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The Association Between Self-reported Sleep Quality and Self-care in Adults With Heart Failure. J Cardiovasc Nurs 2022; 38:E98-E109. [PMID: 37027137 DOI: 10.1097/jcn.0000000000000929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sleep disturbance is one of the most common symptoms among patients with heart failure (HF), and it may affect the ability of patients to perform self-care. There is a lack of evidence on the association between sleep quality and its components and self-care in adults with HF. OBJECTIVE The aim of this study was to evaluate the association between sleep quality and its components and self-care in adults with HF. METHODS This study is a secondary analysis of baseline data from the MOTIVATE-HF study, a randomized controlled trial on patients with HF and their caregivers. Only patients' data were analyzed in this study (n = 498). Sleep quality and self-care were evaluated with the Pittsburgh Sleep Quality Index and the Self-Care of Heart Failure Index v6.2, respectively. RESULTS A habitual sleep efficiency of 75% to 84% was associated with lower self-care maintenance compared with a habitual sleep efficiency of 85% or greater ( P = .031), as was taking sleep medications once or twice a week compared with less than once a week ( P = .001). A frequency of daytime dysfunction less than once a week was associated with lower self-care management compared with a frequency of daytime dysfunction of 3 or more times a week ( P = .025). Taking sleep medications less than once a week was associated with lower self-care confidence compared with taking sleep medications 3 or more times a week ( P = .018). CONCLUSION Poor sleep quality is frequently reported by patients with HF. Sleep efficiency, sleep medications, and daytime dysfunction may influence self-care more than the other sleep quality components.
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Khosravi A, Emamian MH, Hashemi H, Fotouhi A. Components of Pittsburgh Sleep Quality Index in Iranian adult population: an item response theory model. Sleep Med X 2021; 3:100038. [PMID: 34471869 PMCID: PMC8319517 DOI: 10.1016/j.sleepx.2021.100038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 05/28/2021] [Accepted: 06/16/2021] [Indexed: 11/26/2022] Open
Abstract
Objective/background There have been conducted few studies in Iran on the quality of sleep in the general population. This study aimed to use the item response theory (IRT) model to examine the accuracy of the seven components of the Pittsburgh Sleep Quality Index (PSQI) and to provide an appropriate cut-off point for population-based studies. Methods This study was performed using the data of the second phase of the Shahroud Eye Cohort Study (ShECS) in 2014. The sleep quality of 4710 participants was measured through PSQI. Using an IRT model, the seven components of the index are considered as indicators and sleep quality as the latent variable in the measurement model. This model supposed that there is only one hidden component to explain the respondent's behavior to a number of items. Results Results of analyzing different components of PSQI showed that component 6 (using sleep medication) and 7 (daytime dysfunction disorder) had the lowest values of discrimination parameter and component 4 (habitual sleep efficiency) and 1 (sleep quality) had the highest value of discrimination parameter. Persons with an expected sleep quality score of less than or equal to 6.5 will be defined as good sleep quality pattern. Conclusions Since discrimination values for components 6 and 7 are less than the values for other components, the use of the standardized latent scores is emphasized for assessing the quality of sleep in the population. For seven components of PSQI, difficulty and discrimination parameters were estimated using IRT. Using an IRT model persons with an expected sleep quality score ≤ 6.5 will be defined as good sleep quality pattern. Almost 42.9% and 0.2% had poor and very poor sleep quality. Sleep quality, and habitual sleep efficiency components had the highest value of discrimination parameter. Component 6 and 7 play the lowest role in assessing sleep quality in the general population.
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Affiliation(s)
- Ahmad Khosravi
- Center for Health Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Mohammad Hassan Emamian
- Ophthalmic Epidemiology Research Center, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Hassan Hashemi
- Noor Ophthalmology Research Center, Noor Eye Hospital, Tehran, Iran
| | - Akbar Fotouhi
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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Jorge-Samitier P, Fernández-Rodrigo MT, Juárez-Vela R, Antón-Solanas I, Gea-Caballero V. Management of Hypnotics in Patients with Insomnia and Heart Failure during Hospitalization: A Systematic Review. NURSING REPORTS 2021; 11:373-381. [PMID: 34968214 PMCID: PMC8608124 DOI: 10.3390/nursrep11020036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/26/2021] [Accepted: 05/12/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Heart failure is a chronic, progressive syndrome of signs and symptoms, which has been associated to a range of comorbidities including insomnia. Acute decompensation of heart failure frequently leads to hospital admission. During hospital admission, long-term pharmacological treatments such as hypnotics can be modified or stopped. AIM To synthesize the scientific evidence available about the effect of withdrawing hypnotic drugs during hospital admission in patients with decompensated heart failure and insomnia. METHOD A systematic review of the literature following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines was carried out in the following scientific databases: PubMed, Scopus, Dialnet and Cochrane. INCLUSION CRITERIA studies including a population of adults with heart failure and sleep disorders in treatment with hypnotics and admitted to hospital, studies written in English or Spanish and published until June 2020. EXCLUSION CRITERIA studies involving children, patients admitted to intensive care and patients diagnosed with sleep apnea. RESULTS We identified a total of 265 documents; only nine papers met the selection criteria. The most frequently used drugs for the treatment of insomnia in patients with heart failure were benzodiazepines and benzodiazepine agonists; their secondary effects can alter perceived quality of life and increase the risk of adverse effects. Withdrawal of these drugs during hospital admission could increase the risk of delirium. Future research in this area should evaluate the management of hypnotics during hospital admission in patients with decompensated heart failure. In addition, safe and efficient non-pharmacological alternatives for the treatment of insomnia in this population should be tested and implemented.
