Sleep disordered breathing, insomnia, and health related quality of life -- a comparison between age and gender matched elderly with heart failure or without cardiovascular disease

Sleep Deficiency: A Symptoms Perspective: Exemplars from Chronic Heart Failure, Inflammatory Bowel Disease, and Breast Cancer

Sleep deficiency is associated with disabling daytime symptoms, including excessive daytime sleepiness (EDS) and fatigue. The purpose of this article is to discuss the contributions of sleep deficiency and sleep disorders to fatigue and EDS among people with chronic conditions. We use exemplars from the literature on chronic heart failure, inflammatory bowel disease, and breast cancer to (1) describe the prevalence of fatigue and EDS and their consequences; (2) examine the evidence for the contributions of sleep deficiency and sleep disorders to these symptoms; and (3) recommend implications for future research and practice.

Sleep Disorders

AbstractThere are more than 90 recognized sleep disorders, many of which impair sleep and daytime function and adversely impact heath, well-being, and chronic disease risk. Unfortunately, many sleep disorders are undiagnosed or not managed effectively. This review describes how to identify, evaluate, and treat common sleep disorders.

Insomnia with objective, but not subjective, short sleep duration is associated with increased risk of incident hypertension: the Sleep Heart Health Study

STUDY OBJECTIVES

Insomnia with objective short sleep duration has been associated with higher risk of cardiometabolic morbidity. In this study, we examined the association between insomnia with objective short sleep duration, also based on subjective sleep duration, with incident hypertension in the Sleep Heart Health Study.

METHODS

We analyzed data from 1,413 participants free of hypertension or sleep apnea at baseline from the Sleep Heart Health Study, with a median follow-up duration of 5.1 years. Insomnia symptoms were defined based on difficulty falling asleep, difficulty returning to sleep, early morning awakening, or sleeping pill use more than half the days in a month. Objective short sleep duration was defined as polysomnography-measured total sleep time < 6 hours. Incident hypertension was defined based on blood pressure measures and/or use of antihypertensive medications at follow-up.

RESULTS

Individuals with insomnia who slept objectively < 6 hours had significantly higher odds of incident hypertension compared to normal sleepers who slept ≥ 6 hours (odds ratio = 2.00, 95% confidence interval = 1.09-3.65) or < 6 hours (odds ratio = 2.00, 95% confidence interval = 1.06-3.79) or individuals with insomnia who slept ≥ 6 hours (odds ratio = 2.79, 95% confidence interval = 1.24-6.30). Individuals with insomnia who slept ≥ 6 hours or normal sleepers who slept < 6 hours were not associated with increased risk of incident hypertension compared to normal sleepers who slept ≥ 6 hours. Finally, individuals with insomnia who self-reported sleeping < 6 hours were not associated with significantly increased odds of incident hypertension.

CONCLUSIONS

These data further support that the insomnia with objective short sleep duration phenotype based on objective, but not subjective measures, is associated with increased risk of developing hypertension in adults.

CITATION

Dai Y, Chen B, Chen L, et al. Insomnia with objective, but not subjective, short sleep duration is associated with increased risk of incident hypertension: the Sleep Heart Health Study. J Clin Sleep Med. 2023;19(8):1421-1428.

Sleep, circadian rhythm characteristics, and melatonin levels in later life adults with and without coronary artery disease

STUDY OBJECTIVES

The purpose of this study was to conduct a comprehensive assessment of sleep and circadian rhythms in individuals with and without coronary artery disease (CAD).

METHODS

This was a cross-sectional study. Participants were 32 individuals, mean age = 70.9, female 46.9%, 19 with CAD, and 13 without CAD. We assessed sleep quality and 24-hour rest-activity rhythms for 14 days using wrist actigraphy and self-report measures, and circadian rhythm using dim light melatonin onset.

RESULTS

Melatonin levels prior to habitual bedtime were significantly lower in individuals with CAD than in those without CAD (median area under the curve = 12.88 vs 26.33 pg/ml × h, P = .049). The median circadian timing measured by dim light melatonin onset was the same for the 2 groups with 20:26 [hours:minutes] for individuals with CAD and 19:53 for the control group (P = .64, r = .14). Compared to the control group, the CAD group had significantly lower amplitude (P = .03, r =-.48), and lower overall rhythmicity (pseudo-F-statistic P = .004, r = -.65) in their 24-hour rest-activity rhythms.

CONCLUSIONS

This is one of the first studies to comprehensively assess both sleep and circadian rhythm in individuals with CAD. Compared to non-CAD controls, individuals with CAD had lower levels of melatonin prior to habitual bedtime and a lower 24-hour rest-activity rhythm amplitude and overall rhythmicity. Future studies using larger sample sizes should further investigate the possibility of suppressed circadian rhythmicity in individuals with CAD.

