Limited evidence links atypical antipsychotics (AAs) use to sleep related respiratory dysfunction and greater severity of obstructive sleep apnea (OSA). The present paper reviews the published evidence and examines the impact of AA use on the presence and severity of OSA among subjects with clinically suspected OSA after adjusting for several confounds.
Archives of the University of Iowa Sleep Laboratory from 2005 to 2009 were searched for patients using AAs at the time of diagnostic polysomnogram (PSG). PSG data of the 84 AA users with heterogeneous psychiatric disorders (of these 20 diagnosed only with depression) were subsequently compared to PSG data of two randomly selected, non-AA user groups from the same patient pool: (i) 200 subjects with a depressive disorder as the only psychiatric diagnosis, and (ii) 331 mentally healthy controls. PSG data were analyzed adjusting for known demographic, medical, and psychiatric risk factors for OSA.
Prevalence and severity of OSA did not differ significantly across three groups. Sex, age, body mass index (BMI), and neck circumference (NC) independently predicted OSA. Odds ratio for OSA in the subset of AA users carrying the diagnosis of depression (n = 20) compared with subjects without mental illness was 4.53 (p < .05). By contrast, AA users without depression or those with multiple psychiatric diagnoses including depression did not show a statistically significantly elevated OSA risk.
AA use in subjects with depression appears to increase the risk of OSA after controlling for known predisposing factors.
Atypical antipsychotics; Depression; Obstructive sleep apnea; Psychosis; Schizophrenia; Sleep related breathing disorder
Alterations in circadian rhythms can have profound effects on mental health. High co-morbidity for psychiatric disorders has been observed in patients with circadian rhythm disorders, such as delayed sleep phase disorder (DSPD) and in those with an evening-type circadian preference. The aim of this study was to systematically determine the prevalence and type of DSM IV AXIS-I disorders in those with DSPD compared to evening-type controls.
Forty-eight DSPD and 25 evening-type participants took part in this study. Sleep and wake parameters were assessed with actigraphy, diary and questionnaires (Pittsburgh Sleep Quality Index (PSQI) and Functional Outcomes of Sleep Questionnaire (FOSQ)). Evening-type preference was defined by the Horne-Ostberg questionnaire. DSPD was determined by interview according to International Classification of Sleep Disorders criteria. Current and past diagnosis of psychiatric disorders were assessed with a Structured Clinical Interview for DSM-IV disorders.
DSPD was associated with a later wake time, longer sleep time, higher PSQI score, lower Horne-Ostberg and FOSQ scores compared to evening-types. There were no significant differences in the prevalence or type of AXIS-I disorders between those with DSPD or evening type preference. Over 70% of participants met criteria for at least one past AXIS-I disorder. Approximately 40% of both the DSPD and evening-types met criteria for a past diagnosis of mood, anxiety (most frequently phobia) or substance use disorders. Evening types were more likely to have a past diagnosis of more that one AXIS-I disorder.
These results highlight the important link between circadian rhythms and mental disorders. Specifically, an evening circadian chronotype regardless of DSPD status is associated with a risk for anxiety, depressive or substance use disorders.
circadian; sleep; depression; delayed sleep phase disorder
Abnormal sleep duration, either long or short, is associated with disease risk and mortality. Little information is available on sleep duration and its correlates among Chinese women.
Using information collected from 68,832 women who participated in the Shanghai Women’s Health Study (SWHS), we evaluated sleep duration and its correlations with sociodemographic and lifestyle factors, health status, and anthropometric measurements and their indexes using polynomial logistic regression.
The mean age of the study population was 59.6 years (SD=9.0; range: 44.6–79.9 years) at time of sleep duration assessment. Approximately 80% of women reported sleeping 6–8 hours per day, 11.5% slept five hours or less, and 8.7% slept nine hours or more. As expected, age was the strongest predictor for sleep duration and was negatively correlated with sleep duration. In general, sleep duration was positively associated with energy intake, intakes of total meat and fruits, body mass index (BMI), waist-hip ratio (WHR), and waist circumference (WC) after adjustment for age and other factors. Both short and long sleep duration were negatively associated with education level, family income, and leisure-time physical activity and positively associated with number of live births, history of night shift work, and certain chronic diseases, compared to sleep duration around seven hours/day (6.5–7.4 hours/day). Short sleep duration was related to tea consumption and passive smoking. Long sleep duration was related to menopausal status and marital status.
