National Sleep Foundation's sleep quality recommendations: first report

The association of sleep quality and burnout among Chinese medical residents under standardized residency training in a tertiary hospital

PURPOSE

To investigate the impact of sleep quality and chronotype on job burnout among medical residents under standardized residency training (SRT) in a tertiary hospital in Beijing, China.

METHODS

Medical residents in the Department of Internal Medicine of Peking Union Medical College Hospital were assessed by Morning and Evening Questionaire-5 (MEQ-5), Pittsburgh sleep quality index (PSQI), and Maslach Burnout Inventory-General Survey (MBI-GS). Factors associated with burnout were analyzed.

RESULTS

A total of 142 respondents returned completed questionnaires. Burnout was present in 85 (60%) residents. Prevalence of high emotional exhaustion, high depersonalization, and low personal accomplishment were 51%, 28%, and 18%, respectively. The global PSQI score of residents was 5.9 ± 2.4, and the self-reported sleep duration was 6.2 ± 0.8 h/day. The MEQ-5 distribution skewed towards morningness, with a median score of 14.5 [13.0, 16.3]. Poor daytime function significantly predicted emotional exhaustion and depersonalization. Chronotypes were not associated with any of the burnout components.

CONCLUSION

Sleep-related daytime dysfunction was strongly related to burnout. Strategies protecting the sleep of residents should be incorporated into the SRT programs for both efficiency and sustainability considerations.

Symptom Cluster Profiles Among Adults with Insomnia and Heart Failure

OBJECTIVE/BACKGROUND

Both heart failure (HF) and insomnia are associated with high symptom burden that may be manifested in clustered symptoms. To date, studies of insomnia have focused only on its association with single symptoms. The purposes of this study were to: (1) describe daytime symptom cluster profiles in adults with insomnia and chronic HF; and (2) determine the associations between demographic and clinical characteristics, insomnia and sleep characteristics and membership in symptom cluster profiles.

PARTICIPANTS

One hundred and ninety-five participants [M age 63.0 (SD12.8); 84 (43.1%) male; 148 (75.9%) New York Heart Association Class I/II] from the HeartSleep study (NCT0266038), a randomized controlled trial of the sustained effects of cognitive behavioral therapy for insomnia (CBT-I).

METHODS

We analyzed baseline data, including daytime symptoms (fatigue, pain, anxiety, depression, dyspnea, sleepiness) and insomnia (Insomnia Severity Index), and sleep characteristics (Pittsburgh Sleep Quality Index, wrist actigraphy). We conducted latent class analysis to identify symptom cluster profiles, bivariate associations, and multinomial regression.

RESULTS

We identified three daytime symptom cluster profiles, physical (N = 73 participants; 37.4%), emotional (N = 12; 5.6%), and all-high symptoms (N = 111; 56.4%). Body mass index, beta blockers, and insomnia severity were independently associated with membership in the all-high symptom profile, compared with the other symptom profile groups.

CONCLUSIONS

Higher symptom burden is associated with more severe insomnia in people with stable HF. There is a need to understand whether treatment of insomnia improves symptom burden as reflected in transition from symptom cluster profiles reflecting higher to lower symptom burden.

How Are You Sleeping? Why Nutrition Professionals Should Ask Their Patients About Sleep Habits

Current literature has identified relationships among sleep, nutrition, and diet-related chronic diseases; however, knowledge about how sleep influences diet-related diseases is lacking in dietetics practice. This narrative review briefly explains sleep physiology and outlines the relationships between sleep duration and quality and common nutrition-related diseases, including obesity, diabetes, cardiovascular disease, obstructive sleep apnea, and cancer. Additionally, the review discusses how sleep influences wound healing and pregnancy outcomes and why hospitalized patients are likely to experience sleep problems. Plausible mechanisms explaining the relationships between sleep and disease are presented. Finally, commonly used sleep assessment tools and interventions are reviewed. Given the importance of sleep to health, dietitians should not only be aware of the role sleep plays in disease development and prevention but also assess sleep when feasible and refer patients and clients who are at high risk for sleep problems to a sleep clinic or community program that can address sleep issues.Teaching points:Sleep duration and quality influence risk and outcomes of common nutrition-related diseases.Sleep health evaluation is a missing piece in dietetic practice.There are easy-to-use, validated tools that dietitians can use to screen for sleep problems in order to refer patients and clients to sleep experts.

Socioeconomic status and sleep health: a narrative synthesis of 3 decades of empirical research

STUDY OBJECTIVES

This review aims to assess the association between socioeconomic status (SES) and sleep health in the general population and the mediating effects of lifestyle and mental and physical health in this relationship.

METHODS

Observational studies testing the independent association between objective or subjective SES indicators and behavioral/physiological or clinical sleep health variables in the general population were included. PubMed/MEDLINE was searched for reports published from January 1990 to December 2019. The direction of effect was used as the primary effect measure, testing the hypothesis that low SES is associated with poor sleep health outcomes. Results are presented in the form of direction effect plots and synthesized as binomial proportions.

RESULTS

Overall, 336 studies were identified. A high proportion of effects at the expected direction was noted for measures of sleep continuity (100% for sleep latency, 50-100% for awakenings, 66.7-100% for sleep efficiency), symptoms of disturbed sleep (75-94.1% for insomnia, 66.7-100% for sleep-disordered breathing, 60-100% for hypersomnia), and general sleep satisfaction (62.5-100%), while the effect on sleep duration was inconsistent and depended on the specific SES variable (92.3% for subjective SES, 31.7% for employment status). Lifestyle habits, chronic illnesses, and psychological factors were identified as key mediators of the SES-sleep relationship.

CONCLUSIONS

Unhealthy behaviors, increased stress levels, and limited access to health care in low-SES individuals may explain the SES-sleep health gradient. However, the cross-sectional design of most studies and the high heterogeneity in employed measures of SES and sleep limit the quality of evidence. Further research is warranted due to important implications for health issues and policy changes.

CITATION

Papadopoulos D, Etindele Sosso FA. Socioeconomic status and sleep health: a narrative synthesis of 3 decades of empirical research. J Clin Sleep Med. 2023;19(3):605-620.

Efficacy of lifestyle medicine on sleep quality: A meta-analysis of randomized controlled trials

OBJECTIVES

Randomized controlled trials (RCTs) on the efficacy of multicomponent lifestyle medicine (LM) interventions for improving sleep quality have yielded inconsistent findings. This study marks the first meta-analysis to evaluate the efficacy of multicomponent LM interventions in improving sleep quality.

METHODS

We searched six online databases for RCTs that compared multicomponent LM interventions to an active or inactive control group in an adult population and assessed subjective sleep quality as a primary or secondary outcome using validated sleep measures at any post-intervention time-point.

RESULTS

A total of 23 RCTs with 26 comparisons involving 2534 participants were included in the meta-analysis. After excluding outliers, the analysis revealed that multicomponent LM interventions significantly improved sleep quality at immediate post-intervention (d = 0.45) and at short-term follow-up (i.e., <three months) (d = 0.50) relative to an inactive control group. Regarding the comparison with active control, no significant between-group difference was found at any time-point. No meta-analysis was conducted at the medium- and long-term follow-up due to insufficient data. Subgroup analyses supported that multicomponent LM interventions had a more clinically relevant effect on improving sleep quality in participants with clinical levels of sleep disturbance (d = 1.02) relative to an inactive control at immediate post-intervention assessment. There was no evidence of publication bias.

CONCLUSION

Our findings provided preliminary evidence that multicomponent LM interventions were efficacious in improving sleep quality relative to an inactive control at immediate post-intervention and at short-term follow-up. Additional high-quality RCTs targeting individuals with clinically significant sleep disturbance and long-term follow-up are warranted.

Sleep duration, hypnotic drug use, and risk factors: cross- sectional study

Both short sleep duration (SSD) and long sleep duration (LSD) are associated with an increased risk of morbidity and mortality. Here, we aimed to assess the prevalence of sleep duration disturbances among adults in association with demographic, medication use, personal habits, and chronic diseases, while also considering the impact of hypnotic drug use. We performed a cross-sectional study of 9991 adult participants of the Rafsanjan Cohort Study (RCS), as part of the Prospective epidemiological research studies in Iran (PERSIAN). Multivariate logistic regression analyses were conducted to assess the association between short (< 6 h) and long (> 9 h) sleep duration with demographic and lifestyle parameters and common non-communicable diseases. Additionally, we performed stratified analysis to investigate the association of sleep duration with the abovementioned factors and diseases, in groups with and without hypnotic drug use. We found higher odds of SSD significantly associated with age (P < 0.001), BMI (P < 0.001), physical activity (P < 0.001), and depression (P = 0.023). LSD displayed a positive association with the female sex (P < 0.001), opium consumption (P < 0.001), and history of MI (P = 0.045), and a reverse connection with education (P = 0.007), physical activity (P < 0.001) and alcohol consumption (P = 0.027). Stratifying for the hypnotic drug use, our sensitivity analyses indicated that in hypnotic drug users, education (P = 0.034) and physical activity (P < 0.001) were associated with LSD, in this group, significantly increased odds ratio of LSD were associated with opium consumption (P = 0.046) and thyroid dysfunction (P = 0.037). Our findings demonstrated the demographic and lifestyle factors and diseases associated with long and short sleep duration in the population of the RCS. Additionally, after stratifying for hypnotic drug use, our results indicated that some diseases are only associated with abnormal sleep duration upon using hypnotic drugs.

