A reliability and validity study of the Bergen Shift Work Sleep Questionnaire in nurses working three-shift rotations

The "Bergen Shift Work Sleep Questionnaire" (BSWSQ) was developed to systematically assess discrete sleep problems related to different work shifts (day, evening, night shifts) and rest days. In this study, we assessed the psychometric properties of the BSWSQ using a sample of 760 nurses, all working in a three-shift rotation schedule: day, evening, and night shifts. BSWSQ measures insomnia symptoms using seven questions: >30-min sleep onset latency, >30-min wake after sleep onset, >30-min premature awakenings, nonrestorative sleep, being tired/sleepy at work, during free time on work days, and when not working/on vacation. Symptoms are assessed separately for each work shift and rest days, as "never," "rarely," "sometimes," "often," "always," or "not applicable." We investigated the BSWSQ model fit, reliability (test-retest of a subsample, n = 234), and convergent and discriminant validity between the BSWSQ and Epworth Sleepiness Scale, Fatigue Questionnaire, and Hospital Anxiety Depression Scale. We also investigated differences in mean scores between the different insomnia symptoms with respect to different work shifts and rest days. BSWSQ demonstrated an adequate model fit using structural equation modeling: root mean square error of approximation = .071 (90% confidence interval [CI] = .066-.076), comparative fit index = .91, and chi-square/degrees of freedom = 4.41. The BSWSQ demonstrated good reliability (test-retest coefficients p <  .001). We found good convergent and discriminant validity between BSWSQ and the other scales (all coefficients p <  .001). There were significant differences between the overall/composite scores of the various work shifts. Night shift showed the highest score compared to day and evening shifts as well as to rest days (all post hoc comparisons p <  .001). Mean scores of different symptoms also varied significantly within the individual work shifts. We conclude that the BSWSQ meets the necessary psychometric standards, enabling systematic study of discrete insomnia symptoms in different work shifts.

Søvnproblemer blant eldre

Mange eldre sover dårlig, og dårlig søvn påvirker helse og livskvalitet. Vi vil i denne artikkelen ta for oss typiske trekk ved søvnen hos eldre mennesker. Søvnsykdommer deles inn i seks ulike undergrupper: insomnier, døgnrytmeforstyrrelser, søvnrelaterte respirasjonsforstyrrelser, søvnrelaterte bevegelsesforstyrrelser, hypersomnier og parasomnier. Hovedfokuset i artikkelen vil være på insomni, men også de andre søvnsykdommene blir beskrevet. Flere av søvnsykdommene er hyppigere hos eldre enn hos yngre mennesker. I tillegg er mange somatiske og psykiske lidelser assosiert til søvnproblemer, hvorav depresjon regnes som den hyppigste komorbide lidelsen. Grundig anamnese vil avdekke de fleste av søvnsykdommene, og bruk av søvndagbøker gir viktig tilleggsinformasjon. Behandlingsalternativene varierer fra ikke-medikamentelle til medikamentelle tiltak, avhengig av hvilken diagnose som stilles. Langvarig bruk av hypnotika frarådes på grunn av toleranseutvikling og uheldige bivirkninger. Det er viktig at utredning gjøres før behandlingen starter, og korrekt behandling kan ha stor effekt – også hos eldre.  ENGLISH SUMMARY Sleep problems are common among the elderly, and poor sleep affects health and quality of life. In this paper we will cover the characteristics of sleep in elderly patients. Sleep disorders are divided into six subgroups: insomnia, circadian rhythm sleep disorders, sleep related breathing disorders, sleep related movement disorders, hypersomnias, and parasomnias. The main focus of this paper will be on insomnia, but also the other sleep disorders will be described. Several of the sleep disorders are more common among older than younger people. Furthermore, many somatic and psychiatric disorders are associated with sleep problems, with depression being the most common comorbid disorder. A thorough patient history will uncover most of the sleep disorders, and the use of sleep diaries gives important additional information. The treatments of choice vary from non-pharmacological to pharmacological approaches, depending on the diagnosis. Chronic use of hypnotics is discouraged due to risk of tolerance and unfavourable side effects. It is vital to do a proper assessment before treatment is commenced, and appropriate treatment may have large effects – also among elderly patients.Bjorvatn B, Fetveit A. Sleep problems among the elderly. Nor J Epidemiol 2012; 22 (2): 177-186.