In this large, population-based study, we found that sleep duration among middle-aged and elderly Chinese women was associated with several sociodemographic and lifestyle factors and with disease status. The main limitation of the study is the cross-sectional design that does not allow us to draw any causal inference. However, this study provides information for future investigation into the nature of these associations so that recommendations can be developed to reduce sleep problems in middle-aged and elderly Chinese women. It also provides important information on potential confounders for investigation of sleep duration on health outcomes in this population.
Sleep duration; socio-economic factor; lifestyle; health status; BMI; correlation; Chinese
To determine the prevalence of personality disorders and their relation to insomnia parameters among persons with chronic insomnia with hypnotic dependence.
Eighty-four adults with chronic insomnia with hypnotic dependence completed the SCID-II personality questionnaire, two-weeks of sleep diaries, polysomnography, and measures of insomnia severity, impact, fatigue severity, depression, anxiety, and quality of life. Frequencies, between-subjects t-tests and hierarchical regression models were conducted.
Cluster C personality disorders were most prevalent (50%). Obsessive-compulsive personality disorder (OCPD) was most common (n=39). These individuals compared to participants with no personality disorders did not differ in objective and subjective sleep parameters. Yet, they had poorer insomnia-related daytime functioning. OCPD and Avoidant personality disorders features were associated with poorer daytime functioning. OCPD features were related to greater fatigue severity, and overestimation of time awake was trending. Schizotypal and Schizoid features were positively associated with insomnia severity. Dependent personality disorder features were related to underestimating time awake.
Cluster C personality disorders were highly prevalent in patients with chronic insomnia with hypnotic dependence. Features of Cluster C and A personality disorders were variously associated with poorer insomnia-related daytime functioning, fatigue, and estimation of nightly wake-time. Future interventions may need to address these personality features.
insomnia; hypnotic-dependence; personality disorders; Cluster C personality disorders; sleep-wake perception; daytime functioning
Sleep-disordered breathing (SDB) is an increasingly recognized risk factor for cardiovascular disease (CVD). Limited data are available from large African American cohorts.
We examined the prevalence, burden, and correlates of sleep symptoms suggestive of SDB and risk for obstructive sleep apnea (OSA) in the Jackson Heart Study (JHS), an all-African-American cohort of 5,301 adults. Data on selected daytime and nighttime sleep symptoms were collected using a modified Berlin questionnaire during the baseline examination. Risk of OSA was calculated according to published prediction model. Age and multivariable-adjusted logistic regression models were used to examine the associations between potential risk factors and measures of sleep.
Sleep symptoms, burden, and risk of OSA were high among men and women in the JHS and increased with age and obesity. Being married was positively associated with sleep symptoms among women. In men, poor to fair perceived health and increased levels of stress were associated with higher odds of sleep burden, whereas prevalent hypertension and CVD were associated with higher odds of OSA risk. Similar associations were observed among women with slight variations. Sleep duration <7 hours was associated with increased odds of sleep symptoms among women and increased sleep burden among men. Moderate to severe restless sleep was consistently and positively associated with odds of adverse sleep symptoms, sleep burden, and high risk OSA.
Sleep symptoms in JHS had a strong positive association with features of visceral obesity, stress, and poor perceived health. With increasing obesity among younger African Americans, these findings are likely to have broad public health implications.
African-American; epidemiology; Jackson Heart study; health status; obesity; sleep; sleep apnea syndromes; sleep disordered breathing
Sleep disturbance is common during critical illness, yet little is known about its prevalence or role in post-discharge quality of life among high-risk acute lung injury (ALI) patients.
In a prospective cohort of 61 mechanically ventilated ALI patients, we examined the association between insomnia symptoms and quality of life six months after discharge. Subjects completed surveys rating quality of life (MOS SF-36), post-traumatic stress disorder (PCL), and depression (PHQ-9). Using an individual item from the PCL, we defined insomnia symptoms as moderate or greater trouble falling or staying asleep in the past month. We performed multivariable linear regression to examine the association between insomnia symptoms and SF-36 physical and mental component scores, adjusting for PTSD and depression.
Forty subjects (85% of eligible) completed six-month questionnaires; 20 (50%) met criteria for insomnia symptoms. After adjustment for PTSD and depression, insomnia symptoms remained significantly associated with worse physical component scores (adjusted mean difference = -8.8; 95% CI: -15.0, -2.5; P<0.01).
Post-discharge insomnia symptoms were common and significantly associated with physical quality of life impairment among six-month ALI survivors, even after adjustment for PTSD and depression symptoms. Further studies are needed to validate these results and to characterize sleep disturbance after ALI using sleep-specific metrics.
Respiratory Distress Syndrome; Adult/therapy; Quality of Life; Insomnia; Sleep Initiation and Maintenance Disorders; Intensive Care Units
To examine the association between nocturnal sleep duration and weight and caloric intake outcomes among preschool-aged children who are obese and enrolled in a family-based weight management program.
