Sleep disturbance in people with heart failure: implications for self-care

Nighttime sleep and daytime sleepiness patterns among left ventricular assist device patients

Despite the high prevalence of sleep disturbance in the heart failure population, information about its consequence on daytime function in patients with left-ventricular assist devices (LVADs) is limited. This study examined the nighttime and daytime sleep patterns and changes from pre-implant to 6 months post-implant. This study included 32 LVAD patients. Demographics, nighttime and daytime sleep variables were collected pre-implant and at 1, 3, and 6 months post-implant. Wrist actigraphy and self-report questionnaires measured objective and subjective sleep, respectively. Objective nighttime sleep data were sleep efficiency (SE), sleep latency (SL), total sleep time (TST), wake after sleep onset (WASO), and sleep fragmentation (SF). Objective daytime sleep data were nap times. Self-reported Subjective Sleep Quality Scale (SSQS) and Stanford Sleepiness Scale (SSS) were subjective measures. Increased SF and WASO scores and decreased TST and SE scores were found pre-LVAD implant, indicative of poor sleep quality. TST, SE, naptime and SSQS scores were higher at 3 and 6 months post-implant compared to baseline. Decreases in TST and SF scores were observed at 3 and 6 months post-implant along with increases in SSS scores. Increasing SSS scores and decreasing overall scores from pre- and up to 6 months post-implant suggest improvement in daytime function. This study provides information on sleep-daytime function in the LVAD patient population. Improvements in daytime sleepiness do not imply "good" sleep quality, consistent with the extant knowledge in LVAD literature. Future investigations should elucidate the mechanism by which sleep-daytime function influences quality of life.

Sleep Quality in the Advanced Heart Failure ICU

In this study, we evaluated sleep quality changes in persons with advanced heart failure (HF) who were admitted to the intensive care unit. Sleep quality was assessed at admission, during hospitalization, and post-discharge. Statistical tests compared within subject mean sleep quality over time (n = 22). Poor quality sleep was reported by 96% of participants at admission, 96% during hospitalization, and 86% post-discharge. Significant differences were found between timepoints in global sleep quality, subject sleep quality, sleep duration, and habitual sleep efficiency. A greater proportion of these participants had poor global sleep quality during hospitalization than previously reported. Participants reported better sleep post-discharge than admission and during hospitalization. Interventions enhancing hospital sleep, along with home sleep self-management education, would improve HF outcomes. Implementation science methods are warranted to integrate efficacious interventions in this population.

Sleep disturbance in heart failure: A concept analysis

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.

Perceived Stress, Subjective, and Objective Symptoms of Disturbed Sleep in Men and Women with Stable Heart Failure

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 (M_age: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.

Association between sleep quality and self-care in adults with heart failure: A systematic review

BACKGROUND

Sleep disturbance is one of the most common symptoms among heart failure patients. Sleep disturbance reduces quality of life and leads to higher rates of mortality. It may affect the ability of patients to perform adequate self-care. Although some research has evaluated the association between sleep quality and heart failure self-care, a synthesis of the most recent available evidence is lacking.

AIMS

This systematic review aimed to assess the association between sleep quality and self-care in adults with heart failure.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology was used. Medline, CINAHL, PsycINFO and SCOPUS were searched. Observational, case-control and cohort studies were considered. The quality of the studies was evaluated with the Joanna Briggs Institute's Critical Appraisal Tools.

RESULTS

Six articles were included. Association between sleep quality and self-care was reported by three studies. One of these did not find an association between sleep disturbance and heart failure self-care, while the other two studies did. An association between sleep quality and medication adherence was reported by three studies. All three of these studies found associations between these two variables. Studies have measured similar but different constructs. Two studies assessed sleep quality, while four other studies measured excessive daytime sleepiness. Half of the studies examined self-care, while the other half measured medication adherence.

CONCLUSIONS

Although the evidence should be strengthened, sleep quality seems to affect self-care in heart failure patients. The mechanism underlying the effect of sleep quality on heart failure self-care remains unclear. Future longitudinal interaction analyses could be useful to clarify this mechanism.

