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Lodi Rizzini F, Gómez-González AM, Conejero-Cisneros R, Romero-Blanco MJ, Maldonado-Barrionuevo A, Salinas-Sánchez P, Jiménez-Navarro M. Effects of Cardiac Rehabilitation on Sleep Quality in Heart Disease Patients with and without Heart Failure. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16675. [PMID: 36554555 PMCID: PMC9779564 DOI: 10.3390/ijerph192416675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/03/2022] [Accepted: 12/05/2022] [Indexed: 06/17/2023]
Abstract
Insomnia is a modifiable cardiovascular risk factor. Previous studies suggested that attending a cardiac rehabilitation program may improve sleep quality in cardiac patients and pointed out the association between heart failure and poor sleep quality. The primary aim of this study was to evaluate sleep quality in patients attending a Multidisciplinary Cardiac Rehabilitation Program (MRCP), and to compare sleep quality between patients with and without heart failure. A prospective observational study was carried out on a consecutive sample of 240 patients attending an 8-week MRCP; 50 patients (20.8%) were included due to heart failure (NYHA stages I-III) and the rest of them after having undergone any revascularization procedure or valvular surgery. Before and after the completion of the MRCP, the quality of sleep was assessed by the Pittsburgh Sleep Quality Index (PSQI) score. Post-intervention global PSQI scores were statistically significantly lower than those of pre-intervention (p = 0.008), but only 60 patients (25%) registered a clinically significant improvement. When comparing patients with heart failure with those without, no differences in sleep quality were found. This suggests that only a small percentage of patients can achieve clinically significant improvements in sleep quality attending conventional MCRP. Suggestions for future research are given.
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Affiliation(s)
- Fabio Lodi Rizzini
- PhD Program in Biomedicine, Translational Research and New Health Technologies, Faculty of Medicine, University of Málaga, 29010 Malaga, Spain
| | | | | | | | | | - Pablo Salinas-Sánchez
- Department of Human Anatomy, Legal Medicine and History of Science, Faculty of Medicine, University of Málaga, 29010 Malaga, Spain
| | - Manuel Jiménez-Navarro
- Cardiology Department, Virgen de la Victoria University Hospital, IBIMA, CIBERCV, UMA, 29010 Malaga, Spain
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Amisaki R, Kato M, Fujiyama M, Matsuda E, Hattori Y, Hirai M, Yanagihara K, Kinugasa Y, Yamamoto K. Difficulty initiating sleep in patients with heart failure: Impact of left atrial pressure. J Cardiol 2022; 80:365-372. [PMID: 35725947 DOI: 10.1016/j.jjcc.2022.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/26/2022] [Accepted: 06/03/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Patients with heart failure (HF) often complain of sleep discomfort. Previous reports described that difficulty initiating sleep increased the cardiovascular risk in the general population. However, the association between difficulty initiating sleep and cardiac function in patients with HF remains unclear. This study aimed to investigate the associations between difficulty initiating sleep and clinical characteristics and cardiac function in patients with HF. METHODS Eighty-seven patients with HF who underwent overnight polysomnography for suspected sleep-disordered breathing were included. Patients were divided into two groups of the longer sleep latency (SL) group (SL ≥14 min, n = 44) and the shorter SL group (SL <14 min, n = 43). The median value of SL was defined as the time from lights-off to falling asleep. We compared the patients' characteristics, laboratory data, and polysomnographic and echocardiographic indices between the two groups. RESULTS The patients' median age was 67 years, and 85.1 % were men. There was lower beta blocker use [25 (56.8 %) vs. 34 (79.1 %), p = 0.046] and a higher peak mitral early filling velocity to mitral annular velocity ratio (E/e') [16.5 (14.2-21.7) vs. 13.7 (10.9-16.2), p = 0.005] in the longer SL group than in the shorter SL group. In multivariate logistic analysis, E/e' (odds ratio: 1.10, 95 % confidence interval: 1.01 to 1.19; p = 0.032) and systolic blood pressure before sleeping (odds ratio: 1.05, 95 % confidence interval: 1.00 to 1.10; p = 0.033) were significantly associated with a longer SL in patients with HF. CONCLUSIONS Increased left atrial pressure suggested by increased E/e' and increased systolic blood pressure before sleeping is independently associated with difficulty initiating sleep in patients with HF. Management of these hemodynamic imbalances is required to improve difficulty initiating sleep in patients with HF.
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Affiliation(s)
- Ryosuke Amisaki
- Department of Multidisciplinary Internal Medicine, Division of Cardiovascular Medicine and Endocrinology and Metabolism, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Masahiko Kato
- Division of School of Health Science, Department of Pathobiological Science and Technology, Faculty of Medicine, Tottori University, Yonago, Japan.
| | - Misato Fujiyama
- Division of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Eriko Matsuda
- Division of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Yuiko Hattori
- Division of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Masayuki Hirai
- Department of Multidisciplinary Internal Medicine, Division of Cardiovascular Medicine and Endocrinology and Metabolism, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Kiyotaka Yanagihara
- Department of Multidisciplinary Internal Medicine, Division of Cardiovascular Medicine and Endocrinology and Metabolism, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Yoshiharu Kinugasa
- Department of Multidisciplinary Internal Medicine, Division of Cardiovascular Medicine and Endocrinology and Metabolism, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Kazuhiro Yamamoto
- Department of Multidisciplinary Internal Medicine, Division of Cardiovascular Medicine and Endocrinology and Metabolism, Faculty of Medicine, Tottori University, Yonago, Japan
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Olivares MJ, Toledo C, Ortolani D, Ortiz FC, Díaz HS, Iturriaga R, Del Río R. Sleep dysregulation in sympathetic-mediated diseases: implications for disease progression. Sleep 2022; 45:6649852. [DOI: 10.1093/sleep/zsac166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 06/18/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
The autonomic nervous system (ANS) plays an important role in the coordination of several physiological functions including sleep/wake process. Significant changes in ANS activity occur during wake-to-sleep transition maintaining the adequate cardiorespiratory regulation and brain activity. Since sleep is a complex homeostatic function, partly regulated by the ANS, it is not surprising that sleep disruption trigger and/or evidence symptoms of ANS impairment. Indeed, several studies suggest a bidirectional relationship between impaired ANS function (i.e. enhanced sympathetic drive), and the emergence/development of sleep disorders. Furthermore, several epidemiological studies described a strong association between sympathetic-mediated diseases and the development and maintenance of sleep disorders resulting in a vicious cycle with adverse outcomes and increased mortality risk. However, which and how the sleep/wake control and ANS circuitry becomes affected during the progression of ANS-related diseases remains poorly understood. Thus, understanding the physiological mechanisms underpinning sleep/wake-dependent sympathetic modulation could provide insights into diseases involving autonomic dysfunction. The purpose of this review is to explore potential neural mechanisms involved in both the onset/maintenance of sympathetic-mediated diseases (Rett syndrome, congenital central hypoventilation syndrome, obstructive sleep apnoea, type 2 diabetes, obesity, heart failure, hypertension, and neurodegenerative diseases) and their plausible contribution to the generation of sleep disorders in order to review evidence that may serve to establish a causal link between sleep disorders and heightened sympathetic activity.