CITATION

Moon C, Benson CJ, Albashayreh A, Perkhounkova Y, Burgess HJ. Sleep, circadian rhythm characteristics, and melatonin levels in later life adults with and without coronary artery disease. J Clin Sleep Med. 2023;19(2):283-292.

Effects of Cardiac Rehabilitation on Sleep Quality in Heart Disease Patients with and without Heart Failure

Insomnia is a modifiable cardiovascular risk factor. Previous studies suggested that attending a cardiac rehabilitation program may improve sleep quality in cardiac patients and pointed out the association between heart failure and poor sleep quality. The primary aim of this study was to evaluate sleep quality in patients attending a Multidisciplinary Cardiac Rehabilitation Program (MRCP), and to compare sleep quality between patients with and without heart failure. A prospective observational study was carried out on a consecutive sample of 240 patients attending an 8-week MRCP; 50 patients (20.8%) were included due to heart failure (NYHA stages I-III) and the rest of them after having undergone any revascularization procedure or valvular surgery. Before and after the completion of the MRCP, the quality of sleep was assessed by the Pittsburgh Sleep Quality Index (PSQI) score. Post-intervention global PSQI scores were statistically significantly lower than those of pre-intervention (p = 0.008), but only 60 patients (25%) registered a clinically significant improvement. When comparing patients with heart failure with those without, no differences in sleep quality were found. This suggests that only a small percentage of patients can achieve clinically significant improvements in sleep quality attending conventional MCRP. Suggestions for future research are given.

Sleep Deficiency: A Symptoms Perspective: Exemplars from Chronic Heart Failure, Inflammatory Bowel Disease, and Breast Cancer

Sleep deficiency is associated with disabling daytime symptoms, including excessive daytime sleepiness (EDS) and fatigue. The purpose of this article is to discuss the contributions of sleep deficiency and sleep disorders to fatigue and EDS among people with chronic conditions. We use exemplars from the literature on chronic heart failure, inflammatory bowel disease, and breast cancer to (1) describe the prevalence of fatigue and EDS and their consequences; (2) examine the evidence for the contributions of sleep deficiency and sleep disorders to these symptoms; and (3) recommend implications for future research and practice.

Added value of anxiolytic benzodiazepines in predictive models on severe delirium in patients with acute decompensated heart failure: A retrospective analysis

Background

Delirium in patients with acute decompensated heart failure (ADHF) is associated with poor clinical outcomes. Although some medications have been reported as risk factors for delirium, their impact on patients with ADHF is still unclear. This study aimed to determine the association of specific medication use with delirium and their additive predictive value in models based on conventional risk factors.

Methods and results

In this single-center, retrospective study, 650 patients treated for ADHF were included. Fifty-nine patients (9.1%) had delirium. In multivariate analysis, anxiolytic benzodiazepines [odds ratio (OR): 6.4, 95% confidence interval (CI): 2.8–15], mechanical ventilation or noninvasive positive pressure ventilation (OR: 6.0, 95% CI: 2.9–12), depression (OR: 3.2, 95% CI: 1.5–6.5), intensive care or high care unit admission (OR: 2.9, 95% CI: 1.5–5.6), male sex (OR: 2.0, 95% CI: 1–3.7), and age (OR: 1.1, 95% CI: 1–1.1) were independently associated with severe delirium. The predictive model that included anxiolytic benzodiazepines had a significantly better discriminatory ability for the incidence of severe delirium than the conventional model.

Conclusions

The use of anxiolytic benzodiazepines was independently correlated with severe delirium, and their use in models based on conventional risk factors had an additive value for predicting delirium in patients with ADHF.

Diagnostic accuracy and suitability of instruments that screen for obstructive sleep apnoea, insomnia and sleep quality in cardiac patients: a meta-analysis

BACKGROUND

A number of clinical guidelines recommend that all cardiac rehabilitation patients should be screened for potential sleep disorders with a validated screening instrument. There is currently no consensus on what specific tools should be used.

OBJECTIVE

To identify tools that are practical to use in the clinical environment and have high diagnostic accuracy.

METHODS

We systematically searched online databases to identify patient reported outcome instruments that have been used in published research studies to assess the likelihood of obstructive sleep apnoea (OSA) in cardiac patients. In studies that provided diagnostic data, these data were extracted and verified via an evidence-based diagnostic calculator. Where sufficient numbers of studies were available, a meta-analysis was conducted to determine pooled estimates of specificity, sensitivity and diagnostic odds ratios. Selected papers were qualitatively assessed using the Standards for Reporting Diagnostic accuracy studies (STARD).

