Sleep Disturbances in People Living With Heart Failure

Kinesiophobia and associated variables in patients with heart failure

AIMS

Patients with heart failure (HF) can exhibit kinesiophobia, an excessive, debilitating, and irrational fear of movement. This study aimed to enhance the understanding of kinesiophobia in patients with HF by analysing associations with the following variables: musculoskeletal pain, quality of life, quality of sleep, functional capacity, disability, frailty, sex, and age.

METHODS AND RESULTS

In this cross-sectional study, 107 participants were included, with ages ranging from 28 to 97 years (57% men, mean age 73.18 ± 12.68 years). Multiple regression analyses were performed with all variables, including polynomial regressions for variables with a non-linear relationship. Kinesiophobia was significantly correlated (P < 0.01) with musculoskeletal pain, quality of life, quality of sleep, functional capacity, disability, and being at risk of frailty, while age and sex were not statistically significant. Frailty disability and musculoskeletal pain intensity were variables linearly associated with kinesiophobia, while quality of sleep and disability had a non-linear relationship with kinesiophobia.

CONCLUSION

Kinesiophobia needs to be evaluated and better understood in patients with HF to improve physical activity and exercise adherence. This study found that musculoskeletal pain intensity, quality of sleep, disability, and frailty risk have a significant association with kinesiophobia in patients with HF. Our results suggest multi-dimensional associations of kinesiophobia in patients with HF, which require further examination and understanding.

Serial multiple mediators in the relationship between symptom burden and sleep quality among patients with heart failure

BACKGROUND

Sleep disturbance is common in patients with heart failure. The aims of this study were to assess the prevalence of sleep disturbance in patients with heart failure, and to examine the serial multiple mediation effects of psychological distress and sleep hygiene practices on the relationship between symptom burden and sleep quality.

METHODS

We recruited eligible heart failure patients in a large, university-affiliated hospital in Shandong Province, China, from November 2018 to June 2019. The Pittsburgh Sleep Quality Index, Heart Failure Somatic Perception Scale, Hospital Anxiety and Depression Scale, and Sleep Hygiene Practice Scale were used to assess patients' sleep quality, symptom burden, psychological distress, and sleep hygiene practices. The mediation effects were analyzed using the PROCESS tool in SPSS.

RESULTS

Two hundred and thirty seven heart failure patients were included in the final analyses. Among these patients, 189 patients (67.1%) had a sleep disturbance (Pittsburgh Sleep Quality Index score of >5). Higher symptom burden, higher level of psychological distress, and poorer sleep hygiene practices were associated with patients' poorer sleep quality. The psychological distress and sleep hygiene practices had mediation effects on the relationship between symptom burden and sleep quality in patients with heart failure.

CONCLUSIONS

Patients' symptom burden could affect their sleep quality through psychological distress and sleep hygiene practices besides a direct effect. Thus, psychological distress and sleep hygiene practices should be fully considered in the development of interventions to improve patients' sleep quality, apart from alleviating patients' symptom burden.

Factors associated with self-care behaviours among Koreans with heart failure

BACKGROUND

Self-care behaviours are important to improve health outcomes in patients with heart failure. However, little is known about the factors related to the subdimensions of self-care behaviours in these patients.

AIMS

To identify the factors associated with the subdimensions of self-care behaviours among South Korean patients with heart failure.

METHODS

The participants in this cross-sectional descriptive study conducted between October 2016 and January 2017 were 178 patients with heart failure. Self-care behaviours were measured using the EHFScB-9, which has three subdimensions: autonomy-based adherence; provider-directed adherence; and consulting behaviours. Demographic characteristics, experience of heart failure education, physical function, patient health questionnaire-9, Pittsburgh sleep quality index and self-care confidence were also measured. Descriptive statistics and multiple linear regression analysis were conducted.