Forty-one preschool-aged children who were obese (BMI ≥95th percentile) and enrolled in a weight management program completed pre- and posttreatment assessments of body mass, caloric intake, and sleep. Separate linear regression analyses examined the relationship between nocturnal sleep duration and posttreatment body mass index relative to ageand sex-linked norms (BMIz) and caloric intake.
After controlling for pretreatment BMIz, longer posttreatment nocturnal sleep was significantly associated with lower posttreatment BMIz (β=-0.21, p=0.02) and explained a significant proportion of unique variance in posttreatment BMIz (ΔR2=0.04). Similarly, after controlling for pretreatment caloric intake, longer nocturnal sleep duration at posttreatment was significantly associated with lower caloric intake at posttreatment (β=-0.45, p=0.003) and explained a significant proportion of unique variance in posttreatment caloric intake (ΔR2=0.19).
These findings extend the literature on the sleep and weight relationship and suggest that adequate sleep may be an important element in interventions for preschoolers with obesity.
obesity; weight management; sleep; pediatrics; diet; children; behavior; intervention
There are limited data about the role of gender on the relationship between sleep duration and blood pressure (BP) from rural populations.
We conducted a cross-sectional rural population-based study. This report includes 1,033 men and 783 women aged 18–65 years from a cohort of twins enrolled in Anhui, China, between 2005 and 2008. Sleep duration was derived from typical bedtime, wake-up time, and sleep latency as reported on a standard sleep questionnaire. Primary outcomes included measured systolic blood pressure (SBP) and diastolic blood pressure (DBP). High blood pressure (HBP) was defined as SBP≥130 mmHg, DBP ≥85 mmHg, or physician diagnosed hypertension. Linear and logistic regression models were used to assess gender-specific associations between sleep duration and BP or HBP, respectively, with adjustment for known risk factors including adiposity and sleep-related disorder risk from the questionnaires. Generalized estimating equations were used to account for intra-twin pair correlations.
Compared with those sleeping 7 to less than 9 hours, women sleeping <7 hours had a higher risk of HBP (odds ratios [ORs] 3.0, 95% confidence interval [CI], 1.4–6.6); men sleeping ≥9 hours had a higher risk of HBP (ORs=1.5, 95%CI: 1.1–2.2).
Among rural Chinese adults, a gender-specific association of sleep duration with BP exists such that HBP is associated with short sleep duration in women and long sleep duration in men. Longitudinal studies are needed to further examine the temporal relationship and biological mechanisms underlying sleep duration and BP in this population. Our findings underscore the potential importance of appropriate sleep duration for optimal blood pressure.
sleep duration; high blood pressure; gender difference; rural Chinese
Diagnosis of insomnia disorder by Diagnostic and Statistical Manual (DSM)-IV, and as proposed by DSM-V, includes criteria for impairment in occupational- or social functioning due to sleep complaints. This study evaluated the clinical and polysomnographic correlates of impairment in daytime functioning in older adults with insomnia.
In older adults with DSM-IV chronic insomnia (n=68), clinical and demographic information, and measures of health functioning, medical co-morbidity, and polysomnographic sleep were obtained. Four questions that evaluated difficulties or distress in occupational- or social functioning related to sleep complaints were used to code DSM threshold criteria for impairment in daytime functioning. Stepwise regression was used to identify predictors of impairment in daytime functioning.
Impairment in daytime functioning was significantly associated with younger age (p<0.05), and the amount of wake time after sleep onset as assessed by polysomnography (p<0.001), controlling for health functioning and minority racial status.
Amount of wake time after sleep onset uniquely contributes to criteria symptoms of impairment in daytime functioning among older adults with insomnia. Treatments that target sleep maintenance have the potential to improve social and occupational functioning in older adults with sleep complaints.
Background and purpose
The purpose of this study was to compare two parent completed questionnaires, the Modified Simonds & Parraga Sleep Questionnaire (MSPSQ), and the Children’s Sleep Habits Questionnaire (CSHQ), used to characterize sleep disturbances in young children with autism spectrum disorders (ASD). Both questionnaires have been used in previous work in the assessment and treatment of children with ASD and sleep disturbance.
Participants and methods
Parents/caregivers of a sample of 124 children diagnosed with ASD with an average age of six years completed both sleep questionnaires regarding children’s sleep behaviors. Internal consistency of the items for both measures was evaluated as well as the correlation between the two sleep measures. A Receiver Operating Characteristics (ROC) curve analysis was also conducted to examine the predictive power of the MSPSQ.