RESULTS

Of the 21 instruments identified, six detected likelihood of OSA, two assessed daytime sleepiness, five assessed insomnia and eight examined sleep quality. A meta-analysis of 14 studies that assessed diagnostic accuracy of moderate OSA, revealed moderate sensitivity for the Berlin Questionnaire, Sens = 0.49 (95% CI 0.45-0.52) and good sensitivity for the Stop-BANG, Sens = 0.93 (95% CI 0.87-0.96) but poor specificity at standard cut-off criteria.

CONCLUSION

There are promising practical tools available to screen patients with OSA and other sleep disorders in cardiac rehabilitation settings, but specificity could be improved. Additional assessment of sleep quality may enhance prognostic ability with both OSA and insomnia screening.

Prevalence of insomnia among university students in South Asian Region: a systematic review of studies

INTRODUCTION

Insomnia is a global health problem among university students which is associated with various psychiatric problems like depression and anxiety. While different developed and developing countries assessed the prevalence of insomnia in youth, currently there is hardly systematic review of studies found based on the prevalence of insomnia in South Asia.

AIMS

The aim of this study is to systematically review the evidence relating to the prevalence rate of insomnia in university students in South Asian countries.

METHODS

Electronic searches of three databases, PubMed, Cochrane library, and Worldwide science were performed from 2010 to 2020 before April. In total, seven studies were included for evaluating insomnia in South Asian region among university students.

RESULTS

The prevalence rates of insomnia of the seven studies ranged between 35.4% (95% CI: 32.4-38.5%) and 70% (95% CI: 65.7-74.1%). The pooled prevalence of insomnia among university students was 52.1% (95% CI: 41.1-63.1%).

CONCLUSIONS

This review emphasized that insomnia in university students might be a common health issue to give full concentration in their studies and academic performance. Thus, more attention should be given to the determinants of insomnia among university students, so that it could be helpful to identify the main causes of insomnia and effective measures could be taken.

Insomnia and Insomnia Symptoms in Persons With Heart Failure: An Integrative Review

BACKGROUND/OBJECTIVE

Insomnia and insomnia symptoms are highly prevalent in persons with heart failure (HF), and they are associated with several untoward outcomes. The purpose of this integrative review is to describe the correlates, predictors, and outcomes of insomnia and insomnia symptoms in persons with HF.

METHODS

Using integrative review methods, an extensive electronic search of 5 databases was conducted for the period of 2000-2019. Sixteen studies were identified that met the inclusion criteria for review and investigated insomnia or insomnia symptoms in HF.

RESULTS

Various sociodemographic factors, chronic comorbidities, clinical factors, and cognitive-behavioral factors are correlates and predictors of insomnia and insomnia symptoms in persons with HF. Depression, fatigue, daytime sleepiness, poor self-reported physical functioning, decreased exercise capacity, cardiac events, and poor health-related quality of life are significant outcomes of insomnia and insomnia symptoms in persons with HF. The associations of insomnia and insomnia symptoms with age, sex, sleep-disordered breathing, and cognition were not consistent across all studies.

CONCLUSION

Larger studies with diverse age and race groups as well as longitudinal studies and designs that test mediation effects are needed to disentangle complex relationships between insomnia and insomnia symptoms and several of their potential predictors and correlates in HF.

Shift-work nurses' work environments and health-promoting behaviours in relation to sleep disturbance: A cross-sectional secondary data analysis

AIMS AND OBJECTIVES

To examine the association of nursing work environments and health-promoting behaviours with shift-work nurses' sleep disturbance.

BACKGROUND

Shift-work nurses reportedly have sleep problems, which affect their sleep quality and quantity. Given the high risk of developing performance decrements and medication errors in sleep-disturbed nurses, factors related to sleep disturbance among shift-work nurses should be investigated.

DESIGN

A cross-sectional secondary data analysis.

METHODS

Our study analysed data from 339 nurses who had been involved in rotating shift work including night shifts for more than 6 months. To examine associations of nursing work environments and health-promoting behaviours with sleep disturbance, multiple linear regression models were generated. This study is reported in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology guideline.

RESULTS

Nurses with more collegial relations with physicians were significantly less likely to have high levels of sleep disturbance (B = -4.01, p = 0.04). Those with higher levels of sleep disturbance were significantly more likely to report less stress management (B = -9.56, p < 0.01) and higher health responsibility (B = 9.30, p < 0.01).

CONCLUSIONS

To alleviate shift-work nurses' sleep disturbance, organisational supports for collaborative relations with physician and increased healthcare accessibility are needed. Individual nurses should develop healthy lifestyles to reduce occupational stress and alleviate sleep disorders.

RELEVANCE TO CLINICAL PRACTICE

To improve shift-work nurses' sleep, collegial relations with physicians and healthy lifestyles should be promoted.