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Affiliation(s)
- María José Olivares
- Department of Physiology, Laboratory of Cardiorespiratory Control, Pontificia Universidad Católica de Chile , Santiago , Chile
| | - Camilo Toledo
- Department of Physiology, Laboratory of Cardiorespiratory Control, Pontificia Universidad Católica de Chile , Santiago , Chile
- Centro de Excelencia en Biomedicina de Magallanes (CEBIMA), Universidad de Magallanes , Punta Arenas , Chile
| | - Domiziana Ortolani
- Department of Physiology, Laboratory of Cardiorespiratory Control, Pontificia Universidad Católica de Chile , Santiago , Chile
| | - Fernando C Ortiz
- Mechanisms of Myelin Formation and Repair Laboratory, Instituto de Ciencias Biomédicas, Facultad de Ciencias de la Salud, Universidad Autónoma de Chile , Santiago , Chile
| | - Hugo S Díaz
- Department of Physiology, Laboratory of Cardiorespiratory Control, Pontificia Universidad Católica de Chile , Santiago , Chile
- Centro de Excelencia en Biomedicina de Magallanes (CEBIMA), Universidad de Magallanes , Punta Arenas , Chile
| | - Rodrigo Iturriaga
- Department of Physiology, Laboratory of Cardiorespiratory Control, Pontificia Universidad Católica de Chile , Santiago , Chile
- Centro de Excelencia en Biomedicina de Magallanes (CEBIMA), Universidad de Magallanes , Punta Arenas , Chile
| | - Rodrigo Del Río
- Department of Physiology, Laboratory of Cardiorespiratory Control, Pontificia Universidad Católica de Chile , Santiago , Chile
- Centro de Excelencia en Biomedicina de Magallanes (CEBIMA), Universidad de Magallanes , Punta Arenas , Chile
- Centro de Envejecimiento y Regeneración (CARE), Pontificia Universidad Católica de Chile , Santiago , Chile
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Momayyezi M, Fallahzadeh H, Farzaneh F, Momayyezi M. Sleep Quality and Cancer-Related Fatigue in Patients with Cancer. J Caring Sci 2021; 10:145-152. [PMID: 34849358 PMCID: PMC8609120 DOI: 10.34172/jcs.2021.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 12/16/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction: Sleep problems and fatigue are common symptoms reported by cancer patients. In this study, the researchers used a specialized tool to measure fatigue in cancer patients and its relationship with sleep quality in Yazd, Iran.
Methods: This descriptive correlational study included 149 cancer patients (age range: over 18 years) referred to Shahid Sadoughi Hospital in Yazd, Iran. Data were collected by the Pittsburgh Sleep Quality Index (PSQI) and Cancer-Related Fatigue Questionnaire. A PSQI score of ≥5 indicated a poor sleep. Data were analyzed using SPSS Statistics for Windows, version 13.0 (SPSS Inc., Chicago, IL, USA), Pearson’s correlation, t test, analysis of variance (ANOVA), and linear regression.
Results: The mean (SD) PSQI score of patients was 13 (4.85) out of 21. About 69.3% of patients had a poor sleep quality. While the mean (SD) of sleep duration was 5.57 (0.54) hours, it was 69.44 (46.58) minutes for sleep latency. Also, with increasing the mean of sleep quality, the mean of fatigue significantly increased (P < 0.001, R=0.63).
Conclusion: According to the results, there was a relationship between the sleep quality and fatigue in cancer patients, so that patients with better sleep quality had less fatigue.
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Affiliation(s)
- Mahdieh Momayyezi
- Department of Biostatistics and Epidemiology, Center for Healthcare Data Modeling, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Hossein Fallahzadeh
- Department of Biostatistics and Epidemiology, Center for Healthcare Data Modeling, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Fatemeh Farzaneh
- Departement of Biostatistics and Epidemiology, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammad Momayyezi
- Shahid Sadoughi Teaching Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Abstract
It is generally considered that obstructive sleep apnea is a potential cause of heart failure (HF), and insomnia and central sleep apnea are results of HF. However, the number of reports describing the bidirectional relationship between sleep disorder and HF has increased. Sleep disorder may contribute to left ventricular diastolic dysfunction via left atrial overload, left ventricular remodeling, pulmonary hypertension, and atrial fibrillation, which lead to HF with preserved left ventricular ejection fraction. Overnight rostral fluid shift and lung congestion may lead to airflow obstruction in the upper pharynx and stimulate pulmonary irritant receptors, which induce hyperventilation and sleep disorder.
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Affiliation(s)
- Masahiko Kato
- Division of School of Health Science, Department of Pathobiological Science and Technology, Faculty of Medicine, Tottori University, 86 Nishicho, Yonago, Japan.
| | - Kazuhiro Yamamoto
- Department of Cardiovascular Medicine, and Endocrinology and Metabolism, Faculty of Medicine, Tottori University, 36-1 Nishicho, Yonago, Japan
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Zheng T. Sleep disturbance in heart failure: A concept analysis. Nurs Forum 2021; 56:710-716. [PMID: 33665809 DOI: 10.1111/nuf.12566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/18/2021] [Accepted: 02/21/2021] [Indexed: 11/28/2022]
Abstract
AIM This concept analysis aims to analyze the concept of sleep disturbance (SD) in the context of heart failure (HF) to guide the development of a clearly defined definition. BACKGROUND The term "sleep disturbance" has been used in the literature to describe sleep problems and sleep disorders among individuals with HF. Environmental, physical, psychological, behavioral, and developmental factors complicate the phenomenon of SD in HF. DESIGN Walker and Avant's method was used for this concept analysis. DATA SOURCE Published literature from 2000 to 2020 was identified from electronic health profession-related databases. The current definition and usages of SD were abstracted from empirical work and electronic databases. REVIEW METHODS A focused review of abstracts and full text relating to SD in HF was performed. Studies featuring original data and peer-reviewed articles written in English were included to investigate the multifactorial contextual meaning of the concept. RESULTS SD in HF can be described as a condition in which individuals experience difficulty initiating and maintaining sleep, and difficulty continuing or resuming sleep due to frequent nocturnal arousals due to HF symptoms, sleep-disordered breathing, insomnia, and psychological burdens. CONCLUSIONS To evaluate SD in HF, clinicians must examine the underlying causes to provide the contextual meaning of the concept. A clearly defined and distinguishable concept of SD in HF provides a possibility for accurate measurements of sleep quality, exploring interventions, and evaluating outcomes.