More than three quarters of the sample (78%) were identified as poor sleepers on the CSHQ. Cronbach’s alpha for the items on the CSHQ was 0.68 and Cronbach’s alpha for items on the MSPSQ was 0.67. The total scores for MSPSQ and CSHQ were significantly correlated (r =.70, p<.01). After first identifying the poor sleepers based on the CSHQ, an area under the curve was 0.89 for the MSPSQ. Using a cut off score of 56 on the MSPSQ, sensitivity was .86 and specificity was .70.
In this sample of children with ASD, sleep disturbances were common across all cognitive levels. Preliminary findings suggest that, similar to the CSHQ, the MSPSQ has adequate internal consistency. The two measures were also highly correlated. A preliminary cut off of 56 on the MSPSQ offers high sensitivity and specificity commensurate with the widely used CSHQ.
Autism spectrum disorder; sleep disturbance; sleep disturbances; sleep questionnaires; Children’s Sleep Habits Questionnaire; Modified Simonds and Parraga Sleep Questionnaire
The effects of sleep-disordered breathing, sleep restriction, dyssomnias, and parasomnias on daytime behavior in children have been previously assessed. However, the potential relationship(s) between sleep hygiene and children’s daytime behavior remain to be explored. The primary goal of this study was to investigate the relationship between sleep hygiene and problematic behaviors in non-snoring and habitually snoring children.
Parents of 100 5- to 8-year-old children who were reported to snore “frequently” to “almost always,” and of 71 age-, gender-, and ethnicity-matched children who were reported to never snore participated in this study. As part of a larger, ongoing study, children underwent nocturnal polysomnography and parents were asked to complete the Children’s Sleep Hygiene Scale (CSHS) and the Conners’ Parent Rating Scales-Revised (CPRS-R:L).
In the snoring group, strong negative correlations (r = −.39, p <.001) between the CSHS overall sleep hygiene score and the CPRS-R:L DSM-IV total scores emerged. Additionally, several subscales of the CSHS and CPRS-R:L were significantly correlated (p-values from <.000 to .004) in snoring children. No significant correlations were observed between the CSHS and the CPRS-R:L in the non-snoring children.
Parental reports of behavioral patterns in snoring children indicate that poorer sleep hygiene is more likely to be associated with behavior problems, including hyperactivity, impulsivity, and oppositional behavior. In contrast, no significant relationships between sleep hygiene and problem behaviors emerged among non-snoring children. These results indicate that children at risk for sleep disordered breathing are susceptible to daytime behavior impairments when concurrently coupled with poor sleep hygiene practices.
sleep hygiene; behavior problems; children; snoring
Although the epidemiology of insomnia in the general population has received considerable attention in the past 20 years, few studies have investigated the prevalence of insomnia using operational definitions such as those set forth in the ICSD and DSM-IV, specifying what proportion of respondents satisfied the criteria to reach a diagnosis of insomnia disorder.
This is a cross-sectional study involving 25,579 individuals aged 15 years and over representative of the general population of France, the United Kingdom, Germany, Italy, Portugal, Spain and Finland. The participants were interviewed on sleep habits and disorders managed by the Sleep-EVAL expert system using DSM-IV and ICSD classifications.
At the complaint level, too short sleep (15.8%), light sleep (16.6%), and global sleep dissatisfaction (8.5%) were reported by 37% of the subjects. At the symptom level (difficulty initiating or maintaining sleep and non-restorative sleep at least 3 nights per week), 34.5% of the sample reported at least one of them. At the criterion level, (symptoms + daytime consequences), 9.8% of the total sample reported having them. At the diagnostic level, 6.6% satisfied the DSM-IV requirement for positive and differential diagnosis. However, many respondents failed to meet diagnostic criteria for duration, frequency and severity in the two classifications, suggesting that multidimensional measures are needed.
A significant proportion of the population with sleep complaints do not fit into DSM-IV and ICSD classifications. Further efforts are needed to identify diagnostic criteria and dimensional measures that will lead to insomnia diagnoses and thus provide a more reliable, valid and clinically relevant classification.
Insomnia; Epidemiology; classifications; mental disorders
Studies suggest that sleep quality and duration are significantly associated with mortality risk and health conditions, yet such studies are seldom conducted among very old adults. The objective of this study was to examine associations between self-reported sleep quality/duration and subsequent mortality/health among very old adults in China. A second objective determines whether these associations vary by age and gender.
This study used data of the 2005 and 2008 waves from a large, representative survey with a total of 12,671 individuals in 22 provinces in mainland China, in which 3158 respondents were aged 90–99 and 2293 were centenarians. Two self-reported questions about sleep quality and duration were examined while adjusting for numerous socio-demographic, family/social support, health practices, and baseline health factors.
