Sleep Disturbances in Patients with Medical Conditions

Sleep in Psychotic Disorders: Results From Nationwide SUPER Finland Study

Objective

Characterizing sleep in patients with schizophrenia, schizoaffective disorder, bipolar disorder, and psychotic depression.

Methods

This cross-sectional questionnaire study is based on the SUPER study sample, which is part of the Stanley Global Neuropsychiatric Genomics Initiative. The study is a multicentre, nationwide Finnish study consisting of patients (N = 8 623) both in primary and specialized health care. The main measurements were sleep duration, difficulties initiating sleep, early morning awakenings, and fatigue. These results were compared with a nationally representative sample of the Finnish population from the Health 2000 survey (N = 7 167) with frequency and logistic regression analyses.

Results

Patients had more sleep problems compared with the general population, especially young and middle-aged patients (Difficulties initiating sleep in young patients odds ratio = 12.3, 95% CI 9.8-15.4). Long sleep duration was the most deviating property of the sleep characteristics, being particularly common among young patients with schizophrenia (odds ratio = 27.9, 95% CI 22.1-35.2, 47.4% vs 3.3% prevalence). All sleep problems were associated with worse subjective health. We also conducted a latent class analysis, resulting in a cluster relatively free of sleep problems (58% of patients), an insomnia symptom cluster (26%), and a hypersomnia symptom cluster (15%).

Conclusions

In our sample, patients with psychotic disorders have more sleep problems-especially long sleep duration but also insomnia symptoms-compared with the general population. The patients can in a latent class analysis of their sleep symptoms be divided into groups with differing sleep profiles.

Leisure-Time Physical Activity and General Health Mitigate Effects of Job Demands on Nonrestorative Sleep: CDC National Healthy Worksite Project

OBJECTIVE

We sought to determine if leisure-time physical activity (LTPA) modified the adverse relationship between high job demands and nonrestorative sleep (NRS).

METHODS

We conducted a multivariate logistic regression analysis among workers from the cross-sectional National Healthy Worksite Project (n = 4683) using self-report Likert-Scale data on psychological and physical demands of jobs, LTPA and general health in relation to NRS.

RESULTS

Not engaging in LTPA was associated with NRS for workers with jobs at the lowest or highest levels of the physical demand scale (OR 1.64, 95% CI: 0.96-2.81, OR 2.06, 95% CI: 0.95-4.45; respectively) in comparison to those who met LTPA recommendations. When assessing psychological demands, poor general health was associated with NRS at all levels of the scale independent of LTPA.

CONCLUSIONS

LTPA may reduce NRS for workers with jobs at either extreme of physical demands.

Salivary Inflammatory Molecules as Biomarkers of Sleep Alterations: A Scoping Review

Poor sleep quality and sleep disorders are the most common problems in people, affecting health-related quality of life. Various studies show an association between sleep disorders and altered levels of stress hormones and inflammatory cytokines measured in saliva. The main objective of this article is to provide an analysis of the current evidence related to changes in inflammatory markers in the saliva and their associations with sleep quality measurement (both objective and subjective methods) in healthy subjects and in sleep-related disorders. To that end, a scoping review was carried out, following the PRISMA criteria in the bibliographic search in several databases: PubMed, EBSCO, and SCOPUS. Eleven of the articles are from the adult population and two from the child-youth population. They mainly measure the relationship between sleep and interleukin-1β (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor alpha (TNFα) alpha, as well as other inflammatory markers such as myeloperoxidase (MPO) and prostaglandin-endoperoxide synthase 2. An analysis shows the relationship between these salivary biomarkers and sleep quality, especially in the case of IL-6 in both healthy subjects and several pathologies associated with sleep-disorders. The results for TNFα and IL-1β measurements are still inconclusive and the difference with IL-6 was assessed. Two studies reported interventions that result in sleep improvement and are accompanied by the normalization of inflammatory changes detected in the saliva. As it is an easy-to-apply and non-invasive method, the measurement of salivary cytokines can be very useful in chronobiology studies. Further studies are required to determine the sensitivity of salivary inflammatory markers in monitoring biological rhythms and acting as biomarkers in the detection of sleep disorders and sleep interventions.