Objective and Subjective Sleep Patterns in Adults With Maturity-Onset Diabetes of the Young (MODY)

OBJECTIVE

To examine sleep patterns in adults with maturity-onset diabetes of the young (MODY).

RESEARCH DESIGN AND METHODS

Adults with glucokinase (GCK)-MODY and transcription factor (TF)-related MODY (HNF1A, HNF1B, HNF4A) were recruited (n = 24; age 46.0 years, 79% women, BMI 24.7 kg/m2) from The University of Chicago's Monogenic Diabetes Registry. Sleep patterns were assessed by 2-week wrist actigraphy (total 315 nights), one night of a home sleep apnea test, and validated surveys.

RESULTS

Overall, compared with established criteria, 29% of participants had sleep latency ≥15 min, 38% had sleep efficiency ≤85%, 46% had wake after sleep onset >40 min, all indicating poor objective sleep quality. Among all participants, 54% had a sleep duration below the recommended minimum of 7 h, 88% reported poor sleep quality, 58% had obstructive sleep apnea, and 71% reported insomnia. Compared with GCK-MODY, participants with TF-related MODY had poorer objective sleep quality and increased night-to-night variability in sleep patterns.

CONCLUSIONS

Sleep disturbances appear to be common in adults with MODY despite absent traditional risk factors for sleep disorders. Future research investigating the sleep-diabetes relationship is warranted in this population.

Associations between residential environmental health and sleep quality: Potential mechanisms

BACKGROUND

Sleep quality is an important dimension of sleep health. There are few studies on the relationship between residential environment and sleep quality in China. We validated the connection between them and explored the moderating role of spatial-geographic characteristics and the role of emotional stress and somatic function as mediators.

METHODS

Using survey data collected by the Chinese General Social Survey in 2021, 2717 respondents were included in the analysis. First, OLS regression was used for baseline analysis. Second, a generalized ordered logit model was used to analyze the more precise correlations between residential environmental health and sleep quality. Finally, the mediating role of emotional stress and somatic function was explored using the KHB method.

RESULTS

In the baseline analysis, both the positive correlations of residential natural environmental health and residential health resources on people's sleep quality were tested. Further analysis revealed that the correlation of natural environmental health was more about protecting people from poor sleep quality (having "good" and "very good" sleep quality). The residential health resources correlated with whether people reported very good sleep quality. Regional development disparities played a negative moderating role in the relationship between residential health resources and sleep quality. Also, the mediating role of emotional stress and somatic function were supported, and the mediating role of somatic function was higher in proportion.

CONCLUSION

Sleep quality was positively correlated with residential environmental health; the economic development gap between regions played a moderating role; and the correlation was generated by people's emotional stress and somatic function. In the development of public health policy, it is necessary to actively address various environmental issues, provide convenient health facilities in living spaces, and bolster the policy inclinations of less developed areas.

A Wrinkle in Measuring Time Use for Cognitive Health: How should We Measure Physical Activity, Sedentary Behaviour and Sleep?

One new case of dementia is detected every 4 seconds and no effective drug therapy exists. Effective behavioural strategies to promote healthy cognitive ageing are thus essential. Three behaviours related to cognitive health which we all engage in daily are physical activity, sedentary behaviour and sleep. These time-use activity behaviours are linked to cognitive health in a complex and dynamic relationship not yet fully elucidated. Understanding how each of these behaviours is related to each other and cognitive health will help determine the most practical and effective lifestyle strategies for promoting healthy cognitive ageing. In this review, we discuss methods and analytical approaches to best investigate how these time-use activity behaviours are related to cognitive health. We highlight four key recommendations for examining these relationships such that researchers should include measures which (1) are psychometrically appropriate; (2) can specifically answer the research question; (3) include objective and subjective estimates of the behaviour and (4) choose an analytical method for modelling the relationships of time-use activity behaviours with cognitive health which is appropriate for their research question.

Financial Hardship and its Associations with Perceived Sleep Quality in Participants with Type 2 Diabetes and Obstructive Sleep Apnea

OBJECTIVES

The purpose of this study was to explore social determinants of health (SDoH), and disease severity as predictors of sleep quality in persons with both Obstructive Sleep Apnea (OSA) and type 2 diabetes (T2D).

METHODS

Disease severity was measured by Apnea-Hypopnea Index [(AHI) ≥ 5] and HbA1c for glycemic control. SDoH included subjective and objective financial hardship, race, sex, marital status, education, and age. Sleep quality was measured by Pittsburgh Sleep Quality Index (PSQI).

RESULTS

The sample (N = 209) was middle-aged (57.6 ± 10.0); 66% White and 34% African American; and 54% men and 46% women. Participants carried a high burden of disease (mean AHI = 20.7 ± 18.1, mean HbA1c = 7.9% ± 1.7%). Disease severity was not significantly associated with sleep quality (all p >.05). Worse sleep quality was associated with both worse subjective (b = -1.54, p = .015) and objective (b = 2.58, p <.001) financial hardship. Characteristics significantly associated with both subjective and objective financial hardship included being African American, female, ≤ 2 years post high school, and of younger ages (all p < .01).Discussion: Financial hardship is a more important predictor of sleep quality than disease severity, age, sex, race, marital status, and educational attainment, in patients with OSA and T2D.

Associations Between Multidimensional Sleep Health Parameters and Adolescents' Self-reported Light Exposure in the Free-living Environment

The objective of this study was to characterize the associations between light exposure in the free-living environment and multiple dimensions of sleep health of typically developing adolescents. Fifty-six (29 girls, 27 boys) typically developing adolescents (mean age = 13.59, SD = 0.89, range = 12-17 years) participated. For six consecutive nights, sleep was assessed in the home environment using actigraphy. During the same period, participants were asked to fill out a daily sleep log and a daily light exposure log, and to complete questionnaires regarding their alertness and subjective sleep satisfaction. Longer self-reported exposure to daylight in the morning was associated with longer objectively measured sleep duration. Longer self-reported exposures to electronic devices in the evening were associated with later objectively measured sleep onset and offset times, shorter sleep duration, and greater day-to-day sleep variability. Longer morning exposure to outdoor light was associated with a longer sleep duration. Self-reported light exposure was not associated with sleep satisfaction, alertness/sleepiness, or sleep efficiency. Among the covariates, circadian preference accounted for the highest percentage of variance. Adolescents' sleep health is associated with the self-reported duration of exposure to daylight in the morning and to electronic devices in the evening.

The association between multidimensional sleep health and gestational weight gain: nuMoM2b Sleep Duration and Continuity Study

Background

Although poor sleep health is associated with weight gain and obesity in the non-pregnant population, research on the impact of sleep health on weight change among pregnant people using a multidimensional sleep-health framework is needed. This study examined associations among mid-pregnancy sleep health indicators, multidimensional sleep health, and gestational weight gain (GWG).

Methods

We conducted a secondary data analysis of the Nulliparous Pregnancy Outcome Study: Monitoring Mothers-to-be Sleep Duration and Continuity Study (n=745). Indicators of individual sleep domains (i.e., regularity, nap duration, timing, efficiency, and duration) were assessed via actigraphy between 16 and 21 weeks of gestation. We defined "healthy" sleep in each domain based on empirical thresholds. Multidimensional sleep health was based on sleep profiles derived from latent class analysis. Total GWG, the difference between self-reported pre-pregnancy weight and the last measured weight before delivery, was converted to z-scores using gestational age- and BMI-specific charts. GWG was defined as low (<-1 SD), moderate (-1 or +1 SD), and high (>+1 SD).

Results

Nearly 50% of the participants had a healthy sleep profile (i.e., healthy sleep in most domains), whereas others had a sleep profile defined as having varying degrees of poor health in each domain. While indicators of individual sleep domains were not associated with GWG, multidimensional sleep health was related to low and high GWG. Participants with a sleep profile characterized as having low efficiency, late timing, and long sleep duration (vs. healthy sleep profile) had a higher risk (RR 1.7; 95% CI 1.0, 3.1) of low GWG a lower risk of high GWG (RR 0.5 95% CI 0.2, 1.1) (vs. moderate GWG).

Conclusions

Multidimensional sleep health was more strongly associated with GWG than individual sleep domains. Future research should determine whether sleep health is a valuable intervention target for optimizing GWG.

Synopsis

Study question: What is the association between mid-pregnancy multidimensional sleep health and gestational weight gain?What's already known?: Sleep is associated with weight and weight gain outside of pregnancyWhat does this study add?: We identified patterns of sleep behaviors associated with an increased risk of low gestational weight gain.

Factors associated with poor sleep quality in patients with pre-dialysis chronic kidney disease: A systematic review

AIMS

To determine factors associated with poor sleep quality among patients with pre-dialysis chronic kidney disease.

DESIGN

This is a systematic review study guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses statements and checklist.

DATA SOURCES

Empirical evidence was sought in major electronic databases, including Embase, MEDLINE, CINAHL and Airiti library from March to September 2022.

REVIEW METHODS

Studies investigating factors associated with poor sleep quality among adult patients with chronic kidney disease were included. Study participants who received renal replacement therapy and had sleep disorders and serious illnesses such as cancer were excluded. Of the 526 studies that resulted from the search after removing duplicate articles, 20 studies were assessed for quality by using Joanna Briggs Institute and Newcastle-Ottawa Scale by two doctorial prepared nursing scientists.

RESULTS

A total of 20 studies were included in this review. The prevalence of poor sleep quality in these studies ranged from 11% to 97.5%. Demographics (older age and female), physiological conditions (higher body mass index, higher hip circumferences, higher systolic blood pressure, poor cardiovascular function, dyspnoea, pain, cramps, itchiness or moderate to extreme pruritus, lower fasting plasma glucose, electrolyte imbalance, higher total cholesterol and gastrointestinal symptoms), depression, smoking, arousal-related and cognitive arousal behaviours were associated with poor sleep quality.

