[Insomnia--state of the science]

The effect of physical exercise interventions on insomnia: A systematic review and meta-analysis

6-10 % of Europeans suffer from chronic insomnia. They have a higher risk to develop mental and cardiovascular diseases. Treatment of insomnia primarily recommended by the European guideline is cognitive behavioral therapy for insomnia (CBT-I). A quarter of patients treated with CBT-I do not respond sufficiently. The objective of this paper is to examine the influence of exercise interventions on insomnia by conducting a systematic review and meta-analysis. A database search was conducted, including randomized controlled trials (RCT) in which participants had received a diagnosis of insomnia or experienced symptoms thereof. Exercise interventions had to meet the definition of the World Health Organization (WHO), and their implementation was reported according to the FITT (Frequency, Intensity, Time and Type) principle. There was an inactive control and subjective or objective sleep parameters as outcomes. Nineteen studies were included. Results showed a significant improvement for objective (standardized mean difference, SMD = 0.37; confidence interval, CI = [0.17; 0.57]) as well as subjective (SMD = 0.90; CI = [0.61; 1.19]) sleep parameters. Meta-regression showed that the effect increased with intensity of intervention, mean age of participants and percentage of females, but showed high heterogeneity across studies. These results suggest great potential for treating insomnia. Conducting larger trials is advisable to provide precise recommendations.

Effectiveness of an App-Based Short Intervention to Improve Sleep: Randomized Controlled Trial

BACKGROUND

A growing body of evidence for digital interventions to improve sleep shows promising effects. The interventions investigated so far have been primarily web-based; however, app-based interventions may reach a wider audience and be more suitable for daily use.

OBJECTIVE

This study aims to evaluate the intervention effects, adherence, and acceptance of an unguided app-based intervention for individuals who wish to improve their sleep.

METHODS

In a randomized controlled trial, we evaluated the effects of an app-based short intervention (Refresh) to improve sleep compared with a waitlist condition. Refresh is an 8-week unguided intervention covering the principles of cognitive behavioral therapy for insomnia (CBT-I) and including a sleep diary. The primary outcome was sleep quality (insomnia symptoms) as self-assessed by the Regensburg Insomnia Scale (RIS). The secondary outcomes were depression (9-item Patient Health Questionnaire [PHQ-9] score) and perceived insomnia-related impairment.

RESULTS

We included 371 participants, of which 245 reported poor sleep at baseline. About 1 in 3 participants who were allocated to the intervention group never accessed the intervention. Active participants completed on average 4 out of 8 chapters. Retention rates were 67.4% (n=250) at postassessment and 57.7% (n=214) at the 6-month follow-up. At postintervention, insomnia symptoms in the intervention group had improved more than those in the waitlist group, with a small effect (d=0.26) in the whole sample and a medium effect (d=0.45) in the subgroup with poor sleep. Effects in the intervention group were maintained at follow-up. Perceived insomnia-related impairment also improved from pre- to postassessment. No significant intervention effect on depression was detected. Working alliance and acceptance were moderate to good.

CONCLUSIONS

An app-based, unguided intervention is a feasible and effective option to scale-up CBT-I-based treatment, but intervention uptake and adherence need to be carefully addressed.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN53553517; https://www.isrctn.com/ISRCTN53553517.

A cross-sectional study on sleep disturbances and associated factors among nurses

BACKGROUND

Many studies have measured sleep disturbances among nurses globally, but none have addressed this issue in Vietnam. Therefore, this study aimed to assess the prevalence of sleep disturbance and identify associated factors among staff nurses in Vietnam. To identify sleep disturbances and associated factors among staff nurses in Vietnam.

METHODS

A cross-sectional design was used in this study. Participant nurses (n = 420) completed a general information questionnaire, the Vietnamese version of the General Sleep Disturbance Scale (GSDS), the Perceived Stress Scale, and the Short Form 12. Data were collected between July and September 2019 from three public hospitals located in southwestern Vietnam. Data were analyzed using Chi-square, independent Student's t-test, and multivariate logistic regression analysis.

RESULTS

The average GSDS score was 41.10 (SD = 19.48), indicating sleep disturbances among 46.9% of nurses. Age, health condition, stress, and quality of life had an impact on sleep disturbance. Multivariate logistic regression analysis confirmed that nurses with high stress and poor physical health status were more likely to experience sleep disturbances.

CONCLUSION

Vietnamese nursing staff suffers from a high rate of sleep disturbances. Significant predictors included high stress and poor physical health status. Administrators of healthcare services should carefully consider how to conduct interventions to help the nurses handle their sleep disturbances such as stress management and physical health promotion.

