Insomnia and daytime sleepiness are risk factors for depressive symptoms in the elderly

Nursing Home Eligible, Community-Dwelling Older Adults' Perceptions and Beliefs About Sleep: A Mixed-Methods Study

Sleep disturbances are highly prevalent in older adults; little is known about sleep in those who remain living in the community despite qualifying for nursing home placement. We conducted a concurrent, nested, mixed-methods study to describe sleep characteristics and sleep disturbances in this population. Our final sample (n = 40) was Black (100%), female (85%) older adults with a mean (±SD) age of 72 ± 9.5 years. Of these, 35 had objectively measured short or long sleep duration, and 30 had subjectively reported poor sleep quality. Our evidence suggests that sleep disturbances are common in this group, and these older adults had adjusted their expectations and adapted to their sleep disturbances. Given that at-risk older adults may not perceive their sleep disturbances as problematic, clinicians must proactively assess sleep and educate about the importance of sleep. These results reveal modifiable factors with potential to improve health outcomes in this vulnerable population.

Utility of the Compensatory Tracking Task for Objective Differentiation of Hypersomnolence in Depression: A High-Density EEG Investigation

Hypersomnolence is a common and debilitating symptom in mood disorders. However, objective differentiation of excessive daytime sleepiness (EDS) from non-EDS in depression has not yet been achieved. This study compared performance on the Compensatory Tracking Task (CTT) and concurrently-recorded high-density (hd)EEG theta power in 22 patients with major depressive disorder (MDD) and co-occurring EDS against 22 age- and sex-matched patients with MDD but no EDS, as well as 22 age- and sex-matched healthy controls. Though depressed hypersomnolent participants endorsed feeling sleepier than depressed non-hypersomnolent and healthy control participants prior to starting the CTT, no group differences in CTT performance were observed. Average hdEEG theta power was higher during periods of high error on the CTT compared to periods of low error, but did not differ between the groups. Though the CTT still holds promise as an objective neurobehavioral measure, these results do not indicate a capability to differentiate EDS from non-EDS in mood disorders.

Delivering Cognitive Behavioral Therapy for Insomnia in Military Personnel and Veterans

Insomnia is commonly reported by military populations, especially those with comorbid mental and physical health conditions. Co-occurring conditions result in an altered presentation of insomnia symptoms, and complicate provision of cognitive-behavioral therapy for insomnia (CBT-I), requiring supplementary assessment or modifications to traditional techniques. CBT-I has consistently demonstrated positive outcomes for active-duty service members and veterans, even in the context of significant comorbidities such as post-traumatic stress disorder, depression, sleep apnea, and chronic pain. Despite its promise, studies of CBT-I in some populations, including women and individuals with substance use disorders, remain relatively understudied in active-duty and veteran populations.

Characteristics of Self-Reported Sleep and the Risk of Falls and Fractures: The Women's Health Initiative (WHI)

Sleep disturbances are common and may influence falls and fracture directly by influencing bone turnover and muscle strength or indirectly through high comorbidity or poor physical function. To investigate the association between self-reported sleep and falls and fractures, we prospectively studied 157,306 women in the Women's Health Initiative (WHI) using information on sleep quality, sleep duration, and insomnia from questionnaires. Annual self-report of falling two or more times (ie, "recurrent falling") during each year of follow-up was modeled with repeated measures logistic regression models fit by generalized estimating equations. Cox proportional hazards models were used to investigate sleep disturbance and time to first fracture. We examined the risks of recurrent falls and fracture by sleep duration with 7 hours as referent. We examined the risks across categories of sleep disturbance, insomnia status, and sleep quality. The average follow-up time was 7.6 years for falls and 12.0 years for fractures. In multivariable adjusted models, including adjustment for comorbidity, medications, and physical function, women who were short (≤5 hours) and long (≥10 hours) sleepers had increased odds of recurrent falls (odds ratio [OR] 1.28; 95% confidence interval [CI], 1.23 to 1.34 and OR 1.25; 95% CI, 1.09 to 1.43, respectively). Poor sleep quality, insomnia, and more sleep disturbances were also associated with an increased odds of recurrent falls. Short sleep was associated with an increased risk of all fractures, and upper limb, lower limb, and central body fractures, but not hip fractures, with hazard ratios ranging from 1.10 to 1.13 (p < 0.05). There was little association between other sleep characteristics and fracture. In conclusion, short and long sleep duration and poor sleep quality were independently associated with increased odds of recurrent falls. Short sleep was associated with modest increase in fractures. Future long-term trials of sleep interventions should include falls and fractures as endpoints. © 2018 American Society for Bone and Mineral Research.

Depression in sleep disturbance: A review on a bidirectional relationship, mechanisms and treatment

Sleep disturbance is the most prominent symptom in depressive patients and was formerly regarded as a main secondary manifestation of depression. However, many longitudinal studies have identified insomnia as an independent risk factor for the development of emerging or recurrent depression among young, middle‐aged and older adults. This bidirectional association between sleep disturbance and depression has created a new perspective that sleep problems are no longer an epiphenomenon of depression but a predictive prodromal symptom. In this review, we highlight the treatment of sleep disturbance before, during and after depression, which probably plays an important role in improving outcomes and preventing the recurrence of depression. In clinical practice, pharmacological therapies, including hypnotics and antidepressants, and non‐pharmacological therapies are typically applied. A better understanding of the pathophysiological mechanisms between sleep disturbance and depression can help psychiatrists better manage this comorbidity.

CBT for late-life insomnia and the accuracy of sleep and wake perceptions: Results from a randomized-controlled trial

Subjective and objective estimates of sleep are often discordant among individuals with insomnia who typically under-report sleep time and over-report wake time at night. This study examined the impact and durability of cognitive-behavioural therapy for insomnia on improving the accuracy of sleep and wake perceptions in older adults, and tested whether changes in sleep quality were related to changes in the accuracy of sleep/wake perceptions. One-hundred and fifty-nine older veterans (97% male, mean age 72.2 years) who met diagnostic criteria for insomnia disorder were randomized to: (1) cognitive-behavioural therapy for insomnia (n = 106); or (2) attention control (n = 53). Assessments were conducted at baseline, post-treatment, 6-months and 12-months follow-up. Sleep measures included objective (via wrist actigraphy) and subjective (via self-report diary) total sleep time and total wake time, along with Pittsburgh Sleep Quality Index score. Discrepancy was computed as the difference between objective and subjective estimates of wake and sleep. Minutes of discrepancy were compared between groups across time, as were the relationships between Pittsburgh Sleep Quality Index scores and subsequent changes in discrepancy. Compared with controls, participants randomized to cognitive-behavioural therapy for insomnia became more accurate (i.e. minutes discrepancy was reduced) in their perceptions of sleep/wake at post-treatment, 6-months and 12-months follow-up (p < .05). Improved Pittsburgh Sleep Quality Index scores at each study assessment preceded and predicted reduced discrepancy at the next study assessment (p < .05). Cognitive-behavioural therapy for insomnia reduces sleep/wake discrepancy among older adults with insomnia. The reductions may be driven by improvements in sleep quality. Improving sleep quality appears to be a viable path to improving sleep perception and may contribute to the underlying effectiveness of cognitive-behavioural therapy for insomnia.