Risk of obstructive sleep apnea in patients with Sjögren syndrome and Behçet's disease: a nationwide, population-based cohort study

PURPOSE

Patients with obstructive sleep apnea (OSA) have a higher risk of Behçet's disease (BD) and Sjögren syndrome (SS). However, the bidirectional relationship between these autoimmune diseases and OSA is unclear. We investigated the relationship between autoimmune diseases (SS and BD) and OSA.

METHODS

SS and BD patients were identified through the Taiwan National Health Insurance Research Database from 2002 to 2012. Patients with SS or BD were matched according to age and sex with a control group in a ratio of 1:4. The study included 12,926 patients with SS and 51,704 non-SS controls. Similarly, 1221 patients with BD were matched with 4884 non-BD controls. We used a Cox regression model, stratified by age, gender, and comorbidities, to assess the risk of OSA.

RESULTS

OSA was diagnosed in 0.61% of the SS cohort and 1.23% of the BD cohort. The higher overall risk for OSA was observed significantly in patients with SS than in controls (adjusted hazard ratio [HR] = 2.48, 95% confidence interval [CI] = 1.89-3.24). The higher risk was also observed significantly in BD patients than in controls (HR = 1.99, 95% CI = 1.06-3.72). Furthermore, men with SS or BD exhibited HR of 2.62 (95% CI 1.89 to 3.62) and 6.40 (95% CI 2.96 to 13.84) for developing OSA, respectively.

CONCLUSION

Risk of OSA was significantly elevated in SS or BD patients compared with controls. Further study is warranted to elucidate underlying mechanisms.

The Sleep-Immune Crosstalk in Health and Disease

Sleep and immunity are bidirectionally linked. Immune system activation alters sleep, and sleep in turn affects the innate and adaptive arm of our body's defense system. Stimulation of the immune system by microbial challenges triggers an inflammatory response, which, depending on its magnitude and time course, can induce an increase in sleep duration and intensity, but also a disruption of sleep. Enhancement of sleep during an infection is assumed to feedback to the immune system to promote host defense. Indeed, sleep affects various immune parameters, is associated with a reduced infection risk, and can improve infection outcome and vaccination responses. The induction of a hormonal constellation that supports immune functions is one likely mechanism underlying the immune-supporting effects of sleep. In the absence of an infectious challenge, sleep appears to promote inflammatory homeostasis through effects on several inflammatory mediators, such as cytokines. This notion is supported by findings that prolonged sleep deficiency (e.g., short sleep duration, sleep disturbance) can lead to chronic, systemic low-grade inflammation and is associated with various diseases that have an inflammatory component, like diabetes, atherosclerosis, and neurodegeneration. Here, we review available data on this regulatory sleep-immune crosstalk, point out methodological challenges, and suggest questions open for future research.

Sleep disorder diagnoses and clinical outcomes among hospitalized breast cancer patients: a nationwide inpatient sample study

PURPOSE

Sleep disturbances are recognized as a problem for many cancer patients, but little is known about the prevalence of sleep disorders among women hospitalized with breast cancer, or their relationship to in-hospital outcomes. The present study represents a first step toward determining the clinical significance of sleep disorders for hospitalized breast cancer patients with regard to complications, length of hospital stay, and mortality.

METHODS

The relationships between sleep disorders and in-hospital outcomes among 84,424 hospitalized breast cancer patients were examined. This study analyzed the Nationwide Inpatient Sample (NIS) database (2007 to 2011) for all women ages 40 years and older with a primary discharge diagnosis of breast cancer and a secondary discharge diagnosis of sleep disorder. Odds ratios, estimates, and 95% confidence intervals were computed using multivariable regression adjusting for age, comorbidities, race, cancer stage, income, insurance type, residential region, year of discharge, and surgical treatment type.

RESULTS

Among women hospitalized with a primary diagnosis of breast cancer, 2% (n = 1807) also received a diagnosis of a sleep disorder during hospitalization, the majority of which were sleep-related breathing disorders (n = 1274). Although there was no significant association between having a diagnosis of a sleep disorder and in-hospital mortality, patients with a sleep disorder were more likely to also experience complications (OR = 1.58, 95% CI 1.29-1.34) and have longer hospital stays (mean = 0.44 days longer, 95% CI 0.25-0.63).