Clinical assessment and management of sleep disorders in multiple sclerosis: a literature review

The major sleep disorders are common in multiple sclerosis (MS) and are associated with significant morbidity. Despite this, the rate of recognition and management of these conditions are low. All types of sleep disorders are seen in patients with MS: insomnia, circadian rhythm sleep disorders, sleep-related movement disorders, sleep-related breathing disorders, hypersomnia (narcolepsy), and parasomnia (REM sleep behavior disorder; RBD). This literature review covers the prevalence, clinical features, and treatment of sleep disorders in MS. Based on clinical experience, the spectrum of symptoms associated with MS, and the current knowledge of MS pathophysiology, we have also enclosed proposed strategies for clinical assessment and investigation of sleep disorders in MS patients.

Poor sleep in patients with multiple sclerosis

Background

Poor sleep is a frequent symptom in patients with multiple sclerosis (MS). Sleep may be influenced by MS-related symptoms and adverse effects from immunotherapy and symptomatic medications. We aimed to study the prevalence of poor sleep and the influence of socio-demographic and clinical factors on sleep quality in MS- patients.

Methods

A total of 90 MS patients and 108 sex-and age- matched controls were included in a questionnaire survey. Sleep complaints were evaluated by Pittsburgh Sleep Quality Index (PSQI) and a global PSQI score was used to separate good sleepers (≤5) from poor sleepers (>5). Excessive daytime sleepiness, the use of immunotherapy and antidepressant drugs, symptoms of pain, depression, fatigue and MS-specific health related quality of life were registered. Results were compared between patients and controls and between good and poor sleepers among MS patients.

Results

MS patients reported a higher mean global PSQI score than controls (8.6 vs. 6.3, p = 0.001), and 67.1% of the MS patients compared to 43.9% of the controls (p = 0.002) were poor sleepers. Pain (p = 0.02), fatigue (p = 0.001), depression (p = 0.01) and female gender (p = 0.04) were associated with sleep disturbance. Multivariate analyses showed that female gender (p = 0.02), use of immunotherapy (p = 005) and a high psychological burden of MS (p = 0.001) were associated with poor sleep among MS patients.

Conclusions

Poor sleep is common in patients with MS. Early identification and treatment of modifiable risk factors may improve sleep and quality of life in MS.

Insomnia and depressive symptoms in late pregnancy: a population-based study

A population-based questionnaire study of 2,816 women was conducted in week 32 of pregnancy to estimate the prevalence of and risk factors for insomnia and depressive symptoms. The Bergen Insomnia Scale (BIS) measured insomnia. The Edinburgh Postnatal Depression Scale (EPDS) measured depressive symptoms. The prevalence of insomnia (DSM-IV-TR criteria) was 61.9%, and mean BIS score 17.5 (SD = 10.5), significantly higher than among the general population. The prevalence of depressive symptoms (EPDS ≥ 10) was 14.6%. Depressive symptoms were strongly associated with insomnia during late pregnancy, especially with sleep durations <5 or >10 hours, sleep efficiency <75%, daytime impairment, and long sleep onset latency. Pelvic girdle pain and lower back pain was associated with insomnia, but not with depressive symptoms.

Insomnia, nightmare frequency, and nightmare distress in victims of sexual abuse: the role of perceived social support and abuse characteristics

In this study of victims of sexual abuse, the aim was to investigate the role of perceived social support and abuse characteristics in self-reported insomnia, nightmare frequency, and nightmare distress. Four hundred sixty Norwegian victims of sexual abuse completed a questionnaire assessing perceived social support, abuse characteristics, insomnia, nightmare frequency, and nightmare distress. Results show that higher levels of perceived social support were related to lower scores on all symptom outcome measures. Abuse involving oral, genital, or anal penetration was related to more insomnia symptoms. Longer duration of abuse and threatening conducted by the perpetrator were related to higher nightmare frequency, while threats and abuse involving penetration were related to higher degrees of distress associated with nightmares. In conclusion, the present study provides preliminary data indicating that perceived social support may affect the nature of sleep difficulties in sexual abuse victims. Also, more severe forms of sexual abuse are related to higher levels of sleep difficulties.