CONCLUSION

Poor sleep quality was prevalent and influenced kidney function, increased mortality as well as decreased quality of life in patients with pre-dialysis chronic kidney disease. This review synthesizes factors associated with poor sleep quality. Managing these factors can mitigate and prevent poor sleep quality.

IMPACT

Healthcare providers, especially nurses, can assess the risk factors of poor sleep quality and reinforce patients' self-management. Future research should elucidate the assessment and management of risk factors and transfer these into widespread use in the routine care of patients with chronic kidney disease.

The Relationship between Sleep Duration and Metabolic Syndrome Severity Scores in Emerging Adults

BACKGROUND

Research suggests sleep duration can influence metabolic systems including glucose homeostasis, blood pressure, hormone regulation, nervous system activity, and total energy expenditure (TEE), all of which are related to cardiometabolic disease risk, even in young adults. The purpose of this study was to examine the relationship between sleep duration and metabolic syndrome severity scores (MSSS) in a sample of emerging adults (18-24 y/o).

METHODS

Data were collected between 2012 and 2021 from the College Health and Nutrition Assessment Survey, an ongoing, cross-sectional study conducted at a midsized northeastern university. Anthropometric, biochemical, and clinical measures were obtained following an overnight fast and used to assess the prevalence of metabolic syndrome (MetS). MetS severity scores (MSSS) were calculated using race- and sex-specific formulas. Sleep duration was calculated from the difference in self-reported bedtime and wake time acquired through an online survey. ANCOVA was used to examine the relationship between sleep duration and MetS severity score while adjusting for covariates (age, sex, BMI, physical activity level, smoking status, alcohol consumption, and academic major).

RESULTS

In the final sample (n = 3816), MetS (≥3 criteria) was present in 3.3% of students, while 15.4% of students presented with ≥2 MetS criteria. Mean MSSS was -0.65 ± 0.56, and the reported sleep duration was 8.2 ± 1.3 h/day. MSSS was higher among low sleepers (<7 h/day) and long sleepers (>9 h/day) compared to the reference sleepers (7-8 h/day) (-0.61 ± 0.02 and -0.63 ± 0.01 vs. -0.7 ± 0.02, respectively, p < 0.01).

CONCLUSIONS

Our findings suggest short (<7 h/day) and long (>9 h/day) sleep durations raise the risk of MetS in a sample of emerging adults. Further research is needed to elucidate the impact of improving sleep habits on future disease risk.

Effect of sleep deprivation on postural control and dynamic stability in healthy young adults

BACKGROUND

Postural control results from non-linear interactions of multiple neuromusculoskeletal elements and contextual factors. The use of non-linear analyses that consider the temporal evolution of postural adjustments, such as sample entropy, could inform about the changes in postural control due to contextual disturbances such as sleep deprivation.

RESEARCH QUESTION

What are the effects of sleep deprivation on static postural control and dynamic stability in healthy young adults?

METHODS

A quasi-experimental study was performed with 17 healthy young males submitted to 24 h of monitored sleep deprivation. The postural control was measured using sample entropy, area, and total average velocity of the center of pressure on a force platform. The dynamic stability was measured using the Modified Star Excursion Balance Test (SEBTm) composite score for each lower limb. Repeated-measures analysis of variance (baseline × 12 h × 15 h × 18 h × 21 h × 24 h of sleep deprivation) verified the effect of sleep deprivation in the postural control variables. Paired t-test compared the composite score of the SEBTm between baseline and 24 h sleep deprivation.

RESULTS

Sample entropy decreased after 18 h of sleep deprivation (p = 0.032) and 24 h of sleep deprivation (p = 0.001). Despite the significant main effect for the area (p = 0.012) and speed (p = 0.007) of the center of pressure, no pairwise differences were identified in the post hoc analysis. The non-dominant lower limb SEBTm composite score was reduced after 24 h of sleep deprivation (p = 0.033), and no difference was observed in the dominant limb.

SIGNIFICANCE

Sleep deprivation reduced the adaptability in static postural control and dynamic stability of the non-dominant lower limb of healthy young male adults. Sample entropy seemed more sensitive to capture the effects of sleep deprivation than the classical postural control variables.

The effect of caffeine on subsequent sleep: A systematic review and meta-analysis

The consumption of caffeine in response to insufficient sleep may impair the onset and maintenance of subsequent sleep. This systematic review and meta-analysis investigated the effect of caffeine on the characteristics of night-time sleep, with the intent to identify the time after which caffeine should not be consumed prior to bedtime. A systematic search of the literature was undertaken with 24 studies included in the analysis. Caffeine consumption reduced total sleep time by 45 min and sleep efficiency by 7%, with an increase in sleep onset latency of 9 min and wake after sleep onset of 12 min. Duration (+6.1 min) and proportion (+1.7%) of light sleep (N1) increased with caffeine intake and the duration (-11.4 min) and proportion (-1.4%) of deep sleep (N3 and N4) decreased with caffeine intake. To avoid reductions in total sleep time, coffee (107 mg per 250 mL) should be consumed at least 8.8 h prior to bedtime and a standard serve of pre-workout supplement (217.5 mg) should be consumed at least 13.2 h prior to bedtime. The results of the present study provide evidence-based guidance for the appropriate consumption of caffeine to mitigate the deleterious effects on sleep.

Do Sleep-Related Metacognitive Strategies Shape My Sleep? The Relationships between Strategies for Controlling Sleep-Related Intrusive Thoughts and Subjective and Objective Sleep Quality in Young Adulthood and Older Age

This study examined the associations between thought control strategies and subjective and objective sleep quality, across the adult lifespan. One hundred forty-nine individuals without insomnia (age range 18-86 years; M = 45.35, SD = 20.53) completed the Thought Control Questionnaire Insomnia-Revised for assessing sleep-related thought control strategies. Self-reported sleep quality was measured with the Pittsburgh Sleep Quality Index. Then, subjective and objective sleep parameters (i.e., total sleep time, sleep onset latency, sleep efficiency) were recorded through a sleep diary and an actigraph across 7 days. Results from linear mixed-effects models showed that a worry strategy was associated with longer subjective sleep latency and shorter subjective total sleeping time. An aggressive suppression strategy was associated with longer subjective total sleeping time. No such involvement of thought control strategies was detected for subjective sleep efficiency and all of the objective sleep parameters. Other individual differences (i.e., age, sex, circadian preference, self-reported sleep quality) also explained both subjective and objective sleep parameters, though to a different extent depending on the sleep parameter considered. The assessment of sleep-related thought control strategies, along with other individual characteristics, should be considered to account for individual differences in sleep quality and implement practices/interventions to support it in adulthood and older age.

Nutritional Modulation of Sleep Latency, Duration, and Efficiency: A Randomized, Repeated-Measures, Double-Blind Deception Study

PURPOSE

This study aimed to test the hypothesis that a novel nutritional blend composed of tryptophan, glycine, magnesium, tart cherry powder, and l -theanine enhances subjective and objective measures of sleep during free living conditions.

METHODS

In a randomized, repeated-measures crossover and double-blind deception design, participants ( n = 9 males and 7 females, age = 24 ± 3 yr, body mass = 69.8 ± 11.6 kg, stature = 170.8 ± 9.1 cm) completed a 3-d familiarization period, followed by 3-d intervention and placebo trials. Subjective Pittsburgh Quality Sleep Index, Core Consensus Sleep Diary, and Karolinska Sleepiness Scale survey tools, alongside objective actigraphy measures of sleep, were assessed, with daily nutritional intake, activity, and light exposure standardized between trials. Participants provided daily urine samples for assessment of targeted and untargeted metabolomes.

RESULTS

The intervention trial reduced sleep onset latency (-24 ± 25 min; P = 0.002), increased total sleep time (22 ± 32 min; P = 0.01), and increased sleep efficiency (2.4% ± 3.9%; P = 0.03), while also reducing morning sleepiness ( P = 0.02). Throughout the study, 75% of participants remained blinded to sleep assessment as a primary outcome measure, with 56% subjectively indicating improved sleep during the intervention trial. Metabolomic analysis highlighted several significantly altered metabolomes related to sleep regulation between trials, inclusive of 6-sulfatoxymelatonin, d -serine, and l -glutamic acid.

CONCLUSIONS

Data demonstrate that using the proposed blend of novel nutritional ingredients during free living conditions reduced sleep onset latency, increased total sleep duration, and increased sleep efficiency, leading to reduced perceptions of morning sleepiness. These effects may be mediated by the upregulation of key metabolites involved in the neurophysiological modulation of the sleep/wake cycle.

The Sleep Parameters of Paralympic Athletes: Characteristics and Assessment Instruments

CONTEXT

Sleep serves many important functions for athletes, particularly in the processes of learning, memory, recovery, and cognition.

OBJECTIVES

Define the sleep parameters of Paralympic athletes and identify the instruments used to assess and monitor sleep Paralympic athletes.

EVIDENCE ACQUISITION

This systematic review was carried out based on the PRISMA guidelines. The survey was conducted in April 2020, the searches were carried out again in September 2021 to check whether there were new scientific publications in the area of sleep and Paralympic sport, searches were performed in the following databases: PubMed, Web of Science, Scopus, SPORTDiscus, Virtual Health Library (BIREME), and SciELO. This systematic review has included studies that investigated at least one of the following sleep parameters: total sleep time, sleep latency, sleep efficiency, number of awakenings, quality of sleep, daytime sleepiness, and chronotype; the participants were comprised of athletes with disabilities. Studies published at any time in English, Portuguese, and Spanish, were included.