Hazard regressions showed that, when demographic factors are controlled for, Chinese elders who report poor and fair quality of sleep have 26% and 10% higher risk of death over the next three years compared to those with good sleep quality; those who sleep either 6 h or less or 10 h or more per day have an 18–22% higher mortality risk as compared to those who sleep 8 h per day. The increased mortality risks of poorer sleep and too short or too long sleep duration are larger in men than in women and more robust in the oldest-old than in young elders. Logistic regressions show that poor sleep and daily sleep durations of 5 h or less or 10 h or more are also associated with worse health three years later.
Poorer sleep quality and too short or too long sleep duration are associated with higher subsequent mortality risk and lower odds of being in a healthy state among very old Chinese.
China; Healthy longevity survey; Mortality; Gender differentials; Older adults; Oldest-old; Quality of sleep; Sleep duration
The Pittsburgh Sleep Quality Index (PSQI) is a widely used measure of subjective sleep disturbance in clinical populations, including individuals with posttraumatic stress disorder (PTSD). Although the severity of sleep disturbance is generally represented by a global symptom score, recent factor analytic studies suggest that the PSQI is better characterized by a two- or three-factor model than a one-factor model. This study examined the replicability of two- and three-factor models of the PSQI, as well as the relationship between PSQI factors and health outcomes, in a female sample with PTSD.
The PSQI was administered to 319 women with PTSD related to sexual or physical assault. Confirmatory factor analyses tested the relative fit of one-, two-, and three-factor solutions. Bivariate correlations were performed to examine the shared variance between PSQI sleep factors and measures of PTSD, depression, anger, and physical symptoms.
Confirmatory factor analyses supported a 3-factor model with Sleep Efficiency, Perceived Sleep Quality, and Daily Disturbances as separate indices of sleep quality. The severity of symptoms represented by the PSQI factors was positively associated with the severity of PTSD, depression, and physical symptoms. However, these health outcomes correlated as much or more with the global PSQI score as with PSQI factor scores.
These results support the multidimensional structure of the PSQI. Yet, the global PSQI score has as much or more explanatory power as individual PSQI factors in predicting health outcomes.
factor analysis; Pittsburgh Sleep Quality Index; sleep; PTSD; depression; anger; physical symptoms
To determine whether an accurate circadian phase assessment could be obtained from saliva samples collected by patients in their home.
Twenty-four individuals with a complaint of sleep initiation or sleep maintenance difficulty were studied for two evenings. Each participant received instructions for collecting 8 hourly saliva samples in dim light at home. On the following evening they spent 9h in a laboratory room with controlled dim (<20 lux) light, where hourly saliva samples were collected. Circadian phase of dim light melatonin onset (DLMO) was determined using both an absolute threshold (3pg/mL) and a relative threshold (2 standard deviations above the mean of 3 baseline values).
Neither threshold method worked well for one participant who was a `low-secretor'. In four cases the participant's in-lab melatonin levels rose much earlier and/or were much higher than their at-home levels, and one participant appeared to take the at home samples out of order. Overall, the at-home and in-lab DLMO values were significantly correlated using both methods, and differed on average by 37 (±19) minutes using the absolute threshold and by 54 (±36) minutes using the relative threshold.
The at-home assessment procedure was able to determine an accurate DLMO using an absolute threshold in 62.5% of the participants. Thus, an at-home procedure for assessing circadian phase could be practical for evaluating patients for circadian rhythm sleep disorders.
DLMO; circadian phase; melatonin; circadian rhythm sleep disorders
To assess whether functional capacity is a better predictor of coronary heart disease (CHD) than depression or abnormal sleep duration.
Adult civilians in the USA (n=29,818, mean age 48 ± 18 years, range 18–85 years) were recruited by a cross-sectional household interview survey using multistage area probability sampling. Data on chronic conditions, estimated habitual sleep duration, functional capacity, depressed moods and sociodemographic characteristics were obtained.
Thirty-five percent of participants reported reduced functional capacity. The CHD rates among White and Black Americans were 5.2% and 4%, respectively. Individuals with CHD were more likely to report extreme sleep durations [short sleep (≤ 5 h) or long sleep (≥ 9 h); odds ratio (OR) 1.65, 95% confidence interval (CI) 1.38–1.97; P<0.0001], less likely to be functionally active [anchored by the ability to walk one-quarter of a mile without assistance (OR 6.27, 95% CI 5.64–6.98; P<0.0001)] and more likely to be depressed (OR 1.78, 95% CI 1.60–1.99; P<0.0001) than their counterparts. On multivariate regression analysis adjusting for sociodemographic factors and health characteristics, only functional capacity remained an independent predictor of CHD (OR 1.81, 95% CI 1.42–2.31; P<0.0001).