Self-reported sleep and health among Norwegian hospital nurses in intensive care units

AIM AND BACKGROUND

Shift work, and especially night work, is associated with poor health. Nurses, work a variety of work schedules including night work. So far, few studies have specifically investigated sleep and health among intensive care nurses.

DESIGN AND METHODS

We investigated sleep, sleepiness, fatigue, subjective health complaints, anxiety and depression in 150 intensive care nurses (convenience sample representing a response rate of 56·2%). The nurses worked at two major University hospitals in Norway and answered a questionnaire survey.

RESULTS

The intensive care nurses reported poorer sleep, more sleepiness, more fatigue, more anxiety and more depression compared to normative data. Poor sleep was reported by 70% and excessive sleepiness by 25% of the nurses; however, the design of the study did not allow us to determine the causes underlying these findings. Multiple linear regression analyses showed that age was positively associated with sleep problems, fatigue, subjective health complaints and anxiety and depression. In contrast, shift work experience was negatively associated with sleep problems, suggesting better coping with shift work over time.

CONCLUSIONS

Nurses working in intensive care units reported poorer sleep, more sleepiness, more fatigue, more anxiety and more depression compared to Norwegian norm groups. Age was positively related to these complaints, whereas shift work experience was negatively related to poor sleep. More studies are needed on strategies to improve sleep and health in nurses.

Shift work disorder in nurses--assessment, prevalence and related health problems

BACKGROUND

This study investigates the prevalence of symptoms of shift work disorder in a sample of nurses, and its association to individual, health and work variables.

METHODOLOGY/PRINCIPAL FINDINGS

We investigated three different shift work disorder assessment procedures all based on current diagnostic criteria and employing symptom based questions. Crude and adjusted logistic regression analyses were performed with symptoms of shift work disorder as the dependent variable. Participants (n = 1968) reported age, gender, work schedule, commuting time, weekly work hours, children in household, number of nights and number of shifts separated by less than 11 hours worked the last year, use of bright light therapy, melatonin and sleep medication, and completed the Bergen Insomnia Scale, Epworth Sleepiness Scale, Global Sleep Assessment Questionnaire, Diurnal Scale, Revised Circadian Type Inventory, Dispositional Resilience (Hardiness) Scale--Revised, Fatigue Questionnaire, questions about alcohol and caffeine consumption, as well as the Hospital Anxiety and Depression Scale.

CONCLUSIONS/SIGNIFICANCE

Prevalence rates of symptoms of shift work disorder varied from 32.4-37.6% depending on the assessment method and from 4.8-44.3% depending on the work schedule. Associations were found between symptoms of shift work disorder and age, gender, circadian type, night work, number of shifts separated by less than 11 hours and number of nights worked the last year, insomnia and anxiety. The different assessment procedures yielded similar results (prevalence and logistic regression analyses). The prevalence of symptoms indicative of shift work disorder was high. We argue that three symptom-based questions used in the present study adequately assess shift work disorder in epidemiological studies.

An Actigraphic Validation Study of Seven Morningness-Eveningness Inventories

Morningness-eveningness refers to the preference people have regarding the time they like to rise, conduct activities, and go to bed. People denoted as “morning types” (“larks”) like to rise early in the morning and go to bed early, while “evening types” (“owls”) prefer to sleep until later in the day and stay up until later at night. Various self-report instruments that measure morningness-eveningness have been developed. The aim of this study was to validate seven different self-report measures on morningness-eveningness using actigraphic data. One hundred and sixty-six students (mean age 21.4 years, range 19–30) were recruited from the University of Bergen and Bergen University College. The participants completed the self-report measures and wore an actigraph for seven days. The results showed that all self-report measures were in concordance with actigraphy-measured bed times, rise times, and the nadir for physical activity. In addition, some of the instruments were sensitive to differences between morning and evening types in their total sleep time on weekend nights or their stability in the activity curve across days as measured by actigraphy. Both the strengths and weaknesses of the present study are discussed, and proposals for future research are presented.