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Affiliation(s)
- Tao Zheng
- Pre-doctoral Fellow, Omics and Symptom Science Training Program, University of Washington School of Nursing, Registered Nurse, University of Washington Medical Center, Seattle, Washington, USA
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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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Wang ID, Chien WC, Chung CH, Tsai PY, Chang SY, Meng FC, Peng CK. Non-Apnea Sleep Disorder associates with increased risk of incident heart failure-A nationwide population-based cohort study. PLoS One 2019; 14:e0209673. [PMID: 30650103 PMCID: PMC6334965 DOI: 10.1371/journal.pone.0209673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 12/09/2018] [Indexed: 02/04/2023] Open
Abstract
Purpose Non-apnea sleep disorder (NASD) increases the risk of cardiovascular events, such as hypertension and ischemic heart disease (IHD). Patients with heart failure (HF) are at higher risk for sleep disorder; however, there is no documentation on NASD’s association with HF to date. Therefore, our study aimed to determine whether NASD increases the risk of incident HF. Materials and methods Using the outpatient and inpatient data from Taiwan’s Longitudinal Health Insurance Database, we conducted a nationwide cohort study of patients with a first-time diagnosis of NASD in the year 2000 and followed up the risk of incident heart failure until December 31, 2013. We calculated risks and incidence ratios of HF for patients with NASD compared with the general population. The cumulative incidence of NASD and the subsequent risk of HF are assessed by the Kaplan-Meier method and Cox regression using a matched comparison cohort of HF patients without NASD. Results The NASD cohort had an adjusted hazard ratio (HR) of incident HF 19.7% higher than that of the cohort without NASD (95% CI = 1.130–1.270; p<0.001). In the NASD population, the mean interval to HF in males and females were 5.00±3.69 years and 5.00±3.66 years, respectively. The Kaplan-Meier analysis indicated that after the seventh year, the incidence of HF was higher in the NASD cohort than in the control cohort till the end of the follow up. Conclusions Our study demonstrates that NASD patients are associated with a higher risk of incident HF.
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Affiliation(s)
- I-Duo Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wu-Chien Chien
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
- Department of Medical Research, Tri-Service General Hospital, Taipei, Taiwan
| | - Chi-Hsiang Chung
- Department of Medical Research, Tri-Service General Hospital, Taipei, Taiwan
| | - Pei-Yi Tsai
- Department of Radiation Oncology, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Shan-Yueh Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Fan-Chun Meng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chung-Kan Peng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Sleep Medicine Center, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- * E-mail:
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Redeker NS, Jeon S, Andrews L, Cline J, Mohsenin V, Jacoby D. Effects of Cognitive Behavioral Therapy for Insomnia on Sleep-Related Cognitions Among Patients With Stable Heart Failure. Behav Sleep Med 2019; 17:342-354. [PMID: 28745520 PMCID: PMC5904007 DOI: 10.1080/15402002.2017.1357120] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE/BACKGROUND Cognitive behavioral therapy for insomnia (CBT-I) improves insomnia and fatigue among chronic heart failure (HF) patients, but the extent to which sleep-related cognitions explain CBT-I outcomes in these patients is unknown. We examined the effects of CBT-I on sleep-related cognitions, associations between changes in sleep-related cognitions and changes in sleep and symptoms after CBT-I, and the extent to which cognitions mediated the effects of CBT-I. PARTICIPANTS Stable New York Heart Association Class II-III HF patients (total n = 51; n = 26 or 51.0% women; M age = 59.1 ± 15.1 years). METHODS HF patients were randomized in groups to group CBT-I (n = 30) or attention control (HF self-management education, n = 21) and completed actigraphy, the Insomnia Severity Index, Pittsburgh Sleep Quality Index, Dysfunctional Beliefs and Attitudes about Sleep (DBAS) and Sleep Disturbance Questionnaires (SDQ), and self-reported fatigue, depression, anxiety, and sleepiness (baseline, immediately after treatment, six months). We used mixed-effects modeling, mediation analysis with a bootstrapping approach, and Pearson correlations. RESULTS There was a statistically significant group × mult time effect on DBAS. DBAS mediated the effects of CBT-I on insomnia severity and partially mediated CBT-I effects on fatigue. Improvements in dysfunctional cognitions were associated with improved sleep quality, insomnia severity, sleep latency and decreased fatigue, depression, and anxiety, with sustained effects at six months. CONCLUSIONS Improvement in dysfunctional sleep-related cognitions is an important mechanism for CBT-I effects among HF patients who are especially vulnerable to poor sleep and high symptom burden.
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Affiliation(s)
- Nancy S. Redeker
- Yale University School of Nursing, 400 West Campus Drive, West Haven CT
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Kamkar MZ, Khorshidi SR, Maddah SMA, Emami Zeydi A, Modanloo M. A Cross-Sectional Study Examining the Correlation between Nocturnal Melatonin Level and Sleep Quality in Patients Admitted To the Cardiac Care Unit. Open Access Maced J Med Sci 2018; 6:2342-2347. [PMID: 30607188 PMCID: PMC6311474 DOI: 10.3889/oamjms.2018.451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 11/09/2018] [Accepted: 11/10/2018] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND: Quality of sleep, as a basic need, is an important factor for surviving patients in hospitals. Many factors may contribute to disturbing patients sleep, such as continuous ambient light, is required for healthcare providers to monitor patients. Ambient light can influence patients’ quality of sleep due to melatonin secretion. AIM: Study aimed to determine the correlation between nocturnal melatonin levels and sleep quality in patients admitted to the Cardiac Care Units (CCU). MATERIAL AND METHODS: This cross-sectional study was done on inpatients of CCUs at Amir-Almomenin Hospital in Kordkoy city, a cardiac referral hospital in the northeastern of Iran in 2015. Sixty-eight inpatients were selected through convenience sampling. Before data gathering light level of CCUs was measured every one hour in 2 days, the quality of nocturnal sleep was investigated through Verran and Snyder-Halpern (VSH) Sleep Scale at the second night of admission urinary melatonin level was measured at the same night in all urine excreted between 22:00 pm and 07:00 am. RESULTS: The mean and standard deviation (SD) score of sleep quality in three dimensions of sleep disturbance, sleep effectiveness and sleep supplementation were 336.6 ± 149.9, 269.0 ± 82.2, and 175.2 ± 30.7, respectively. Also, the mean and SD of nocturnal urinary melatonin levels was 323.02 ± 136.21 pg/ml. There was not a significant correlation between level of nocturnal melatonin and three domains of sleep quality; sleep disturbance (r = 0.005, P = 0.968), sleep effectiveness (r = 0.090, P = 0.464), and sleep supplementation (r = -0.037, P = 0.763). CONCLUSION: According to the result, most CCUs patients suffer from sleep disturbance. However, there was no correlation between the level of melatonin and sleep quality. There is a need for recognising the reasons for sleep disturbances in Cardiac Care Units. It is imperative for care providers to be able to recognise the causes of sleep disturbances and to modify environmental factors such as ambient light to improve sleep quality in hospitalised patients.