RESULTS

The mean age was 62 ± 12 years, and 37% were women. Younger age (P=0.023), no experience of heart failure education (P=0.039), poor physical function (P=0.003), poor sleep quality (P=0.037) and lower self-care confidence (P=0.001) were significantly associated with poor autonomy-based adherence. Being employed (P=0.042), poor sleep quality (P=0.042) and lower levels of self-care confidence (P=0.001) were associated with poor provider-directed adherence. Younger age (P=0.001) and lower self-care confidence (P=0.001) were associated with lower engagement in consulting behaviours.

CONCLUSION

The three subdimensions of self-care behaviours were associated with different psychosocial factors, necessitating the development of tailored interventions and educational materials based on unique self-care behaviour patterns in patients with heart failure.

Sleep quality is associated with psychosocial functioning and health-related quality of life in pediatric transplant recipients

This study examined patient-reported sleep quality in a single-center cross-sectional sample of adolescents with solid organ transplants and evaluated associations between sleep quality, psychosocial functioning (ie, depression/anxiety symptoms), and HRQOL. Health disparities associated with minority race/ethnicity and socioeconomic variables were also examined. Sixty-nine adolescents (M = 16.51 years; SD = 1.63) who received a solid organ transplant (kidney: n = 25; liver: n = 24; heart: n = 20) completed self-report measures of sleep quality, psychosocial functioning, and HRQOL. Adolescent transplant recipients endorsed significantly lower levels of sleep quality (ie, falling asleep) compared with previously published norms of healthy peers (t = -3.60; P ≤ .001). Higher sleep quality was significantly associated with fewer anxiety and depressive symptoms (r = -.31 to -.40), and higher physical and psychosocial HRQOL (r = .33-.43). Adolescents from minority backgrounds had significantly worse sleep quality compared with non-Hispanic Whites. Adolescent transplant recipients, particularly those from minority backgrounds, may be at increased risk for experiencing poor sleep quality. Suboptimal sleep is a risk factor for higher levels of anxiety and depressive symptoms, as well as lower levels of physical and psychosocial HRQOL. Sleep is an important modifiable factor that, if improved, may contribute to lower anxiety/depressive symptoms and better HRQOL in adolescent transplant recipients.

Associations of Subjective Sleep Quality and Daytime Sleepiness With Cognitive Impairment in Adults and Elders With Heart Failure

This study examined the association of subjective nighttime sleep quality and daytime sleepiness with cognitive impairment in 105 adults (< 60 years old) and 167 elders (≥ 60 years old) with heart failure. Nighttime sleep quality and daytime sleepiness were measured by the Pittsburgh Sleep Quality Index and the Epworth Sleepiness Scale. Cognitive impairment was assessed using a neuropsychological battery measuring attention, memory, and processing speed. Multivariate logistic regression was used. In adults, daytime sleepiness was associated with cognitive impairment, whereas poor nighttime sleep quality was associated with cognitive impairment in elders. Age may play an important role in how sleep impacts cognition in persons with heart failure. Improving nighttime sleep quality and daytime sleepiness in this population may improve cognition.

Quality of life improves in patients with chronic heart failure and Cheyne-Stokes respiration treated with adaptive servo-ventilation in a nurse-led heart failure clinic

AIMS AND OBJECTIVES

The aim of this study was to investigate if quality of life improved in chronic heart failure patients with Cheyne-Stokes respiration treated with adaptive servo-ventilation in nurse-led heart failure clinic.

BACKGROUND

Cheyne-Stokes respiration is associated with decreased quality of life in patients with chronic heart failure. Adaptive servo-ventilation is introduced to treat this sleep-disordered breathing.

DESIGN

Randomised, controlled design.

METHODS

Fifty-one patients (ranging from 53-84 years), New York Heart Association III-IV and/or left ventricular ejection fraction ≤40% and Cheyne-Stokes respiration were randomised to an intervention group who received adaptive servo-ventilation or a control group. Minnesota Living with Heart Failure Questionnaire was used to assess quality of life at randomisation and after three months. Both groups were followed in the nurse-led heart failure clinic.

RESULT

Adaptive servo ventilation improved quality of life-scores both in a per protocol analysis and in an intention to treat analysis. Twenty-one patients dropped out of the study, nine in the control and 12 in the intervention group.