Why Do Our Cancer Patients Sleep So Badly? Sleep Disorders in Cancer Patients: A Frequent Symptom with Multiple Causes

INTRODUCTION

On the one hand, sleep disorders in cancer patients are reported in 30-50% of cancer patients. On the other hand, specific causes for these sleep disorders are little known. This study was done to evaluate factors which may affect sleep of cancer patients. To our knowledge, this is the first study which includes return to work as one factor of sleep disturbance.

METHODS

107 patients with various types of cancer treated in 2 hospitals were interviewed with a battery of questionnaires after having given informed consent. The questionnaires intended to detect abnormalities of sleep and related pain, breathing disorders, restless legs syndrome, depression, rumination, medication, and psychosocial distress. The study was approved by the ethics committee of the University of Marburg.

RESULTS

The analysis of the 6 sleep-related questionnaires indicated a sleep disorder of any kind in 68% of all patients. Insomnia symptoms were present in 48 patients (44.9%). Pain, depression, anxiety, and worries about the workplace were significantly related to sleep disorders.

CONCLUSION

Sleep disorders are common in cancer patients. The causes are manifold and should be considered by caregivers during diagnosis, therapy, and aftercare of cancer patients. Tumour patients should actively be asked about sleep disorders. If these are present, they should be addressed, and as they have a large impact on quality of life, treatment options should be offered in cooperation with sleep specialists.

Eszopiclone for insomnia

BACKGROUND

Insomnia is a major public health issue affecting between 6% to 10% of the adult population in Western countries. Eszopiclone is a hypnotic drug belonging to a newer group of hypnotic agents, known as new generation hypnotics, which was marketed as being just as effective as benzodiazepines for this condition, while being safer and having a lower risk for abuse and dependence. It is the aim of the review to integrate evidence from randomised controlled trials and to draw conclusions on eszopiclone's efficacy and safety profile, while taking methodological features and bias risks into consideration.

OBJECTIVES

To assess the efficacy and safety of eszopiclone for the treatment of insomnia compared to placebo or active control.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled trials (CENTRAL), MEDLINE, Embase, PsycINFO, PSYNDEX and registry databases (WHO trials portal, ClinicalTrials.gov) with results incorporated from searches to 10 February 2016. To identify trials not registered in electronic databases, we contacted key informants and searched reference lists of identified studies. We ran an update search (21 February 2018) and have placed studies of interest in awaiting classification/ongoing studies. These will be incorporated into the next version of the review, as appropriate.

SELECTION CRITERIA

Parallel group randomised controlled trials (RCTs) comparing eszopiclone with either placebo or active control were included in the review. Participants were adults with insomnia, as diagnosed with a standardised diagnostic system, including primary insomnia and comorbid insomnia.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted outcome data; one reviewer assessed trial quality and the second author cross-checked it.

MAIN RESULTS

A total of 14 RCTs, with 4732 participants, were included in this review covering short-term (≤ 4 weeks; 6 studies), medium-term (> 4 weeks ≤ 6 months; 6 studies) and long-term treatment (> 6 months; 2 studies) with eszopiclone. Most RCTs included in the review included participants aged between 18 and 64 years, three RCTs only included elderly participants (64 to 85 years) and one RCT included participants with a broader age range (35 to 85 years). Seven studies considered primary insomnia; the remaining studies considered secondary insomnia comorbid with depression (2), generalised anxiety (1), back pain (1), Parkinson's disease (1), rheumatoid arthritis (1) and menopausal transition (1).Meta-analytic integrations of participant-reported data on sleep efficacy outcomes demonstrated better results for eszopiclone compared to placebo: a 12-minute decrease of sleep onset latency (mean difference (MD) -11.94 min, 95% confidence interval (CI) -16.03 to -7.86; 9 studies, 2890 participants, moderate quality evidence), a 17-minute decrease of wake time after sleep onset (MD -17.02 min, 95% CI -24.89 to -9.15; 8 studies, 2295 participants, moderate quality evidence) and a 28-minute increase of total sleep time (MD 27.70 min, 95% CI 20.30 to 35.09; 10 studies, 2965 participants, moderate quality evidence). There were no significant changes from baseline to the first three nights after drug discontinuation for sleep onset latency (MD 17.00 min, 95% CI -4.29 to 38.29; 1 study, 291 participants, low quality evidence) and wake time after sleep onset (MD -6.71 min, 95% CI -21.25 to 7.83; 1 study, 291 participants, low quality evidence). Adverse events during treatment that were documented more frequently under eszopiclone compared to placebo included unpleasant taste (risk difference (RD) 0.18, 95% CI 0.14 to 0.21; 9 studies, 3787 participants), dry mouth (RD 0.04, 95% CI 0.02 to 0.06; 6 studies, 2802 participants), somnolence (RD 0.04, 95% CI 0.02 to 0.06; 8 studies, 3532 participants) and dizziness (RD 0.03, 95% CI 0.01 to 0.05; 7 studies, 2933 participants). According to the GRADE criteria, evidence was rated as being of moderate quality for sleep efficacy outcomes and adverse events and of low quality for rebound effects and next-day functioning.