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Affiliation(s)
- Pablo Jorge-Samitier
- Hospital Clínico Lozano Blesa, Avenida San Juan Bosco, 15, 50009 Zaragoza, Spain;
- Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, C/Domingo Miral s/n, 50009 Zaragoza, Spain
| | - María Teresa Fernández-Rodrigo
- Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, C/Domingo Miral s/n, 50009 Zaragoza, Spain
| | - Raúl Juárez-Vela
- Faculty of Medicine, University of Salamanca, Avenida Alfonso X El Sabio SN, 37008 Salamanca, Spain;
| | - Isabel Antón-Solanas
- Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, C/Domingo Miral s/n, 50009 Zaragoza, Spain
- Research Group GENIAPA (GIIS094), Institute of Research of Aragon, Avenida San Juan Bosco, 13, 50009 Zaragoza, Spain
| | - Vicente Gea-Caballero
- Nursing School La Fe, Adscript Center of the University of Valencia, Research Group GREIACC, Health Research Institute La Fe, 46026 Valencia, Spain;
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Gaffey AE, Jeon S, Conley S, Jacoby D, Ash GI, Yaggi HK, O’Connell M, Linsky SJ, Redeker NS. Perceived Stress, Subjective, and Objective Symptoms of Disturbed Sleep in Men and Women with Stable Heart Failure. Behav Sleep Med 2021; 19:363-377. [PMID: 32394733 PMCID: PMC7658015 DOI: 10.1080/15402002.2020.1762601] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective/Background: Sleep disturbance is prevalent among patients with heart failure (HF) and is associated with increased morbidity and mortality. Stress also affects health and quality of life among patients with cardiovascular disease and likely plays a prominent role in HF. However, little is known about the associations between stress and sleep among HF patients.Participants: One hundred fifty-three stable New York Heart Association (NYHA) Classification I-IV HF patients with at least low symptoms of insomnia (Mage:63.0 ± 12.8, 42% Women).Methods: We examined baseline stress, sleep disturbance, and sleep-related characteristics from a randomized controlled trial of cognitive behavioral therapy for insomnia, including the Perceived Stress Scale, Insomnia Severity Index, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Sleep Disturbance Questionnaire, Dysfunctional Beliefs about Sleep Scale, PROMIS Cognitive Ability, SF-36 Mental Health, and wrist actigraphy. We used Pearson correlations and general linear models to assess stress-sleep associations, including the potential moderating effects of sex and symptom severity (NYHA).Results: There were moderate-to-large correlations between stress and self-reported sleep disturbance, dysfunctional beliefs about sleep, cognitive ability, and mental health (p's < 0.01). High stress was associated with more objectively-measured (i.e., actigraph-assessed) awakenings and sleep fragmentation among women than men (β = - 0.04, p < 0.01; β = - 0.71, p = 0.04). Relationships between stress and objectively-measured sleep did not vary by symptom severity.Conclusions: Perceived stress is related to sleep disturbance among HF patients, and effects may be sex-dependent. Subsequent research should determine the temporal links between sleep and stress, and optimal opportunities for intervention among HF patients.
