Prevalence and Determinants of Insomnia After a Myocardial Infarction

Cognitive behavioral therapy for the treatment of insomnia in patients with cardiovascular diseases: a meta-analysis with GRADE analysis

Insomnia, as a difficulty in initiating and maintaining sleep, coupled with cardiovascular diseases (CVDs) increase the risk of aggravate daytime symptoms, mortality, and morbidity. Cognitive behavioral therapy (CBT) is thought to have a significant impact on insomnia treatment, but in patients with CVDs, there is a paucity of data. To provide a comprehensive appraisal on the impact of CBT on the treatment of insomnia in patients with CVDs. We searched Ovid, Scopus, Web of science, and Cochrane central, to randomized controlled trials (RCTs) from inception till November 2022. Outcomes of interest were insomnia severity index (ISI), Pittsburgh Sleep Quality Index (PSQI), sleep efficiency (SE), Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS), and sleep disorders questionnaire (SDQ). Pooled data were analyzed using mean difference (MD) with its 95% confidence interval (CI) in a random effect model using STATA 17 for Mac. Nine RCTs comprising 365 patients were included in the analysis. CBT significantly reduced scores of ISI (MD =  - 3.22, 95%  CI - 4.46 to - 1.98, p < 0.001), PSQI (MD =  - 2.33, 95%  CI - 3.23 to - 1.44, p < 0.001), DBAS (MD =  - 0.94, 95%  CI - 1.3 to - 0.58, p < 0.001), SDQ (MD =  - 0.38, 95%  CI - 0.56 to - 0.2, p < 0.001). Also, it increased the score of SE (MD = 6.65, 95% CI 2.54 to 10.77, p < 0.001). However, there was no difference in terms of ESS. CBT is an easy and feasible intervention with clinically significant improvement in insomnia symptoms. Further large-volume studies are needed to assess sustained efficacy.

Cognitive factors and processes in models of insomnia: A systematic review

Cognition is central to the experience of insomnia. Although unhelpful thoughts about and around insomnia are a primary treatment target of cognitive behaviour therapy for insomnia, cognitive constructs are termed and conceptualised differently in different theories of insomnia proposed over the past decades. In search of consensus in thinking, the current systematic review identified cognitive factors and processes featured in theoretical models of insomnia and mapped any commonality between models. We systematically searched PsycINFO and PubMed for published theoretical articles on the development, maintenance and remission of insomnia, from inception of databases to February, 2023. A total of 2458 records were identified for title and abstract screening. Of these, 34 were selected for full-text assessment and 12 included for analysis and data synthesis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We identified nine distinguishable models of insomnia published between 1982 and 2023 and extracted 20 cognitive factors and processes featured in these models; 39 if sub-factors were counted. After assigning similarity ratings, we observed a high degree of overlap between constructs despite apparent differences in terminologies and measurement methods. As a result, we highlight shifts in thinking around cognitions associated with insomnia and discuss future directions.

Predictors of health-related quality of life in outpatients with coronary heart disease

Introduction

Health-related quality of life (HRQoL) is an important treatment target in patients with coronary heart disease (CHD) and is associated with poor outcomes. Therefore, it is of clinical importance to identify the key determinants of HRQoL among these patients. There is, however, limited knowledge of how a comprehensive set of psychosocial factors influence HRQoL. We aimed to determine the relative associations of clinical and psychosocial factors with mental and physical components of HRQoL in a sample of CHD outpatients.

Methods

This cross-sectional study included 1,042 patients 2-36 (mean 16) months after a CHD event recruited from two general Norwegian hospitals with a combined catchment area making up 7% of the Norwegian population, representative with regards to demographic and clinical factors. We collected data on HRQoL, demographics, comorbidities, coronary risk factors, and psychosocial factors. HRQoL was assessed using the Short Form 12 (SF12), which comprises a Mental Component Scale (MCS), and the Physical Component Scale (PCS). Crude and multi-adjusted linear regression analyses were used to investigate the association between covariates and MCS and PCS.