[Sleep Disorders in Old Age]

Sleep Disorders in Old Age Abstract. Sleep disorders increase with age. Older patients rarely complain about sleep disorders, therefore it is important to ask about sleep problems. Insomnias, sleep-disordered breathing and restless legs syndrome tend to increase with older age. It is important to consider that sleep disorders may be the first symptom of a depression, anxiety disorder or neurodegenerative disorders such as dementias. Many factors can influence sleep in old age: it is important to inquire after sleeping habits including naps during the day, medication and comorbidity. Treatment depends on the causes. Insomnias should be treated mainly with non-pharmacological means such as cognitive behaviour therapy.

Sleep Outcomes With Cognitive Behavioral Therapy for Insomnia Are Similar Between Older Adults With Low vs. High Self-Reported Physical Activity

We examined whether baseline self-reported physical activity is associated with the efficacy of cognitive behavioral therapy for insomnia (CBT-I) in older veterans. Community-dwelling veterans aged 60 years and older with insomnia received CBT-I in a randomized controlled trial. Participants who received active treatment were divided into low and high physical activity based on self-report. Sleep outcomes were measured by sleep diary, questionnaire and wrist actigraphy; collected at baseline, post-treatment, 6-month and 12-month follow-up. Mixed-effects models compared differences between physical activity groups in change in sleep outcome from baseline to each follow-up, and equivalence tests examined if physical activity groups were clinically equal. There were no significant differences in sleep outcomes between physical activity groups. Equivalence tests suggested possible equality in physical activity groups for five of seven sleep outcomes. Efficacy of CBT-I in older veterans was not associated with self-reported physical activity at baseline. Older adults with insomnia who report low levels of physical activity can benefit from CBT-I.

Sleep Environment and Insomnia in Elderly Persons Living at Home

The aim of this study was to draw a portrait of the sleep environment of elderly persons living in private households and to determine its relationship with the presence of insomnia. A sample of 599 individuals aged 70 years and older responded to questions about the comfort of their pillow and mattress and the noise level and brightness of their bedroom at night and in the morning. They were also asked whether or not they shared their bed or bedroom with a sleep partner. The Insomnia Severity Index was used to assess insomnia severity. Over 40% of the study participants were using a pillow that was not very comfortable, and almost 30% said that their bedroom was not completely quiet. Binomial logistic regression results revealed that two variables were significantly associated with insomnia symptoms: a pillow rated as moderately comfortable to very uncomfortable and a bedroom that was not completely quiet. No other sleep environment characteristics considered in this study were associated with the risk of insomnia. These results indicate that a nonnegligible proportion of the elderly population endures a suboptimal sleep environment. Although it is difficult to predict the real impact of changes to the sleep environment, this study supports the proposal that simple, minor changes to the bedroom can promote sleep in the elderly.

An Update on Dual Orexin Receptor Antagonists and Their Potential Role in Insomnia Therapeutics

STUDY OBJECTIVES

Current pharmacological options for the treatment of insomnia insufficiently meet the needs of all insomnia patients. Approved treatments are not consistently effective in improving sleep onset and sleep maintenance, while also having complicated safety profiles. These limitations highlight the unmet need for additional medications and treatment strategies. Initial research suggests that the dual orexin receptor antagonists (DORAs) may offer an additional pharmaceutical option to treat insomnia in some patients.

METHODS

We reviewed the existing literature on dual orexin receptor antagonists in PubMed databases using the search terms "orexin receptor antagonist," "almorexant" "filorexant," "lembroexant" and "suvorexant"; searches were limited to English language primary research articles, clinical trials, and reviews.

RESULTS

Targeting the orexin receptor system for treatment of insomnia offers an additional and alternative pharmacological approach to more common gamma aminobutyric acid agonist sedative hypnotic treatment. Effectiveness is not well established in the current literature; however, the literature does suggest efficacy. Preclinical reports also suggest the potential for treatment in individuals with comorbid Alzheimer disease and insomnia.

CONCLUSIONS

DORAs offer an additional treatment option for insomnia. More clinical trials are needed to robustly evaluate their safety and effectiveness in several subclasses of individuals with insomnia. Given the published literature, head-to-head comparisons to existing treatment for insomnia are warranted.

Excessive Daytime Sleepiness Is Associated With Depression Scores, But Not With Sleep-Disordered Breathing in Patients With Cardiovascular Diseases

BACKGROUND

Excessive daytime sleepiness (EDS) is a significant public health concern, with sleep-disordered breathing (SDB) being a common cause. However, their precise relationship in patients with cardiovascular disease (CVD) is unclear. Furthermore, whether comorbid psychological disorders could contribute to EDS remains unknown. We aimed to assess the prevalence of EDS and its related factors, including SDB and depression, in patients with CVD.Methods and Results:We analyzed data from 1,571 patients admitted for various CVDs in a single university hospital (median age, 67 [56-76] years; 29.6% women). We assessed EDS using the Japanese version of the Epworth Sleepiness Scale (ESS; median 6.0 [4.0-9.0]). The presence of EDS (ESS >10, n=297 [18.9%]) did not differ between patients with and without SDB, which was screened with nocturnal pulse oximetry. In contrast, the patients with EDS had higher depression scores (Hospital Anxiety and Depression Scale subscore for depression [HADS-D] and Patient Healthcare Questionnaire [PHQ]-9). The depression scores, measured by HADS-D (odds ratio [OR] 1.14; 95% confidence interval [CI], 1.07-1.22) and PHQ-9 (OR, 1.14; 95% CI, 1.07-1.20) were independent determinants of EDS. These relationships among EDS, SDB, and depression were consistent among the subgroups with cardiovascular comorbidities.

CONCLUSIONS

The presence of EDS is associated with depressive symptoms, but not with SDB, in patients with CVD, suggesting that these patients should be thoroughly assessed for psychological disturbances.

Daytime Sleepiness in Patients Diagnosed with Sarcoidosis Compared with the General Population

Background

The aim of this study was to analyze daytime sleepiness in a sample of patients diagnosed with sarcoidosis.

Methods

A sample of 1197 German sarcoidosis patients was examined with the Epworth Sleepiness Scale (ESS), the Fatigue Assessment Scale, the Hospital Anxiety and Depression Scale, the Pittsburgh Sleep Quality Index, and the Short-Form Health Survey (SF-8). The patients' ESS mean scores were compared with those obtained from a large general population sample.

Results

Exactly 50% of the patients reached the criterion (ESS > 10) for excessive daytime sleepiness, compared with only 22.1% in the general population. The effect size for the mean score difference between both samples was d=0.62. The number of affected organs and the number of concomitant diseases proved to be significant independent predictors of daytime sleepiness. Sleepiness was associated with fatigue (r=0.45), anxiety (r=0.23), depression (r=0.28), sleep problems (r=0.23), and detriments in physical (r=-0.29) and mental (r=-0.28) quality of life.