Insomnia and Insomnia Symptoms in Persons With Heart Failure: An Integrative Review

BACKGROUND/OBJECTIVE

Insomnia and insomnia symptoms are highly prevalent in persons with heart failure (HF), and they are associated with several untoward outcomes. The purpose of this integrative review is to describe the correlates, predictors, and outcomes of insomnia and insomnia symptoms in persons with HF.

METHODS

Using integrative review methods, an extensive electronic search of 5 databases was conducted for the period of 2000-2019. Sixteen studies were identified that met the inclusion criteria for review and investigated insomnia or insomnia symptoms in HF.

RESULTS

Various sociodemographic factors, chronic comorbidities, clinical factors, and cognitive-behavioral factors are correlates and predictors of insomnia and insomnia symptoms in persons with HF. Depression, fatigue, daytime sleepiness, poor self-reported physical functioning, decreased exercise capacity, cardiac events, and poor health-related quality of life are significant outcomes of insomnia and insomnia symptoms in persons with HF. The associations of insomnia and insomnia symptoms with age, sex, sleep-disordered breathing, and cognition were not consistent across all studies.

CONCLUSION

Larger studies with diverse age and race groups as well as longitudinal studies and designs that test mediation effects are needed to disentangle complex relationships between insomnia and insomnia symptoms and several of their potential predictors and correlates in HF.

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.

Activity Sensors to Evaluate the Effect of Sacubitril/Valsartan on Quality-of-Life in Heart Failure: rational and design of the AWAKE-HF study

Aims

Limited data are available regarding the ability of sacubitril/valsartan to provide clinically meaningful health‐related quality of life (HRQoL) improvements among individuals with heart failure (HF). Objective measurement of physical activity and sleep using actigraphy can provide insight into daily functioning and HRQoL.

Methods and results

We designed an 18 week, multicenter, randomized, double‐blind, double‐dummy, parallel‐group study to objectively assess changes in function and HRQoL directly after initiating sacubitril/valsartan vs. enalapril in participants with HF in their home environments. A total of 136 outpatient, ambulatory participants with New York Heart Association Class II or III HF with reduced ejection fraction (HFrEF) will be included in the study. Patients will undergo a 2 week baseline observational phase (continuing current HF treatment); data from the second week of this phase will be the baseline value for comparison with those of subsequent periods. Patients will then enter an 8 week blinded‐treatment phase (randomly assigned 1:1 to sacubitril/valsartan or enalapril), followed by an 8 week open‐label extension phase (treatment with only sacubitril/valsartan). The primary efficacy endpoint is the change in mean activity counts during the most active 30 min of the participant's day between baseline and the final randomized treatment phase measurement. Secondary endpoints include the change in mean sleep activity during the randomized and open‐label phases; questionnaires will also assess HRQoL measures. Rather than analysing pooled actigraphy data, the researchers are considering each participant to be acting as his or her own control.

Conclusions

This will be the first study to assess the effects of sacubitril/valsartan on objective measures of sleep and activity in individuals with HFrEF within the context of their daily lives. Wearable accelerometer devices will be used to gain insight into how the medication affects physical activity and sleep.

Effects of early mobilization protocol performed after cardiac surgery on patient care outcomes

AIM

This study aimed to determine the effects of an early mobilization protocol performed in patients who underwent cardiac surgery on post-operative outcomes.

BACKGROUND

Post-operative complications are common in patients undergoing cardiac surgery. Early mobilization is recommended for patients who undergo cardiac surgery to prevent complications and achieve successful outcomes in post-operative care.

DESIGN

The study design was quasi-experimental with a control group.

METHODS

Participants were patients who underwent cardiac surgery between January and October 2015. The study included 102 patients (51 patients each in the experimental and control groups). The introductory characteristics form, the Richards-Campbell Sleep Questionnaire (RCSQ), duration of hospital stay (post-operatively), and development of a post-operative late complications form were used to collect data.

RESULTS

The study results revealed that patients in the experimental group had better improvement in RCSQ scores, shorter duration of hospitalization, and fewer late complications after surgery than patients in the control group.

CONCLUSION

Early mobilization is feasible in adult cardiac surgery patients and has significant benefits. More research is recommended into the effectiveness of early mobilization in different patient groups.