Results

Mean age was 61 [standard deviation (SD) 10] years, 20% were females, 18% had type D personality, 20% significant depression symptoms, 14% significant symptoms of anxiety whereas 45% reported insomnia. The presence of type D personality (β: -0.19), significant symptoms of depression (β: -0.15), and the presence of insomnia (β: -0.13) were negatively associated with MCS, but not PCS in multi-adjusted analyses. The presence of chronic kidney disease (β: -0.11) was associated with reduced MCS, whereas the presence of chronic obstructive pulmonary disease (β: -0.08) and low physical activity (β: -0.14) were negatively associated with PCS. Younger age was associated with lower MCS, whereas older age was associated with lower PCS.

Discussion

We conclude that Type D personality, depressive symptoms, insomnia, and chronic kidney disease were the strongest determinants of the mental component of HRQoL. Assessing and managing these psychological factors among CHD outpatients may improve their mental HRQoL.

Evaluating the Feasibility and Efficacy of A Novel CBTi/SMT Treatment Protocol for Cardiac Rehab Patients: A Non-Randomized Pilot Trial

INTRODUCTION

Cardiac patients and those with chronic medical conditions often suffer from comorbidities such as insomnia and mood disorders. Previous treatment protocols have focused on resolving symptoms of anxiety and depression in this population using Stress Management Training (SMT). However, these treatments have neglected the importance of sleep problems in these patients. This pilot trial sought to address this by examining the feasibility of a novel CBTi/SMT treatment protocol.

METHODS

42 participants attending a Cardiac Rehab (CR) exercise program registered in this 7-week non-randomized pilot trial. The primary objective of the pilot trial was to determine the feasibility of the protocol for retention and adherence rates. Secondarily, the authors sought to examine the potential efficacy of the program in terms of treating insomnia, depression, anxiety, emotion dysregulation, and arousal.

RESULTS

29 participants attended at least 1 class, with 21 participants completing the program. The average attendance for the program completers was 6 out of 7 classes (SD = 0.8) with four days of practice each week (SD = 1.6) for 33 minutes daily (SD = 16.8). Moreover, the number of participants meeting clinical threshold for insomnia, anxiety, and/or depression was significantly reduced at post-treatment and follow-up. Similarly, raw scores on the relevant scales were significantly reduced at both timepoints.

CONCLUSION

This pilot trial provided preliminary evidence for the feasibility and efficacy of targeting sleep improvement with a combined CBTi/SMT protocol. This provides the groundwork for future RCTs to establish the effectiveness of targeting insomnia in a range of medical populations.

Prevalence, Impact, and Trajectories of Sleep Disturbance in Cardiac Rehabilitation: A NARRATIVE REVIEW AND SUGGESTIONS FOR EVALUATION AND TREATMENT

OBJECTIVE

The aim of this review was to summarize literature examining the prevalence, impact, and trajectories of sleep disturbance in cardiac rehabilitation (CR) patients and discuss how CR programs may incorporate targeted evaluation and interventions to promote sleep health.

REVIEW METHODS

A narrative review of literature allowed for an examination of the prevalence of sleep disturbance in CR patients, the effects of sleep disturbance on CR outcomes, and trajectories of sleep disturbance in CR.

SUMMARY

Sleep disturbance is prevalent in CR patient populations and is related to clinical and functional outcomes. Sleep may be an important biobehavioral process to target in CR to improve important patient outcomes and achieve secondary prevention goals.

Sleep disturbance after acute coronary syndrome: A longitudinal study over 12 months

Background

Sleep disturbance has been associated with poor prognosis in patients with acute coronary syndrome (ACS). This study examined the course of sleep disturbance and associated factors in patients with ACS who were followed for one year.