Conclusions

The issue of excessive daytime sleepiness should be considered in the management of sarcoidosis.

Insomnia in the Elderly: A Review

BACKGROUND

Insomnia remains one of the most common sleep disorders encountered in the geriatric clinic population, frequently characterized by the subjective complaint of difficulty falling or maintaining sleep, or nonrestorative sleep, producing significant daytime symptoms including difficulty concentrating and mood disturbances.

METHODS

A search of the literature was conducted to review the epidemiology, definition, and age-related changes in sleep, as well as factors contributing to late-life insomnia and scales utilized for the assessment of insomnia in older people. The aim is to summarize recent diagnostic guidelines and both nonpharmacological and pharmacological strategies for the management of insomnia in the older population.

RESULTS

Insomnia remains a clinical diagnosis. There are several demographic, psychosocial, biologic, and behavioral factors that can contribute to late-life insomnia. Older adults are at higher risk for the medical and psychiatric effects of insomnia.

CONCLUSIONS

The most important aspect in evaluation of insomnia is detailed history taking and thorough physical examination. Nonpharmacological treatment options have favorable and enduring benefits compared to pharmacological therapy.

Course, risk factors, and mental health outcomes of excessive daytime sleepiness in rural Chinese adolescents: A one-year prospective study

BACKGROUND

This study aimed to examine the one-year incidence and persistence of excessive daytime sleepiness (EDS) in rural Chinese adolescents and their risk factors. In addition, we also aimed to explore the potential bidirectional associations of EDS with anxiety symptoms and depressive symptoms.

METHODS

A total of 3736 adolescents from 5 high schools from rural area in the south China were eligible for follow-up. Among them, 2787 responded to follow-up after one year. EDS was defined as having a total score of the Epworth Sleepiness Scale over 10.

RESULTS

The one-year persistence rate and incidence rate of EDS were 27.6% and 9.3%, respectively. After controlling for age and sex, new incident EDS was significantly associated with perceived high study stress, depressive symptoms, insomnia symptoms, and high life events at baseline. Baseline EDS predicted new onsets of depression and anxiety at follow-up. Cross-lagged analyses further revealed that there were bidirectional associations between EDS and anxiety symptom and between EDS and depressive symptoms. Persistent EDS was only associated with eveningness chronotype. In particular, short sleep duration and obesity were associated with neither new incidence nor persistence of EDS in this population.

LIMITATIONS

All measures relied on self-reported questionnaires rather than objective assessments, which might have led to report bias.

CONCLUSIONS

We have identified a number of risk factors of the one-year incidence of EDS (such as perceived high study stress, depressive symptoms, insomnia symptoms, and high life events) and persistence of EDS (eveningness chronotype) in rural adolescents. There is a reciprocal relationship of EDS with anxiety and depression. In this population, sleep loss and obesity seem not related to the course of EDS.

Sleep behavior and depression: Findings from the China Kadoorie Biobank of 0.5 million Chinese adults

BACKGROUND

Mixed results have shown the association between sleep behavior and depression, but evidence relating the joint effect of sleep duration and sleep disturbances is limited, especially in Chinese population.

METHODS

A total of 512,891 adults aged 30-79 years from China Kadoorie Biobank (CKB) were included. Depression was defined by Composite International Diagnostic Inventory-short form (CIDI-SF). Sleep duration and sleep disturbances, including difficulty initiating and maintaining sleep (DIMS), early morning awakening (EMA), daytime dysfunction (DDF) and any sleep disturbances (ASD), were obtained by a self-reported questionnaire. Logistic regression was applied to examine the association between sleep behavior and depression.

RESULTS

About 23.1% of participants reported short sleep duration (≤ 6h), and 5.1% reported long sleep duration (> 9h). Compared with normal sleep duration (7-9h), both groups were associated greater likelihood of having depression (short sleep: OR = 2.32, 95%CI: 2.14-2.51; long sleep: OR = 1.56, 96%CI: 1.34-1.81). Participants reported sleep disturbances were significantly associated with depression (odds ratios ranged from 3.31 to 4.17). Moreover, the associations tended to be stronger for those who reported both abnormal sleep duration and sleep disturbances (p for interactions < 0.05), especially for those who slept long.

LIMITATIONS

The cross-sectional nature of the study design limits the interpretation of the results.

CONCLUSIONS

Abnormal sleep duration and sleep disturbances were associated with depression. The associations were stronger for abnormal sleep duration accompanied with sleep disturbances, especially for a long duration. More attention should be paid on these persons in clinical practice.

Sleep and mood in older adults: coinciding changes in insomnia and depression symptoms

The aim of this analysis was to test if changes in insomnia symptoms and global sleep quality are associated with coinciding changes in depressed mood among older adults. We report on results yielded from secondary analysis of longitudinal data from a clinical trial of older adults (N = 49) aged 55 to 80 years who reported at least moderate levels of sleep problems. All measures were collected at baseline and after the trial ten weeks later. We computed change scores for two separate measures of disturbed sleep, the Athens Insomnia Scale (AIS) and the Pittsburgh Sleep Quality Index (PSQI), and tested their association with change in depressed mood (Beck Depression Inventory-II; BDI-II) in two separate linear regression models adjusted for biological covariates related to sleep (sex, age, body mass index, and NF-κB as a biological marker previously correlated with insomnia and depression). Change in AIS scores was associated with change in BDI-II scores (β = 0.38, p < 0.01). Change in PSQI scores was not significantly associated with change in BDI-II scores (β = 0.17, p = 0.26). Our findings suggest that improvements over ten weeks in insomnia symptoms rather than global sleep quality coincide with improvement in depressed mood among older adults.

Is insomnia a risk factor for new-onset asthma? A population-based study in Taiwan

OBJECTIVES

To determine whether insomnia at baseline is a risk factor for new-onset asthma.

METHODS

We recruited 48 871 patients with insomnia (insomnia group) newly diagnosed between 2002 and 2007, and 97 742 matched controls without insomnia (control group) from Taiwan's Longitudinal Health Insurance Database 2000. All of the patients were followed up for 4 years to see whether new-onset asthma developed. Patients with previous asthma or insomnia were excluded. The Poisson regression was used to estimate the incidence rate ratios (IRRs) and 95% CIs of asthma. Cox proportional hazard regression was used to calculate the risk of asthma between the two groups.

RESULTS

After a 4-year follow-up, 424 patients in the insomnia group and 409 in the control group developed asthma. The incidence rate of asthma was significantly higher in the insomnia group (22.01vs10.57 per 10 000 person-years). Patients with insomnia have a higher risk of developing new-onset asthma during the 4-year follow-up (HR: 2.08, 95% CI 1.82 to 2.39). The difference remained significant after adjustment (adjusted HR: 1.89, 95% CI 1.64 to 2.17).