EVIDENCE SYNTHESIS

Data extraction and study selection were performed by 2 researchers independently, and a third author was consulted as necessary. The search returned a total of 407 studies. Following the screening based on exclusion and inclusion criteria, a total of 13 studies were considered. Paralympic athletes have a low amount (7.06 h) of sleep with poor quality and sleep latency (28.05 min), and 57.2% have daytime sleepiness, with the majority belonging to the indifferent chronotype (53, 5%). Moreover, 11 studies assess sleep using subjective instruments (questionnaires), and 2 studies used an objective instrument (actigraphy).

CONCLUSIONS

Sleep disorders are common among Paralympic athletes, poor sleep quality and quantity, and high rates of daytime sleepiness. Subjective methods are most commonly used to assess sleep.

The Influence of Different Training Load Magnitudes on Sleep Pattern, Perceived Recovery, and Stress Tolerance in Young Soccer Players

ABSTRACT

Ferreira, ABdM, Ribeiro, BLL, Batista, EdS, Dantas, MP, and Mortatti, AL. The influence of different training load magnitudes on sleep pattern, perceived recovery, and stress tolerance in young soccer players. J Strength Cond Res 37(2): 351-357, 2023-The aim of this study was to analyze the influence of 3 weeks on sleep parameters, perceived recovery, and stress tolerance in young soccer players using different training load magnitudes. A total of 13 young male soccer athletes (15.9 ± 0.5 years; 68.7 ± 6.1 kg; 170 ± 7 cm) who performed 3 typical training weeks with different workloads were analyzed. The external training load (ETL) was verified by the PlayerLoad method, and the internal training load (ITL) was determined using the session rating of perceived exertion method. Sleep was monitored using a wrist-actigraphy monitor. Sleep variables, including total time in bed (TTB), total sleep time (TST), sleep latency (SL), wake after sleep onset (WASO), and sleep efficiency (SE), were evaluated across all nights of sleep. The recovery status was assessed with the perceived recovery status (PRS) scale, and the stress tolerance was monitored using the "daily analysis of life demands of athletes" questionnaire. There was an increase in sleep time during the week with the highest training load (week 2) (TTB: +35 minutes, TST: +46 minutes, SL: -5 minutes, SE: +3%). There was no difference in the PRS or in the stress tolerance during the evaluation weeks. A very large within-individual correlation was observed between ITL and ETL ( r = 0.78) and moderate within-individual correlation between ETL and TST ( r = 0.34), between ITL and TST ( r = 0.45), and between ITL and SE ( r = 0.359). These results showed that there was an increase in TST during a microcycle with intensified loads, without impairing bedtime and resulting in maintenance of the perceived recovery or stress tolerance values.

Sleep Patterns Fluctuate Following Training and Games across the Season in a Semi-Professional, Female Basketball Team

Quantifying athlete sleep patterns may inform development of optimal training schedules and sleep strategies, considering the competitive challenges faced across the season. Therefore, this study comprehensively quantified the sleep patterns of a female basketball team and examined variations in sleep between nights. Seven semi-professional, female basketball players had their sleep monitored using wrist-worn activity monitors and perceptual ratings during a 13-week in-season. Sleep variables were compared between different nights (control nights, training nights, training nights before games, nights before games, non-congested game nights, and congested game nights), using generalized linear mixed models, as well as Cohen's d and odds ratios as effect sizes. Players experienced less sleep on training nights before games compared to control nights, training nights, nights before games, and congested game nights (p < 0.05, d = 0.43-0.69). Players also exhibited later sleep onset times on non-congested game nights compared to control nights (p = 0.01, d = 0.68), and earlier sleep offset times following training nights before games compared to all other nights (p < 0.01, d = 0.74-0.79). Moreover, the odds of players attaining better perceived sleep quality was 88% lower on congested game nights than on nights before games (p < 0.001). While players in this study attained an adequate sleep duration (7.3 ± 0.3 h) and efficiency (85 ± 2%) on average across the in-season, they were susceptible to poor sleep on training nights before games and following games. Although limited to a team-based case series design, these findings suggest basketball coaches may need to reconsider scheduling team-based, on-court training sessions on nights prior to games and consider implementing suitable psychological and recovery strategies around games to optimize player sleep.

Determinants of Sleep Quality: A Cross-Sectional Study in University Students

When entering the university setting, poor sleep quality is reportedly prevalent among students and has been linked to a range of adverse health outcomes, including reduced academic performance. Moreover, determinants of sleep quality are not yet fully understood. This study was designed to (1) assess the prevalence of poor sleep quality and (2) identify determinants of sleep quality in German university students. In total, 1,684 undergraduate and graduate students (50.6% female, mean age 22.87 ± 3.15 years) from multiple academic disciplines completed a cross-sectional online survey assessing socio-demographic, health, and study-related indicators and sleep quality using the Pittsburgh Sleep Quality Index (PSQI). In our sample, 820 (48.7%) met the PSQI cut-off score (>5) for poor sleep quality. Multiple regression analysis showed that older age, being a business student, lower subjective social status, poorer self-rated health, stress, exhaustion, and poor academic performance significantly predicted poor sleep quality. Our findings document a high prevalence of poor sleep quality among university students and suggest that business students, especially, might be exposed to a greater risk for poor sleep quality. Furthermore, the results of this study are valuable for academic staff to develop tailored interventions to promote healthy sleep-in university students.

Understanding the Need for Sleep to Improve Cognition

The restorative function of sleep is shaped by its duration, timing, continuity, subjective quality, and efficiency. Current sleep recommendations specify only nocturnal duration and have been largely derived from sleep self-reports that can be imprecise and miss relevant details. Sleep duration, preferred timing, and ability to withstand sleep deprivation are heritable traits whose expression may change with age and affect the optimal sleep prescription for an individual. Prevailing societal norms and circumstances related to work and relationships interact to influence sleep opportunity and quality. The value of allocating time for sleep is revealed by the impact of its restriction on behavior, functional brain imaging, sleep macrostructure, and late-life cognition. Augmentation of sleep slow oscillations and spindles have been proposed for enhancing sleep quality, but they inconsistently achieve their goal. Crafting bespoke sleep recommendations could benefit from large-scale, longitudinal collection of objective sleep data integrated with behavioral and self-reported data.

Pregnant Women's Attitudes and Beliefs towards Sleep and Exercise: A Cross-Sectional Survey

As many as 80% of women report experiencing poor sleep throughout pregnancy. Exercise is associated with many health benefits during pregnancy and is established as a non-pharmacological method to improve sleep in both pregnant and non-pregnant populations. Given the importance of sleep and exercise during pregnancy, the aim of this cross-sectional study was to (1) examine pregnant women's attitudes and beliefs towards sleep and exercise during pregnancy, and (2) investigate the barriers women face to achieving good sleep and engaging in healthy levels of exercise. Participants were comprised of 258 pregnant Australian women (31.3 ± 5.1 years) who completed a 51-question online survey. Almost all (98%) participants believed exercise during pregnancy to be safe, whilst over half (67%) believed participating in more exercise will improve their sleep. Over 70% of participants reported experiencing barriers such as physical symptoms related to pregnancy that negatively impacted their ability to exercise. Almost all (95%) participants reported experiencing barriers to sleep in their current pregnancy. Present findings suggest that overcoming intrapersonal barriers should be a priority for any intervention aiming to improve sleep or increase exercise levels in pregnant populations. Findings from the present study highlight the need for a better understanding of women's sleep experiences during pregnancy, and demonstrate how exercise may improve sleep and health outcomes.

Physical Activity and Sleep in Adults and Older Adults in Southern Brazil

Good sleep quality is a well-known indicator of physical and mental health, well-being, and overall vitality. This study aimed to verify the association between the practice of physical activity and sleep duration and quality in adults and older adults in southern Brazil. A cross-sectional population-based study was carried out with 820 individuals of both sexes aged 18 years or more, where sociodemographic variables were collected and also health-related variables. This study included 523 (63.8%) women and 297 (36.2%) men, and the prevalence of adequate sleep hours was 41.5% (95%CI: 39.1; 44.9). People who performed leisure walking were 34% more likely to present adequate sleep duration (PR: 1.34; 95%CI: 1.10; 1.64) compared to those who did not perform leisure walking. Individuals who met the recommendations for moderate or vigorous physical activity were more likely to have good sleep quality (PR: 1.16; 95%CI: 1.01; 1.34). Future health behavior modification strategies to improve sleep quality at the population level should consider encouraging lifestyle improvements, thus increasing the practice of physical activities.

Physical Activity Levels and Sleep in Schoolchildren (6-17) with and without School Sport

There is strong evidence to support the association between daily physical activity and sleep parameters in children and adolescents. Physical activity and outdoor play are favourably associated with most sleep outcomes in school children. The aim is to find out the levels of physical activity and the quality of sleep in Basque schoolchildren aged between six and seventeen and to analyse the possible differences between those who carry out some kind of physical sports activity and those who do not. The sample consisted of 1082 schoolchildren (50.1% male and 49.9% female). Differences between groups were compared using the Mann-Whitney U test (2 samples) and Kruskal-Wallis one-factor ANOVA (k samples). A total of 723 (66.94%) of the participants said they practiced some physical sports activity. The accelerometers obtained significant differences in all levels of physical activity, as well as in sleep efficiency, with higher levels of physical activity (sedentary p = 0.001; light p = 0.017; moderate p = 0.009; vigorous p = 0.001 and moderate-to-vigorous physical activity p = 0.002) and better sleep efficiency (p = 0.002) in those schoolchildren who perform some type of physical sports activity. A significant difference in time spent in sedentary activities was also observed between primary and secondary school pupils of both sexes and regardless of the degree of physical sports activity completion.