Methods

Study participants were 180 patients (mean age 59.6 years, 81.7% men) with ACS admitted to a tertiary hospital to undergo acute coronary intervention. Sleep disturbance was interviewer-assessed at admission (n = 180), at 3 months (n = 146), and at 12 months (n = 101) using the Jenkins Sleep Scale (JSS)-4, with a total of 414 assessments over one year. Random linear mixed regression models were used to evaluate the relationship between sociodemographic factors, cardiac diseases severity, perceived distress during ACS, comorbidities, medication, health behaviors, and sleep disturbance over time.

Results

At admission, 3 months, and 12 months, 56.7%, 49.3%, and 49.5% of patients, respectively, scored above the mean value for sleep disturbance in the general population (JSS-4 score ≥5). There was a significant decrease in continuous JSS-4 scores over time [estimate (SE) = -0.211 (0.074), p = 0.005]. Female sex [0.526 (0.206), p = 0.012], greater fear of dying [0.074 (0.026), p = 0.004], helplessness during ACS [0.062 (0.029), p = 0.034], and a history of depression [0.422 (0.171), p = 0.015] were independently associated with higher JSS-4 scores over time.

Conclusion

Despite a decrease from admission to 3 months, sleep disturbance is prevalent in the first year after ACS. Female sex, depression history, and distress during ACS identify patients at increased risk of developing persistent sleep disturbance and may inform interventions to prevent sleep disturbance.

Worry and rumination predict insomnia in patients with coronary heart disease: a cross-sectional study with long-term follow-up

STUDY OBJECTIVES

Insomnia is highly prevalent and associated with anxiety and depression in patients with coronary heart disease patients. The development of effective psychological interventions is needed. Worry and rumination are potential risk factors for the maintenance of insomnia, anxiety, and depression that may be modified by psychological treatment grounded in the Self-Regulatory Executive Function model. However, the relationships between worry, rumination, anxiety and depression, and insomnia are not known. Therefore, we investigated these relationships both cross-sectionally and longitudinally among patients with coronary heart disease.

METHODS

A cross-sectional study consecutively included 1,082 patients in 2014-2015, and 686 were followed up after mean of 4.7 years. Data were gathered from hospital records and self-report questionnaires comprising assessment of worry (Penn State Worry Questionnaire), rumination (Ruminative Responses Scale), anxiety and depression (Hospital Anxiety and Depression Scale), and insomnia (Bergen Insomnia Scale).

RESULTS

Insomnia correlated moderately with all other psychological variables (R 0.18-0.50, all P values < .001). After adjustments for anxiety and depression, odds ratios for insomnia at baseline were 1.27 (95% confidence interval 1.08-1.50) and 1.60 (95% confidence interval 1.31-1.94) per 10 points increase of worry and rumination, respectively. Corresponding odds ratios for insomnia at follow-up were 1.28 (95% confidence interval 1.05-1.55) and 1.38 (95% confidence interval 1.09-1.75). Depression was no longer significantly associated with insomnia after adjustments for worry and rumination, but anxiety remained significant.

CONCLUSIONS

Worry and rumination predicted insomnia both cross-sectionally and prospectively, even after controlling for anxiety and depression, although anxiety remained significant. Future studies may test psychological interventions targeting these factors in patients with coronary heart disease and insomnia.

CITATION

Frøjd LA, Papageorgiou C, Munkhaugen J, et al. Worry and rumination predict insomnia in patients with coronary heart disease: a cross-sectional study with long-term follow-up. J Clin Sleep Med. 2022;18(3):779-787.

Psychometric Properties of the Insomnia Severity Index Among Arabic Chronic Diseases Patients

Introduction

The Insomnia Severity Index (ISI) is a self-administrated questionnaire most frequently used to assess insomnia in clinical and non-clinical populations.

Objective

To evaluate the psychometric properties of the Arabic ISI among patients diagnosed with chronic diseases.