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Affiliation(s)
- Allison E. Gaffey
- Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510,VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516,Corresponding Author: Yale School of Medicine, Department of Internal Medicine, 333 Cedar Street, New Haven, CT 06510, Phone: (203) 932-5711 ext. 3332,
| | - Sangchoon Jeon
- Yale School of Nursing, 400 West Campus Drive, Orange, CT 06477
| | - Samantha Conley
- Yale School of Nursing, 400 West Campus Drive, Orange, CT 06477
| | - Daniel Jacoby
- Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510
| | - Garrett I. Ash
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516,Department of Internal Medicine (General), Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510
| | - Henry K. Yaggi
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516,Department of Internal Medicine (Pulmonary, Critical Care, and Sleep Medicine), Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510
| | | | - Sarah J. Linsky
- Yale School of Nursing, 400 West Campus Drive, Orange, CT 06477
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Jorge-Samitier P, Durante A, Gea-Caballero V, Antón-Solanas I, Fernández-Rodrigo MT, Juárez-Vela R. Sleep Quality in Patients with Heart Failure in the Spanish Population: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E7772. [PMID: 33114209 PMCID: PMC7660645 DOI: 10.3390/ijerph17217772] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/16/2020] [Accepted: 10/21/2020] [Indexed: 01/19/2023]
Abstract
Background: Heart failure is a major problem in western societies. Sleep Disorders maintain a bidirectional relationship with heart failure, as shown by studies conducted in other countries. This study aims to describe the quality of sleep in Spanish patients with heart failure. Materials and methods: We carried out a cross-sectional study to analyze the quality of sleep in a sample of 203 patients with a diagnosis of heart failure admitted to an Internal Medicine Service. The Pittsburg Sleep Quality Index (PSQI) was used to evaluate sleep quality in our sample over a one-month period. Results: 75% of the sample presented sleep disorders. The most common problems included the interruption of sleep (73.5% nocturia and 30% breathing difficulties); 35% had poor sleep efficiency; 33% showed a decrease in daytime performance; 84% had used hypnotics at some point to induce sleep and 35% used them regularly. Conclusions: This is the first study to report on the perceived sleep quality of patients with heart failure in Spain. Self-perception of sleep quality differed from that estimated by the PSQI. The prevalence of the use of sleep-inducing medication was very high. The diurnal dysfunction generated by sleep disorders in a heart failure environment can contribute to the development of self-care and cognitive deterioration problems.
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Affiliation(s)
- Pablo Jorge-Samitier
- Department of Physiatry and Nursing, University of Zaragoza, Hospital Clínico Lozano Blesa, Avda. San Juan Bosco, 15, 50009 Zaragoza, Spain;
| | - Angela Durante
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier, 1 00133 Rome, Italy;
| | - Vicente Gea-Caballero
- Nursing School La Fe, Adscript Center of University of Valencia, Research Group GREIACC, Health Research Institute La Fe, 46026 Valencia, Spain
| | - Isabel Antón-Solanas
- Department of Physiatry and Nursing, University of Zaragoza, Research Group GENIAPA, Calle Domingo Miral s/n, 50009-Zaragoza, Spain;
| | | | - Raúl Juárez-Vela
- School of Nursing, University of La Rioja, Research Group GRUPAC and Research Institute IDI-Paz, C/Duquesa de la Victoria 88, 26004 Logroño, La Rioja, Spain;
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Spedale V, Luciani M, Attanasio A, Di Mauro S, Alvaro R, Vellone E, Ausili D. Association between sleep quality and self-care in adults with heart failure: A systematic review. Eur J Cardiovasc Nurs 2020; 20:192–201. [PMID: 33909891 DOI: 10.1177/1474515120941368] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 04/14/2020] [Accepted: 06/22/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Sleep disturbance is one of the most common symptoms among heart failure patients. Sleep disturbance reduces quality of life and leads to higher rates of mortality. It may affect the ability of patients to perform adequate self-care. Although some research has evaluated the association between sleep quality and heart failure self-care, a synthesis of the most recent available evidence is lacking. AIMS This systematic review aimed to assess the association between sleep quality and self-care in adults with heart failure. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology was used. Medline, CINAHL, PsycINFO and SCOPUS were searched. Observational, case-control and cohort studies were considered. The quality of the studies was evaluated with the Joanna Briggs Institute's Critical Appraisal Tools. RESULTS Six articles were included. Association between sleep quality and self-care was reported by three studies. One of these did not find an association between sleep disturbance and heart failure self-care, while the other two studies did. An association between sleep quality and medication adherence was reported by three studies. All three of these studies found associations between these two variables. Studies have measured similar but different constructs. Two studies assessed sleep quality, while four other studies measured excessive daytime sleepiness. Half of the studies examined self-care, while the other half measured medication adherence. CONCLUSIONS Although the evidence should be strengthened, sleep quality seems to affect self-care in heart failure patients. The mechanism underlying the effect of sleep quality on heart failure self-care remains unclear. Future longitudinal interaction analyses could be useful to clarify this mechanism.