Functional capacity was an independent predictor of CHD in the study population, whereas depression and sleep duration were not independent predictors.
Functional capacity; Depression; Sleep duration; Coronary heart diseas; Physical activity; Mood
Sleep problems are a frequent distressing symptom in cancer patients, yet little is known about their treatment. Sleep problems and depression frequently co-occur, leading healthcare professionals to treat depression with the expectation that sleep problems will also improve. The purpose of this study was to compare the effect of paroxetine to placebo on sleep problems via a secondary data analysis of a RCT designed to compare the effects of paroxetine to placebo on fatigue in cancer patients undergoing chemotherapy. A previously published report found a significant effect of paroxetine on depression in this cohort.
A total of 426 patients were randomized following Cycle 2 of chemotherapy to receive either 20 mg of paroxetine or placebo. Sleep problems were assessed using questions from the Hamilton Depression Inventory three times during chemotherapy.
A total of 217 patients received paroxetine and 209 received placebo. Significantly fewer patients taking paroxetine reported sleep problems compared to patients on placebo (Paroxetine 79% versus Placebo 88%; p < 0.05). These differences remained significant even after controlling for baseline sleep problems and depression (p < 0.05).
Paroxetine had a significant benefit on sleep problems in both depressed and non-depressed cancer patients. However, rates of sleep problems remained high even among those effectively treated for depression with paroxetine. There is a need to develop and deliver sleep-specific interventions to effectively treat sleep-related side effects of cancer treatments. These findings suggest that sleep problems and depression are prevalent and co-morbid. Cancer progression, its response to treatment, and overall patient survival are intricately linked to host factors, such as inflammatory response and circadian rhythms, including sleep/wake cycles. Sleep problems and depression are modifiable host factors that can influence inflammation and impact cancer progression and quality of life. Future research should focus on discovering the pathogenesis of sleep dysregulation and depression in cancer so that better treatment approaches can be developed to ameliorate these symptoms.
Sleep disordered breathing (SDB) is more common in obese adults, but not all obese adults have SDB. The aim of these analyses was to determine what predicted SDB in a sample of obese adults.
We conducted cross-sectional analysis of 139 obese men and women aged 18–50 years who are chronic short sleepers. Habitual sleep duration and sleep efficiency were estimated using 2 weeks of wrist actigraphy. Respiratory Disturbance Index (RDI) was assessed by a portable screening device. SDB was defined as RDI≥15 events/hour. Subjective sleep quality, sleepiness, and sociodemographic characteristics were evaluated by questionnaires.
Increased sleep duration from actigraphy was associated with reduced odds of SDB (OR 0.44 per hour, p=.043). Neither subjective sleep quality nor sleepiness was associated with SDB. Male sex, older age, and increased waist circumference were associated with increased odds of SDB.
In this sample of obese adults, subjective measures of sleep quality and sleepiness were not indicators of SDB. These results suggest that in obese patients, physicians should not rely on subjective measures to determine who should be referred for a clinical sleep study. A wider use of portable apnea screening devices should be considered in non symptomatic, Non-Hispanic white males.
sleep-disordered breathing; obese; actigraphy; subjective sleep quality; sleepiness; apnea
To investigate the cross-sectional association between COPD severity and disturbed sleep and the longitudinal association between disturbed sleep and poor health outcomes.
98 adults with spirometrically-confirmed COPD were recruited through population-based, random-digit telephone dialing. Sleep disturbance was evaluated using a 4-item scale assessing insomnia symptoms as: difficulty falling asleep, nocturnal awakening, morning tiredness, and sleep duration adequacy. COPD severity was quantified by: FEV1 and COPD Severity Score, which incorporates COPD symptoms, requirement for COPD medications and oxygen, and hospital-based utilization. Subjects were assessed one year after baseline to determine longitudinal COPD exacerbations and emergency utilization and were followed for a median 2.4 years to assess all-cause mortality.
Sleep disturbance was cross-sectionally associated with cough, dyspnea, and COPD Severity Score but not FEV1. In multivariable logistic regression, controlling for sociodemographics and body-mass index, sleep disturbance longitudinally predicted both incident COPD exacerbations (OR=4.7; p=0.018) and respiratory-related emergency utilization (OR=11.5; p=0.004). In Cox proportional hazards analysis, controlling for the same covariates, sleep disturbance predicted poorer survival (HR=5.0; p=0.013). For all outcomes, these relationships persisted after also controlling for baseline FEV1 and COPD Severity Score.