CONCLUSIONS

This large population-based study suggests that insomnia at baseline is a risk factor for developing asthma.

Nocturnal sleep architecture in idiopathic hypersomnia: a systematic review and meta-analysis

BACKGROUND

Current sleep medicine nosology places increased importance on nocturnal polysomnographic sleep recordings in the diagnosis of central nervous system disorders of hypersomnolence, particularly idiopathic hypersomnia (IH).

OBJECTIVE

Determine what differences in sleep staging and architecture exist between IH and healthy controls using meta-analysis.

METHODS

Systematic review identified relevant studies that included nocturnal polysomnography data for IH and healthy control groups. Meta-analysis compared standardized mean differences (Hedge's g) for total sleep time (TST), sleep onset latency (SOL), sleep efficiency (SE), rapid eye movement (REM) sleep percentage, slow wave sleep (SWS) percentage, and REM latency (REML). Moderator analyses were also conducted for variables with significant heterogeneity among studies.

RESULTS

The meta-analysis included 10 studies. Relative to controls, IH demonstrated increased TST (pooled g = 0.92; 95% CI: 0.46 to 1.38, p < 0.0001) and REM percentage (pooled g = 0.36, 95% CI: 0.09 to 0.64, p = 0.01), decreased SOL (pooled g = -0.46; 95% CI: -0.81 to -0.12, p = 0.009) and SWS percentage (pooled g = -0.28, 95% CI: -0.50 to -0.07, p = 0.01), without significant differences in SE (pooled g = 0.03; 95% CI: -0.32 to 0.38, p = 0.86) or REML (pooled g = 0.14, 95% CI: -0.21 to 0.49, p = 0.42). Moderator analysis demonstrated a significant effect of sex on SE, with a higher proportion of women to men significantly predicting lower SE between in IH and controls (p < 0.0001).

CONCLUSIONS

IH is associated with several changes in sleep staging and architecture relative to healthy persons, including alterations in REM and SWS not currently delineated in nosological constructs. Further research is indicated to clarify how these findings are related the pathophysiology of IH and related disorders.

An Aggregate Measure of Sleep Health Is Associated With Prevalent and Incident Clinically Significant Depression Symptoms Among Community-Dwelling Older Women

Objectives

Sleep can be characterized along multiple dimensions. We investigated whether an aggregate measure of sleep health was associated with prevalent and incident clinically significant depression symptoms in a cohort of older women.

Methods

Participants were older women (mean age 80.1 years) who completed baseline (n = 6485) and follow-up (n = 3806) visits, approximately 6 years apart, in the Study of Osteoporotic Fractures (SOF). Self-reported sleep over the past 12 months was categorized as "good" or "poor" across 5 dimensions: satisfaction with sleep duration, daytime sleepiness, mid-sleep time, sleep onset latency, and sleep duration. An aggregate measure of sleep health was calculated by summing the number of "poor" dimensions. Clinically significant depression symptoms were defined as a score ≥6 on the Geriatric Depression Scale. Relationships between sleep health and depression symptoms were evaluated with multivariate logistic regression, adjusting for health measures and medications.

Results

Individual sleep health dimensions of sleep satisfaction, daytime sleepiness, mid-sleep time, and sleep onset latency were significantly associated with prevalent depression symptoms (odds ratios [OR] = 1.26-2.69). Sleep satisfaction, daytime sleepiness, and sleep onset latency were significantly associated with incident depression symptoms (OR = 1.32-1.79). The number of "poor" sleep health dimensions was associated in a gradient fashion with greater odds of prevalent (OR = 1.62-5.41) and incident (OR = 1.47-3.15) depression symptoms.

Conclusion

An aggregate, multidimensional measure of sleep health was associated with both prevalent and incident clinically-significant depression symptoms in a gradient fashion. Future studies are warranted to extend these findings in different populations and with different health outcomes.

Excessive Sleepiness and Longer Nighttime in Bed Increase the Risk of Cognitive Decline in Frail Elderly Subjects: The MAPT-Sleep Study

Objective: To identify self-reported sleep-wake disturbances that increase the risk of cognitive decline over 1-year follow-up in frail participants.

Background: Risk factors for cognitive impairment need to be better identified especially at earliest stages of the pathogenesis. Sleep-wake disturbances may be critical factors to consider and were thus being assessed in this at-risk population for cognitive decline.

Methods: Frail elderly participants aged ≥70 years were selected from a subsample of the Multi-domain Alzheimer Preventive Trial (MAPT) for a sleep assessment (MAPT-sleep study) at 18-month follow-up (M18). Sleep-wake disturbances were evaluated using a clinical interview (duration of daytime and nighttime sleep, time in bed, number of naps, and presence of clinically-defined sleep disorders) and numerous validated questionnaires [Epworth Sleepiness Scale for excessive daytime sleepiness (EDS), Insomnia Severity Scale and Berlin Questionnaire]. Cognitive decline was defined as a difference between the MMSE and cognitive composite scores at M24 and M36 that was ranked in the lowest decile. Multivariate logistic regression models adjusted for several potential confounding factors were performed.

Results: Among the 479 frail participants, 63 developed MMSE-cognitive decline and 50 cognitive composite score decrease between M24 and M36. Subjects with EDS had an increased risk of MMSE decline (OR = 2.46; 95% CI [1.28; 4.71], p = 0.007). A longer time spent in bed during night was associated with cognitive composite score decline (OR = 1.32 [1.03; 1.71], p = 0.03). These associations persisted when controlling for potential confounders. Patients with MMSE score decline and EDS had more naps, clinically-defined REM-sleep Behavior Disorder, fatigue and insomnia symptoms, while patients with cognitive composite score decline with longer time in bed had increased 24-h total sleep time duration but with higher wake time after onset.

Conclusions: The risk of cognitive decline is higher in frailty subjects with EDS and longer nighttime in bed. Early detection of sleep-wake disturbances might help identifying frail subjects at risk of cognitive decline to further propose sleep health strategies to prevent cognitive impairment.

http://www.clinicaltrials.gov NCT00672685; Date of registration May, 2nd 2008.

Sleepiness in the Elderly

Excessive daytime sleepiness has pathologic causes and numerous adverse consequences; therefore, it requires medical attention in older adults. Excessive sleepiness in older adults is often multifactorial and may signal an underlying sleep disorder, chronic medical condition, undiagnosed mood disorder, or side effects of medications. It is associated with increased risk for cognitive decline and dementia in the elderly. Excessive sleepiness often requires a multi-method assessment in this age group. It is pertinent to take a systematic, step-by-step treatment approach geared toward the underlying cause, and to treat sleepiness directly, when the cause cannot be eliminated to prevent adverse outcomes.

Interplay among pain intensity, sleep disturbance and emotion in patients with non-specific low back pain

Background

Low back pain (LBP) is the most common problem worldwide. There are several negative consequences of LBP, such as sleep disorders, work leave, disability, depression, anxiety, and poor quality of life. In this study, we designed to evaluate the prevalence of sleep disturbance in patients with non-specific LBP(NSLBP), and cross-correlation among sleep disorder, anxiety, depression and pain intensity in patients with NSLBP.