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Affiliation(s)
- Valentina Spedale
- Department of Biomedicine and Prevention, University of Rome 'Tor Vergata', Italy
| | - Michela Luciani
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | | | - Stefania Di Mauro
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Rosaria Alvaro
- Department of Biomedicine and Prevention, University of Rome 'Tor Vergata', Italy
| | - Ercole Vellone
- Department of Biomedicine and Prevention, University of Rome 'Tor Vergata', Italy
| | - Davide Ausili
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
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7
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Tang L, Liu W, Yang Y, Han W, Li K. Relationship between sleep and cognitive function in patients with heart failure: A systematic review. J Psychosom Res 2020; 130:109913. [PMID: 31918359 DOI: 10.1016/j.jpsychores.2019.109913] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 12/09/2019] [Accepted: 12/24/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The aim of this systematic review is to synthesize relevant evidence and illustrate the relationship between sleep and cognitive function in patients with heart failure. METHODS A literature search was conducted on Embase, PubMed, Web of Science, CINAHL, PsychINFO, Cochrane Library, China National Knowledge Infrastructure (CNKI) and Wan Fang to identify relevant studies. RESULTS Seven studies, which enrolled a total of 1218 heart failure patients, were included in this review. These articles investigating the relationship between sleep and cognitive performance in patients with heart failure had inconsistent results. Five studies confirmed that sleep quality and insomnia were significantly associated with cognitive function, including global cognition, attention, and executive function, whereas the other two studies indicated no statistically significant relationship between sleep and cognitive function. CONCLUSION Although limited evidence restricts the overall conclusions, this review might provide new opportunities to identify patients with heart failure that are at high risk for cognitive decline. Further studies across a longer period are needed to confirm the relationship between sleep and cognitive function in patients with heart failure.
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Affiliation(s)
- Liya Tang
- School of Nursing, Jilin University, Changchun, China
| | - Wenping Liu
- Department of Neurology, The Second Hospital of Jilin University, Changchun, China
| | - Yuhang Yang
- School of Nursing, Jilin University, Changchun, China
| | - Wenwen Han
- School of Nursing, Jilin University, Changchun, China
| | - Kun Li
- School of Nursing, Jilin University, Changchun, China.
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8
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Harris KM, Schiele SE, Emery CF. Pilot randomized trial of brief behavioral treatment for insomnia in patients with heart failure. Heart Lung 2019; 48:373-380. [DOI: 10.1016/j.hrtlng.2019.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 06/07/2019] [Accepted: 06/13/2019] [Indexed: 01/07/2023]
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9
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Sleep quality among adult patients with chronic dermatoses. Postepy Dermatol Alergol 2019; 36:659-666. [PMID: 31997991 PMCID: PMC6986286 DOI: 10.5114/ada.2019.84007] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/19/2019] [Indexed: 11/17/2022] Open
Abstract
Chronic dermatoses, including atopic dermatitis, psoriasis, prurigo nodularis, chronic spontaneous urticaria and hidradenitis suppurativa, as well as accompanying subjective symptoms (itch and pain), have a great impact on patients’ well-being. Skin plays an important role in the physiological sleep process. This review attempts to analyze the association between chronic dermatoses in adults and sleep quality in recent studies. Polysomnography and actigraphy are performed for the objective assessment of sleep quality. Questionnaire-based subjective evaluations of sleep quality, including the Pittsburgh Sleep Quality Index and Medical Outcomes Study Sleep Scale, are useful in clinical studies and clinical practice. Subjective symptoms such as itch and pain have an essential influence on sleep quality and general quality of life in patients with chronic skin diseases.
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10
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Walter FA, Ede D, Hawkins MAW, Dolansky MA, Gunstad J, Josephson R, Moore SM, Hughes JW. Sleep quality and daytime sleepiness are not associated with cognition in heart failure. J Psychosom Res 2018; 113:100-106. [PMID: 30190041 DOI: 10.1016/j.jpsychores.2018.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 08/07/2018] [Accepted: 08/08/2018] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Fawn A Walter
- Kent State University, Department of Psychological Sciences, P.O. Box 5190, Kent, OH 44240, USA
| | - David Ede
- Kent State University, Department of Psychological Sciences, P.O. Box 5190, Kent, OH 44240, USA
| | - Misty A W Hawkins
- Oklahoma State University, Department of Psychology, 116 N. Murray, Stillwater, OK 74078, USA
| | - Mary A Dolansky
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - John Gunstad
- Kent State University, Department of Psychological Sciences, P.O. Box 5190, Kent, OH 44240, USA
| | - Richard Josephson
- Harrington Heart & Vascular Institute, University Hospitals, Cleveland, OH, USA; College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Shirley M Moore
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Joel W Hughes
- Kent State University, Department of Psychological Sciences, P.O. Box 5190, Kent, OH 44240, USA.