Prevalence and correlates of delayed sleep phase in high school students

PURPOSE

To investigate prevalence and correlates of delayed sleep phase, characterized by problems falling asleep in the evening and rising at adequate times in the morning, in a large sample of Norwegian high school students.

METHODS

A randomized sample of 1285 high school students (aged 16-19 years) participated in an internet based study answering questions about sleep habits, height, weight, smoking, alcohol use, school grades, and anxiety and depression symptoms. Delayed sleep phase was operationalized as difficulties falling asleep before 2 a.m. at least three nights per week together with much or very much difficulty waking up in the morning.

RESULTS

The results show a prevalence of delayed sleep phase of 8.4%. In all, 68% of these students (5.7% of the total sample) also reported problems advancing their sleep period as well as one daytime consequence (oversleeping at least two days a week or experiencing much/very much sleepiness at school). Delayed sleep phase was associated with lower average school grades, smoking, alcohol usage, and elevated anxiety and depression scores.

CONCLUSIONS

Delayed sleep phase appears to be common amongst Norwegian adolescents and is associated with negative outcomes such as lower average school grades, smoking, alcohol usage, and elevated anxiety and depression scores.

Subjective and objective sleepiness among oil rig workers during three different shift schedules

OBJECTIVES

Examine sleepiness in three different shift work schedules (within-subject design) in the offshore oil industry.

METHODS

Sleepiness was measured in 19 oil rig workers, using subjective (Karolinska Sleepiness Scale; Accumulated Time with Sleepiness) and objective measures (reaction time). The work schedule consisted of two weeks of 12 h day work (day shifts), two weeks of 12 h night work (night shifts), and two weeks of swing shift work (one week of night work followed by one week of day work).

RESULTS

Sleepiness was highest during the first days of night and swing shifts, and also in the middle of the swing shift work period, but gradually decreased as the days on the night shift progressed. While at home following the two-week work period, the workers reported more subjective sleepiness after night shift than after day or swing shifts. Reaction time tests during the work period showed no significant differences between the shift schedules. There was a significant shorter reaction time the last day compared to the beginning or middle of the work period.

CONCLUSIONS

Subjective sleepiness was higher during the first days of night work compared to day work, and also when the swing shift workers changed from night work to day work in the middle of the two-week work period. Subjective sleepiness was increased at home following night shifts compared to after day and swing shifts, suggesting that swing shift workers adapted their circadian rhythm during their second period of work, during the day shift week, offshore.

A self-help book is better than sleep hygiene advice for insomnia: a randomized controlled comparative study

The objective was to compare the effects of two types of written material for insomnia in a randomized trial with follow-up after three months. Insomniacs were recruited through newspaper advertisements to a web-based survey with validated questionnaires about sleep, anxiety, depression, and use of sleep medications. A self-help book focusing on cognitive behavioral therapy for insomnia was compared to standard sleep hygiene advice; 77 and 78 participants were randomized to self-help book or sleep hygiene advice, respectively. The response rate was 81.9%. The self-help book gave significantly better scores on the sleep questionnaires compared to sleep hygiene advice. The proportion using sleep medications was reduced in the self-help book group, whereas it was increased in the sleep hygiene group. Compared to pre-treatment, the self-help book improved scores on the sleep (effect sizes 0.61-0.62) and depression (effect size 0.18) scales, whereas the sleep hygiene advice improved scores on some sleep scales (effect sizes 0.24-0.28), but worsened another (effect size -0.36). In addition, sleep hygiene advice increased the number of days per week where they took sleep medications (effect size -0.50). To conclude, in this randomized controlled trial, the self-help book improved sleep and reduced the proportion using sleep medications compared to sleep hygiene advice. The self-help book is an efficient low-threshold intervention, which is cheap and easily available for patients suffering from insomnia. Sleep hygiene advice also improved sleep at follow-up, but increased sleep medication use. Thus, caution is warranted when sleep hygiene advice are given as a single treatment.