Alcohol consumption and sleep deprivation among Ghanaian adults: Ghana Demographic and Health Survey

ABSTRACT

Heavy consumption of alcohol has shown to be associated with sleep disturbances among adult and elderly people in high income settings. So far, the relationship between alcohol drinking and sleeping pattern has not been studied in an African setting. Therefore, in this study we investigated whether alcohol consumption has any influence on sleeping hours among adult men and women in Ghana.

METHODS

Data for this survey were extracted from Ghana Demographic and Health Survey (GDHS 2008). GDHS is the only cross-sectional survey conducted on men and women aged above 15 years that collected information on variables such as sleeping hours and alcohol consumption. The analysis was controlled for various demographic, socioeconomic, household level factors, and smoking.

RESULTS

Prevalence of sleeping 1-3 h, 4-6 h, and >7 h was respectively 1.5% (1.2-2.0), 14.1% (12-16.5), and 84.4% (82.1-86.4), and that of alcohol use was 26.9% (23.4-30.6). In the multivariable regression analysis, compared with non-drinkers, those reported drinking had significantly lower odds of sleeping for at least 7 h. In the adjusted model, drinkers had 0.8 times (adjusted OR = 0.803, (95% CI [0.690-0.935])) lower odds of sleeping for at least 7 h. The odds for sleeping 4-6 h were not statistically significant. In the stratified analysis, the odds of sleeping for at least seven were comparatively lower among women (adjusted OR = 0.657, (95% CI [0.509-0.849]) then among men (adjusted OR = 0.867, (95% CI [0.740-0.965]).

CONCLUSION

Men and women who reported consuming alcohol had significantly lower odds of getting adequate sleep (>7 h). The sleep-disrupting effect of alcohol appeared to be more prominent among women than among men. Currently there is not sufficient evidence on alcohol consumption and sleep disorder among Ghanaian population or any other country in the region. Further studies are required to understand sleeping patterns and the burden of alcohol drinking in this population to design intervention programs.

Sleep quality and daytime sleepiness are not associated with cognition in heart failure

BACKGROUND

Individuals with heart failure (HF) exhibit comorbid impairments in both sleep and cognitive performance. Sleep quality has been associated with impaired cognitive performance in HF patients, but reports are inconsistent. In this study, we examined associations between sleep quality, daytime sleepiness, and cognitive function in HF.

METHODS AND RESULTS

Participants were 267 (age = 69.1 ± 9.3) mostly Caucasian (74.9%), male (59.6%) stable HF patients recruited from outpatient settings. This cross-sectional study was a secondary analysis of a prospective observational study. Cognitive function domains assessed included: global cognitive function, attention, memory, and executive function. Sleep quality and daytime sleepiness were assessed using the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS), respectively. Separate multiple hierarchical linear regressions were conducted to determine associations between cognitive function and sleep quality and daytime sleepiness, after controlling for sex, New York Heart Association (NYHA) class, education, depressive symptoms, and medical comorbidities. Cognitive function was not associated with sleep quality or daytime sleepiness after alpha inflation corrections were applied.

CONCLUSIONS

Cognitive function in HF is not associated with sleep quality or daytime sleepiness; other factors may exert greater influence on cognitive performance.

The Association of Sleep Disturbances With Quality of Life in Heart Failure Patient–Caregiver Dyads

Sleep disturbance is common in patients with heart failure and their family caregivers. The purpose of this study was to determine whether sleep disturbances of patients and their spousal caregivers predicted their own and their partners’ quality of life (QoL) in 78 heart failure patient–spousal caregiver dyads. Sleep disturbance was assessed using a composite score of four common sleep complaints. QoL was assessed by the physical and mental well-being subscales of the Short-Form 12 Health Survey. The multilevel dyadic actor–partner interdependence model analysis was used to determine the association between sleep disturbance and QoL. Each individual’s sleep disturbance predicted their own poor physical and mental well-being while spousal caregivers’ sleep disturbance predicted their partners’ mental well-being. Results indicated that patients’ mental well-being is sensitive to their spouses’ sleep disturbance. Interventions targeting improving sleep and QoL may have to include both patients and spousal caregivers.

Feasibility and Efficacy of a Self-Management Intervention for Insomnia in Stable Heart Failure

BACKGROUND

Chronic insomnia is common among patients with heart failure (HF) and may contribute to fatigue and poor function. However, to date there have been no randomized controlled trials focused on treatment of insomnia or daytime symptoms in this population.

OBJECTIVES

The purpose of this study was to examine the preliminary efficacy, feasibility, and acceptability of a self-management intervention (cognitive behavioral therapy [CBT-I]) for insomnia among patients with stable HF.