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Wennogle LP, Hoxie H, Peng Y, Hendrick JP. Phosphodiesterase 1: A Unique Drug Target for Degenerative Diseases and Cognitive Dysfunction. ADVANCES IN NEUROBIOLOGY 2018; 17:349-384. [PMID: 28956339 DOI: 10.1007/978-3-319-58811-7_13] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The focus of this chapter is on the cyclic nucleotide phosphodiesterase 1 (PDE1) family. PDE1 is one member of the 11 PDE families (PDE 1-11). It is the only phosphodiesterase family that is calcium/calmodulin activated. As a result, whereas other families of PDEs 2-11 play a dominant role controlling basal levels of cyclic nucleotides, PDE1 is involved when intra-cellular calcium levels are elevated and, thus, has an "on demand" or activity-dependent involvement in the control of cyclic nucleotides in excitatory cells including neurons, cardiomyocytes and smooth muscle. As a Class 1 phosphodiesterase, PDE1 hydrolyzes the 3' bond of 3'-5'-cyclic nucleotides, cyclic adenosine monophosphate (cAMP) and cyclic guanosine monophosphate (cGMP). Here, we review evidence for this family of enzymes as drug targets for development of therapies aimed to address disorders of the central nervous system (CNS) and of degenerative diseases. The chapter includes sections on the potential for cognitive enhancement in mental disorders, as well as a review of PDE1 enzyme structure, enzymology, tissue distribution, genomics, inhibitors, pharmacology, clinical trials, and therapeutic indications. Information is taken from public databases. A number of excellent reviews of the phosphodiesterase family have been written as well as reviews of the PDE1 family. References cited here are not comprehensive, rather pointing to major reviews and key publications.
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Affiliation(s)
- Lawrence P Wennogle
- Alexandria Center for Life Science, Intra-Cellular Therapies, Inc., New York, 10016, NY, USA.
| | - Helen Hoxie
- Alexandria Center for Life Science, Intra-Cellular Therapies, Inc., New York, 10016, NY, USA
| | - Youyi Peng
- Rutgers University, 7 College Ave, New Brunswick, NJ, 08901, USA
| | - Joseph P Hendrick
- Alexandria Center for Life Science, Intra-Cellular Therapies, Inc., New York, 10016, NY, USA
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12
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Byun E, Kim J, Riegel B. Associations of Subjective Sleep Quality and Daytime Sleepiness With Cognitive Impairment in Adults and Elders With Heart Failure. Behav Sleep Med 2017; 15:302-317. [PMID: 27116617 DOI: 10.1080/15402002.2015.1133418] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This study examined the association of subjective nighttime sleep quality and daytime sleepiness with cognitive impairment in 105 adults (< 60 years old) and 167 elders (≥ 60 years old) with heart failure. Nighttime sleep quality and daytime sleepiness were measured by the Pittsburgh Sleep Quality Index and the Epworth Sleepiness Scale. Cognitive impairment was assessed using a neuropsychological battery measuring attention, memory, and processing speed. Multivariate logistic regression was used. In adults, daytime sleepiness was associated with cognitive impairment, whereas poor nighttime sleep quality was associated with cognitive impairment in elders. Age may play an important role in how sleep impacts cognition in persons with heart failure. Improving nighttime sleep quality and daytime sleepiness in this population may improve cognition.
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Affiliation(s)
- Eeeseung Byun
- a Department of Family Health Care Nursing , University of California San Francisco School of Nursing , San Francisco , California
| | - Jinyoung Kim
- b School of Nursing , University of Pennsylvania , Philadelphia , Pennsylvania
| | - Barbara Riegel
- c Biobehavioral Health Sciences Department, School of Nursing , University of Pennsylvania, Philadelphia , Pennsylvania
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13
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Moon C, Yoon JY, Bratzke LC. The Role of Heart Failure, Daytime Sleepiness, and Disturbed Sleep on Cognition. West J Nurs Res 2016; 39:473-491. [PMID: 27784834 DOI: 10.1177/0193945916675587] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Disturbed sleep and daytime sleepiness may interfere with possible direct relationships between heart failure (HF) and cognition, yet there is limited research investigating this relationship. We aimed to investigate possible mediating roles of disturbed sleep and daytime sleepiness on the relationship between HF and selected cognitive domains among individuals with and without HF. In a cross-sectional design study, we examined the data of 841 older adults with and without HF from the Aging, Demographics, and Memory Study (ADAMS). We found individuals with HF were likely to have a higher degree of disturbed sleep and daytime sleepiness. Both disturbed sleep and daytime sleepiness were significant predictors of cognition. We found that only daytime sleepiness mediated the relationship between the presence of HF and cognitive domains, such as in attention, memory, and executive function after controlling for covariates. Interventions to improve daytime sleepiness among individuals with HF may also help improving cognition.
