence was significantly associated with disease severity in MSA.
Conclusion: This study shows that sleep disorders are more common in patients with MSA than in those with PD after the same duration of the disease, reflecting the more diffuse underlying pathological process in MSA.
doi:10.1136/jnnp.72.6.798
PMCID: PMC1737902  PMID: 12023429
24.  Alteration of sleep microstructure in psychiatric disorders 
Macrostructure describes the temporal organization of sleep based on successive epochs of conventional length, while microstructure, which is analyzed on the basis of the scoring of phasic events, provides additional important dynamic characteristics in the evaluation of both normal and pathological sleep processes. Relationships between sleep, sleep disorders, and psychiatric disorders are quite complex, and it clearly appears that both the macrostructure and the microstructure of sleep are valuable physiologically and clinically Psychiatric patients often complain about their sleep, and they may show sleep abnormalities that increase with the severity of their illness. Changes in the occurrence and frequency of phasic events during sleep may be associated with specific psychiatric disorders, and may provide valuable information for both diagnosis and prognosis of these disorders.
PMCID: PMC3181747  PMID: 16416707
sleep microstructure; phasic event; arousal; psychiatric disorder
25.  Effect of depression on sleep: Qualitative or quantitative? 
Indian Journal of Psychiatry  2009;51(2):117-121.
Background:
The present study was designed to assess whether subjective sleep patterns differ between: (i) depressed patients and controls, and (ii) between subjects with different severity of depression. Based on available literature, it was hypothesized that sleep patterns must be different between the above mentioned groups.
Materials and Methods:
This study included 60 subjects with major depressive disorder and 40 subjects in the control group. Subjects with sleep disturbance secondary to any other factor, e.g., medical illness, environmental factors, other psychiatric illness etc, were not included in the study. Depression severity was assessed in the subjects with depression with the help of Beck Depression Inventory II. Subjective sleep complaints were noted in the presence of a reliable informant, preferably bed partner. All the information was recorded in a semistructured performa. Statistical analysis was done with the help of SPSS v 11.0. The Chi square and Fisher exact tests were used for categorical variables; independent t-test and one way ANOVA were applied for numerical variables. Ordinal variables were analyzed using Mann Whitney U and Kruskall-Wallis tests.
Results:
Depression and control groups were similar in age (P = 0.32) and gender (P = 0.14) distribution. Subjects in the depression group had lesser total sleep time (P = 0.001), longer sleep latency (P = 0.001), frequent awakenings (P = 0.04), greater wake-after-sleep onset and offset times (both P = 0.001), lesser sleep efficiency, and tended to wake up early (Mann Whitney U = 913.5; P = 0.05). Subjects with severe depression were different from the mild and moderate groups with regards to total sleep time (P = 0.002), night-time sleep (P = 0.007), and sleep efficiency (P = 0.001) even when the three groups were comparable in age.
Conclusion:
Depression is associated with sleep disturbances, not only qualitatively, but also quantitatively. Sleep disturbance arises only after a critical level of depression is reached, and depression of varying severity may selectively affect different sleep parameters.
doi:10.4103/0019-5545.49451
PMCID: PMC2755175  PMID: 19823630
Depression; sleep; severity of depression

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