METHODS

We conducted a pilot randomized controlled trial (RCT) in which patients with stable Class I-III HF (n = 25/52.1% women; mean age = 59 ± 14.8 years) were randomized in groups to CBT-I (n = 29) or an attention control condition (HF self-management with sleep hygiene; n = 19). Participants completed 2 weeks of wrist actigraphy, the insomnia severity index, and measures of fatigue, depression, sleepiness, and functional performance at baseline and follow-up. We computed the size of the effects on the dependent variables and used MANOVA to evaluate the effects of CBT-I on insomnia and fatigue.

RESULTS

CBT-I was feasible and acceptable and had a statistically significant effect on insomnia and fatigue, while controlling for the effects of comorbidity and age.

CONCLUSIONS

CBT-I has short-term efficacy as a treatment for chronic insomnia among patients with stable HF. Future studies are needed to address its sustained effects.

A systematic review of studies on the prevalence of insomnia in university students

OBJECTIVES

Many studies have shown that insomnia is a common problem among university students, but there are wide variations in the prevalence of insomnia. In this systematic review, we aimed to explore the prevalence of insomnia among university students using scientific and conclusive methods.

STUDY DESIGN

A systematic review is designed to analyze the studies reporting on prevalence of insomnia among university students.

METHODS

Systemic searches were conducted in PubMed, BioMed Central, EBSCO, ScienceDirect, Ovid LWW and Medline databases between January 2000 and July 2014, The Meta analyst software was used to calculate the prevalence rate of each study, the pooled means of prevalence rates and 95% CIs across studies were then calculated and presented.

RESULTS

Seven articles that met the inclusion and exclusion criteria were selected. The overall sample size in the current review was 16,478, with a minimum of 219 and a maximum of 10,322. The prevalence rates of the seven studies ranged between 9.4% (95%CI 8.8-10.0%) and 38.2% (95% CI 35.4-41.1%). Overall, the total students studied with a weighted mean prevalence of 18.5% (95% CI 11.2-28.8%), considerably higher than rates of 7.4% (95% CI 5.8-9.0%) reported in general population.

CONCLUSIONS

This review emphasized that insomnia prevalence in university students is considerably higher than that in general population, suggested that more attention should be paid to insomnia in university students.

Prevalence of sleep disorders among ESRD patients

Sleep disorders are common among the patients undergoing dialysis in end stage renal disease (ESRD). Although variable, their prevalence has been reported to be higher when compared to the general population. The most frequently reported complaints are insomnia, restless leg syndrome (RLS), sleep-disordered breathing and excessive daytime sleepiness (EDS). The aim of this study was to assess the prevalence of sleep disorders in end stage renal disease patients on regular hemodialysis (group I with 30 patients) and CKD patients (group II with 30 patients) in comparison to 30 normal population (control group). In addition to laboratory investigations which included creatinine clearance using Cockroft and Gault formula, hemoglobin level (Hb), blood urea, serum creatinine, serum albumin, serum calcium and phosphorus and lipid profile, all subjects underwent one night of laboratory-based polysomnography (PSG) consisting of a standard montage of electroencephalography (EEG) (C3/A1 and O2/C3 or O1/C4), monopolar left and right electrooculography (EOG) referenced to the opposite mastoid, surface mentalis electromyography (EMG), respiratory airflow (measured by thermistor) and effort (piezoelectric sensors), electrocardiography (ECG), anterior tibialis EMG and pulse oximetry. For hemodialysis subjects, this study was performed on a night immediately following hemodialysis treatment. The results showed that patients on hemodialysis have sleep disorders, and that sleep disorders are common in group I and II than control group. The percentage of sleep disorders in hemodialysis patients were as follows: insomnia (69%), followed by obstructive sleep apnea syndrome OSAS (24%), RLS and periodic limb movement PLM (18%), nightmares (13%), EDS (12%), sleepwalking (2%), possible rapid eye movement behavior disorders RED (2%), possible narcolepsy (1.4%). While the percentage of sleep disorders in CKD patients were as follows: insomnia (54%), followed by RLS (19%), PLM (12%), OSAS (16%), nightmares (15%), EDS (15%), sleepwalking (4%), possible RBD (3%), possible narcolepsy (1%). There was inverse correlation between sleep disorders and Hb, albumin and creatinine clearance; also there was positive correlation between sleep disorder and phosphorus. We concluded that the sleep disorders are common in CKD patients either on conservative management or on regular hemodialysis. Treatment of anemia, hyperphosphatemia and hypoalbuminemia may improve sleep disorders among those patients.

Is sleep quality related to cognition in individuals with heart failure?

OBJECTIVE

To examine how self-reported sleep quality and daytime symptoms are associated with selected domains of cognitive function among individuals with heart failure (HF).

BACKGROUND

HF patients suffer from poor sleep quality and cognitive decline. The relationship between sleep and cognition has not been well documented among individuals with HF.