AUTHORS' CONCLUSIONS

Eszopiclone appears to be an efficient drug with moderate effects on sleep onset and maintenance. There was no or little evidence of harm if taken as recommended. However, as certain patient subgroups were underrepresented in RCTs included in the review, findings might not have displayed the entire spectrum of possible adverse events. Further, increased caution is required in elderly individuals with cognitive and motor impairments and individuals who are at increased risk of using eszopiclone in a non-recommended way.

[Sleep disorders in neurological diseases]

Sleep disorders can be diagnosed in approximately 15 % of the population and have been shown to increase with age. The relationship between sleep disorders and neurological disorders, however, is still insufficiently considered in the clinical practice. Sleep disorders can be an early symptom of the disease, such as the presence of rapid eye movement (REM) sleep behavior disorder (RBD) as an early indicator of neurodegeneration. Sleep disorders have also been shown to be a main symptom of various neurological syndromes, such as in restless legs syndrome (RLS), periodic limb movement disorder (PLMD) and narcolepsy. The international classification of sleep disorders 2nd edition (ICSD 2) describes the main diagnoses, insomnia, circadian rhythm sleep disorders, sleep-related breathing disorders and hypersomnia but all of these can also appear as symptoms in various neurological diseases. Parasomnias are largely considered a differential diagnosis to nocturnal epilepsy. In this review, the main sleep disorders are described with a particular focus on how they relate to neurological diseases; in particular, how they influence disease-related symptoms and how they affect the course of the disease.

Behavioural and Cognitive-Behavioural Treatments of Parasomnias

Parasomnias are unpleasant or undesirable behaviours or experiences that occur predominantly during or within close proximity to sleep. Pharmacological treatments of parasomnias are available, but their efficacy is established only for few disorders. Furthermore, most of these disorders tend spontaneously to remit with development. Nonpharmacological treatments therefore represent valid therapeutic choices. This paper reviews behavioural and cognitive-behavioural managements employed for parasomnias. Referring to the ICSD-3 nosology we consider, respectively, NREM parasomnias, REM parasomnias, and other parasomnias. Although the efficacy of some of these treatments is proved, in other cases their clinical evidence cannot be provided because of the small size of the samples. Due to the rarity of some parasomnias, further multicentric researches are needed in order to offer a more complete account of behavioural and cognitive-behavioural treatments efficacy.

[The contributions by Emil Kraepelin to the knowledge on sleep disorders and their treatment]

While Emil Kraepelin's comprehensive psychiatric oeuvre has attracted researchers' attention, his studies on sleep disorders and their treatment as well as on the interconnections between sleep and mental disorders so far seem to have been neglected.This article identifies and analyzes Kraepelin's sporadic contributions on the pathology of sleep, the comorbidities and treatment made between 1883 and 1924 in textbooks and isolated papers as well as in a presentation that was also published and compares them with current opinions in sleep research.Kraepelin never published a dedicated work on sleep, apart from a summary of the different narcotics; however, his occasional statements reveal astonishing insights and in particular his clear etiologically oriented classification of sleep disorders is captivating. Similar to the current classification, Kraepelin conceptualized sleep disorders as symptoms or rather a complex of symptoms and also identified associated diseases which once again are very near to current opinion. Apart from this his recommendations on sleep hygiene and, in a second step, pharmacological treatment of pathological sleep patterns are still clinically relevant. As early as the end of the nineteenth century Kraepelin laid down an algorithm of treatment which is very similar to the current clinical guidelines. At Kraepelin's time it seemed impossible to reach an agreement on classification and treatment issues of sleep disturbances and even though there has been an ongoing discussion until the present day, an agreement at least about guidelines could be reached. Against this background Kraepelin's contributions can still be regarded as a proposal for best practice.