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Affiliation(s)
- Mohammad Zaman Kamkar
- Department of Psychiatry, Golestan Research Center of Psychiatry, Golestan University of Medical Sciences, Gorgan, Iran
| | - Sommayeh Rezvani Khorshidi
- Department of Medical-Surgical Nursing, Faculty of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Iran
| | | | - Amir Emami Zeydi
- Department of Medical-Surgical Nursing, Nasibeh School of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mahnaz Modanloo
- Nursing Research Center, Golestan University of Medical Sciences, Gorgan, Iran
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Kanno Y, Yoshihisa A, Watanabe S, Takiguchi M, Yokokawa T, Sato A, Miura S, Shimizu T, Nakamura Y, Abe S, Sato T, Suzuki S, Oikawa M, Saitoh SI, Takeishi Y. Prognostic Significance of Insomnia in Heart Failure. Circ J 2016; 80:1571-7. [DOI: 10.1253/circj.cj-16-0205] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yuki Kanno
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Akiomi Yoshihisa
- Department of Cardiology and Hematology, Fukushima Medical University
- Department of Advanced Cardiac Therapeutics, Fukushima Medical University
| | - Shunsuke Watanabe
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Mai Takiguchi
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Tetsuro Yokokawa
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Akihiko Sato
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Shunsuke Miura
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Takeshi Shimizu
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Yuichi Nakamura
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Satoshi Abe
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Takamasa Sato
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Satoshi Suzuki
- Department of Cardiology and Hematology, Fukushima Medical University
- Department of Advanced Cardiac Therapeutics, Fukushima Medical University
| | - Masayoshi Oikawa
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Shu-ichi Saitoh
- Department of Cardiology and Hematology, Fukushima Medical University
| | - Yasuchika Takeishi
- Department of Cardiology and Hematology, Fukushima Medical University
- Department of Advanced Cardiac Therapeutics, Fukushima Medical University
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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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13
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Zuurbier LA, Luik AI, Leening MJG, Hofman A, Freak-Poli R, Franco OH, Stricker BH, Tiemeier H. Associations of heart failure with sleep quality: the Rotterdam Study. J Clin Sleep Med 2015; 11:117-21. [PMID: 25406270 DOI: 10.5664/jcsm.4454] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 10/09/2014] [Indexed: 02/03/2023]
Abstract
STUDY OBJECTIVES The prevalence of sleep disturbances and heart failure increases with age. We aimed to evaluate the associations of incident heart failure and cardiac dysfunction with changes in sleep quality. METHODS This prospective population-based study was conducted in the Rotterdam Study. Of the 3445 eligible persons (mean age 72.0±7.1 years) available for cross-sectional analyses, 8.9% (n = 307) had prevalent clinical heart failure. In longitudinal analyses, 1989 eligible persons (mean age 70.0±5.8 years) were followed for an average of 6.5±0.4 years, of which 4.6% (n = 91) had prevalent or incident clinical heart failure. Heart failure was assessed according to European Society of Cardiology criteria. To estimate cardiac function, we measured left ventricular fractional shortening, left ventricular systolic function, and E/A ratio by echocardiography. Heart failure and cardiac dysfunction were studied with linear regression in relation to sleep quality, assessed by the Pittsburgh Sleep Quality Index. RESULTS No associations between clinical heart failure and sleep quality were observed in cross-sectional analyses. Clinical heart failure predicted a reduction of sleep quality (B = 1.00 points on the Pittsburgh Sleep Quality Index; 95% CI 0.40, 1.60) in longitudinal assessment. This association was driven by the sleep onset latency and sleep quality components of the Pittsburgh Sleep Quality Index. Cardiac dysfunction was not related to sleep quality in cross-sectional or longitudinal analyses. CONCLUSIONS Clinical heart failure, but not cardiac dysfunction measured by echocardiography, increases the risk of poor sleep quality in the general population over time. These findings suggest that clinical manifestations of heart failure negatively affect sleep.
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Affiliation(s)
- Lisette A Zuurbier
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Annemarie I Luik
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Maarten J G Leening
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands: Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Albert Hofman
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Rosanne Freak-Poli
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands: Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Oscar H Franco
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Bruno H Stricker
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands: Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands: Inspectorate for Health Care, The Hague, The Netherlands
| | - Henning Tiemeier
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands: Department of Child and Adolescent Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands: Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
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Andrews LK, Coviello J, Hurley E, Rose L, Redeker NS. "I'd eat a bucket of nails if you told me it would help me sleep:" perceptions of insomnia and its treatment in patients with stable heart failure. Heart Lung 2014; 42:339-45. [PMID: 23998381 DOI: 10.1016/j.hrtlng.2013.05.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 05/06/2013] [Accepted: 05/08/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND Poor sleep, including insomnia, is common among patients with heart failure (HF). However, little is known about the efficacy of interventions for insomnia in this population. Prior to developing interventions, there is a need for better understanding of patient perceptions about insomnia and its treatment. OBJECTIVES To evaluate HF patients' perceptions about 1) insomnia and its consequences; 2) predisposing, precipitating, and perpetuating factors for insomnia; 3) self-management strategies and treatments for insomnia; and 4) preferences for insomnia treatment. METHODS The study, guided by the "3 P" model of insomnia, employed a parallel convergent mixed methods design in which we obtained qualitative data through focus groups and quantitative data through questionnaires (sleep quality, insomnia severity, dysfunctional beliefs and attitudes about sleep; sleep-related daytime symptoms and functional performance). Content analysis was used to evaluate themes arising from the focus group data, and descriptive statistics were used to analyze the quantitative data. The results of both forms of data collection were compared and synthesized. RESULTS HF patients perceived insomnia as having a negative impact on daytime function and comorbid health problems, pain, nocturia, and psychological factors as perpetuating factors. They viewed use of hypnotic medications as often necessary but disliked negative daytime side effects. They used a variety of strategies to manage their insomnia, but generally did not mention their sleep concerns to physicians whom they perceived as not interested in sleep. CONCLUSIONS HF patients believe insomnia is important and multi-factorial. Behavioral treatments, such as cognitive behavioral therapy, for insomnia may be efficacious in modifying perpetuating factors and likely to be acceptable to patients.
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Affiliation(s)
- Laura Kierol Andrews
- Yale University School of Nursing, 100 Church St. South, New Haven, CT 06536, USA.