Sleepless nights and sleepy days: a qualitative study exploring the experiences of patients with chronic heart failure and newly verified sleep-disordered breathing

BACKGROUND

Sleep-disordered breathing, including obstructive sleep apnoea and central sleep apnoea, is a common disorder among patients with chronic heart failure. Obstructive sleep apnoea is often treated with continuous positive airway pressure, but central sleep apnoea lacks a clear treatment option. Knowledge of how sleep-disordered breathing is experienced (e.g. difficulties and care needs) and handled (e.g. self-care actions) by the patients is limited, but needed, to provide patient-centred care.

AIM

To explore how newly verified sleep-disordered breathing is experienced by patients with chronic heart failure.

METHODS

Data were collected through semi-structured interviews and analysed with qualitative content analysis. Seventeen participants (14 men, three women), mean age 60 years (range 41-80) diagnosed with chronic heart failure and objectively verified sleep-disordered breathing (nine obstructive, seven central and one mixed) were strategically selected from heart failure outpatient clinics at two Norwegian university hospitals.

RESULTS

Patients with chronic heart failure and newly verified sleep-disordered breathing (SDB) described experiences of poor sleep that had consequences for their daily life and their partners. Different self-care strategies were revealed, but they were based on 'common sense' and were not evidence-based. The awareness of having SDB was varied; for some, it gave an explanation to their trouble while others were surprised by the finding.

CONCLUSION

Patients with chronic heart failure and sleep-disordered breathing experienced reduced sleep quality, influencing their daily life. Possible underlying causes of disrupted sleep, such as sleep-disordered breathing, should be identified to establish proper patient-centred treatment strategies. There is a need for new strategies to approach patients with chronic heart failure (i.e. those with central sleep apnoea) who are not subject to continuous positive airway pressure treatment for their sleep-disordered breathing.

Relationship between sleep disturbance and self-care in adults with type 2 diabetes

AIMS

Type 2 diabetes (T2D) is a metabolic disorder requiring intensive self-care to maintain optimal glycemic control. Sleep disturbance is common in T2D patients and likely impairs glycemic control. Our aim was to examine the relationship between sleep disturbance and self-care in adults with T2D.

METHODS

This study used a correlational design. Sixty-four adults with T2D were recruited. Validated instruments were used to measure self-care, subjective sleep disturbance, and covariates (e.g., diabetes distress, self-efficacy, fatigue, and daytime sleepiness). Over an 8-day period, the ActiGraph-wGT3X was used to measure objective sleep outcomes (e.g., total sleep time and number of awakenings). Bivariate correlation and multiple linear regression analyses were conducted.

RESULTS

The mean age of the participants was 60.6 (SD 6.8) years (range 50-78), and 51.6% were women. Controlling for covariates, subjective sleep disturbance (β = - 0.26), diabetes distress (β = - 0.39), and daytime sleepiness (β = - 0.21) were strong predictors of diabetes self-care (R² = 0.51, p < 0.001). When objective sleep parameters were used, the number of awakenings (β = - 0.23) also predicted self-care along with diabetes distress, fatigue, and daytime sleepiness (R² = 0.57, p < 0.001).

CONCLUSIONS

Subjective sleep disturbance and frequent nocturnal awakenings are associated with worse diabetes self-care in adults with T2D. Healthcare providers are recommended to include comprehensive sleep assessment at every clinical visit. Diabetes educators may consider including sleep-related education in their diabetes self-management classes and/or counseling sessions.

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.

Assessing the usability by clinicians of VISION: A hierarchical display of patient-collected physiological information to clinicians

BACKGROUND

The inability of patients to accurately and completely recount their clinical status between clinic visits reduces the clinician's ability to properly manage their patients. One way to improve this situation is to collect objective patient information while the patients are at home and display the collected multi-day clinical information in parallel on a single screen, highlighting threshold violations for each channel, and allowing the viewer to drill down to any analog signal on the same screen, while maintaining the overall physiological context of the patient. All this would be accomplished in a way that was easy for the clinician to view and use.