CONCLUSION

Use of adaptive servo-ventilation improved quality of life in chronic heart failure patients with Cheyne-Stokes respiration. However, the drop-out rate was high.

RELEVANCE TO CLINICAL PRACTICE

Chronic heart failure patients come regularly to the nurse-led heart failure clinic. The heart failure nurses' competency has to include knowledge of equipment to provide support and continuity of care to the patients.

A critical analysis of the proposal of the Institute of Medicine to replace myalgic encephalomyelitis and chronic fatigue syndrome by a new diagnostic entity called systemic exertion intolerance disease

The Institute of Medicine (IOM) recently published their report in response to an assignment "to define diagnostic criteria for Myalgic Encephalomyelitis (ME)/chronic fatigue syndrome (CFS), to propose a process for reevaluation of these criteria in the future, and to consider whether a new name for this disease is warranted". The basic pre-assumption of the IOM committee for the development of evidence-based diagnostic criteria for ME/CFS was that ME and CFS denote conditions with similar symptoms, hence ME/CFS. The IOM committee recommends: (1) that ME/CFS will be renamed 'systemic exertion intolerance disease' (SEID); and that a new code should be assigned to SEID in the International Classification of Diseases (ICD), replacing the existing codes for ME (a neurological disease: G93.3) and CFS ('signs, symptoms, and abnormal clinical and laboratory findings, not elsewhere classified': R53.82); (2) that a diagnosis of SEID should be made if the new diagnostic criteria are met; (3) that the Department of Health and Human Services develops a toolkit appropriate for screening and diagnosing patients; and (4) that a multidisciplinary group re-examines the new diagnostic criteria when necessary. This editorial reviews the working procedure of the IOM and two of the outcomes: the recommendation to introduce a new clinical entity (SEID) and new diagnostic criteria. Based upon the contents of the report, and the arguments of the IOM, a search of PubMed and the archive of the Journal of Chronic Fatigue Syndrome using the search terms ME (and old synonyms) and CFS, and a search of PubMed related to the five core symptoms of SEID was conducted. Reviewing the working method and the recommendations, it is concluded that the new diagnostic criteria for SEID are based upon important methodological shortcomings and that the introduction of SEID to replace both ME and CFS has several profound negative consequences outweighing the advantages.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Sleeping difficulties reported by patients with heart failure

The study aimed to describe the reports of heart failure patients on the factors that cause difficulties to sleep and the association of these factors with the quality of sleep. This cross-sectional study involved a non-probabilistic sample of 400 patients (mean age 57.8 years, 64.8% were men, average education of 6.1 years, 82.5% in functional class II or III) with heart failure. The main factors associated with sleeping difficulty were: nocturia, interrupted sleep at night and breathing difficulty. Sleeping difficulties in heart failure patients are diverse and there is an association between these difficulties and quality of sleep. Most of these disorders warrant professional nursing interventions.

[Factors associated to sleep pattern in heart failure patients]

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.

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

Purpose:

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

Methods:

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

Results:

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

Conclusions:

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

Sleep and daytime sleepiness of patients with left ventricular assist devices: a longitudinal pilot study

CONTEXT

No empirical longitudinal data on sleep and daytime sleepiness patterns in patients with an implantable left ventricular assist device (LVAD) exist.

OBJECTIVE

(1) To describe the sleep patterns (sleep onset latency, sleep efficiency, sleep fragmentation index, total sleep time, and wake after sleep onset), sleep quality, and daytime sleepiness variables and (2) to determine the change in the pattern of these variables before and up to 6 months after LVAD implantation.

DESIGN

A longitudinal descriptive repeated-measures design was used. Patients wore wrist actigraphs (AW64 Actiwatch), which objectively measured sleep, for 3 consecutive days and nights before LVAD implant and at the first and second week and first, third, and sixth month after implantation. During these periods, patients also completed questionnaires on sleep quality and daytime sleepiness. Patients-Twelve of 15 patients completed the 6-month data. Data were analyzed by using descriptive statistics and repeated-measures analysis of variance.