Disturbed sleep is cross-sectionally associated with worse COPD and is longitudinally predictive of COPD exacerbations, emergency health care utilization, and mortality.
chronic obstructive pulmonary disease; cognitive performance; insomnia; mortality; outcomes
Scheduled exposure to bright light (phototherapy) has been used, with varying degrees of success, to treat sleep disruption in older individuals. Most of these studies have been done in institutional settings and have used several hours of daily light exposure. Such a regimen in the home setting may be untenable, especially when the individual with the sleep disruption has memory impairment and is being cared for by a family member. As such, we examined the effectiveness of a “user-friendly” phototherapy protocol that would be readily usable in the home environment.
We exposed a group of 54 older caregiver/care recipient dyads, in which the care recipient had a memory impairment, to two weeks of morning bright light phototherapy. Dyads were exposed to either bright white (~4,200 lux) or dim red (~90 lux) light for 30 minutes every day, starting within 30 minutes of arising. All subjects also received sleep hygiene therapy. Objective (actigraphy) and subjective measures of sleep and mood were obtained at baseline and at the end of the two weeks of phototherapy.
In care recipients, actigraphy- and log-determined time in bed and total sleep time declined in the active condition (p<0.05, ANOVA); there was no corresponding change in subjective insomnia symptoms (p’s>0.37, ANOVA). The decrease in time in bed was associated with an earlier out of bed time in the morning (p<0.001, Pearson correlation). The decrease in total sleep time was associated with a decrease in sleep efficiency (p<0.001, Pearson correlation) and an increase in wake after sleep onset (p<0.001, Pearson correlation). In caregivers, there were no differential changes in actigraphic measures of sleep (p’s>0.05, ANOVA). Actigraphy-measured wake after sleep onset and sleep efficiency did, however, improve in both conditions, as did sleepiness, insomnia symptoms, and depressive symptomatology (p’s<0.05, ANOVA).
Exposure to this regimen of phototherapy diminished sleep in older individuals with memory impairments. Their caregivers, however, experienced an improvement in sleep and mood that appeared independent of the phototherapy and likely due to participation in this protocol or the sleep hygiene therapy.
sleep; Alzheimer’s; phototherapy; light; caregiver; circadian; clinical trial
Iron-deficiency anemia (IDA) continues to be the most common single nutrient deficiency in the world. An estimated 20-25% of the world’s infants have IDA, with at least as many having iron deficiency without anemia. Infants are at particular risk due to rapid growth and limited dietary sources of iron. We found that infants with IDA showed different motor activity patterning in all sleep-waking states and several differences in sleep states organization. Sleep alterations were still apparent years after correction of anemia with iron treatment in the absence of subsequent IDA. We suggest that altered sleep patterns may represent an underlying mechanism that interferes with optimal brain functioning during sleep and wakefulness in former IDA children.
iron deficiency anemia; infancy; sleep; REM sleep; NREM sleep; childhood
The few population-based, prospective studies that have examined risk factors of incident insomnia were limited by small sample size, short follow-up, and lack of data on medical disorders or polysomnography. We prospectively examined the associations between demographics, behavioral factors, psychiatric and medical disorders, and polysomnography with incident chronic insomnia.
From a random, general population sample of 1741 individuals of the adult Penn State Sleep Cohort, 1395 were followed-up after 7.5 years. Only subjects without chronic insomnia at baseline (n=1246) were included in this study. Structured medical and psychiatric history, personality testing, and 8-hour polysomnography were obtained at baseline. Structured sleep history was obtained at baseline and follow-up.
Incidence of chronic insomnia was 9.3%, with a higher incidence in women (12.9%) than in men (6.2%). Younger age (20–35 years), non-white ethnicity, and obesity increased the risk of chronic insomnia. Poor sleep and mental health were stronger predictors of incident chronic insomnia compared to physical health. Higher scores in MMPI-2, indicating maladaptive personality traits, and excessive use of coffee at baseline predicted incident chronic insomnia. Polysomnographic variables, such as short sleep duration or sleep apnea, did not predict incident chronic insomnia.
Mental health, poor sleep, and obesity, but not sleep apnea, are significant risk factors for incident chronic insomnia. Focusing on these more vulnerable groups and addressing the modifiable risk factors may help reduce the incident of chronic insomnia, a common and chronic sleep disorder associated with significant medical and psychiatric morbidity and mortality.
chronic insomnia; incidence; physical health; mental health; general population
To establish the psychometric properties of a self-report measure of daytime sleepiness for school-aged children.