METHODS

Patients used five mobile devices to collect six heart failure-related clinical variables: body weight, systolic and diastolic blood pressure, pulse rate, blood oxygen saturation, physical activity, and subjective input. Fourteen clinicians practicing in a heart failure clinic rated the display using the System Usability Scale that, for acceptability, had an expected mean of 68 (SD, 12.5). In addition, we calculated the Intraclass Correlation Coefficient of the clinician responses using a two-way, mixed effects model, ICC (3,1).

RESULTS

We developed a single-screen temporal hierarchical display (VISION) that summarizes the patient's home monitoring activities between clinic visits. The overall System Usability Scale score was 92 (95% CI, 87-97), p < 0.0001; the ICC was 0.89 (CI, 0.79-0.97), p < 0.0001.

CONCLUSION

Clinicians consistently found VISION to be highly usable. To our knowledge, this is the first single-screen, parallel variable, temporal hierarchical display of both continuous and discrete information acquired by patients at home between clinic visits that presents clinically significant information at the point of care in a manner that is usable by clinicians.

The Role of Heart Failure, Daytime Sleepiness, and Disturbed Sleep on Cognition

Disturbed sleep and daytime sleepiness may interfere with possible direct relationships between heart failure (HF) and cognition, yet there is limited research investigating this relationship. We aimed to investigate possible mediating roles of disturbed sleep and daytime sleepiness on the relationship between HF and selected cognitive domains among individuals with and without HF. In a cross-sectional design study, we examined the data of 841 older adults with and without HF from the Aging, Demographics, and Memory Study (ADAMS). We found individuals with HF were likely to have a higher degree of disturbed sleep and daytime sleepiness. Both disturbed sleep and daytime sleepiness were significant predictors of cognition. We found that only daytime sleepiness mediated the relationship between the presence of HF and cognitive domains, such as in attention, memory, and executive function after controlling for covariates. Interventions to improve daytime sleepiness among individuals with HF may also help improving cognition.

Diagnosis of Dilated Cardiomyopathy: Patient Reaction and Adaptation-Case Study and Review of the Literature

Objective. Heart failure remains a major cause of morbidity and mortality. Given that heart failure generally has a chronic course, it is important to appreciate the impact it can have on the quality of life of patients and also their partners or family carers. Method. Questionnaires were given to a patient newly diagnosed with dilated cardiomyopathy, during his hospital admission, as well as after discharge. The responses are summarised and explored in the discussion section, where we used review of the literature to discuss the implications of a new diagnosis of heart failure. Results. The patient's responses to the questionnaires suggest certain anxieties that are part of his adaptation to the diagnosis of heart failure. Conclusion. Depression is a common comorbid condition in patients with heart failure. Various tools can be used to screen for depression in patients with heart failure. Both pharmacological and nonpharmacological options are available. Rapid evaluation of ongoing problems and active participation by a psychiatrist can ensure that the patient receives the best possible clinical care.

The Daily Lives of People With HIV Infection: A Qualitative Study of the Control Group in an Expressive Writing Intervention

Emotional disclosure is an expressive writing technique used in psychotherapy to process traumatic and stressful life experiences. While emotional disclosure interventions frequently use control groups, there are few qualitative analyses of these control groups. Our study's purpose was to analyze the control essays written by HIV-infected informants about their daily activities in an augmented written emotional disclosure intervention. Latent and manifest qualitative content analyses revealed prevalent contextual themes within the data. The emergent themes were socioeconomic status (SES), self-care, religiosity/spirituality, and social support. Emotional disclosure control subjects contributed substantial findings in terms of SES, self-care, resiliency, religiosity/spirituality, and social support and altruism.

Sleep in octogenarians during the postoperative phase after transcatheter or surgical aortic valve replacement

Background:

Octogenarians with aortic stenosis are an increasing population of patients admitted for surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI). Although adequate sleep is important after illness and surgery, it has scarcely been studied in the immediate postoperative phase.

Aims:

To determine and compare the nature of self-reported sleep and insomnia, and recorded sleep–wake patterns in octogenarians during the in-hospital postoperative phase after SAVR or TAVI.

Methods:

A prospective cohort design was used that included octogenarian patients undergoing SAVR or TAVI at a regional university hospital. Self-reports were used to document sleep and insomnia, and actigraphy was used to record sleep–wake patterns. Data were collected at baseline preoperatively, and then daily for the first five postoperative days.