The association between sleep quality and telomere length: A systematic literature review

Several sleep parameters present an elevated risk for processes that contribute to cellular aging. Short sleep duration, sleep apnoea, and insomnia are significantly associated with shorter telomeres, a biological marker of cellular aging. However, there has been no review or analysis of studies that have examined the association between the psychological construct of sleep quality and telomere length. The present study aimed to provide a systematic review of the association between sleep quality and telomere length. A systematic review of English articles was conducted using MEDLINE/PubMed, PsycINFO, Google Scholar, and Web of Science electronic databases, with the final search conducted on 3rd September 2021. Search terms included sleep quality, poor sleep, insomnia, sleep difficulties, sleep issue*, non-restorative sleep, telomere*, cellular aging, and immune cell telomere length. Study eligibility criteria included human participants aged 18 years or older and a reproducible methodology. Study appraisal and synthesis were completed using a systematic search in line with a PICOS approach (P = Patient, problem, or population; I = Intervention, prognostic factor, exposure; C = Comparison, control, or comparator; O = Outcomes; S = Study designs). Twenty-two studies met review inclusion criteria. Qualitative synthesis of the literature indicated insufficient evidence overall to support a significant association between sleep quality and telomere length. Limitations across studies were addressed, such as the assessment of examined constructs. Findings highlight important targets for future research, including the standardised operationalisation of the sleep quality construct and experimental study designs. Research in this area has clinical significance by identifying possible mechanisms that increase the risk for age-related disease and mortality. PROSPERO Registration No.: CRD 42021233139.

Case Report: Effect of low energy availability and training load on sleep in a male combat sport athlete

Purpose

The aim of this case report was to describe the sleep responses in a male combat sport athlete, who was engaging in both chronic (CWL) and acute (AWL) weight loss practices in order to reduce body mass for a national competition.

Methods

During the first seven weeks of training (Phases 1 and 2), the athlete adhered to a daily energy intake (EI) equating to their resting metabolic rate (1700 kcal·day^-1) followed by a reduction in EI (915-300 kcal·day^-1) in the 5 days before weighing in (Phase 3). Nocturnal sleep was monitored throughout the 8-week training period using wristwatch actigraphy and frequent measurements of body mass/composition, daily exercise energy expenditure and training load (TL) were taken.

Results

The athlete was in a state of low energy availability (LEA) during the entire training period. There was a very large decrease in LEA status during phase 3 compared with phases 1 and 2 (3 vs. 20 kcal·kgFFM·day^-1) and there was a small decrease in TL during phase 3 compared with phase 2 (410 vs. 523 AU). The athlete's sleep efficiency increased throughout the training period, but total sleep time displayed a small to moderate decrease in phase 3 compared with phases 1 and 2 (386 vs. 429 and 430 min). However, correlational analysis demonstrated trivial to small, non-significant relationships between sleep characteristics and the athlete's LEA status and TL.

Conclusion

These findings suggest that CWL and AWL practices that cause fluctuations in LEA and TL may be implemented without compromising the sleep of combat sport athletes.

A Delayed Evening Meal Enhances Sleep Quality in Young Rugby Players

The aim of this study was to examine the effect of delayed evening mealtime on sleep quality in young athletes. Twelve rugby players (age 15.8 ± 0.7 years) participated in a crossover within-participant design. Adolescents spent five consecutive days in each of two conditions, separated by a 2-week washout period: routine dinner (3.5 hr before bedtime) and late dinner (LD, 1.5 hr before bedtime). Other mealtimes as well as bedtime and wake-up time were usual and remained the same in both conditions. Their schedules, dietary intakes, and physical activity were controlled and kept constant throughout the study. Sleep was assessed using polysomnography on the first and the last nights in the individual rooms of the boarding school. An increase in total sleep time by 24 min (p = .001, d = 1.24) and sleep efficiency by 4.8% was obtained during LD (p = .001, d = 1.24). Improvement in sleep efficiency was mainly due to a lower wake after sleep onset (-25 min, p = .014, d = -3.20), a decrease of microarousals (-25%, p = .049, d = -0.64), and awakenings ≥90 s (-30%, p < .01, d = -0.97) in LD compared to routine dinner. There were no significant differences in sleep architecture except for a shorter slow-wave sleep (N3) latency (-6.9 min, p = .03, d = -0.778) obtained during LD. In this study, evening dinner 1.5 hr before bedtime leads to better quality and less fragmented sleep compared to evening dinner 3.5 hr before bedtime in young athletes.

Different sleep pattern in over-weight/obese women with polycystic ovary syndrome

CONTEXT

Sleep duration and sleep quality have important health implications although our knowledge of objectively measured sleep variables in women with Polycystic Ovary Syndrome (PCOS) is limited.

OBJECTIVE

To compare sleep variables assessed by actigraphy in over-weight/obese women with PCOS and controls, and to assess sleep variables after behavioral modification intervention in comparison with minimal intervention in a randomized trial.

DESIGN

Randomized controlled trial, and a control group.

SETTING

Outpatient gynecological clinic at a university hospital in Sweden.

PARTICIPANTS

39 women fulfilling all Rotterdam PCOS criteria, randomized to behavioral modification intervention or minimal intervention and 21 controls with no other metabolic disease, all aged 18-40 years with a BMI ≥ 27 kg/m².

INTERVENTION

A four-month behavioral modification intervention including weekly group meetings focusing on behavioral and healthy lifestyle aspects. Minimal intervention reflecting standard care.

MAIN OUTCOME MEASURE

Sleep durations and sleep efficiency assessed by actigraphy.

RESULTS

Compared to the control group, women with PCOS had significantly shorter time in bed (501 vs 548 min, p= 0.049), sleep time over 24 hours (448 vs 567 min, p=0.005) and sleep time at night (434 vs 511 min, p=0.002), poorer sleep efficiency (87 vs 93%, p<0.001), and longer wakefulness after sleep onset (64 vs 38 min, p<0.001). However, total sleep time at night for women with PCOS (7.2hrs) was within the normal range. Following behavioral modification intervention, the reduction from baseline in sleep over 24 hours and in the daytime sleep were significant compared to the minimal intervention group (78 min, p=0.009 and 43 min, p=0.003 respectively).

CONCLUSIONS

We found over-weight/obese women with PCOS to have normal sleep duration, but worse sleep efficiency than controls. Behavioral modification intervention seems to reduce the amount of daytime sleep, suggesting improved sleep behavior.

CLINICAL TRIALS REGISTRATION

https://doi.org/10.1186/ISRCTN48947168, identifier ISRCTN48947168.

Sleep Variability in UK Long Distance Heavy Goods Vehicle Drivers

OBJECTIVES

Sleep variability levels are unknown in heavy goods vehicle (HGV) drivers yet are associated with adverse health outcomes and reduced driver vigilance when high.

METHODS

Two hundred and thirty-three HGV drivers recruited across 25 UK depots provided sleep variability, sleep duration, and sleep efficiency data via wrist-worn accelerometry (GENEActiv) over 8 days. Sleep variability indicators included social jetlag (the difference in midpoint of the sleep window between work and nonworkdays) and intraindividual variability of sleep window onset time, out-of-bed time, and sleep duration.

RESULTS

Fifty-three percent of drivers experienced social jetlag (≥1 hour), and 27% experienced high (>2 hours) social jetlag. Drivers with the highest sleep variability had the shortest sleep duration and lowest sleep efficiency during workdays.

CONCLUSIONS

Drivers with high sleep variability may experience more fatigue when driving given the poor sleep outcomes during workdays observed.

Evaluating the influence of sleep quality and quantity on glycemic control in adults with type 1 diabetes

BACKGROUND

Sleep quality disturbances are frequent in adults with type 1 diabetes. However, the possible influence of sleep problems on glycemic variability has yet to be studied in depth. This study aims to assess the influence of sleep quality on glycemic control.

MATERIALS AND METHODS

An observational study of 25 adults with type 1 diabetes, with simultaneous recording, for 14 days, of continuous glucose monitoring (Abbott FreeStyle Libre system) and a sleep study by wrist actigraphy (Fitbit Ionic device). The study analyzes, using artificial intelligence techniques, the relationship between the quality and structure of sleep with time in normo-, hypo-, and hyperglycemia ranges and with glycemic variability. The patients were also studied as a group, comparing patients with good and poor sleep quality.

RESULTS

A total of 243 days/nights were analyzed, of which 77% (n = 189) were categorized as poor quality and 33% (n = 54) as good quality. Linear regression methods were used to find a correlation (r =0.8) between the variability of sleep efficiency and the variability of mean blood glucose. With clustering techniques, patients were grouped according to their sleep structure (characterizing this structure by the number of transitions between the different sleep phases). These clusters showed a relationship between time in range and sleep structure.

CONCLUSIONS

This study suggests that poor sleep quality is associated with lower time in range and greater glycemic variability, so improving sleep quality in patients with type 1 diabetes could improve their glycemic control.