METHODS

In this descriptive, cross-sectional study, 68 individuals with HF (male: 63%, mean age = 72 years, SD = 11) completed sleep questionnaires and a neuropsychological battery.

RESULTS

Participant had mean Pittsburgh Sleep Quality Index score of 5.04 (SD = 2.8). Regression analyses demonstrated neither sleep quality or excessive daytime sleepiness (EDS) were related to cognitive function, but daytime dysfunction was related to lower letter fluency and attention index.

CONCLUSION

Contrary to some earlier reports, subjective sleep and EDS in this group of individuals was not associated with cognitive decline.

Sleep disordered breathing, hypoxia and inflammation: associations with sickness behaviour in community dwelling elderly with and without cardiovascular disease

BACKGROUND

Inflammation can induce a cluster of symptoms, referred to as sickness behaviour (e.g., depressive symptoms, sleep disturbances, pain and fatigue). Cardiovascular disease (CVD) and sleep disordered breathing (SDB) are common in older adults. CVD is associated with an increased inflammatory activity and in SDB, hypoxia can also increase inflammation. The purpose of this study is to explore if SDB-related hypoxia is associated differently with inflammation and the presence of sickness behaviour in older adults with and without CVD.

METHODS

Three hundred and thirty-one older adults, whose mean age is 78 years, underwent one-night polygraphic recording to measure SDB and hypoxia. CVD was established by a clinical investigation. Questionnaires were used to measure sickness behaviour and depressive symptoms. High sensitivity C-reactive protein was used as a marker of inflammation.

RESULTS

Structural Equation Modelling showed that SDB-related hypoxia was associated with inflammation (β > 0.40) which mediated indirect associations with sickness behaviour (β = 0.19) and depressive symptoms (β = 0.11), but only in those with CVD (n = 119). In this model, inflammation had a direct effect on sickness behaviour (β = 0.43) and an indirect effect on depressive symptoms (β = 0.24). Hypoxia had the strongest effect (i.e., β = 0.41; significant) on inflammation, whereas the AHI or ODI had weak and non-significant effects (β = 0.03 and β = 0.15).

CONCLUSIONS

Older adults with CVD and SDB are at a particular risk of developing sickness behaviour and depressive symptoms. The effect of SDB was mainly caused by hypoxia, suggesting that hypoxia is an important marker of SDB severity in older adults with CVD.

"I'd eat a bucket of nails if you told me it would help me sleep:" perceptions of insomnia and its treatment in patients with stable heart failure

BACKGROUND

Poor sleep, including insomnia, is common among patients with heart failure (HF). However, little is known about the efficacy of interventions for insomnia in this population. Prior to developing interventions, there is a need for better understanding of patient perceptions about insomnia and its treatment.

OBJECTIVES

To evaluate HF patients' perceptions about 1) insomnia and its consequences; 2) predisposing, precipitating, and perpetuating factors for insomnia; 3) self-management strategies and treatments for insomnia; and 4) preferences for insomnia treatment.

METHODS

The study, guided by the "3 P" model of insomnia, employed a parallel convergent mixed methods design in which we obtained qualitative data through focus groups and quantitative data through questionnaires (sleep quality, insomnia severity, dysfunctional beliefs and attitudes about sleep; sleep-related daytime symptoms and functional performance). Content analysis was used to evaluate themes arising from the focus group data, and descriptive statistics were used to analyze the quantitative data. The results of both forms of data collection were compared and synthesized.

RESULTS

HF patients perceived insomnia as having a negative impact on daytime function and comorbid health problems, pain, nocturia, and psychological factors as perpetuating factors. They viewed use of hypnotic medications as often necessary but disliked negative daytime side effects. They used a variety of strategies to manage their insomnia, but generally did not mention their sleep concerns to physicians whom they perceived as not interested in sleep.

CONCLUSIONS

HF patients believe insomnia is important and multi-factorial. Behavioral treatments, such as cognitive behavioral therapy, for insomnia may be efficacious in modifying perpetuating factors and likely to be acceptable to patients.

The contribution of hypoxia to the association between sleep apnoea, insomnia, and cardiovascular mortality in community-dwelling elderly with and without cardiovascular disease

AIMS

This study explores if nightly hypoxia (i.e. percentage of sleep time with oxygen saturation lower than 90% (SaO2<90%)) contributed to the association between sleep-disordered breathing (SDB) and insomnia in community-dwelling elderly with and without cardiovascular disease (CVD). A second aim was to explore a potential cut-off score for hypoxia to predict insomnia and the association of the cut-off with clinical characteristics and cardiovascular mortality.

METHOD

A total of 331 community-dwelling elderly aged 71-87 years underwent one-night polygraphic recordings. The presence of insomnia was recorded by a self-report questionnaire. The presence of CVD was objectively established and mortality data were collected after three and six years.