CONCLUSION

Hospitalized breast cancer patients with a sleep disorder were more likely to experience clinical complications and stay longer in the hospital. It remains an open and important question for future research whether interventions to improve sleep during hospitalization would help to improve clinical outcomes.

Experience of sleep disruption in primary Sjögren's syndrome: A focus group study

INTRODUCTION

Primary Sjögren's syndrome is the third most common systemic autoimmune rheumatic disease, following rheumatoid arthritis and systemic lupus erythematosus, and results in dryness, fatigue, discomfort and sleep disturbances. Sleep is relatively unexplored in primary Sjögren's syndrome. We investigated the experiences of sleep disturbances from the viewpoint of primary Sjögren's syndrome patients and their partners and explored the acceptability of cognitive behavioural therapy for insomnia.

METHOD

We used focus groups to collect qualitative data from 10 patients with primary Sjögren's syndrome and three partners of patients. The data were recorded, transcribed verbatim and analysed using thematic analysis.

RESULTS

Five themes emerged from the data: (a) Experience of sleep disturbances; (b) variation and inconsistency in sleep disturbances; (c) the domino effect of primary Sjögren's syndrome symptoms; (d) strategies to manage sleep; (e) acceptability of evidence-based techniques. Sleep disturbances were problematic for all patients, but specific disturbances varied between participants. These included prolonged sleep onset time and frequent night awakenings and were aggravated by pain and discomfort. Patients deployed a range of strategies to try and self-manage. Cognitive behavioural therapy for insomnia was seen as an acceptable intervention, as long as a rationale for its use is given and it is tailored for primary Sjögren's syndrome.

CONCLUSION

Primary Sjögren's syndrome patients described a range of sleep disturbances. Applying tailored, evidence-based sleep therapy interventions may improve sleep, severity of other primary Sjögren's syndrome symptoms and functional ability.

Biomarkers as Common Data Elements for Symptom and Self-Management Science

PURPOSE

Biomarkers as common data elements (CDEs) are important for the characterization of biobehavioral symptoms given that once a biologic moderator or mediator is identified, biologically based strategies can be investigated for treatment efforts. Just as a symptom inventory reflects a symptom experience, a biomarker is an indicator of the symptom, though not the symptom per se. The purposes of this position paper are to (a) identify a "minimum set" of biomarkers for consideration as CDEs in symptom and self-management science, specifically biochemical biomarkers; (b) evaluate the benefits and limitations of such a limited array of biomarkers with implications for symptom science; (c) propose a strategy for the collection of the endorsed minimum set of biologic samples to be employed as CDEs for symptom science; and (d) conceptualize this minimum set of biomarkers consistent with National Institute of Nursing Research (NINR) symptoms of fatigue, depression, cognition, pain, and sleep disturbance.

DESIGN AND METHODS

From May 2016 through January 2017, a working group consisting of a subset of the Directors of the NINR Centers of Excellence funded by P20 or P30 mechanisms and NINR staff met bimonthly via telephone to develop this position paper suggesting the addition of biomarkers as CDEs. The full group of Directors reviewed drafts, provided critiques and suggestions, recommended the minimum set of biomarkers, and approved the completed document. Best practices for selecting, identifying, and using biological CDEs as well as challenges to the use of biological CDEs for symptom and self-management science are described. Current platforms for sample outcome sharing are presented. Finally, biological CDEs for symptom and self-management science are proposed along with implications for future research and use of CDEs in these areas.

FINDINGS

The recommended minimum set of biomarker CDEs include pro- and anti-inflammatory cytokines, a hypothalamic-pituitary-adrenal axis marker, cortisol, the neuropeptide brain-derived neurotrophic factor, and DNA polymorphisms.

CONCLUSIONS

It is anticipated that this minimum set of biomarker CDEs will be refined as knowledge regarding biologic mechanisms underlying symptom and self-management science further develop. The incorporation of biological CDEs may provide insights into mechanisms of symptoms, effectiveness of proposed interventions, and applicability of chosen theoretical frameworks. Similarly, as for the previously suggested NINR CDEs for behavioral symptoms and self-management of chronic conditions, biological CDEs offer the potential for collaborative efforts that will strengthen symptom and self-management science.

CLINICAL RELEVANCE

The use of biomarker CDEs in biobehavioral symptoms research will facilitate the reproducibility and generalizability of research findings and benefit symptom and self-management science.