Prevalence of insomnia and its association with quality of life among Macau residents shortly after the summer 2022 COVID-19 outbreak: A network analysis perspective

BACKGROUND

The latest wave of the coronavirus disease 2019 (COVID-19) pandemic in Macau began on 18 June 2022 and was more serious than previous waves. Ensuing disruption from the wave is likely to have had a variety of negative mental health consequences for Macau residents including increased risk for insomnia. This study investigated the prevalence and correlates of insomnia among Macau residents during this wave as well as its association with quality of life (QoL) from a network analysis perspective.

METHODS

A cross-sectional study was conducted between 26 July and 9 September 2022. Univariate and multivariate analyses explored correlates of insomnia. Analysis of covariance (ANCOVA) examined the relationship between insomnia and QoL. Network analysis assessed the structure of insomnia including "Expected influence" to identify central symptoms in the network, and the flow function to identify specific symptoms that were directly associated with QoL. Network stability was examined using a case-dropping bootstrap procedure.

RESULTS

A total of 1,008 Macau residents were included in this study. The overall prevalence of insomnia was 49.0% (n = 494; 95% CI = 45.9-52.1%). A binary logistic regression analysis indicated people with insomnia were more likely to report depression (OR = 1.237; P < 0.001) and anxiety symptoms (OR = 1.119; P < 0.001), as well as being quarantined during the COVID-19 pandemic (OR = 1.172; P = 0.034). An ANCOVA found people with insomnia had lower QoL (F_(1,1,008) = 17.45, P < 0.001). "Sleep maintenance" (ISI2), "Distress caused by the sleep difficulties" (ISI7) and "Interference with daytime functioning" (ISI5) were the most central symptoms in the insomnia network model, while "Sleep dissatisfaction" (ISI4), "Interference with daytime functioning" (ISI5), and "Distress caused by the sleep difficulties" (ISI7) had the strongest negative associations with QoL.

CONCLUSION

The high prevalence of insomnia among Macau residents during the COVID-19 pandemic warrants attention. Being quarantined during the pandemic and having psychiatric problems were correlates of insomnia. Future research should target central symptoms and symptoms linked to QoL observed in our network models to improve insomnia and QoL.

Two nights of home polysomnography in healthy 7-14-year-old children - Feasibility and intraindividual variability

OBJECTIVE

Attended polysomnography (PSG) is the gold standard for childhood sleep evaluation. There is, however, only limited information regarding repeated ambulatory PSG in children. We aimed to test whether in hospital attached level 2 home PSG is feasible and reproducible in healthy children.

METHODS

We recruited healthy children aged 7-14 years to undergo two nights of full level 2 PSG. The PSG equipment was attached at the hospital on the day of the sleep test and all recordings were performed at home. Subjective sleep quality, nocturnal urine production, sleep time and number of awakenings were documented for a week in connection to the first PSG night.

RESULTS

Thirty-three children were recruited of whom 32 children (aged 11 ± 2.1 years) underwent two nights of PSG. All 64 PSGs were technically adequate for sleep evaluation. We found mean sleep efficiency of 94% and mean total sleep time of 8.4 h. Sleep stages distribution with 5.9% N1, 46.8% N2, 24.3% N3 and 22.8% REM sleep. We found poorer subjective sleep quality, more self-reported awakenings, and shorter total sleep time on nights with PSG compared to nights without PSG with no differences between PSG study nights. No differences in nocturnal urine production were found between nights with and without PSG. The comparison of PSG variables between the two PSG nights revealed no first night effect.

CONCLUSIONS

Type 2 PSG recording is feasible for sleep evaluation in children 7-14 years of age producing good data quality. We found no first night effect on PSG variables. www.

CLINICALTRIALS

gov Registration number: NCT03477812.

Changes in sleep quality and sleep disturbances in the general population from before to during the COVID-19 lockdown: A systematic review and meta-analysis

Introduction

This systematic review and meta-analysis aims to explore changes in sleep quality and sleep disturbances in the general population from before to during the COVID-19 lockdown.

Methods

The protocol was registered in PROSPERO (CRD42021256378) and the PRISMA guidelines were followed. The major databases and gray literature were systematically searched from inception to 28/05/2021 to identify observational studies evaluating sleep changes in the general population during the lockdown with respect to the pre-lockdown period. A random effects meta-analysis was undertaken for studies reporting (a) the means of the Pittsburgh Sleep Quality Index (PSQI) global scores or the means of the sleep onset latency (SOL) times (minutes - min) before and during the lockdown, (b) the percentages of poor sleep quality before and during the lockdown, or (c) the percentages of changes in sleep quality. Subgroup analysis by risk of bias and measurement tool utilized was carried out. A narrative synthesis on sleep efficiency, sleep disturbances, insomnia and sleep medication consumption was also performed.

Results

Sixty-three studies were included. A decline in sleep quality, reflected in a pooled increase in the PSQI global scores (standardized mean difference (SMD) = 0.26; 95% CI 0.17-0.34) and in SOL (SMD = 0.38 min; 95% CI 0.30-0.45) were found. The percentage of individuals with poor sleep quality increased during the lockdown (pooled relative risk 1.4; 95% CI 1.24-1.61). Moreover, 57.3% (95% CI 50.01-61.55) of the individuals reported a change in sleep quality; in 37.3% (95% CI 34.27-40.39) of these, it was a worsening. The studies included in the systematic review reported a decrease in sleep efficiency and an increase in sleep disturbances, insomnia, and in sleep medication consumption.

Discussion

Timely interventions are warranted in view of the decline in sleep quality and the increase in sleep disturbances uncovered and their potentially negative impact on health. Further research and in particular longitudinal studies using validated instruments examining the long-term impact of the lockdown on sleep variables is needed.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021256378, identifier CRD42021256378.

Association between sleep and problematic behaviours in gifted children: a polysomnographic study

Neurological uniqueness, maladaptive behaviours, as well as atypical sleep patterns are reported to be defining characteristics of giftedness, but this has received little empirical support. We studied the polysomnography recorded sleep of gifted and typically-developing children together with features of maladaptive behaviours. The association of sleep macrostructure and sleep instability with maladaptive behaviours was also investigated in gifted children. In all, 19 gifted children (74% boys) and 17 typically-developing children (76% boys) aged 6-12 years were studied. Giftedness was identified using Renzulli's three-factor definition. The microarousal index, number of awakenings, and number of Stage shifts between sleep stages throughout the night were computed as sleep instability parameters. Maladaptive behaviours were assessed using the Child Behaviour Checklist. We found significantly more Stage N1 and less Stage N3 in gifted children compared to typically-developing children. More Stage N1 sleep was correlated with more externalising problems and less Stage N3 sleep was correlated with more internalising problems. Gifted children also displayed more rapid eye movement (REM) sleep, but this was not significantly correlated with behavioural scales. Gifted children displayed two opposing trends of sleep instability: more instability involving N1 sleep and less instability involving N2, N3 and REM sleep. More total Stage shifts were correlated with more internalising and externalising problems. The results of this study provide initial evidence of polysomnography-based characteristics of giftedness. Further studies are needed to explore common pathways linking sleep alterations and maladaptive behaviours in children with giftedness.

Theoretical construct into blocks of actigraphic-derived sleep parameters

Actigraphic parameters can provide indication of people's sleep quality during their daily lives. However, there is a need for clear guidelines on the understanding of the different actigraphic parameters. The present study aims to propose a conceptual and theoretical framework for known actigraphic-derived parameters, which is able to describe the alternation between rest and wake phases during the nocturnal sleep, explaining their main characteristics and interrelations that can be replicated in future studies. Forty Sport Sciences students at the University of Milan (20 males; mean age ± SD, 22 ± 3 y) completed the validated Italian version of Morningness-Eveningness Questionnaire (MEQ) and wore an actigraph (Motion Watch 8®, Cambridge Neurotechnology, Cambridge, UK) for seven days. A framework was developed to depict the interactions between the actigraphic parameters and how they objectively describe sleep, according to which the parameters are organized into three different functional blocks related to different aspects of sleep. Correlations analyses were conducted to explore the relationships among the primary actigraphic parameters within and across the functional blocks. The proposed framework is a purely theoretical construct that provides a simple interpretation of known actigraphic parameters guiding researchers and practitioners in the use of these parameters either for research or clinical purposes.

A lower sleep regularity index (SRI) is associated with relapse in individuals with alcohol use disorder following inpatient treatment

The sleep regularity index (SRI) is used to measure an individual's sleep/wake consistency over time. The SRI has been associated with certain health risks; to date, research investigating the relationship between the SRI and relapse in individuals with alcohol use disorder (AUD) is lacking. The aim of this work was to evaluate the SRI and relapse in individuals with AUD following inpatient treatment. Individuals with AUD (n = 77, mean age = 49.5 ± 10.86) were assessed for 28-days following discharge from an inpatient treatment program. Logistic regression was applied to examine the impact of SRI on relapse as the outcome variable of interest. Sleep quality was lower in individuals who relapsed compared to those who did not. Moreover, SRI scores were significantly worse in those who relapsed compared to those who did not. Over the entire patient cohort, lower weekly SRI scores were significantly correlated with longer weekly nap duration. Logistic regression model results indicated that the overall SRI was a significant predictor of relapse. The SRI represents a relevant aspect of sleep health and should be considered when assessing an individual's sleeping patterns. Behavior based interventions related to the importance of individualized consistency in sleep and wake patterns may be particularly important for treatment seeking individuals with AUD not only during inpatient treatment, but also once these individuals have transitioned into their outpatient phase of recovery. These findings support the notion of SRI as a separate facet of sleep health worth investigating in at-risk, disease specific groups.