Aim

In this study, we designed to evaluate the prevalence of sleep disturbance in patients with NSLBP, and cross-correlation among sleep disorder, anxiety, depression and pain intensity in patients with NSLBP.

Methods

A cross-sectional self-assessment questionnaire survey was carried out in an outpatient clinic. Anonymous assessments were used to characterize the presence of NSLBP, PSQI, VAS, SF-36 form, ODI, BAI and BDI. Cross-correlation among the severity of NSLBP and sleep disturbance, anxiety, depression and life quality were evaluated.

Results

Patients with NSLBP have a higher incidence of sleep disorder, anxiety and depression, and higher ODI scores than healthy people without LPB (P < 0.01). NSLBP patients with sleep disorders have more severe anxiety, depression, an increased VAS score and poor daily living (P < 0.05). NSLBP patients with anxiety have declined sleep quality, poor daily living, decreased work and social skills, and increased LBP severity (P < 0.05). NSLBP patients with depression have declined sleep quality, poor daily living, decreased work and social skills (P < 0.05). Significant associations were found between the severity of NSLBP and sleep disorders, anxiety and ODI scores.

Conclusion

Psychological and social factors play an important role in the development of NSLBP. NSLBP leads to sleep disorders, which decrease the sleep quality and increase the unpleasant emotions and memories in return; these can exacerbate the severity of LBP, with the cycle repeating to form a vicious circle.

Incidence, worsening and risk factors of daytime sleepiness in a population-based 5-year longitudinal study

Excessive daytime sleepiness (EDS) is highly prevalent in the general population; however little is known about its evolution and predictors. Our objectives were to document its natural history, provide estimates of its prevalence, incidence and persistence rates, and to identify predictors of increased daytime sleepiness (DS) in a longitudinal community study of 2157 adults over 5 years. Participants completed postal assessment at baseline and at each yearly follow-up. DS was evaluated by the Epworth Sleepiness scale (ESS). At baseline, 33% reported EDS (ESS > 10) with 33% of them reported persistent EDS. Of those without EDS at baseline, 28% developed incident EDS (15% were persistent) and 31% increased DS (augmentation ≥4-points between two consecutive evaluations). Younger age and depression were independent predictors of incident EDS and DS increase while lower coffee consumption, smoking, insomnia, tiredness and chronic pain were associated with incident EDS, and living alone with DS increase only. Persistent vs transient EDS or DS showed association with poor general health including metabolic diseases. Thus, sleepiness fluctuated over time and it was predicted by common lifestyle and psychological factors potentially modifiable. However, persistent sleepiness was associated with chronic medical diseases thus highlighting a homogeneous group at risk requiring a dedicated management.

Sleep Duration of Inpatients With a Depressive Disorder: Associations With Age, Subjective Sleep Quality, and Cognitive Complaints

Sleep complaints and sleep disturbances are common in depression; however, the association of sleep duration and subjective sleep quality has been rarely investigated. Thus, subjective sleep quality and sleep duration were analyzed in depressed inpatients. Questionnaire data comprising clinical and sleep-related questions were sampled over a one-year period from adult inpatients with depressive syndromes. Sleep duration and items related to sleep quality were analyzed by means of group comparisons (sleep duration categories) and correlation analyses. Data of 154 patients (age 58.2±17.0 years, 63.6% women) were analyzed. Mean sleep duration was 7.2±2.1 h (16.9% of patients were below and 7.1% above age-specific recommendations), 25-40% of patients reported almost always daytime sleepiness, non-restorative sleep, attention deficits, or memory complaints with significant correlations between all variables (P<0.05). Sleep duration and sleep quality indicators showed significant curvilinear associations (quadratic contrast, P<0.05); i.e. extremely low and high sleep durations were associated with unfavorable sleep quality and subjective cognitive impairment. Non-recommended low or high sleep durations occur in a substantial proportion of patients with depression, and both were associated with poor sleep quality and subjectively impaired cognitive functions. Clinicians should be aware of these relationships. During hospitalization, a more individualized sleep-wake schedule should be applied.

Hypersomnolence, Hypersomnia, and Mood Disorders

Relationships between symptoms of hypersomnolence, psychiatric disorders, and hypersomnia disorders (i.e., narcolepsy and idiopathic hypersomnia) are complex and multidirectional. Hypersomnolence is a common complaint across mood disorders; however, patients suffering from mood disorders and hypersomnolence rarely have objective daytime sleepiness, as assessed by the current gold standard test, the Multiple Sleep Latency Test. An iatrogenic origin of symptoms of hypersomnolence, and sleep apnea syndrome must be considered in a population of psychiatric patients, often overweight and treated with sedative drugs. On the other hand, psychiatric comorbidities, especially depression symptoms, are often reported in patients with hypersomnia disorders, and an endogenous origin cannot be ruled out. A great challenge for sleep specialists and psychiatrists is to differentiate psychiatric hypersomnolence and a central hypersomnia disorder with comorbid psychiatric symptoms. The current diagnostic tools seem to be limited in that condition, and further research in that field is warranted.

Longitudinal associations of hypersomnolence and depression in the Wisconsin Sleep Cohort Study

BACKGROUND

Hypersomnolence is common in depression, however longitudinal associations of excessive daytime sleepiness (EDS), long habitual sleep duration, and objective sleep propensity with depressive symptomatology are not well established.

METHODS

Data from adults participating in the Wisconsin Sleep Cohort Study who had multiple assessments at 4-year intervals were utilized in analyses. Conditional (intrasubject) logistic regression estimated the likelihood of development of depression and three primary hypersomnolence measures: subjective EDS [Epworth Sleepiness Scale (ESS) >10], habitual sleep duration ≥9h/day, and increased physiological sleep propensity [multiple sleep latency test (MSLT) mean sleep latency <8min].

RESULTS

After adjusting for all covariates, the odds for development of depression were significantly increased 1.67-fold (95% CI 1.02-2.73, p=0.04) in participants who also developed subjective EDS. However, development of increased physiological sleep propensity on the MSLT was associated with a trend towards reduced odds for development of depression (odds ratio 0.50, 95% CI 0.24-1.06, p=0.07). No significant longitudinal association between excessive sleep duration and depression was observed.

LIMITATIONS

Depression was not verified by psychiatric interview and an objective measure of sleep duration was not utilized.

CONCLUSIONS

Our results demonstrate a significant longitudinal association between increased subjective EDS and depression. However, increased physiological sleep propensity on the MSLT was paradoxically marginally protective against the development of depression. Further research is indicated to determine the mechanism underling divergent effects of various aspects of hypersomnolence on the course of mood disorders.