Personality factors related to shift work tolerance in two- and three-shift workers

This study aimed to investigate whether different personality variables were associated with shift work tolerance, and whether these potential associations were moderated by various types of shift work. The sample comprised 1505 nurses who worked either two or three rotating shifts. Personality traits were measured in terms of morningness, flexibility, languidity and hardiness. Morningness reflects the tendency to be alert relatively early in the morning and sleepy relatively early in the evening. Flexibility denotes the ability to both work and sleep at odd times of the day, while languidity concerns the tendency to become tired/sleepy when cutting down on sleep. Hardiness relates to resilience to stressful life events. The dependent variables in this study comprised of measures of insomnia, sleepiness, depression and anxiety. Hierarchical regression analyses, which controlled for demographic variables and work load, revealed that Morningness was significantly and negatively related to insomnia. The Morningness by Shift type interaction was overall significant for depressive symptoms. Morningness was near significantly associated with lower levels of depressive symptoms in three-shift workers, but unrelated to depressive symptoms in two-shift workers. Flexibility was associated with higher levels of depressive symptoms. Flexibility by Shift type interaction was significant for insomnia, indicating that flexibility was negatively associated with insomnia for three-shift workers and unrelated with insomnia for two-shift workers. Languidity was associated with higher levels of sleepiness, depressive and anxiety symptoms. Hardiness was associated with lower levels of all four dependent variables.

The relationship between media use in the bedroom, sleep habits and symptoms of insomnia

This postal questionnaire study investigated the use of media in the bedroom and its relationships with sleep habits and symptoms of insomnia. The sample comprised 2500 individuals aged 16-40 years drawn randomly from the Norwegian national register. A total of 816 (34.0%) completed and returned the questionnaire. Respondents were asked how often they used computers, television sets, DVD players, game consoles and mobile telephones and listened to music/radio in their bedrooms. They also reported sleep habits on weekdays and at weekends/days off and symptoms of insomnia. After controlling for gender, age, anxiety and depression, the respondents who used a computer in the bedroom 'often' compared to 'rarely' rose later on weekdays and at weekends/days off, turned off the lights to go to sleep later at weekends/days off, slept more hours at weekends/days off and had a greater discrepancy between turning off the lights to go to sleep on weekdays and at weekends/days off. Respondents who used a mobile telephone in their bedrooms at night 'often' compared to 'rarely' turned off the lights to go to sleep later on weekdays and at weekends/days off, and rose later at weekends/days off. No such differences were found with the use of the other media. There were also no significant differences in symptoms of insomnia. This study indicates that the use of computers and mobile telephones in the bedroom are related to poor sleep habits, but that media use in the bedroom seems to be unrelated to symptoms of insomnia.

Prevalence of different parasomnias in the general population

OBJECTIVE

To estimate lifetime and current prevalence (defined as having experienced the specific parasomnia at least once during the last 3 months) of different parasomnias in the general population. In addition, to study the relationship between the different parasomnias and gender, depressive mood, and symptoms of sleep apnea, insomnia and restless legs, as well as estimating the prevalence of having multiple parasomnias.

METHODS

Population based cross-sectional study. One thousand randomly selected adults (51% female), 18years and above, participated in a telephone interview in Norway.

RESULTS

Lifetime prevalence of the different parasomnias varied from about 4% to 67%. For sleep walking lifetime prevalence was 22.4% and current prevalence 1.7%. For the other parasomnias, lifetime and current prevalence were as follows: sleep talking 66.8% and 17.7%, confusional arousal 18.5% and 6.9%, sleep terror 10.4% and 2.7%, injured yourself during sleep 4.3% and 0.9%, injured somebody else during sleep 3.8% and 0.4%, sexual acts during sleep 7.1% and 2.7%, nightmare 66.2% and 19.4%, dream enactment 15.0% and 5.0%, sleep related groaning 31.3% and 13.5%, and sleep-related eating 4.5% and 2.2%. Depressive mood was associated with confusional arousal, sleep terror, sleep-related injury, and nightmare. There were few associations between the parasomnias and gender and symptoms of sleep apnea, insomnia, and restless legs, respectively. About 12% reported having five or more parasomnias.

CONCLUSIONS

This is one of few population based studies investigating the prevalence of parasomnias. Several parasomnias were highly prevalent in the general population. The data need to be interpreted with caution due to methodological issues, i.e., low response rate and single questions.