Methods

A cross-sectional and descriptive correlational design was used. A total of 1,005 patients with chronic diseases completed the seven items of the Arabic ISI version. The scale was assessed in terms of acceptability, internal consistency, and validity. Construct validity was explored with the use of principal factor analysis and confirmatory factor analysis, to examine the dimensional structure of the ISI.

Results

The Cronbach's alpha coefficient for the Arabic ISI was 0.82, which shows good reliability. The total ISI score did not have floor or ceiling effects. There was evidence of discriminate validity. The Principal Component Analysis (PCA) indicated two factors (four items loading on Factor I and three items loading on Factor II). The construct validity of PCA in terms of two factors was explored by confirmatory factor analysis to examine the dimensional structure of the ISI. The confirmatory factor analysis showed an absolute fit for the two-factor model.

Conclusion

The results support the two-factor structure of ISI. The Arabic version of the ISI demonstrated good reliability and validity for assessing insomnia in patients diagnosed with chronic diseases.

A comprehensive description of self-reported health and life satisfaction in cardiac arrest survivors

BACKGROUND

Self-reported health and life satisfaction are considered important outcomes in people surviving cardiac arrest. However, most previous studies have reported limited aspects on health, often based on composite scores, and few studies have focused on life satisfaction. Investigating health aspects with a broad and detailed perspective is important to increase the knowledge of life after cardiac arrest from the perspective of survivors. In addition, the knowledge of potential differences in health among survivors related to place of arrest (in-hospital cardiac arrest; IHCA or out-of-hospital cardiac arrest; OHCA) is scarce. The aim was to describe and compare self-reported health and life satisfaction in IHCA and OHCA survivors.  METHODS: This observational cross-sectional study included adult cardiac arrest survivors six months after resuscitation, treated at five Swedish hospitals between 2013 and 2018. Participants received a study specific questionnaire including Health Index (HI), EQ-5D 5 Levels (EQ-5D-5L), Minimal Insomnia Sleeping Scale (MISS), Multidimensional Scale of Perceived Social Support (MSPSS), Hospital Anxiety and Depression Scale (HADS), and Satisfaction With Life Scale (SWLS). In order to present characteristics descriptive statistics were applied. The Mann-Whitney U test, chi-square test or Fishers' exact test were used to compare differences in self-reported health and life satisfaction between in-hospital- and out-of-hospital cardiac arrest survivors RESULTS: In total, 212 survivors participated. Based on scale scores and general measures, the median scores of health and life satisfaction among survivors were high: HI total = 29, EQ VAS = 80, and SWLS = 20. According to HI, most problems were reported for tiredness (37.3 %) and strength (26.4 %), while pain/discomfort (57.5 %) and anxiety/depression (42.5 %) where most common according to EQ-5D-5L. Except for EQ-5D-5L mobility (p = 0.023), MSPSS significant other (p = 0.036), and MSPSS family (p = 0.043), no health differences in relation to place of arrest were identified.

CONCLUSIONS

Although general health and life satisfaction were good among cardiac arrest survivors, several prevalent health problems were reported regardless of place of arrest. To achieve an improved understanding of health in cardiac arrest survivors, it is important to assess specific symptoms as a complement to composite scores of general, physical, emotional, and social health.

Insomnia in patients with coronary heart disease: prevalence and correlates

STUDY OBJECTIVES

The aim of this study was to determine the prevalence of insomnia and its association with clinical and psychosocial factors in a large sample of outpatients with coronary heart disease.

METHODS

The sample comprised 1,082 patients, mean age 62 years (21% female), who participated in the cross-sectional NORwegian CORonary Prevention Study. Patients who were hospitalized with myocardial infarction and/or a coronary revascularization procedure in 2011-2014 responded to a self-report questionnaire and participated in a clinical examination with blood samples 2-36 (mean, 16) months later. Insomnia was assessed using the Bergen Insomnia Scale, a questionnaire based on the criteria for the clinical diagnosis of insomnia as described in the Diagnostic and Statistical Manual of Mental Disorders, fourth version. We performed bivariate logistic regressions for crude analysis and backward stepwise logistic regressions for multiadjusted odds ratios (OR).