Sleep Health: Reciprocal Regulation of Sleep and Innate Immunity

Sleep disturbances including insomnia independently contribute to risk of inflammatory disorders and major depressive disorder. This review and overview provides an integrated understanding of the reciprocal relationships between sleep and the innate immune system and considers the role of sleep in the nocturnal regulation of the inflammatory biology dynamics; the impact of insomnia complaints, extremes of sleep duration, and experimental sleep deprivation on genomic, cellular, and systemic markers of inflammation; and the influence of sleep complaints and insomnia on inflammaging and molecular processes of cellular aging. Clinical implications of this research include discussion of the contribution of sleep disturbance to depression and especially inflammation-related depressive symptoms. Reciprocal action of inflammatory mediators on the homeostatic regulation of sleep continuity and sleep macrostructure, and the potential of interventions that target insomnia to reverse inflammation, are also reviewed. Together, interactions between sleep and inflammatory biology mechanisms underscore the implications of sleep disturbance for inflammatory disease risk, and provide a map to guide the development of treatments that modulate inflammation, improve sleep, and promote sleep health.

Can sleep disturbance influence changes in mental health status? Longitudinal research evidence from ageing studies in England and Japan

BACKGROUND

Little is known about the role of sleep disturbance in relation to changes in depressive states. We used data obtained from the participants aged 65 and over in the English Longitudinal Study of Ageing (ELSA, waves four and five, N = 3108) and the Japan Gerontological Evaluation Study (JAGES, 2010 and 2013 sweeps, N = 7527) to examine whether sleep disturbance is longitudinally associated with older adults' patterns of depressive states.

METHODS

We created four patterns of depressive states (non-case, recovered, onset, repeatedly depressive) by combining responses to the measures (scoring four or more on seven items from the Center for Epidemiological Studies Depression Scale for the ELSA participants and scoring five or more for the Geriatric Depression Scale-15 for the JAGES participants) obtained at the baseline and follow-up. Sleep disturbance was assessed through responses to three questions on sleep problems. Age, sex, partnership status, household equivalised income, alcohol and cigarette use, and physical function were treated as confounders in this study. Additionally, information on sleep medication was available in JAGES and was included in the statistical models.

RESULTS

More ELSA participants were non-depressive cases and reported no sleep disturbances compared with the JAGES participants. Findings from multinomial logistic regression analysis showed that more sleep disturbance was associated with the onset group in ELSA (RRR = 2.37, 95% CI = 1.44-3.90) and JAGES (RRR = 2.41, 95% CI = 1.79-3.25) as well as the recovery (RRR = 3.42, 95% CI = 1.98-5.90, RRR = 2.71, 95% CI = 1.95-3.75) and repeatedly depressed group (RRR = 7.24, 95% CI = 3.91-13.40, RRR = 5.16, 95% CI = 3.82-6.98).

CONCLUSIONS

Findings suggest that the association between sleep disturbance and depression in older adults is complex.

Performance of screening questionnaires for obstructive sleep apnea during pregnancy: A systematic review and meta-analysis

This review aims to evaluate the performance of obstructive sleep apnea (OSA) screening questionnaires during pregnancy. A systematic review and meta-analysis was performed using MEDLINE Scopus, CINAHL, and the Cochrane library. A bivariate meta-analysis was applied for pooling of diagnostic parameters. Six of the total 4719 articles met the inclusion criteria. The Berlin questionnaire (BQ, N = 604) and Epworth sleepiness scale (ESS, N = 420) were the most frequently used screening tools during pregnancy. The pooled prevalence of OSA during pregnancy was 26.7% (95%CI: 16.9%, 34.4%, I² = 83.15%). BQ performance was poor to fair with pooled sensitivity and specificity of 0.66 (95%CI: 0.45, 0.83; I² = 78.65%) and 0.62 (95%CI: 0.48, 0.75; I² = 81.55%), respectively. BQ performance was heterogeneous depending on type of reference test and pregnancy. Sensitivity increased if diagnosis was based on polysomnography (0.90), and respiratory disturbance index (0.90). However, sensitivity decreased if screening was performed in early pregnancy (≤20 weeks gestation: 0.47), and high-risk pregnancy (0.44). Performance of ESS was poor with pooled sensitivity and specificity of 0.44 (95%CI: 0.33, 0.56; I² = 32.8%) and 0.62 (95%CI: 0.48, 0.75; I² = 81.55%), respectively. In conclusion, BQ and ESS showed poor performance during pregnancy, hence a new OSA screening questionnaire is needed. Registration: PROSPERO registration CRD42015025848.

Insomnia and the risk of depression: a meta-analysis of prospective cohort studies

BACKGROUND

Observational studies suggest that insomnia might be associated with an increased risk of depression with inconsistent results. This study aimed at conducting a meta-analysis of prospective cohort studies to evaluate the association between insomnia and the risk of depression.

METHODS

Relevant cohort studies were comprehensively searched from the PubMed, Embase, Web of Science, and China National Knowledge Infrastructure databases (up to October 2014) and from the reference lists of retrieved articles. A random-effects model was used to calculate the pooled risk estimates and 95 % confidence intervals (CIs). The I ² statistic was used to assess the heterogeneity and potential sources of heterogeneity were assessed with meta-regression. The potential publication bias was explored by using funnel plots, Egger's test, and Duval and Tweedie trim-and-fill methods.

RESULTS

Thirty-four cohort studies involving 172,077 participants were included in this meta-analysis with an average follow-up period of 60.4 months (ranging from 3.5 to 408). Statistical analysis suggested a positive relationship between insomnia and depression, the pooled RR was 2.27 (95 % CI: 1.89-2.71), and a high heterogeneity was observed (I ²  = 92.6 %, P < 0.001). Visual inspection of the funnel plot revealed some asymmetry. The Egger's test identified evidence of substantial publication bias (P <0.05), but correction for this bias using trim-and-fill method did not alter the combined risk estimates.

CONCLUSIONS

This meta-analysis indicates that insomnia is significantly associated with an increased risk of depression, which has implications for the prevention of depression in non-depressed individuals with insomnia symptoms.

Leisure-Time Physical Activity and Sedentary Behavior and Their Cross-Sectional Associations with Excessive Daytime Sleepiness in the French SU.VI.MAX-2 Study

BACKGROUND

The potential benefit of physical activity in terms of decreasing excessive daytime sleepiness (EDS) prevalence is unclear, especially in aging adults.

PURPOSE

We aimed to elucidate the associations among physical activity, sedentariness, and EDS in middle-aged and older adults.

METHODS

We conducted a cross-sectional analysis using data from a subsample of participants in the SU.VI.MAX-2 observational study (2007-2009; N = 4179; mean age = 61.9 years). EDS was defined as a score >10 on the Epworth Sleepiness Scale. Leisure-time physical activity and different types of sedentary behavior were assessed with the Modifiable Activity Questionnaire. The associations were examined with multivariable logistic regression models.