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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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Laugsand LE, Strand LB, Platou C, Vatten LJ, Janszky I. Insomnia and the risk of incident heart failure: a population study. Eur Heart J 2013; 35:1382-93. [PMID: 23462728 DOI: 10.1093/eurheartj/eht019] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
AIMS Insomnia is highly prevalent among heart failure patients, but only a few small studies have investigated insomnia symptoms and risk of heart failure. We aimed to assess the prospective association between self-reported insomnia symptoms and the risk of incident heart failure in a large Norwegian cohort. METHODS AND RESULTS Baseline data on insomnia symptoms, including difficulty initiating sleep, difficulty maintaining sleep and having non-restorative sleep, socio-demographic variables, and health status, including established cardiovascular risk factors, were collected from 54 279 men and women 20-89 years of age who participated in the Nord-Trøndelag Health study (HUNT) between 1995 and 1997 and were free from known heart failure at baseline. The cohort was followed for incident heart failure from baseline through 2008. We used Cox proportional hazard models to assess the association of baseline insomnia symptoms with the risk of heart failure. A total of 1412 cases of heart failure occurred during a mean follow-up of 11.3 years (SD = 2.9 years), either identified at hospitals or by the National Cause of Death Registry. There was a dose-dependent association between the number of insomnia symptoms and risk of heart failure. The multi-adjusted hazard ratios were 0.96 (0.57-1.61), 1.35 (0.72-2.50), and 4.53 (1.99-10.31) for people with one, two, and three insomnia symptoms, compared with people with none of the symptoms (P for trend 0.021). CONCLUSIONS Insomnia is associated with an increased risk of incident heart failure. If our results are confirmed by others and causation is proved, evaluation of insomnia symptoms might have consequences for cardiovascular prevention.
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Affiliation(s)
- Lars E Laugsand
- Department of Public Health, Faculty of Medicine, Norwegian University of Science and Technology, NTNU, Trondheim N-7491, Norway
| | - Linn B Strand
- Department of Public Health, Faculty of Medicine, Norwegian University of Science and Technology, NTNU, Trondheim N-7491, Norway
| | - Carl Platou
- Department of Public Health, Faculty of Medicine, Norwegian University of Science and Technology, NTNU, Trondheim N-7491, Norway HUNT Research Centre, Norwegian University of Technology and Science, Trondheim, Norway Medical Department, Nord-Trøndelag Health Trust, Levanger, Norway
| | - Lars J Vatten
- Department of Public Health, Faculty of Medicine, Norwegian University of Science and Technology, NTNU, Trondheim N-7491, Norway
| | - Imre Janszky
- Department of Public Health, Faculty of Medicine, Norwegian University of Science and Technology, NTNU, Trondheim N-7491, Norway Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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Varoneckas G, Podlipskyte A, Alonderis A, Martinkenas A. Sleep disordered breathing in coronary heart disease patients with mild and moderate heart failure. Health (London) 2013. [DOI: 10.4236/health.2013.58a2006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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18
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Johansson P, Broström A. Insomnia is associated to depressive symptoms in patients with chronic heart failure. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/ojn.2013.31005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Daneshmandi M, Neiseh F, SadeghiShermeh M, Ebadi A. Effect of eye mask on sleep quality in patients with acute coronary syndrome. J Caring Sci 2012; 1:135-43. [PMID: 25276688 DOI: 10.5681/jcs.2012.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Accepted: 11/11/2011] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Sleep is one of the basic human needs and sleep deprivation causes nu-merous adverse effects on the human body and mind. Due to reduced sleep quality in patients with acute coronary syndrome, this study was carried out to determine the effect of eye mask on sleep quality in patients with acute coronary syndrome. METHODS In this two-group controlled clinical trial, sixty patients with acute coronary syndrome in the coronary care units of Baqiyatallah Hospital in Tehran in 2010 were selected by purposeful sampling method and randomly allocated to two groups of case and control. In the case group, in the second night stay, the intervention of eye mask was done per night and by using the Petersburg's sleep quality index; sleep quality was evaluated during and at the end of hospitalization. Then data were analyzed by paired t-test, independent t-test, Spearman and Pearson's correlation coefficient and SPSS software version 19. RESULTS Total sleep quality score of the case group was significantly decreased after intervention (4.86 ± 1.88) from before intervention (10.46 ± 4.09) (p < 0.000). In addi-tion, total score of sleep quality after intervention in the case group (4.86 ± 1.88) was significant different from the control group (8.43 ± 1.97) (p < 0.005). CONCLUSION Using eye mask, as an economical and uncomplicated method, can improve sleep quality in patients with acute coronary syndrome in the coronary care units and can be used as an alternative method of treatment instead of drug therapy.
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Affiliation(s)
- Mohammad Daneshmandi
- MSc , Instructor, Department of Nursing, Faculty of Nursing, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Fatemeh Neiseh
- MSc , Postgraduate Student, Department of Nursing, Faculty of Nursing, Baqiyatallah University of Medical Sciences, Tehran,Iran
| | - Mehdi SadeghiShermeh
- MSc , Instructor, Department of Nursing, Faculty of Nursing, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Abbas Ebadi
- PhD ,Assistant Professor, Department of Nursing, Faculty of Nursing, Baqiyatallah University of Medical Sciences, Tehran, Iran
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Redeker NS, Adams L, Berkowitz R, Blank L, Freudenberger R, Gilbert M, Walsleben J, Zucker MJ, Rapoport D. Nocturia, sleep and daytime function in stable heart failure. J Card Fail 2012; 18:569-75. [PMID: 22748491 PMCID: PMC3389347 DOI: 10.1016/j.cardfail.2012.05.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 05/01/2012] [Accepted: 05/04/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND The aim of this study was to evaluate nocturia severity and nocturia-related differences in sleep, daytime symptoms and functional performance among patients with stable heart failure (HF). METHODS AND RESULTS In this cross-sectional observational study, we recruited 173 patients [mean age 60.3 ± 16.8 years; female n = 60 (35%); mean left ventricular ejection fraction 32 ± 14.6%] with stable chronic HF from HF disease management programs in the northeastern United States. Participants reported nocturia and completed a 6-minute walk test (6MWT), 1 night of ambulatory polysomnography, and the SF-36 Medical Outcomes Study, Epworth Sleepiness, Pittsburgh Sleep Quality Index, Multidimensional Assessment of Fatigue, and Centers for the Epidemiological Studies of Depression scales. Participants reported 0 (n = 30; 17.3%), 1-2 (n = 87; 50.2%), and ≥3 (n = 56; 32.4%) nightly episodes of nocturia. There were decreases in sleep duration and efficiency, REM and stage 3-4 sleep, physical function, and 6MWT distance and increases in the percentage of wake time after sleep onset, insomnia symptoms, fatigue, and sleepiness across levels of nocturia severity. CONCLUSIONS Nocturia is common, severe, and closely associated with decrements in sleep and functional performance and increases in fatigue and sleepiness in patients with stable HF.
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Affiliation(s)
- Nancy S Redeker
- Yale University School of Nursing, 100 Church Street South, New Haven, CT 06536-07040, USA.