RESULTS

We found long sleep onset latencies and low sleep efficiency across time periods. High sleep fragmentation index was noted at baseline and 1 week after LVAD. Short total sleep times, long wake-after-sleep-onset durations, and poor sleep quality were evident at baseline and persisted up to 6 months after LVAD implantation. Low alertness level, a manifestation of sleepiness, was common during late morning to early evening hours. However, only sleep efficiency and wake after sleep onset showed significant changes in pattern (P < .05).

CONCLUSION

Sleep disturbance and daytime sleepiness may be prevalent before and up to 6 months after LVAD implantation, warranting further investigation.

Sleep and Daytime Sleepiness of Patients with Left Ventricular Assist Devices: A Longitudinal Pilot Study

Context

No empirical longitudinal data on sleep and daytime sleepiness patterns in patients with an implantable left ventricular assist device (LVAD) exist.

Objective

(1) To describe the sleep patterns (sleep onset latency, sleep efficiency, sleep fragmentation index, total sleep time, and wake after sleep onset), sleep quality, and daytime sleepiness variables and (2) to determine the change in the pattern of these variables before and up to 6 months after LVAD implantation.

Design

A longitudinal descriptive repeated-measures design was used. Patients wore wrist actigraphs (AW64 Actiwatch), which objectively measured sleep, for 3 consecutive days and nights before LVAD implant and at the first and second week and first, third, and sixth month after implantation. During these periods, patients also completed questionnaires on sleep quality and daytime sleepiness.

Patients

Twelve of 15 patients completed the 6-month data. Data were analyzed by using descriptive statistics and repeated-measures analysis of variance.

Results

We found long sleep onset latencies and low sleep efficiency across time periods. High sleep fragmentation index was noted at baseline and 1 week after LVAD. Short total sleep times, long wake-after-sleep-onset durations, and poor sleep quality were evident at baseline and persisted up to 6 months after LVAD implantation. Low alertness level, a manifestation of sleepiness, was common during late morning to early evening hours. However, only sleep efficiency and wake after sleep onset showed significant changes in pattern (P < .05).

Conclusion

Sleep disturbance and daytime sleepiness may be prevalent before and up to 6 months after LVAD implantation, warranting further investigation.

Self-reported health-related quality of life and sleep disturbances in Taiwanese people with heart failure

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.

Sleep Disturbances and their Relationship to Cardiovascular Disease

Sleep disturbances are a common problem with chronic insomnia occurring in 10% of the general adult population and obstructive sleep apnea present in 4% and 2% of middle-aged men and women respectively. In addition, Americans are sleeping fewer hours per night than they did 20 years ago. There is now increasing evidence that reductions and increases in sleep duration, and various sleep disorders including obstructive sleep apnea and insomnia may be causal factors in the development of cardiovascular disease. Some of the evidence linking disturbances of sleep with cardiovascular disease is described in this review.

Physical activity may promote sleep in cardiac patients suffering from insomnia

Data obtained from a national household survey in Greece (n=1005) were used to assess the relationship between physical activity and insomnia in a group of subjects suffering from several major disabling physical illnesses. A self-administered questionnaire with questions pertaining to general health and related issues was given to the participants. The Short Form-36, the Athens Insomnia Scale (AIS), and the International Physical Activity Questionnaire (IPAQ) were included in the assessment. Half (49.5%) of the participants had moderate or vigorous physical activity and 33.4% had a chronic somatic disease. The prevalence of insomnia in the total sample was 25.3% (n=254); subjects having moderate or vigorous physical activity were 56% less likely to have insomnia in univariate analysis. Multiple analysis revealed a significant interaction of physical activity with heart failure or myocardial ischemia (OR=0.054, 95% CI: 0.003-0.95), indicating that subjects having moderate or vigorous physical activity and heart failure or myocardial ischemia had lower odds for having insomnia compared to individuals with heart problems and low physical activity levels. Consequently, cardiac patients suffering from insomnia seem to benefit from physical exercise. Since sleep disorders are quite frequent in cardiac patients and may result in both physical and psychological complications which deteriorate even further their quality of life and health, our results need replication in this particularly vulnerable population.