Sleep Quality and Self-Reported Symptoms of Anxiety and Depression Are Associated with Physical Activity in Patients with Severe COPD

Sleep quantity, quality and symptoms of depression or anxiety potentially affect the level of daily physical activity (PAL) and plausibly counteracts benefits from pulmonary rehabilitation programs. Their collective impact on PAL is sparsely investigated, particularly in patients with severely progressed chronic obstructive pulmonary disease (COPD). Aim: To investigate if sleep quantity, quality and symptoms from self-reported hospital anxiety and depression scores (HADS) are associated with PAL. Methods: In this exploratory cross-sectional study data were analysed from 148 participants with COPD; GOLD grade II-IV; GOLD group B to D (52% female, mean 69.7 ± SD of 8.4 years, FEV1% predicted 33.6 ± 10.9, 6MWD 327 ± 122 m, CAT 20 ± 7 points), eligible for conventional outpatient hospital-based pulmonary rehabilitation. Participants had sleep and PAL measured 24 h per day for five consecutive days with an activPAL monitor. Adjusted negative binomial regression was applied to investigate the associations with PAL. Results: Participants walked median (25th, 75th percentile) of 2358 (1325.75; 3822.25) steps per day and 14% walked >5000 steps per day on average. Time in bed (TIB) were a median (25th, 75th percentile) of 8.3 (7.1; 9.7) hours and numbers of nocturnal sleeping bouts (NSB) were 1.5 (0.8; 3), Anxiety (HADS-A) and depression (HADS-D) scores were median (25th, 75th percentile) of 5 (3; 8) points and 3 (2; 6) points, respectively, whereof 29% (HADS-A) and 15% (HADS-D) reported scores ≥8 points indicating significant symptoms. The fully adjusted rate ratio (RR) for steps per day for TIB (hours) [RR 0.97 (95% CI: 0.92; 1.02)], NSB (numbers) [RR 1.02 (95% CI: 0.97; 1.07)] were not significantly associated with number of steps per day, while there was a significantly association with number of steps per day for HADS-A [RR 1.04 (95% CI: 1.01; 1.07)] and HADS-D [RR 0.95 (95% CI: 0.91; 0.99)]. Conclusion: This exploratory cross-sectional study found a statistically significant association between HADS-A and HADS-D with numbers of steps per day in patients with severe COPD.

Validation of the Sleep Quality Questionnaire among senior students in Benin City, Nigeria

Background

The Sleep Quality Questionnaire (SQQ) is a short and easy-to-understand resourceful tool for measuring poor sleep quality; however, it remains to be validated.

Aim

The focus of this study is to determine its reliability and validity among Nigerian adolescents.

Setting

Four gender-mixed schools within Benin City, Nigeria were selected to participate in the study.

Methods

Questionnaires containing the SQQ, the Sleep Condition Indicator (SCI), which is a validated scale, and the Hospital Anxiety and Depression Scale (HADS) from 377 students selected from the junior and senior secondary school students were analysed.

Results

The mean age calculated was 14.78 years for 174 male and 203 female students. Cronbach's alpha for the SQQ scale was 0.70. It correlated strongly with the SCI (rho = 0.93, p = 0.00), weakly with the HADS depression (rho = -0.19, p < 0.01) and anxiety (rho = -0.30, p < 0.01), but had no association with gender. Factor analysis revealed three factors with an eigenvalue greater than 1. Factors 1-3 accounted for 31.78%, 15.16% and 11.26% of the variance, respectively, totalling 58.2%. The reliability of each of the three factors was as follows: factor 1, 0.75; factor 2, 0.47; and factor 3, 0.62. The SQQ demonstrated good specificity and sensitivity at a cut-off point of 18.

Conclusion

It is therefore recommended that the SQQ be included in the screening of sleep-related problems in adolescents, both in the primary and secondary care settings in Nigeria.

Contribution

The research shows that the Sleep Quality Questionnaire is both a reliable and valid screening tool among adolescents in Nigeria. Its brevity and simplicity further promote its use in clinical and non-clinical settings.

Sleep and Daily Positive Emotions – Is Heart Rate Variability a Mediator?

Abstract. Sleep quality is considered a basic dimension of emotional health. The psychophysiological mechanisms underlying the associations between sleep quality and positive emotions are still largely unknown, yet autonomic regulation may play a role. This study employed a two-day ecological momentary assessment methodology in a sample of young adults to investigate whether subjective sleep quality reported in the morning was associated with daily positive emotional experience and whether this association was mediated by heart rate variability (HRV), a measure of cardiac vagal tone. Sleep quality was assessed using an electronic sleep diary upon awakening, while resting HRV and positive emotions were inspected at random times throughout the day using photoplethysmography and an electronic diary, respectively. Relevant confounding variables such as smoking, alcohol intake, and physical exercise between each measurement were also assessed. The sample included 121 participants (64.8% females, Mage = 25.97 ± 5.32 years). After controlling for relevant confounders including health behaviors and psychiatric comorbidities, mediation analysis revealed that greater sleep quality positively predicted daily HRV (β = .289, p < .001) which, in turn, had a direct influence on positive emotions (β = .244, p = .006). Also, sleep quality directly predicted positive emotional experience (β = .272, p = .001). Lastly, the model showed an indirect effect between sleep quality and positive emotions via HRV (β = .071, 95% BCI [.011, .146]). Results support the view of HRV as a process variable linking sleep to positive emotions. Experimental data is needed to consolidate the present findings.

Associations of siesta and total sleep duration with hypertension or cardiovascular diseases in middle-aged and older adults

BACKGROUND

Whether the ratio of siesta duration in the total sleep duration was associated with the occurrence of hypertension or cardiovascular diseases (CVDs) was unclear.

HYPOTHESIS

To explore the associations of siesta, and siesta ratio with hypertension or CVDs in middle-aged and older adults.

METHODS

This cohort study collected the data of 9247 middle-aged and older adults. The associations of siesta, and siesta ratio with hypertension were analyzed in 7619 participants while the associations of siesta, and siesta ratio with CVDs were analyzed in 8685 participants via univariate and multivariate logistic regression analysis.

RESULTS

Total sleep duration < 6 h (odd ratio [OR] = 1.168, 95% confidence interval [CI]: 1.023-1.335) and siesta ratios ≥ 0.4 (OR = 1.712, 95% CI: 1.129-2.594) were associated with increased risk of hypertension in middle-aged and older adults. Siesta ratio ≥ 0.4 was linked with higher risk of hypertension in males aged ≥ 60 years and total sleep duration < 6 h was correlated with elevated risk of hypertension in males < 60 years. The risk of CVDs was elevated in people with siesta duration < 0.5 h (OR = 2.053, 95% CI: 1.323-3.185). In females ≥60 years, the sleep duration at night < 6 h was associated with increased risk of CVDs. In females < 60 years, increased risk was observed in those with siesta duration < 0.5 h and sleep duration at night < 6 h.

CONCLUSION

Short sleep duration or high siesta ratio were associated with higher risk of hypertension. Short siesta duration, sleep duration at night or total sleep duration were correlated with an elevated risk of CVDs.

Method to quantify the impact of sleep on cardiac neuroautonomic functionality: application to the prediction of cardiovascular events in the Multi-Ethnic Study of Atherosclerosis

We introduce the concept of cardiac neuroautonomic renewability and a method for its quantification. This concept refers to the involuntary nervous system's capacity to improve cardiac control in response to restorative interventions, such as sleep. We used the change in heart rate fragmentation (ΔHRF), before sleep onset compared with after sleep termination, to quantify the restorative effects of sleep. We hypothesized that the ability to improve cardiac neuroautonomic functionality would diminish with age and be associated with lower risk of major adverse cardiovascular events (MACE). We analyzed the ECG channel of polysomnographic recordings from an ancillary investigation of the Multi-Ethnic Study of Atherosclerosis (MESA). In a cohort of 659 participants (mean ± SD age, 69.7 ± 8.8; 42% male), HRF was significantly (P < 0.001) lower after sleep (before: 74 ± 12%, after: 67 ± 13%). Furthermore, the magnitude of the decrease significantly (P < 0.001) diminished with cross-sectional age. In addition, a larger reduction in HRF following sleep (i.e., higher ΔHRF) was associated with lower risk of MACE, independent of traditional cardiovascular risk factors and current measures of sleep quality. Specifically, over a mean follow-up period of 6.4 ± 1.6 yr, in which 60 participants had their first MACE, a one-SD (12%) increase in ΔHRF was associated with a 36% (95% CI: 12%-53%) decrease in the risk of MACE. The results demonstrate the restorative impact of sleep on heart rate control. As such they support the concept of cardiac neuroautonomic renewability and the utility of ΔHRF for its quantification.