RESULTS

In total, 488 patients (45%) reported insomnia, and 24% of these patients had used sleep medication in the previous week. Anxiety symptoms (OR: 5.61) were the strongest determinants of insomnia, followed by female sex (OR: 1.88), diabetes (OR: 1.83), eating fish fewer than three times a week (OR: 1.69), type D personality (OR: 1.69), and C-reactive protein ≥ 2 mg/L (OR:1.58), in multiadjusted analyses.

CONCLUSIONS

Insomnia was highly prevalent in coronary heart disease outpatients. Psychological factors, lifestyle factors, and subclinical inflammation were associated with insomnia. Our results emphasize the need to identify patients with insomnia and provide appropriate management of insomnia in outpatients with coronary heart disease.

Longitudinal sleep characteristics and hypertension status: results from the Wisconsin Sleep Cohort Study

AIMS

Sleep characteristics such as short sleep duration or sleep-disordered breathing are established predictors of hypertension. However, few studies have used in-lab polysomnography with a longitudinal design to measure how hypertension is associated with different sleep stages over time. The purpose of this study is to examine whether hypertension is associated with the longitudinal course of sleep quality over time.

METHODS

The current study evaluated data from the Wisconsin Sleep Cohort Study, which consists of 1525 adults in a community-based population of middle-aged to older adults followed for approximately 12-25 years. Sleep characteristics were objectively measured using polysomnography and subjectively assessed using a self-report questionnaire on insomnia complaints. We used linear mixed-effects regression models and cumulative logit models to assess whether the interaction of hypertension and time is associated with objective and subjective sleep.

RESULTS

We found people with hypertension exhibited a greater decline in total sleep time in rapid eye movement sleep (%) over time than those without hypertension (P < 0.05). Individuals with hypertension had less decline in % N3 sleep over time than those without hypertension (P < 0.05). Among the subjective insomnia complaints, our findings indicate hypertensive individuals have a higher probability of having higher levels of 'difficulties in falling asleep' compared with people without hypertension.

CONCLUSION

These findings suggest that hypertension is associated with modified longitudinal changes of objective and subjective sleep characteristics.

The effect of nurse-led Internet-based cognitive behavioural therapy for insomnia on patients with cardiovascular disease: A randomized controlled trial with 6-month follow-up

Aim

To test the effect of nurse‐led Internet‐based cognitive behavioural therapy for insomnia (I‐CBTI), tailored for patients with cardiovascular disease (CVD), with a 6‐month follow‐up.

Design

A two‐arm parallel‐group randomized controlled trial (RCT) registered at clinicaltrials.gov (NTC03938805) and reported according to the CONSORT checklist.

Methods

Forty‐eight patients (mean age 72 years, 65% men) diagnosed with CVD and insomnia were randomized to either 9‐week nurse‐led I‐CBTI with support, or an Internet‐based self‐study programme without support (control group). Insomnia Severity Index (ISI) and Short Form Health Survey (SF‐12) were used as primary and secondary outcomes.

Results

ISI showed a significant treatment effect of I‐CBTI compared to the control group at 9‐week follow‐up. The mean ISI score in the I‐CBTI group at 9 weeks post‐treatment was maintained at the 6‐month follow‐up. Patients' adherence to I‐CBTI was associated with a better effect on both the ISI and SF‐12.

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.

Analysis of the evidence of related factors, associated conditions and at-risk populations of the NANDA-I nursing diagnosis insomnia

Objectives

To summarize evidence in the literature on the predictors of insomnia in adults and to determine correspondences with diagnostic indicators of the NANDA-I diagnosis Insomnia.

Methods

An integrative review performed in Pubmed, Virtual Health Library and CINAHL. Forty-eight articles published in Portuguese, English or Spanish from 2011 to 2018 were included. An analysis of correspondence between the predictors and the NANDA-I related factors and associated conditions for Insomnia was performed.