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21
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Riegel B, Ratcliffe SJ, Weintraub WS, Sayers SL, Goldberg LR, Potashnik S, Weaver TE, Pressler SJ. Double jeopardy: the influence of excessive daytime sleepiness and impaired cognition on health-related quality of life in adults with heart failure. Eur J Heart Fail 2012; 14:730-6. [PMID: 22510422 DOI: 10.1093/eurjhf/hfs054] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
AIMS To determine how excessive daytime sleepiness (EDS) and impaired cognition contribute to health-related quality of life (HRQL) in heart failure (HF). METHODS AND RESULTS Adults with chronic HF were enrolled into a prospective cohort study. Data were obtained from 280 subjects enrolled from three sites in the northeastern USA; 242 completed the 6-month study. At baseline, cohorts with and without EDS were identified using the Epworth Sleepiness Scale. Each EDS group was further subdivided into those with and without impaired cognition using a battery of five neuropsychological tests. Two disease-specific measures, the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Functional Outcomes of Sleep Questionnaire (FOSQ), were used to measure HRQL. General linear modelling of square-transformed variables was used to test the hypothesis that cohort membership was a significant predictor of HRQL. At 6 months the remaining sample was 62.5 [standard deviation (SD) 12] years old, mostly male (63%), white (65%), and functionally compromised [72% New York Heart Association (NYHA) class III/IV]. The cohort with both EDS and impaired cognition had the lowest KCCQ overall summary score (60.5 ± 22.5) compared with the cohort without EDS or impaired cognition (74.6 ± 17.4, P ≤ 0.001). A similar effect was seen on the FOSQ (16.0 ± 2.8 vs. 18.5 ± 2.2, P < 0.001). CONCLUSION Impaired cognition alone did not explain poor HRQL, but the addition of EDS poses a significant risk for poor HRQL. Interventions designed to influence EDS may improve HRQL in this population.
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Affiliation(s)
- Barbara Riegel
- University of Pennsylvania School of Nursing, Philadelphia, PA 19104-4217, USA.
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Dos Santos MA, da Cruz DDALM, Barbosa RL. [Factors associated to sleep pattern in heart failure patients]. Rev Esc Enferm USP 2012; 45:1105-12. [PMID: 22031370 DOI: 10.1590/s0080-62342011000500011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Accepted: 02/02/2011] [Indexed: 11/21/2022] Open
Abstract
The objective of this study was to describe sleep patterns in patients with heart failure (HF) and analyze associations between sleep and the following variables: gender, age, fatigue, fatigue on exertion, physical activity, functional class, drug therapy, dyspnea, and body mass index. The nonprobability sample consisted of 400 patients (mean age 57.8 years; 64.8% were men, average schooling of 6.1 years; 82.5% Functional Class II or III). The prevalence of poor sleepers was 68.5%, and 46.5% rated sleep as poor or very poor. Scores suggest that the bad sleeper category was associated with: female, unemployed, fatigue, fatigue on exertion, dyspnea and higher functional classes of HF. The proportion of poor sleepers among patients with HF is among the highest in chronic diseases. Dyspnea and fatigue, common symptoms of this disease, significantly increase the chance of being a bad sleeper.
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Jang Y, Shin J, Cho S, Kim G, Chiriboga DA. The interactive role of chronic medical conditions and sleep disturbance in predicting depressive symptoms among Korean American older adults. Aging Ment Health 2011; 15:198-203. [PMID: 21140307 PMCID: PMC5788280 DOI: 10.1080/13607860903493366] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES This study examined the independent and interactive effects of chronic medical conditions and sleep disturbance on depressive symptomatology. The sample (N = 675) consisted of community-dwelling Korean American older adults, a group that has been found to be particularly high in depressive symptomatology. METHODS A hierarchical regression model of depressive symptoms was estimated with an array of predictors: (a) demographic variables, including immigration history, (b) chronic medical conditions, (c) sleep disturbance, and (d) an interaction between chronic medical conditions and sleep disturbance. RESULTS After controlling for the effects of demographic variables, both chronic medical conditions and sleep disturbance were identified as independent risk factors for depressive symptoms. Moreover, their interaction was significant, indicating that the coexistence of chronic medical conditions and sleep disturbance was significantly associated with higher levels of depressive symptoms (β = 0.15, p < 0.01). CONCLUSION Our findings call attention to sleep hygiene among older individuals with chronic medical conditions and recommend that sleep quality should be closely monitored and assessed by healthcare professionals.
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Affiliation(s)
- Yuri Jang
- Department of Aging and Mental Health Disparities, University of South Florida, Tampa, FL, USA.
| | | | - Soyeon Cho
- Department of Human Services, City University of New York, NY, USA
| | - Giyeon Kim
- Center for Mental Health and Aging, Department of Psychology, The University of Alabama, AL, USA
| | - David A. Chiriboga
- Department of Aging and Mental Health Disparities, University of South Florida, Tampa, USA
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Self-reported health-related quality of life and sleep disturbances in Taiwanese people with heart failure. J Cardiovasc Nurs 2011; 25:503-13. [PMID: 20938252 DOI: 10.1097/jcn.0b013e3181e15c37] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND RESEARCH OBJECTIVE Health-related quality of life (HRQOL) has been viewed as the most important clinical outcome of heart failure (HF) management. However, information about the predictors of HRQOL in Taiwanese people with HF is limited, especially for the effects of sleep disturbances on HF. PURPOSE The purpose of this study was to identify predictors of HRQOL in Taiwanese people with HF, especially focusing on the extent to which sleep variables are related to HRQOL. METHODS A cross-sectional, descriptive correlational design was used. A nonprobability sample of 125 participants was recruited from the outpatient departments of 2 hospitals located in southern Taiwan. Participants were face-to-face individually interviewed to complete the Kansas City Cardiomyopathy Questionnaire, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, and Charlson Comorbidity Index. Data for concomitant health problems and HF characteristics were collected from the medical records. RESULTS The mean Kansas City Cardiomyopathy Questionnaire overall summary score for HRQOL in this sample was 70.50 (SD, 19.63). Health-related quality of life physical symptom had the highest score, and the psychological satisfaction domain had the lowest. Six predictors of the HRQOL were identified by using a 3-step hierarchical multiple regression analysis with forward method. The predictors were education (R² = 0.09), New York Heart Association functional class (R² = 0.398), Charlson Comorbidity Index number (R² = 2.6), subjective sleep quality (R² = 0.037), sleep disturbances (R² = 0.015), and sleep latency (R² = 0.018), and together they accounted for a total of 58.5% of the variance in HRQOL. CONCLUSIONS Nurses should use a holistic perspective to help patients understand and manage the impact of HF on their daily lives. Effective interventions for improving HRQOL should be designed based on patients' needs and lifestyles. The study findings could serve as a baseline for further longitudinal studies to explore the long-term effects of correlates and causal relationships among the variables in this Taiwanese population with HF.