Sleep disturbance as a predictor of time to drug and alcohol use treatment in primary care

BACKGROUND

Sleep Disturbances (SDs) are a symptom common to mental health disorders (MHD) and substance use disorders (SUD). We aimed to identify the value of SD as a predictor for subsequent treatment of illicit drug and alcohol use disorders (SUDs) in primary care and relative to the predictive value of mental health disorders (MHDs).

METHODS

We used electronic health records data from ambulatory primary care in a safety net Boston area healthcare system from 2013 to 2015 (n = 83,920). SUD (separated into illicit drug use disorder and alcohol use disorder) and MHD were identified through ICD-9 codes and medical record documentation. We estimated Cox proportional hazard models to examine the risk of SUD across four comparison groups (SD only, SD and MHD, MHD only, and neither SD nor MHD).

RESULTS

Compared to patients with no sleep or MHD, patients with SD had a greater risk for subsequent SUD treatment. Approximately one-fifth of patients with SD were treated for an illicit drug use disorder and approximately 12% were treated for alcohol use disorder. Risk for SUD treatment, estimated at over 30% by the end of the study, was greatest for patients with a MHD, either alone or comorbid with SD. Risk was greater for older patients and men, and lower for minority patients.

CONCLUSIONS

SD and MHD, individually and comorbid, significantly predict subsequent treatment of illicit drug and alcohol use disorder in primary care. Screening and evaluation for SD should be a routine practice in primary care to help with identifying potential SUD risk.

New Onset Insomnia in a Pediatric Patient: A Case of Anti-NMDA Receptor Encephalitis

Anti-NMDAR encephalitis is becoming more widely recognized as a cause of encephalopathy in both adults and children. Certain clinical features such as mood lability, movement disorders, speech dysfunction, seizures, and autonomic instability in a pediatric patient should prompt immediate concern and evaluation for autoimmune encephalitis among providers. We present the case of a pediatric patient with anti-NMDAR encephalitis in which the symptom prompting medical evaluation was insomnia. Insomnia has not previously been emphasized in the literature as a presenting feature of this disease in children and has a broad differential. Recognition of the symptoms of anti-NMDAR encephalitis and its variable presentation are key to early diagnosis and prompt initiation of treatment which may help to improve outcomes.

Locus Ceruleus Norepinephrine Release: A Central Regulator of CNS Spatio-Temporal Activation?

Norepinephrine (NE) is synthesized in the Locus Coeruleus (LC) of the brainstem, from where it is released by axonal varicosities throughout the brain via volume transmission. A wealth of data from clinics and from animal models indicates that this catecholamine coordinates the activity of the central nervous system (CNS) and of the whole organism by modulating cell function in a vast number of brain areas in a coordinated manner. The ubiquity of NE receptors, the daunting number of cerebral areas regulated by the catecholamine, as well as the variety of cellular effects and of their timescales have contributed so far to defeat the attempts to integrate central adrenergic function into a unitary and coherent framework. Since three main families of NE receptors are represented-in order of decreasing affinity for the catecholamine-by: α2 adrenoceptors (α2Rs, high affinity), α1 adrenoceptors (α1Rs, intermediate affinity), and β adrenoceptors (βRs, low affinity), on a pharmacological basis, and on the ground of recent studies on cellular and systemic central noradrenergic effects, we propose that an increase in LC tonic activity promotes the emergence of four global states covering the whole spectrum of brain activation: (1) sleep: virtual absence of NE, (2) quiet wake: activation of α2Rs, (3) active wake/physiological stress: activation of α2- and α1-Rs, (4) distress: activation of α2-, α1-, and β-Rs. We postulate that excess intensity and/or duration of states (3) and (4) may lead to maladaptive plasticity, causing-in turn-a variety of neuropsychiatric illnesses including depression, schizophrenic psychoses, anxiety disorders, and attention deficit. The interplay between tonic and phasic LC activity identified in the LC in relationship with behavioral response is of critical importance in defining the short- and long-term biological mechanisms associated with the basic states postulated for the CNS. While the model has the potential to explain a large number of experimental and clinical findings, a major challenge will be to adapt this hypothesis to integrate the role of other neurotransmitters released during stress in a centralized fashion, like serotonin, acetylcholine, and histamine, as well as those released in a non-centralized fashion, like purines and cytokines.