Results

There was a correspondence of the predictors found in this review with NANDA-I related factors and associated conditions, except for grieving and frequent naps during the day. Smoking, caffeine intake, dysfunctional sleep beliefs, obesity and caregiver role strain are possible new related factors; chronic illness is a possible new associated condition and individuals going through changes in marital status, economically disadvantaged, female gender, increasing age and night shift worker are possible new at-risk populations.

Conclusion

The predictors of insomnia that had a correspondence with the NANDA-I elements can support the evidence base of the nursing diagnosis. The predictors found without a correspondence with the diagnosis can be considered for inclusion in the NANDA-I classification, thereby supporting the clinical reasoning of nurses and students.

Sleep Disturbances in Patients With Coronary Heart Disease: A Systematic Review

STUDY OBJECTIVES

Investigation into sleep and coronary heart disease (CHD) has predominantly been focused on sleep disturbances as a risk factor for developing CHD. Objectively measured and self-reported sleep at a patient level has only been sparsely and not systematically reported. Therefore, we set out to review the literature for studies using objectively measured and self-reported sleep in patients with CHD. The review focuses on patients with acute coronary syndrome (ACS) and stable CHD.

METHODS

A systematic review performed in four databases adhering to the PRISMA guidelines applying a qualitative synthesis of evidence.

RESULTS

Following ACS, we found sleep architecture to be significantly disturbed with changes normalizing over a period of up to 6 months. With increasing severity of CHD, sleep disturbances were more pronounced; however, the modulating effects of sleep-disordered breathing and ejection fraction on sleep in patients with CHD are conflicting. Overall, studies were predominantly cross-sectional in design and of low methodological quality. Polysomnography was the predominant outcome assessment tool and validated self-reported assessment tools were limited.

CONCLUSIONS

Future investigations in sleep and CHD applying both a longitudinal design and investigating objective and self-reported sleep assessments are warranted.

SYSTEMATIC REVIEW REGISTRATION

Registry: PROSPERO, Title: Sleep measures in relation to coronary heart disease: a systematic review, Identifier: CRD42017056377, URL: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=56377.

Reducing Coronary Heart Disease Risk Through Treatment of Insomnia Using Web-Based Cognitive Behavioral Therapy for Insomnia: A Methodological Approach

Objective: Observational data demonstrate increased risk of recurrent acute coronary syndrome in patients with comorbid insomnia. We conducted a pragmatic randomized controlled pilot study to address knowledge gaps and inform future large-scale randomized trials to test the impact of Web-based cognitive behavioral therapy for insomnia (wCBT-I) on coronary heart disease (CHD) outcomes. Participants: Thirty-five adults recruited from Brigham and Women's and Cleveland Clinic Hospitals with insomnia, defined by Insomnia Severity Index (ISI) score ≥ 10 and symptoms of at least 3 months, and comorbid CHD identified from medical records. Methods: We randomized 34 patients to either general sleep education coupled with wCBT-I or general sleep education alone followed by an opportunity for treatment after the study (a wait-list control) to evaluate feasibility and uptake of insomnia treatment in patients with heart disease. Participants completed the ISI at baseline and 6 weeks to assess insomnia severity. Results: Twenty-nine adults completed the trial, yielding an 85% retention rate, and adherence rate in the treatment arm was 80%. Mean age was 71.6 ± 9.5 years, 75% were male, and mean body mass index (BMI) was 29 ± 4.5 kg/m². Baseline ISI scores were 15.6. There was a 6.2 ± 5.3 point reduction in ISI scores in the intervention arm and a 3.3 ± 5.1 reduction in the control arm (p value 0.1). Conclusion: Web-based CBT-I intervention was feasible in an older sample with prevalent CHD and resulted in clinically meaningful improvement in insomnia severity, though statistical significance was limited by lack of power.