RESULTS

In both patients with CVD (n=119) or without CVD (n=212) SDB was associated with hypoxia (p<0.005). Only in the patients with CVD was hypoxia associated with insomnia (p<0.001) which mediated an indirect effect (p<0.05) between SDB and insomnia. Hypoxia of more than 1.5% of sleep time with SaO2<90% was found to be a critical level for causing insomnia. According to this criterion 32% (n=39) and 26% (n=55) of those with and without CVD had hypoxia, respectively. These groups did not differ with respect to age, gender, body mass index, diabetes, hypertension, respiratory disease or levels of SDB. However, in the CVD group, hypoxia was associated with cardiovascular mortality at the three-year follow-up (p=0.008) and higher levels of insomnia (p=0.002).

CONCLUSION

In the elderly with CVD, SDB mediated by hypoxia can be associated with more insomnia and a worse prognosis.

The effect of a supervised exercise training programme on sleep quality in recently discharged heart failure patients

BACKGROUND

Sleep disturbances, including insomnia and sleep-disordered breathing, are a common complaint in people with heart failure and impair well-being. Exercise training (ET) improves quality of life in stable heart failure patients. ET also improves sleep quality in healthy older patients, but there are no previous intervention studies in heart failure patients.

AIM

The aim of this study was to examine the impact of ET on sleep quality in patients recently discharged from hospital with heart failure.

METHODS

This was a sub-study of a multisite randomised controlled trial. Participants with a heart failure hospitalisation were randomised within six weeks of discharge to a 12-week disease management programme including exercise advice (n=52) or to the same programme with twice weekly structured ET (n=54). ET consisted of two one-hour supervised aerobic and resistance training sessions, prescribed and advanced by an exercise specialist. The primary outcome was change in Pittsburgh Sleep Quality Index (PSQI) between randomisation and week 12.

RESULTS

At randomisation, 45% of participants reported poor sleep (PSQI≥5). PSQI global score improved significantly more in the ET group than the control group (-1.5±3.7 vs 0.4±3.8, p=0.03). Improved sleep quality correlated with improved exercise capacity and reduced depressive symptoms, but not with changes in body mass index or resting heart rate.

CONCLUSION

Twelve weeks of twice-weekly supervised ET improved sleep quality in patients recently discharged from hospital with heart failure.

Association between sleep-disordered breathing, sleep-wake pattern, and cognitive impairment among patients with chronic heart failure

AIMS

Chronic heart failure (CHF) and sleep-disordered breathing (SDB) are often co-existing problems among the elderly. Apnoeic events may cause cognitive impairment. The aim of the study was to compare sleep and wake patterns, insomnia, daytime sleepiness, and cognitive function in community-dwelling CHF patients, with and without SDB, and to investigate the association between sleep-related factors and cognitive dysfunction.

METHODS AND RESULTS

In this cross-sectional observational study, SDB was measured with an ApneaLink device and defined as an apnoea-hypopnoea index (AHI) ≥15/h of sleep. Sleep and wake patterns were measured with actigraphy for 1 week. Insomnia was measured with the Minimal Insomnia Symptom Scale, daytime sleepiness with the Epworth Sleepiness Scale, and cognitive function with a neuropsychological test battery. A total of 137 patients (68% male, median age 72 years, 58% NYHA functional class II) were consecutively included. Forty-four per cent had SDB (AHI ≥15). The SDB group had significantly higher saturation time below 90%, more difficulties maintaining sleep, and lower levels of daytime sleepiness compared with the non-SDB group. Cognitive function and sleep and wake patterns did not differ between the SDB and the non-SDB group. Insomnia was associated with decreased global cognition.

CONCLUSION

The prevalence of cognitive dysfunction was low in this population with predominantly mild to moderate CHF. This might have influenced the lack of associations between cognitive function and SDB. Insomnia was the only sleep-related factor significantly influencing cognition.

What is the best measure of daytime sleepiness in adults with heart failure?

PURPOSE

To identify the best screening measure of daytime sleepiness in adults with heart failure (HF).

DATA SOURCES

A total of 280 adults with HF completed the Epworth Sleepiness Scale, the Stanford Sleepiness Scale, and a single Likert item measuring daytime sleepiness. The sensitivity and specificity of these self-report measures were assessed in relation to a measure of daytime dysfunction from poor sleep quality.

CONCLUSIONS

Only 16% of the sample reported significant daytime dysfunction because of poor sleep quality. Those reporting daytime dysfunction were likely to be younger (p < .001), to be unmarried (p = .002), to have New York Heart Association (NYHA) functional class IV HF (p = .015), and to report low income (p = .006) and fewer hours of sleep (p = .015). The measure of daytime sleepiness that was most sensitive to daytime dysfunction was a single Likert item measured on a 10-point (1-10) scale. Patients with a score ≥4 were 2.4 times more likely to have daytime dysfunction than those with a score <4.