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Redeker NS, Jeon S, Muench U, Campbell D, Walsleben J, Rapoport DM. Insomnia symptoms and daytime function in stable heart failure. Sleep 2010; 33:1210-6. [PMID: 20857868 PMCID: PMC2938862 DOI: 10.1093/sleep/33.9.1210] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES To evaluate insomnia symptoms and the extent to which they are associated with clinical and demographic patient characteristics, daytime symptoms, and functional performance in patients with stable heart failure (HF). DESIGN Cross-sectional, observational. SETTING Five structured HF disease management programs in the Northeastern U.S. PARTICIPANTS 173 stable chronic HF patients INTERVENTIONS N/A. MEASUREMENTS AND RESULTS Full polysomnography was obtained for one night in participants' homes. Participants completed the six-minute walk test, Medical Outcomes Study SF-36, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Multi-Dimensional Assessment of Fatigue Scale, Centers for the Epidemiological Studies of Depression Scale, and questionnaire items eliciting insomnia symptoms (self-reported difficulty initiating and maintaining sleep and waking too early in the morning). Over half of HF patients reported insomnia symptoms. These were associated with increased daytime symptoms (depression, fatigue), excessive daytime sleepiness, and functional performance in models that statistically controlled for clinical and demographic covariates. These relationships were not explained by sleep disordered breathing. CONCLUSIONS Insomnia symptoms are common in patients with stable heart failure and are associated with daytime symptoms and decrements in functional performance.
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Affiliation(s)
- Nancy S Redeker
- Yale University School of Nursing, New Haven, CT 06536-0740, USA.
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Sundin K, Bruce E, Barremo AS. Elderly women's experiences of support when living with congestive heart failure. Int J Qual Stud Health Well-being 2010; 5:10.3402/qhw.v5i2.5064. [PMID: 20640021 PMCID: PMC2875970 DOI: 10.3402/qhw.v5i2.5064] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2010] [Indexed: 11/22/2022] Open
Abstract
Heart failure is a chronic syndrome that has physiological, psychological and social effects. The aim of the study was to illuminate the meanings of support as experienced by elderly women with chronic heart failure. Narrative interviews were conducted with five elderly women with chronic heart failure. A phenomenological hermeneutic method of interpretation was used. The meanings of support were experienced by the women out of two perspectives, that is, when support is present and when there is a lack of support. The findings were revealed in two themes: "Feeling confident means support" and "Feeling abandoned". The women do not wish to be a burden. They want to be independent as much as possible to defend their dignity. An important support to the women is that they are understood and confirmed in their illness. Supportive relations are most valuable, that is, a relationship that supports the women's independence. If there is no supportive relationship, they feel like a burden to others and they feel lonely; this loneliness creates suffering and counteracts wellbeing and health.
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Affiliation(s)
- Karin Sundin
- Department of Nursing, Campus Örnsköldsvik, Umeå University, Örnsköldsvik, Sweden
| | - Elisabeth Bruce
- Department of Nursing, Campus Örnsköldsvik, Umeå University, Örnsköldsvik, Sweden
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Hayes D, Anstead MI, Ho J, Phillips BA. Insomnia and chronic heart failure. Heart Fail Rev 2008; 14:171-82. [PMID: 18758945 DOI: 10.1007/s10741-008-9102-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Accepted: 07/01/2008] [Indexed: 11/29/2022]
Abstract
Insomnia is highly prevalent in patients with chronic disease including chronic heart failure (CHF) and is a significant contributing factor to fatigue and poor quality of life. The pathophysiology of CHF often leads to fatigue, due to nocturnal symptoms causing sleep disruption, including cough, orthopnea, paroxysmal nocturnal dyspnea, and nocturia. Inadequate cardiac function may lead to hypoxemia or poor perfusion of the cerebrum, skeletal muscle, or visceral body organs, which result in organ dysfunction or failure and may contribute to fatigue. Sleep disturbances negatively affect all dimensions of quality of life and is related to increased risk of comorbidities, including depression. This article reviews insomnia in CHF, cardiac medication side-effects related to sleep disturbances, and treatment options.
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Affiliation(s)
- Don Hayes
- Department of Pediatrics, University of Kentucky College of Medicine J410 Kentucky Clinic, 740 South Limestone Street, Lexington, KY 40536, USA.
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Abstract
Heart failure (HF) is associated with high levels of sleep disturbance and sleep disorders, including insomnia, periodic limb movements during sleep, and sleep disordered breathing. Recent studies underscore the importance of disturbances in sleep, a multidimensional biobehavioral phenomenon, to the pathophysiological processes associated with the development of HF, excess morbidity and mortality, and decrements in quality of life and functional performance. Managing disturbed sleep requires specific self-care strategies that must be incorporated into other self-care tasks associated with HF. Decrements in functioning associated with disturbed sleep may also have a negative impact on the self-care capacity and self-care behaviors of people with HF. The purposes of this article are to evaluate the state of the science relative to the nature of sleep disturbance experienced by people with HF and to discuss the implications of sleep, sleep disorders, and sleep-promoting interventions for self-care of people with HF.
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Affiliation(s)
- Nancy S Redeker
- Yale University School of Nursing, New Haven, CT 06536-0740, USA.
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Yang JY, Huang JW, Kao TW, Peng YS, Lu CS, Chen DL, Yang CS, Yang CC, Tsai DM, Liao CS, Chang HW, Wu WC, Wu MS, Wu KD, Chang CJ, Tsai TJ, Chen WY. Impact of spiritual and religious activity on quality of sleep in hemodialysis patients. Blood Purif 2008; 26:221-5. [PMID: 18305384 DOI: 10.1159/000118845] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2007] [Accepted: 11/30/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND Sleep disorders are common in hemodialysis (HD) patients. This study examined the relationship between quality of sleep (QoS) and religious/spiritual activity in HD patients. METHODS The study subjects were 861 HD patients from 14 dialysis clinics in Taiwan. QoS and religious/spiritual activity were evaluated by the Pittsburgh Sleep Quality Index (PSQI) questionnaire and the Royal Free Questionnaire respectively. RESULTS There was no difference in clinical parameters between the good and poor sleepers. Although total scores of religious and spiritual activity did not correlate with global PSQI score, patients who held strong 'spiritual' beliefs reported more problems in 'sleep disturbances', while those who exercised religious beliefs more strongly reported less trouble in 'daytime dysfunction'. CONCLUSION There is no significant correlation between QoS and religious/spiritual activity globally. However, the spiritual and religious activity did associate with different components of QoS.