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Affiliation(s)
- Chooza Moon
- 1 University of Wisconsin-Madison, Madison, WI, USA
| | - Ju Young Yoon
- 2 College of Nursing and Research Institute of Nursing Science, Seoul National University, Seoul, South Korea
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14
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Cleutjens FAHM, Pedone C, Janssen DJA, Wouters EFM, Incalzi RA. Sleep quality disturbances and cognitive functioning in elderly patients with COPD. ERJ Open Res 2016; 2:00054-2016. [PMID: 27957482 PMCID: PMC5140015 DOI: 10.1183/23120541.00054-2016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 06/18/2016] [Indexed: 02/03/2023] Open
Abstract
Information about the association between cognitive functions, such as copying function, and sleep disturbances in patients with chronic obstructive pulmonary disease (COPD) is lacking. This cross-sectional observational study aimed to investigate the association between copying function and self-reported sleep quality disturbances and disease severity in an elderly COPD population. Cognitive function performances, assessed using the Mini-Mental State Examination, were compared in 562 ambulatory COPD patients with and without sleep disturbances; assessed using the Established Populations for Epidemiologic Studies of the Elderly questionnaire; and stratified by Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades. Sleep disturbances overall were not correlated with cognitive functioning. A trend was revealed towards worse design copying in patients with sleep disturbances overall. GOLD I patients with difficulties falling asleep and nocturnal awakenings had worse copying ability compared to GOLD I patients without these sleep disturbances. Copying ability was worse for GOLD III than GOLD I, orientation was worse for GOLD II than GOLD I and language was worse for GOLD II and III than GOLD I. To conclude, sleep disturbances seem to be a weak correlate of cognitive functioning, and are not a marker of disease severity. Sleep disturbances are a weak correlate of cognitive functioning in COPDhttp://ow.ly/gUhD301PvcQ
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Affiliation(s)
- Fiona A H M Cleutjens
- Dept of Research and Education, CIRO Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands
| | - Claudio Pedone
- Dept of Geriatrics, University Campus Bio-Medico, Rome, Italy
| | - Daisy J A Janssen
- Dept of Research and Education, CIRO Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands
| | - Emiel F M Wouters
- Dept of Research and Education, CIRO Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands
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15
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Abstract
The purpose of this investigation is to examine differences in rest-activity patterns and sleep characteristics in older adults with heart failure (HF) and healthy older adults. The sample included older adults with HF (n = 20) and a reference group of healthy older adults (n = 20). Traditional cosinor analysis was used to assess three parameters of rest-activity from wrist actigraphy data: amplitude (range of activity), mesor (mean activity), and acrophase (time of peak activity). Traditional sleep characteristics were also determined from actigraphy data: total sleep time (TST), sleep latency (SL), sleep efficiency (SE), and wake after sleep onset (WASO). The HF group demonstrated significantly lower mesor and amplitude than the reference group (p < .01). The HF group had significantly greater TST (p < .01), but the groups had similar SE, SL, and WASO. Despite similar sleep characteristics to healthy older adults, overall rest-activity patterns were significantly dampened in those with HF.
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16
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Hinz A, Glaesmer H, Brähler E, Löffler M, Engel C, Enzenbach C, Hegerl U, Sander C. Sleep quality in the general population: psychometric properties of the Pittsburgh Sleep Quality Index, derived from a German community sample of 9284 people. Sleep Med 2016; 30:57-63. [PMID: 28215264 DOI: 10.1016/j.sleep.2016.03.008] [Citation(s) in RCA: 239] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 03/03/2016] [Accepted: 03/14/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Pittsburgh Sleep Quality Index (PSQI) is frequently used to assess sleep problems in patients. The aim of this study was to provide reference values for this questionnaire, to test psychometric properties, and to analyze associations with psychological, sociodemographic, and behavioral factors. METHODS A German community sample comprising 9284 adult residents (aged 18-80 years) was surveyed using the PSQI and several other questionnaires. RESULTS According to the generally accepted cut-off (PSQI > 5), 36% of the general population slept badly. Females reported significantly more sleep problems than males (mean scores: M = 5.5 vs. M = 4.4, respectively; effect size d = 0.35), but there was no linear association between age and sleep quality. Sleep problems were correlated with fatigue, quality of life (physical as well as mental), physical complaints, anxiety, and lack of optimism. Sleep quality was also strongly associated with socioeconomic status, professional situation (poorest sleep quality in unemployed people), and obesity. In addition to the results of the PSQI total score, mean scores of specific components of sleep quality were presented (sleep latency, sleep duration, and use of sleep medication). CONCLUSION The PSQI proved to be a suitable instrument for measuring sleep quality. Gender differences, psychological factors, and obesity should be taken into account when groups of patients are compared with respect to sleep problems.
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Affiliation(s)
- Andreas Hinz
- Department of Medical Psychology and Medical Sociology, University of Leipzig, Leipzig, Germany.