RESULTS

In the adjusted multivariable model, total leisure-time physical activity (modeled in quartiles, Q) was significantly, inversely associated with EDS (odds ratios (OR)Q4 vs Q1 = 0.70, 95 % confidence interval (CI) = 0.54-0.89). The association persisted in analyses restricted to individuals not taking sleep medication (ORQ4 vs Q1 = 0.72, 95 % CI = 0.54-0.95). In turn, time spent watching television and time spent reading appeared protective against EDS (ORQ4 vs Q1 = 0.73, 95 % CI = 0.57-0.94; ORQ4 vs Q1 = 0.76, 95 % CI = 0.60-0.97, respectively), whereas time spent on a computer appeared to confer an increased risk for EDS (ORQ4 vs Q1 = 1.30, 95 % CI = 1.05-1.62). When physical activity and sedentariness were modeled jointly, using WHO recommendation-based cutoffs for high/low levels, no significant associations were observed in the fully adjusted models.

CONCLUSIONS

The findings reinforce public health recommendations promoting behavior modification and specifically moderate-intensity exercise in middle-aged and older adults. The association of high physical activity/low sedentariness with EDS, which was not supported by the data, merits further investigation before firm conclusions could be drawn.

Risk factors for late-life depression: A prospective cohort study among older women

Depression prevention requires identifying key risk contributors. Prior studies have identified several factors related to late-life depression but have seldom addressed factors jointly or in dose-response fashion. This study aimed to examine a wide range of potential predisposing factors and to estimate individual and joint contributions to risk of late-life depression in women. A total of 21,728 women aged ≥65years, without prior depression, in the Nurses' Health Study conducted in the United States were followed from 2000 to 2010. Demographic, social, lifestyle/behavioral and health variables were selected a priori from the literature or previous findings in this cohort. Depression was defined as physician/clinician-diagnosed depression, regular antidepressant use, or the presence of severe depressive symptoms. During 10-year follow-up, 3945 incident cases were identified. After simultaneous multivariable-adjustment, multiple factors in the domains of social stress (lower self-rated societal position and high volume of caregiving to disabled/ill relatives), unfavorable lifestyle (smoking, physical inactivity, heavy or binge drinking), and poor physical health (multiple comorbidity burden, excessive sleep, difficulty falling/staying asleep, bodily pain, and physical/functional limitation or disability) were significantly associated with higher depression risk; many featured dose-response relationships. Sensitivity analyses that excluded outcomes within 2years yielded similar estimates. The total population attributable fraction for all factors was 55.5%. Physical/functional limitation accounted for one-quarter of population attributable fraction, followed by problematic sleep, inadequate exercise, and pain (combining for one-third of population attributable fraction). Efforts to remediate or prevent these factors may contribute to an efficient strategy for late-life depression prevention in women.

The relative association of obstructive sleep apnea, obesity and excessive daytime sleepiness with incident depression: a longitudinal, population-based study

BACKGROUND

It is postulated that obstructive sleep apnea (OSA) is a risk factor for the development of depression. However, obesity and excessive daytime sleepiness (EDS) are associated with both OSA and depression. The goal of this study was to examine the relative contribution of OSA, obesity and EDS to incident depression.

METHODS

A representative random sample of 1137 adults without depression from the Penn State Adult Cohort was followed up after 7.5 years. All subjects underwent a full medical examination and polysomnography at baseline. OSA was defined as an apnea/hypopnea index (AHI) ⩾5, overweight as a body mass index (BMI) of 25-29.9 kg m(-)(2), obesity as a BMI⩾30 kg m(-)(2) and EDS as moderate-to-severe drowsiness/sleepiness and/or irresistible sleep attacks.

RESULTS

Overweight, obesity and EDS were associated with incident depression, whereas OSA alone was not. Overweight was associated with incident depression in women, while obesity and EDS were associated with incident depression in both genders. The association of overweight and obesity with incident depression was independent of premorbid emotional distress, while that of EDS was not. The association between BMI and EDS with incident depression was stronger in women 20-40 years old. The severity of EDS predicted incident depression in those with OSA, while AHI or oxygen desaturation did not.

CONCLUSIONS

Overweight, obesity and EDS are the main predictors of incident depression. Obesity may be linked to depression through psychobiological mechanisms, while EDS may be an early sign of depression. Obesity should be a target of our preventative strategies for depression.

Rest-Activity Patterns in Older Adults with Heart Failure and Healthy Older Adults

The purpose of this investigation is to examine differences in rest-activity patterns and sleep characteristics in older adults with heart failure (HF) and healthy older adults. The sample included older adults with HF (n = 20) and a reference group of healthy older adults (n = 20). Traditional cosinor analysis was used to assess three parameters of rest-activity from wrist actigraphy data: amplitude (range of activity), mesor (mean activity), and acrophase (time of peak activity). Traditional sleep characteristics were also determined from actigraphy data: total sleep time (TST), sleep latency (SL), sleep efficiency (SE), and wake after sleep onset (WASO). The HF group demonstrated significantly lower mesor and amplitude than the reference group (p < .01). The HF group had significantly greater TST (p < .01), but the groups had similar SE, SL, and WASO. Despite similar sleep characteristics to healthy older adults, overall rest-activity patterns were significantly dampened in those with HF.

Cognitive Behavioral Therapy for Insomnia in Older Veterans Using Nonclinician Sleep Coaches: Randomized Controlled Trial

OBJECTIVES

To test a new cognitive behavioral therapy for insomnia (CBT-I) program designed for use by nonclinicians.

DESIGN

Randomized controlled trial.

SETTING

Department of Veterans Affairs healthcare system.

PARTICIPANTS

Community-dwelling veterans aged 60 and older who met diagnostic criteria for insomnia of 3 months duration or longer (N = 159).

INTERVENTION

Nonclinician "sleep coaches" delivered a five-session manual-based CBT-I program including stimulus control, sleep restriction, sleep hygiene, and cognitive therapy (individually or in small groups), with weekly telephone behavioral sleep medicine supervision. Controls received five sessions of general sleep education.

MEASUREMENTS

Primary outcomes, including self-reported (7-day sleep diary) sleep onset latency (SOL-D), wake after sleep onset (WASO-D), total wake time (TWT-D), and sleep efficiency (SE-D); Pittsburgh Sleep Quality Index (PSQI); and objective sleep efficiency (7-day wrist actigraphy, SE-A) were measured at baseline, at the posttreatment assessment, and at 6- and 12-month follow-up. Additional measures included the Insomnia Severity Index (ISI), depressive symptoms (Patient Health Questionnaire-9 (PHQ-9)), and quality of life (Medical Outcomes Study 12-item Short-form Survey version 2 (SF-12v2)).

RESULTS

Intervention subjects had greater improvement than controls between the baseline and posttreatment assessments, the baseline and 6-month assessments, and the baseline and 12-month assessments in SOL-D (-23.4, -15.8, and -17.3 minutes, respectively), TWT-D (-68.4, -37.0, and -30.9 minutes, respectively), SE-D (10.5%, 6.7%, and 5.4%, respectively), PSQI (-3.4, -2.4, and -2.1 in total score, respectively), and ISI (-4.5, -3.9, and -2.8 in total score, respectively) (all P < .05). There were no significant differences in SE-A, PHQ-9, or SF-12v2.