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Affiliation(s)
- Ju-Yeh Yang
- Department of Internal Medicine, Far Eastern Memorial Hospital, Panchiao, Taiwan
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31
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Gary R, Lee SYS. Physical function and quality of life in older women with diastolic heart failure: effects of a progressive walking program on sleep patterns. ACTA ACUST UNITED AC 2007; 22:72-80. [PMID: 17541316 DOI: 10.1111/j.0889-7204.2007.05375.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This preliminary study tested the effects of a home-based walking intervention on total sleep time (TST), nocturnal awakenings, depressive symptoms, physical function, and quality of life (QOL) in older women with diastolic heart failure (DHF). Twenty-three women (mean age, 68+/-11 years) with New York Heart Association class II or III DHF were randomized to either a 12-week home-based walking intervention (n=13) or education-only program (control, n=10). No between-group differences were found in women in the intervention and control groups on any of the outcome variables. When outcomes were compared within each group at baseline and 12 weeks, intervention-group patients had improvement in TST (P<.01) and heart failure-related QOL (P<.05) and a trend for decreased depressive symptoms (P<.07). Women randomized to the control group had no change in any outcomes. These preliminary findings suggest that a progressive walking program may improve TST and QOL in older women with DHF. Findings from this study support the need for larger studies to evaluate the long-term benefits of a walking program on sleep patterns, QOL, and psychologic function in this population.
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Affiliation(s)
- Rebecca Gary
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA 30322, USA.
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32
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Abstract
Approximately 10% to 70% of people living with chronic heart failure (HF) experience significant sleep disturbances, which have been shown to impair their health-related quality of life and overall functional performance. Research findings, however, report inconsistent conclusions about sleep disturbances and their adverse effects on HF. The purpose of this article is to review several research studies addressing sleep disturbances in patients with HF and to highlight contradictory and inconsistent findings. Further nursing research about the phenomena related to sleep disturbances in people with HF is warranted so that evidence-based assessments and interventions can be tested in the future.
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Affiliation(s)
- Hsing-Mei Chen
- School of Nursing, The University of Texas at Austin, Austin, TX 78701, USA.
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Ingelsson E, Lind L, Arnlöv J, Sundström J. Sleep disturbances independently predict heart failure in overweight middle-aged men. Eur J Heart Fail 2007; 9:184-90. [PMID: 16884954 DOI: 10.1016/j.ejheart.2006.05.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2006] [Revised: 04/24/2006] [Accepted: 05/22/2006] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Sleep disturbances are associated with manifest heart failure (HF). However, the relationship between sleep disturbances and incident HF has been less studied. AIMS To investigate self-reported sleep disturbances as predictors of HF in a longitudinal, community-based cohort of 2314 middle-aged men. METHODS AND RESULTS Data on self-reported sleep disturbances, as well as established risk factors for HF were collected and analyzed using Cox proportional hazards analyses. In multivariable Cox proportional hazards models adjusted for established risk factors for HF, the presence at baseline of sleep disturbances (hazard ratio [HR], 1.52; 95% confidence interval [CI], 1.16-1.99; p=0.002) was an independent risk factor for HF. There was evidence of effect modification between BMI and sleep disturbances. In multivariable-adjusted models, sleep disturbance (HR, 1.58; 95% CI, 1.13-2.21; p=0.008) was an independent risk factor for HF in overweight participants (BMI>25), but not in normal-weight participants (BMI< or =25). All results remained similar in a sub-sample excluding all participants suffering from a myocardial infarction during follow-up. CONCLUSIONS Self-reported sleep disturbances imply an increased risk of subsequent HF in overweight middle-aged men, via mechanisms largely independent of established risk factors for HF, including an interim myocardial infarction.
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Affiliation(s)
- Erik Ingelsson
- Department of Public Health and Caring Sciences, Section of Geriatrics, Uppsala University, Uppsala Science Park, SE-751 85 Uppsala, Sweden.
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Abstract
Heart failure is reaching epidemic proportions in the United States, causing a constellation of disabling symptoms. Cognitive impairment in people with heart failure may be more common than previously known with multiple etiologies from both the disease process and the treatment. Exemplars from a research study are used to illustrate the perspective of heart failure patients. Given the critical importance of memory deficits on patient education, potential nursing interventions to address the issue of cognitive impairment are described.
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Affiliation(s)
- Angela P Clark
- University of Texas at Austin School of Nursing, 78701, USA.
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35
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Redeker NS, Stein S. Characteristics of sleep in patients with stable heart failure versus a comparison group. Heart Lung 2006; 35:252-61. [PMID: 16863897 DOI: 10.1016/j.hrtlng.2005.10.007] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2005] [Accepted: 10/11/2005] [Indexed: 11/20/2022]
Abstract
BACKGROUND Sleep disturbance seems to be common among patients with heart failure (HF). However, little is known about the objective and subjective characteristics of sleep in these patients during daily life or the extent to which the sleep of patients with HF differs from the sleep of other adults. METHODS We examined the extent to which self-reported and objective characteristics of sleep differ between patients with HF with stable systolic blood pressure (n = 59) and a comparison group of adults who did not have HF (n = 59). RESULTS The patients with HF had a significantly lower percentage of wake after sleep onset and more frequent wake bouts, as measured with wrist actigraphs. There were no group-related differences in sleep duration. Sixty-seven percent of the patients with HF compared with 51% of the comparison group had poor global sleep quality, and 44% of the patients with HF versus 18.6% of the comparison group reported excessive daytime sleepiness. CONCLUSION Future research is needed to examine the causes and consequences of disturbed sleep continuity and poor sleep quality and the effects of sleep-promotion strategies designed for patients with HF.
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Affiliation(s)
- Nancy S Redeker
- University of Medicine and Dentistry of New Jersey, School of Nursing, Newark, New Jersey 07101-1709, USA
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Redeker NS, Hilkert R. Sleep and Quality of Life in Stable Heart Failure. J Card Fail 2005; 11:700-4. [PMID: 16360966 DOI: 10.1016/j.cardfail.2005.07.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2005] [Revised: 07/06/2005] [Accepted: 07/11/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Functional performance and mental health are significant quality of life concerns for heart failure (HF) patients. Poor sleep also appears to be common. We examined the extent to which sleep was associated with functional performance and mental health among persons who had stable systolic HF. METHODS AND RESULTS Sixty-one patients with stable systolic HF wore wrist actigraphs to record nocturnal sleep and daily activity for 3 days while living at home, performed 6-minute walks (6MWT), and completed the Pittsburgh Sleep Quality Index and the Medical Outcomes Study SF-36 questionnaire. Self-reported sleep quality and actigraph-recorded wake time and wake bout time explained 9% to 20% of the variance in the functional performance variables (daytime activity level, 6MWT, self-reported physical function), and mental health, after controlling for age, gender, comorbidity, and New York Heart Association class. Time in bed was negatively associated with functional performance. There were no statistically significant relationships between sleep duration and functional performance. CONCLUSIONS Self-reported sleep quality and sleep continuity (sleep that is undisturbed by nocturnal awakenings) are associated with functional performance and mental health in stable systolic HF patients. Effective treatment of sleep problems may contribute to improvement in quality of life.
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Affiliation(s)
- Nancy S Redeker
- University of Medicine & Dentistry of New Jersey, School of Nursing, Newark, New Jersey 07101-1709, USA
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