Three-hundred eighty-eight children ages 8–12 years (inclusive) from pediatrician’s offices, sleep clinic/labs, children’s hospitals, schools, and the general population. A multi-method approach was used to validate the Children’s Report of Sleep Patterns – Sleepiness Scale (CRSP-S), including self-report measures (questions about typical sleep), parent-report measures (CSHQ, proxy version of CRSP-S, CSHS, Morningness-Eveningness), and objective measures (actigraphy and PSG).
The CRSP-S was shown to be internally consistent (Cronbach’s alpha = .77) and the scale’s unidimensionality was supported by a one-factor confirmatory factor analysis. A Rasch-Masters Partial Credit model demonstrated that items cover a broad range of sleepiness experiences with minimal redundancy, gaps in coverage, or bias against age, gender, or clinical groups. Test-retest reliability was .82. Construct and convergent validity were demonstrated with actigraphy, parental reports of children’s sleepiness, sleep disturbances, sleep hygiene, circadian preference, as well as comparison of groups of children (e.g., sleep clinic/lab versus school children).
The CRSP-S is a reliable and valid self-report measure of sleepiness for school-aged children. As an adjunct to parental report measures and objective measures of sleep, the CRSP-S provides a brief and psychometrically robust measure of children’s sleepiness. Children who endorse sleepiness should have a more detailed screening for underlying sleep disruptors or causes of insufficient sleep.
children; sleepiness; validation; measurement; self-report
Birth order may play a role in autoimmune diseases and early childhood infections, both factors implicated in the etiology of narcolepsy. We investigated the association between birth order and narcolepsy risk in a population-based case-control study in which all study subjects were HLA-DQB1*0602 positive.
Subjects were 18-50 years old, residents of King County, Washington, and positive for HLA-DQB1*0602. Birth order was obtained from administered interviews. We used logistic regression to generate odds ratios adjusted for income and African American race.
Analyses included 67 cases (mean age 34.3 [SD=9.1], 70.2% female) and 95 controls (mean age 35.1 [SD=8.8], 58.1% female). Associations for birth order were as follows: First born (cases 38.8% vs. controls 50.2%, OR=1.0; Reference), second born (cases 29.9% vs. controls 32.9%, OR=1.6; 95% CI 0.7, 3.7), third born or higher (cases 31.3% vs. controls 16.8%, OR=2.5; 95% CI 1.0, 6.0). A linear trend was significant (p<0.05). Sibling number, sibling gender, having children, and number of children did not differ significantly between narcolepsy cases and controls.
Narcolepsy risk was significantly associated with higher birth order in this population-based study of genetically susceptible individuals. This finding supports an environmental influence on narcolepsy risk through an autoimmune mechanism, early childhood infections, or both.
Narcolepsy; Birth order; HLA-DQB1*0602; genetics; autoimmune
Polymorphisms in the TCRA and P2RY11, two immune related genes, are associated with narcolepsy in Caucasians and Asians. In contrast, CPT1B/CHKB polymorphisms have only been shown to be associated with narcolepsy in Japanese, with replication in a small group of Koreans. Our aim was to study whether these polymorphisms are associated with narcolepsy and its clinical characteristics in Chinese patients with narcolepsy.
We collected clinical data on 510 Chinese patients presenting with narcolepsy/hypocretin deficiency. Patients were included either when hypocretin deficiency was documented (CSF hypocretin-1 ≤110 pg/ml, n=91) or on the basis of the presence of clear cataplexy and HLA-DQB1*0602 positivity (n=419). Genetic data was compared to typing obtained in 452 controls matched for geographic origin within China. Clinical evaluations included demographics, the Stanford Sleep Inventory (presence and age of onset of each symptom), and Multiple Sleep Latency Test (MSLT) data.
Chinese narcolepsy was strongly and dose dependently associated with TCRA (rs1154155C) and P2RY11 (rs2305795A) but not CPT1B/CHKB (rs5770917C) polymorphisms. CPT1B/CHKB polymorphisms were not associated with any specific clinical characteristics. TCRA rs1154155A homozygotes (58 subjects) had a later disease onset, but this was not significant when corrected for multiple comparisons, thus replication is needed. CPT1B/CHKB or P2RY11 polymorphisms were not associated with any specific clinical characteristics.
The study extends on the observation of a strong multiethnic association of polymorphisms in the TCRA and P2RY11 with narcolepsy, but does not confirm the association of CPT1B/CHKB (rs5770917) in the Chinese population.
narcolepsy; TCR alpha; P2RY11; CPT1B/CHKB; hypocretin; orexin; MSLT; HLADQB1*0602