Evaluating machine learning models to classify occupants' perceptions of their indoor environment and sleep quality from indoor air quality

A variety of factors can affect a person's perception of their environment and health, but one factor that is often overlooked in indoor settings is the air quality. To address this gap, we develop and evaluate four Machine Learning (ML) models on two disparate datasets using Indoor Air Quality (IAQ) parameters as primary features and components of self-reported IAQ satisfaction and sleep quality as target variables. In each case, we compare models to each other as well as to a simple model that always predicts the majority outcome. In the first analysis, we use open-source data collected from 93 California residences to predict occupant's satisfaction with their indoor environment. Results indicate building ventilation rate, Relative Humidity (RH), and formaldehyde are most influential when predicting IAQ perception and do so with an accuracy greater than the simplified model. The second analysis uses IAQ data gathered from a field study we conducted with 20 participants over 11 weeks to train similar models. We obtain accuracy and F1 scores similar to the simplified model where PM_2.5 and TVOCs represent the most important predictors. Our results underscore the ability of IAQ to affect a person's perception of their built environment and health and highlight the utility of ML models to explore the strength of these relationships.Implications: The results from this study show that two outcome variables - occupant's indoor air quality (IAQ) satisfaction and perceived sleep quality - are related to the measured IAQ parameters but not heavily influenced by typical values measured in apartments and homes. This study highlights the ability of machine learning models as exploratory analysis tools to determine underlying relationships within and across datasets in addition to understanding the importance of certain features on the outcome variable. We compare four different models and find that the random forest classifier has the best performance in both analysis on IAQ satisfaction and perceived sleep quality. It is a suitable model for predicting IAQ-related subjective metrics and also provides value insight into the feature importance of the IAQ parameters. The accuracy of any of these machine learning models in predicting occupants' comfort or sleep quality is limited by the dataset size, how data is collected, and range of data. This study identifies the factors that are important to IAQ perception: ventilation rate, relative humidity, and concentrations of formaldehyde, NO2, and particulate matter. It indicates that sensors that can measure these variables are necessary for future, related studies that model occupants' IAQ satisfaction. However, this study does not find strong relationships between any of the IAQ parameters measured in this study and perceived sleep quality despite the logical pathway between these many pollutants and respiratory issues. A prediction model of IAQ perception or sleep quality can be integrated into home management systems to automatically adjust building operations such as ventilation rates in smart buildings. Once buildings are equipped with a network of low-cost sensors that measure concentrations of pollutants and operating conditions of the ventilation system, the prediction model can be used to predict the occupants' comfort and facilitate the control of the ventilation system.

Characterising Psycho-Physiological Responses and Relationships during a Military Field Training Exercise

Over a 15-day period, that included an eight-day field trial, the aims of this study were to (1) quantify the physical workload, sleep and subjective well-being of soldiers in training; (2a) Explore relationships between workload and well-being, and (2b) sleep and well-being; (3) Explore relationships between workload, sleep, and well-being.

METHODS

Sixty-two Combat Engineer trainees (59 male, 3 female; age: 25.2 ± 7.2 years) wore an ActiGraph GT9X to monitor daily energy expenditure, physical activity, and sleep. Rating of perceived exertion (RPE), sleep quality, and fatigue were measured daily, subjective well-being was reported days 1, 5, 9, 13 and 15. Multi-level models were used for the analysis.

RESULTS

Well-being was affected by a combination of variables including workload, subjective sleep quality, sleep duration, and sleep efficiency. RPE and subjective sleep quality were consistently significant parameters within the models of best fit.

CONCLUSIONS

Perceptions of well-being were lower during the field training when physical workload increased, and sleep decreased. Energy expenditure was comparatively low, while daily sleep duration was consistent with field training literature. Subjective assessments of workload and sleep quality were consistently effective in explaining variations in well-being and represent an efficient approach to monitor training status of personnel.

Can air purification improve sleep quality? A 2‐week randomised‐controlled crossover pilot study in healthy adults

Insufficient quantity and quality of sleep is a public health concern that can be addressed by interventions for improving sleep outcomes. Environmental factors such as poor air quality are a potential target for intervention, particularly in light of associations between air pollution and worse sleep. The aim of this pilot study was to investigate the effects of using an air purifier on sleep outcomes and mood in 30 healthy adults. There were two conditions: (i) air purifier with a high-efficiency particulate air filter; (ii) air purifier with a placebo filter. Participants undertook both conditions, each over 2 weeks with a 2-week washout, following a counterbalanced, double-blind design. Daily sleep outcomes were measured with actigraphy watches and sleep diaries, whilst daily mood was assessed with the Positive and Negative Affect Schedule. The Insomnia Severity Index, the Pittsburgh Sleep Quality Index, and symptoms of anxiety and depression were measured pre- and post-. The purifier filter was associated with increased total sleep time for an average of 12 min per night, and increased total time in bed for an average of 19 min per night relative to the placebo. There were several sleep and mood outcomes for which no changes were observed, and time awake after sleep onset was higher for the purifier filter. Air quality was better during the high-efficiency particulate air filter condition. These findings offer positive indications that environmental interventions that improve air quality can have benefits for sleep outcomes in healthy populations who are not exhibiting clinical sleep disturbances.

Determinants of natural adult sleep: An umbrella review

BACKGROUND

Sleep has a major impact on health, which makes it a relevant topic for research and health practitioners. Research on sleep determinants, i.e. factors that positively or negatively influence sleep, is fragmented.

OBJECTIVE

The purpose of this umbrella review is to provide an overview of the current evidence on determinants of natural adult sleep.

METHODS

A comprehensive literature search was performed on determinants of sleep. Reviews and meta-analyses on natural adult sleep were included. Six electronic databases (PubMed, WoS, Embase, CINAHL, PsycInfo and Cochrane) were used for the search, last accessed September 2021. The quality of the selected articles was assessed using the AMSTAR2 tool. Results were categorized in four main categories: biological, behavioral, environmental and personal/socio-economical determinants.

RESULTS

In total 93 reviews and meta-analyses resulted in a total of 30 identified determinants. The impact of each determinant differs per individual and per situation. Each determinant was found to affect different sleep parameters and the relationship with sleep is influenced by both generic and specific moderators.

DISCUSSION

A comprehensive overview on relevant sleep determinants provides a practical and scientifically based starting point to identify relevant intervention approaches to secure or improve individual sleep quality. The difference in aggregation level of the determinants and in measurement methods are the major limitations of this umbrella review. Extending existing generic sleep hygiene rules with an overview of all types of potential determinants will enhance the awareness of the complexity and can be used to improve the effect of sleep interventions in health promotion.

TRIAL REGISTRATION

The umbrella review was registered with PROSPERO (registration ID CRD42020149648) https://www.google.com/search?client=firefox-b-d&q=CRD42020149648.

Effect of sleep and fatigue on cardiovascular performance in young, healthy subjects

Physical performance could be negatively affected by sleep deficiency and fatigue. The present study assesses the role of sleep quality, fatigue and motivation on cardiovascular performance (VO₂peak, Wmax, and HRmax) in a sample of active young subjects. The current study is a cross-sectional design. Ninety-six university students (males 54.2%; 21.5 ± 2.9 yrs) completed an incremental exercise test on a bicycle ergometer. Sleep, fatigue, and motivation were assessed with the Pittsburgh Sleep Quality Index and two visual analogue scales, respectively. Differences in VO₂peak, Wmax, HRmax, self-perceived fatigue and motivation were compared between good and bad sleepers and sleep duration >/<7.5 h, while regression analysis defined the predictors of VO₂peak, Wmax, and HRmax_. In the male sample, good and bad sleepers' differences were significant only for self-perceived fatigue (p = 0.04). The female sample showed no statistically significant differences between good and bad sleepers and different sleep durations. In the male sample, linear regression analysis showed a significant inverse correlation between Wmax and the PSQI score (-0.4, p = 0.004). The stepwise regression model indicated that sleep (β = -0.3, p = 0.02) was a significant predictor of VO₂peak in males accounting for 20% of the variance, whereas physical performance seems more affected by fatigue (β = -0.4, p = 0.03) in females. In conclusion, chronic inadequate and self-reported sleep quality seems to be one of the factors compromising cardiovascular performance in males.

Middle school start times and young adolescent sleep, behavioral health, and academic performance outcomes: a narrative review

STUDY OBJECTIVES

This narrative review aims to synthesize peer-reviewed and gray literature research that associates middle school start times to adolescent sleep, health, and academic performance.

METHODS

A systematic search of publications in PubMed, Scopus, ERIC, APA PsycInfo, CINAHL, ProceedingsFirst, and ProQuest Dissertations and Theses from 2002-2020 was conducted. Studies with middle school students that had either an empirical evaluation of the implementation of a change in school start time or a comparison of schools with different school start times, and which also reported outcomes related to sleep and health and quantitative academic measures were included. School characteristics, student demographics, study design, start times, and outcomes were extracted from the full-text review.

RESULTS

The review identified 1,136 articles; after removing duplicates, 845 were screened. Following title and abstract review, 18 articles were eligible for full-text review. Nine studies did not meet inclusion criteria. Half of the reviewed 10 studies used cross-sectional designs, 8 evaluated sleep, 6 evaluated behavioral health, and 3 evaluated academic performance.

CONCLUSIONS

Late middle school start times can improve adolescents' sleep and reduce daytime sleepiness by increasing total sleep time and delaying waketime. The current studies provide promising evidence that late-start times can improve tardiness, executive function, negative affect and mood, grade-point average, and standardized test scores. Methodologically robust research on delayed middle school start times can inform public policy and promote change.

CITATION

Barlaan DR, Pangelinan BA, Johns A, Schweikhard A, Cromer LD. Middle school start times and young adolescent sleep, behavioral health, and academic performance outcomes: a narrative review. J Clin Sleep Med. 2022;18(11):2681-2694.

The Influence of Sleep Quality on Patient Safety Learning of Nursing Students

We investigated the influence of nursing students' sleep quality on their patient safety (PS) competence (i.e., knowledge of the dimensions of PS). The investigation surveyed 242 nursing students in a Saudi university. The majority of the surveyed students were characterized as having poor sleep quality. Notably, more male students experienced poor sleep quality than female students. The students reported the highest confidence in "culture of safety" and "managing safety risk"; they exhibited the poorest confidence in "working in teams." Increased length of sleep latency decreased sleep efficiency, and increased daytime sleepiness-related dysfunction was associated with reduced PS competence.