CONCLUSION

Manual-based CBT-I delivered by nonclinician sleep coaches improves sleep in older adults with chronic insomnia.

Use of Selective Serotonin Reuptake Inhibitors and Sleep Quality: A Population-Based Study

STUDY OBJECTIVES

Poor sleep is a risk factor for the development and recurrence of depression. Selective serotonin reuptake inhibitor (SSRI) use is consistently associated with good subjective sleep in clinically depressed patient populations. However, studies in the general population are lacking. Our objective was to investigate the association between SSRIs and subjective sleep in a middle-aged and elderly population in a daily practice setting.

METHODS

We included participants from the prospective Rotterdam Study cohort. Participants had up to two subjective sleep measurements assessed with Pittsburgh Sleep Quality Index ([PSQI], number of measurements = 14,770). SSRI use was based on pharmacy records. We assessed the association between SSRIs and PSQI score and its sub-components, with nonusers of any antidepressant as reference. Analyses were, among others, adjusted for presence of depressive symptoms and concurrent psycholeptic drug use.

RESULTS

We included 9,267 participants, average baseline age 66.3 y (standard deviation 10.6), and 57.6% women. SSRI use was significantly associated with a 0.78-point lower PSQI score (95% confidence interval [CI] -1.11; -0.44) which reflects better sleep, compared with non-use. The association was more prominent in continuous SSRI users (-0.71 points, 95% CI -1.18; -0.24). Of the sub-components, SSRIs were associated with 0.70-h longer sleep duration (95% CI 0.56; 0.85), higher sleep quality, higher sleep efficiency, and in contrast more daytime dysfunction.

CONCLUSIONS

SSRI use was associated with better subjective sleep, after adjustment for depressive symptoms and concurrent psycholeptic drug use. This suggests that, in clinical practice in the middle-aged and elderly population, the sleep quality of some persons may benefit from, continued, SSRI use.

Normative values of the Epworth Sleepiness Scale (ESS), derived from a large German sample

PURPOSE

Daytime sleepiness is associated with several medical problems. The aim of this paper is to provide normative values for one of the most often used questionnaires measuring daytime sleepiness, the Epworth Sleepiness Scale (ESS).

METHODS

A large sample of 9711 people from the German general population took part in this study. In addition to the ESS, several other questionnaires were used, and sociodemographic and behavioral factors were recorded.

RESULTS

Normative values for the ESS are given. According to the generally accepted criterion ESS > 10, 23 % of the sample showed excessive daytime sleepiness. Males reported significantly more daytime sleepiness than females (effect size d = 0.19). In the age range of 40-80 years, a continuous decline of daytime sleepiness was observed. Psychometric properties of the ESS were good. Alcohol intake and nicotine consumption were marginally associated with daytime sleepiness, and obese people reported significantly more sleepiness than people of normal weight (OR = 1.39).

CONCLUSIONS

The normative tables allow clinicians and researchers to assess the degree of their patients' daytime sleepiness, especially in the upper range of scores.

Excessive daytime sleepiness and antipathogen drug consumption in the elderly: a test of the immune theory of sleep

The evolutionary reasons for sleep remain controversial. The immune theory of sleep suggests that sleep is essential to the immune system, allowing organisms to allocate more energy to their immunity. This hypothesis was tested by exploring the links between excessive daytime sleepiness (EDS) and vulnerability to infectious diseases in a large (n = 9294) cohort of elderly individuals, with information on socio-demographics, daily habits, and medical characteristics. At the two-year and four-year follow-ups, we obtained individual data from the national healthcare insurance about all medications prescribed to the participants between 2001 and 2003 (n = 2865). We found an independent positive association between EDS and the consumption of some anti-pathogen drugs. This relationship was mostly explained by fungal and parasitic infections rather than by viral and bacterial ones. These results, although based on correlations, are consistent with the idea that EDS as a proxy of altered sleep quality/quantity may affect the efficiency of the immune system, and hence vulnerability to infections.

Is Zolpidem Associated with Increased Risk of Fractures in the Elderly with Sleep Disorders? A Nationwide Case Cross-Over Study in Taiwan

Background

We conducted a study using a case-crossover design to clarify the risk of acute effects of zolpidem and benzodiazepine on all-sites of fractures in the elderly.

Design of study

Case-crossover design.

Methods and Materials

Elderly enrollees (n = 6010) in Taiwan’s National Health Insurance Research Database with zolpidem or benzodiazepine use were analyzed for the risk of developing fractures.

Results

After adjusting for medications such as antipsychotics, antidepressants, and diuretics, or comorbidities such as hypertension, osteoarthritis, osteoporosis, rheumatoid arthritis and depression, neither zolpidem nor benzodiazepine was found to be associated with increased risk in all-sites fractures. Subjects without depression were found to have an increased risk of fractures. Diazepam is the only benzodiazepine with increased risk of fractures after adjusting for medications and comorbidities. Hip and spine were particular sites for increased fracture risk, but following adjustment for comorbidities, the associations were found to be insignificant.

Conclusion

Neither zolpidem nor benzodiazepine was associated with increased risk of all-site fractures in this case cross-over study after adjusting for medications or comorbidities in elderly individuals with insomnia. Clinicians should balance the benefits and risks for prescribing zolpidem or benzodiazepine in the elderly accordingly.

Sleep Disturbances in Mood Disorders

The article provides an overview of common and differentiating self-reported and objective sleep disturbances seen in mood-disordered populations. The importance of considering sleep disturbances in the context of mood disorders is emphasized, because a large body of evidence supports the notion that sleep disturbances are a risk factor for onset, exacerbation, and relapse of mood disorders. In addition, potential mechanisms for sleep disturbance in depression, other primary sleep disorders that often occur with mood disorders, effects of antidepressant and mood-stabilizing drugs on sleep, and the adjunctive effect of treating sleep in patients with mood disorders are discussed.

Exercise and Sleep in Community-Dwelling Older Adults

Insomnia and other sleep complaints are highly prevalent in community-dwelling older adults yet often go under detected. Age-related physiological changes may affect sleep, but sleep disturbances and complaints should not be considered normal in this population. Various physiological, psychological, and social consequences have been associated with insomnia and sleep complaints. Treatment options are available so it is imperative to diagnose and treat these individuals to promote healthy aging. Exercise is known to have a wide variety of health benefits, but unfortunately most older adults engage in less exercise with advancing age. This paper describes age-related changes in sleep, clinical correlates of insomnia, consequences of untreated insomnia, and nonpharmacological treatments for insomnia in older adults, with a focus on the relationship between exercise and sleep in community-dwelling older adults with insomnia or sleep complaints. Possible mechanisms explaining the relationship between exercise and sleep are discussed. While the research to date shows promising evidence for exercise as a safe and effective treatment for insomnia and sleep complaints in community-dwelling older adults, future research is needed before exercise can be a first-line treatment for insomnia and sleep complaints in this population.