| | - Heide Glaesmer
- Department of Medical Psychology and Medical Sociology, University of Leipzig, Leipzig, Germany
| | - Elmar Brähler
- Department of Medical Psychology and Medical Sociology, University of Leipzig, Leipzig, Germany; Clinic for Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Markus Löffler
- Institute for Medical Informatics, Statistics, and Epidemiology (IMISE), University of Leipzig, Leipzig, Germany; LIFE - Leipzig Research Center for Civilization Diseases, University of Leipzig, Leipzig, Germany
| | - Christoph Engel
- Institute for Medical Informatics, Statistics, and Epidemiology (IMISE), University of Leipzig, Leipzig, Germany; LIFE - Leipzig Research Center for Civilization Diseases, University of Leipzig, Leipzig, Germany
| | - Cornelia Enzenbach
- Institute for Medical Informatics, Statistics, and Epidemiology (IMISE), University of Leipzig, Leipzig, Germany; LIFE - Leipzig Research Center for Civilization Diseases, University of Leipzig, Leipzig, Germany
| | - Ulrich Hegerl
- Department of Psychiatry, University of Leipzig, Leipzig, Germany
| | - Christian Sander
- Department of Psychiatry, University of Leipzig, Leipzig, Germany
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17
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Lo JC, Groeger JA, Cheng GH, Dijk DJ, Chee MWL. Self-reported sleep duration and cognitive performance in older adults: a systematic review and meta-analysis. Sleep Med 2016; 17:87-98. [PMID: 26847980 DOI: 10.1016/j.sleep.2015.08.021] [Citation(s) in RCA: 221] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 07/13/2015] [Accepted: 08/08/2015] [Indexed: 12/19/2022]
Affiliation(s)
- June C Lo
- Centre for Cognitive Neuroscience, Neuroscience and Behavioral Disorders Program, Duke-NUS Graduate Medical School, Singapore.
| | - John A Groeger
- Department of Psychology, University of Hull, Hull, United Kingdom
| | - Grand H Cheng
- Counselling & Psychology Department, Hong Kong Shue Yan University, Hong Kong
| | - Derk-Jan Dijk
- Surrey Sleep Research Centre, University of Surrey, Guildford, United Kingdom
| | - Michael W L Chee
- Centre for Cognitive Neuroscience, Neuroscience and Behavioral Disorders Program, Duke-NUS Graduate Medical School, Singapore.
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18
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Byun E, Gay CL, Lee KA. Sleep, Fatigue, and Problems With Cognitive Function in Adults Living With HIV. J Assoc Nurses AIDS Care 2015; 27:5-16. [PMID: 26547298 DOI: 10.1016/j.jana.2015.10.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 10/06/2015] [Indexed: 11/16/2022]
Abstract
Up to 50% of people living with HIV have some neurocognitive impairment. We examined associations of sleep and fatigue with self-reported cognitive problems in 268 adults living with HIV. Multivariate regression was used to examine associations between cognitive problems, self-reported sleep quality, actigraphy-measured total sleep time and wake after sleep onset, and fatigue severity. Poorer self-reported sleep quality (p < .001), short or long total sleep time (<7 or >8 vs. 7-8 hours, p = .015), and greater fatigue (p < .001) were associated with lower self-reported cognitive function scores after controlling for demographic and clinical characteristics. However, objective measure of wake after sleep onset was unrelated to self-reported cognitive function scores. Findings suggest that assessing and treating poor sleep and complaints about fatigue would be areas for intervention that could have a greater impact on improving cognition function than interventions that target only cognitive problems.
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19
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The Course of Sleep Problems in Patients With Heart Failure and Associations to Rehospitalizations. J Cardiovasc Nurs 2015; 30:403-10. [DOI: 10.1097/jcn.0000000000000176] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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20
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Moon C, Phelan CH, Lauver DR, Bratzke LC. Is sleep quality related to cognition in individuals with heart failure? Heart Lung 2015; 44:212-8. [PMID: 25796476 DOI: 10.1016/j.hrtlng.2015.02.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 01/30/2015] [Accepted: 02/08/2015] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Chooza Moon
- University of Wisconsin-Madison, School of Nursing, 701 Highland Avenue, Madison, WI 53705, USA.
| | - Cynthia H Phelan
- University of Wisconsin-Madison, School of Nursing, 701 Highland Avenue, Madison, WI 53705, USA; William S. Middleton Memorial Veterans Hospital Geriatrics Research, Education and Clinical Center (GRECC), 2500 Overlook Terrace, Madison, WI 53705, USA
| | - Diane R Lauver
- University of Wisconsin-Madison, School of Nursing, 701 Highland Avenue, Madison, WI 53705, USA
| | - Lisa C Bratzke
- University of Wisconsin-Madison, School of Nursing, 701 Highland Avenue, Madison, WI 53705, USA
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21
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Lo JC, Loh KK, Zheng H, Sim SKY, Chee MWL. Sleep duration and age-related changes in brain structure and cognitive performance. Sleep 2014; 37:1171-8. [PMID: 25061245 DOI: 10.5665/sleep.3832] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
STUDY OBJECTIVES To investigate the contribution of sleep duration and quality to age-related changes in brain structure and cognitive performance in relatively healthy older adults. DESIGN Community-based longitudinal brain and cognitive aging study using a convenience sample. SETTING Participants were studied in a research laboratory. PARTICIPANTS Relatively healthy adults aged 55 y and older at study commencement. INTERVENTIONS N/A. MEASUREMENTS AND RESULTS Participants underwent magnetic resonance imaging and neuropsychological assessment every 2 y. Subjective assessments of sleep duration and quality and blood samples were obtained. Each hour of reduced sleep duration at baseline augmented the annual expansion rate of the ventricles by 0.59% (P = 0.007) and the annual decline rate in global cognitive performance by 0.67% (P = 0.050) in the subsequent 2 y after controlling for the effects of age, sex, education, and body mass index. In contrast, global sleep quality at baseline did not modulate either brain or cognitive aging. High-sensitivity C-reactive protein, a marker of systemic inflammation, showed no correlation with baseline sleep duration, brain structure, or cognitive performance. CONCLUSIONS In healthy older adults, short sleep duration is associated with greater age-related brain atrophy and cognitive decline. These associations are not associated with elevated inflammatory responses among short sleepers. CITATION Lo JC, Loh KK, Zheng H, Sim SK, Chee MW. Sleep duration and age-related changes in brain structure and cognitive performance.