IMPLICATIONS FOR PRACTICE

Complaints of daytime dysfunction because of poor sleep are not common in adults with HF. Routine use of a single question about daytime sleepiness can help nurse practitioners to identify those HF patients with significant sleep issues that may require further screening.

An Exploratory Study of Sleep Quality, Daytime Function, and Quality of Life in Patients with Mechanical Circulatory Support

Purpose:

To identify and describe: (1) characteristics of sleep quality, daytime sleepiness, and quality of life (QOL) pre and post implantation of a left ventricular assist device (LVAD); (2) changes in sleep quality, daytime sleepiness, and QOL at baseline and 6 months post implant; and (3) relationships among the sleep quality, daytime sleepiness, and QOL variables.

Methods:

We employed an exploratory research design. Fifteen patients with continuous/non-pulsatile flow LVAD consented to partake in the study. However, only 12 patients completed the baseline and 6-month post-LVAD implant data. We used the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and Minnesota Living with Heart Failure Questionnaire (MLHFQ) to measure study variables. Data were analyzed using IBM SPSS 19.0 software.

Results:

Patients reported worse sleep quality accompanied by daytime sleepiness particularly at baseline, and persisting up to 6 months post LVAD implant. A significant improvement in QOL was observed at 6 months post implant, but remained at poor levels. Correlations among sleep disturbance and daytime dysfunction components of PSQI and global daytime sleepiness (ESS) with QOL were strong (Pearson's correlations r>.60; p values <.05).

Conclusions:

We report the first empirical data describing the characteristics and correlations among sleep quality, daytime sleepiness, and QOL in patients with LVADs. Our findings offer beginning evidence about the sleep-QOL connection in this population which warrants attention in clinical practice and research. Further research is required to clearly elucidate these phenomena in patients with mechanical circulatory support and other implantable artificial organs.

Determinants of excessive daytime sleepiness and fatigue in adults with heart failure

Little is known about excessive daytime sleepiness (EDS) in heart failure (HF). The aim of this cross-sectional descriptive study was to describe the prevalence of EDS and factors associated with it in HF. A secondary purpose was to explore the correlates of fatigue. We enrolled a consecutive sample of 280 adults with a confirmed diagnosis of chronic HF from three outpatient settings in the northeastern United States. Patients with major depressive illness were excluded. Clinical, sociodemographic, behavioral, and perceptual factors were explored as possible correlates of EDS. Using an Epworth Sleepiness Scale score > 10, the prevalence of EDS was 23.6%. Significant determinants of EDS were worse sleep quality (p = .048), worse functional class (p = .004), not taking a diuretic (p = .005), and lack of physical activity (p = .04). Only sleep quality was associated with fatigue (p < .001). Sleep-disordered breathing was not significantly associated with EDS or with fatigue. These factors may be amenable to intervention.

The impact of sleep quality and daytime sleepiness on global quality of life in community-dwelling patients with heart failure

BACKGROUND AND RESEARCH OBJECTIVE

Although it is well established that symptom burden in heart failure (HF) often leads to poor health-related quality of life (QOL), the contributions of quality of sleep and daytime sleepiness to the overall perception and satisfaction with life in the HF population have yet to be determined. We thus tested the hypothesis that quality of sleep and daytime sleepiness are significant predictors of QOL as measured by the World Health Organization Quality of Life-BREF (WHOQOL-BREF) in patients with HF.

SUBJECTS AND METHODS

Included were 88 medically stable patients with echocardiographically documented HF. This cross-sectional study used a correlational design, and data were collected using self-report questionnaires including the Chinese version of the Pittsburgh Sleep Quality Index (CPSQI), Epworth Sleepiness Scale, and WHOQOL-BREF Taiwan version. Multiple linear regression analyses were used to address the study hypotheses.

RESULTS AND CONCLUSIONS

With the exception of the environmental domain (P = .078), poor sleepers had significantly lower scores in physical (P < .001), psychological (P = .001), and social (P = .040) domains of the WHOQOL-BREF. Multivariate regression analysis revealed that age, CPSQI, perceived health status, and comorbidities significantly predicted the physical QOL (adjusted R2 = 0.59, P < .001). For the psychological QOL, only perceived health status and CPSQI score remained in the regression model (adjusted R2 = 0.28, P = .016). For the environmental QOL, perceived health status and Epworth Sleepiness Scale were the only predictors remaining in the model (adjusted R2 = 0.17, P < .001). The findings from this study add support to the evidence that in medically stable persons with HF, poor sleep independently predicts the overall perception and satisfaction with life, in particular, in the physical and psychological domains of QOL, whereas daytime sleepiness independently predicts the environmental QOL.