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Affiliation(s)
- June C Lo
- Center for Cognitive Neuroscience, Neuroscience and Behavioral Disorders Program, Duke-NUS Graduate Medical School, Singapore
| | - Kep Kee Loh
- Center for Cognitive Neuroscience, Neuroscience and Behavioral Disorders Program, Duke-NUS Graduate Medical School, Singapore
| | - Hui Zheng
- Center for Cognitive Neuroscience, Neuroscience and Behavioral Disorders Program, Duke-NUS Graduate Medical School, Singapore
| | - Sam K Y Sim
- Center for Cognitive Neuroscience, Neuroscience and Behavioral Disorders Program, Duke-NUS Graduate Medical School, Singapore
| | - Michael W L Chee
- Center for Cognitive Neuroscience, Neuroscience and Behavioral Disorders Program, Duke-NUS Graduate Medical School, Singapore
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22
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Alosco ML, Brickman AM, Spitznagel MB, Griffith EY, Narkhede A, Cohen R, Sweet LH, Hughes J, Rosneck J, Gunstad J. Reduced cerebral blood flow and white matter hyperintensities predict poor sleep in heart failure. BEHAVIORAL AND BRAIN FUNCTIONS : BBF 2013; 9:42. [PMID: 24171759 PMCID: PMC3816301 DOI: 10.1186/1744-9081-9-42] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 10/27/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND Poor sleep is common in heart failure (HF), though mechanisms of sleep difficulties are not well understood. Adverse brain changes among regions important for sleep have been demonstrated in patients with HF. Cerebral hypoperfusion, a correlate of sleep quality, is also prevalent in HF and a likely contributor to white matter hyperintensities (WMH). However, no study to date has examined the effects of cerebral blood flow, WMH, and brain volume on sleep quality in HF. METHODS Fifty-three HF patients completed the Pittsburgh Sleep Quality Index and underwent brain magnetic resonance imaging to quantify brain and WMH volume. Transcranial Doppler ultrasonography assessed cerebral blood flow velocity of the middle cerebral artery (CBF-V of the MCA). RESULTS 75.5% of HF patients reported impaired sleep. Regression analyses adjusting for medical and demographic factors showed decreased CBF-V of the MCA and greater WMH volume were associated with poor sleep quality. No such pattern emerged on total brain or regional volume indices. CONCLUSIONS Decreased cerebral perfusion and greater WMH may contribute to sleep difficulties in HF. Future studies are needed to confirm these findings and clarify the effects of cerebral blood flow and WMH on sleep in healthy and patient samples.
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Affiliation(s)
| | - Adam M Brickman
- Department of Neurology, Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | | | - Erica Y Griffith
- Department of Neurology, Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Atul Narkhede
- Department of Neurology, Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Ronald Cohen
- Departments of Neurology Psychiatry and the Institute on Aging, Center for Cognitive Aging and Memory, University of Florida, Florida, Gainesville, USA
| | | | - Joel Hughes
- Department of Psychology, Kent State University, Kent, OH, USA
- Department of Psychiatry, Summa Health System Akron City Hospital, Akron, OH, USA
| | - Jim Rosneck
- Department of Psychiatry, Summa Health System Akron City Hospital, Akron, OH, USA
| | - John Gunstad
- Department of Psychology, Kent State University, Kent, OH, USA
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23
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Hjelm C, Strömberg A, Arestedt K, Broström A. Association between sleep-disordered breathing, sleep-wake pattern, and cognitive impairment among patients with chronic heart failure. Eur J Heart Fail 2013; 15:496-504. [PMID: 23392278 DOI: 10.1093/eurjhf/hft014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- Carina Hjelm
- Department of Medical and Health Sciences, Division of Nursing Science, Linköping University, Linköping, Sweden.
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