Results:

SAVR patients experienced the most insomnia on postoperative nights later in recovery, while TAVI patients experienced the most insomnia on postoperative nights early in recovery. The median total sleep time, as measured by actigraphy, was 6.4 h, and the median sleep efficiency was 79% for the five postoperative nights, but no differences were found between SAVR and TAVI patients on this parameter. All patients slept more during daytime than at night, with SAVR patients having significantly more total sleep hours for all five days than TAVI patients (p < 0.01).

Conclusion:

Octogenarians with aortic stenosis had disturbed self-reported sleep, increased insomnia, and disturbed sleep–wake patterns postoperatively, resulting in more daytime sleep and inactivity. In patients undergoing SAVR or TAVI, sleep evolves differently during the in-hospital postoperative phase.

What matters to patients with heart failure? The influence of non-health-related goals on patient adherence to self-care management

OBJECTIVE

To describe the life goals of heart failure (HF) patients and to determine whether adherence is influenced by the extent to which these priorities are perceived as compatible with HF self-care regimens.

METHOD

Forty HF outpatients identified their top-five life goals and indicated the compatibility of HF self-care regimens (diet, exercise, weighing) with these priorities. HF knowledge, self-efficacy and reported adherence were also assessed.

RESULTS

Patients valued autonomy and social relationships as much as physical health. However, the rated importance of these domains did not predict adherence. Adherence positively correlated with the extent to which the regimen, specifically exercise, was considered compatible with life goals (r=.34, p<.05). Exercise adherence also correlated with illness severity and self-efficacy (rs=-.42 and .36, p<.05, respectively). The perceived compatibility of physical activity with personal goals predicted 11% of the variance in exercise adherence above and beyond that accounted for by illness severity and self-efficacy (FΔ (1, 36)=7.11, p<.05).

CONCLUSIONS

Patients' goals outside of the illness management context influence self-care practices.

PRACTICE IMPLICATIONS

Exploring patients' broad life goals may increase opportunities to resolve ambivalence and enhance motivation for self-care adherence.

Effect of diabetes mellitus on sleep quality

Diabetes mellitus (DM) is a highly prevalent condition affecting about 347 million people worldwide. In addition to its numerous clinical implications, DM also exerts a negative effect on patient’s sleep quality. Impaired sleep quality disrupts the adequate glycemic control regarded as corner stone in DM management and also lead to many deleterious effects causing a profound impact on health related quality of life. This article outlines various factors leading to impaired sleep quality among diabetics and delineates how individual factor influences sleep. The article also discusses potential interventions and lifestyle changes to promote healthy sleep among diabetics.

Prevalence of sleep disorders among ESRD patients

Sleep disorders are common among the patients undergoing dialysis in end stage renal disease (ESRD). Although variable, their prevalence has been reported to be higher when compared to the general population. The most frequently reported complaints are insomnia, restless leg syndrome (RLS), sleep-disordered breathing and excessive daytime sleepiness (EDS). The aim of this study was to assess the prevalence of sleep disorders in end stage renal disease patients on regular hemodialysis (group I with 30 patients) and CKD patients (group II with 30 patients) in comparison to 30 normal population (control group). In addition to laboratory investigations which included creatinine clearance using Cockroft and Gault formula, hemoglobin level (Hb), blood urea, serum creatinine, serum albumin, serum calcium and phosphorus and lipid profile, all subjects underwent one night of laboratory-based polysomnography (PSG) consisting of a standard montage of electroencephalography (EEG) (C3/A1 and O2/C3 or O1/C4), monopolar left and right electrooculography (EOG) referenced to the opposite mastoid, surface mentalis electromyography (EMG), respiratory airflow (measured by thermistor) and effort (piezoelectric sensors), electrocardiography (ECG), anterior tibialis EMG and pulse oximetry. For hemodialysis subjects, this study was performed on a night immediately following hemodialysis treatment. The results showed that patients on hemodialysis have sleep disorders, and that sleep disorders are common in group I and II than control group. The percentage of sleep disorders in hemodialysis patients were as follows: insomnia (69%), followed by obstructive sleep apnea syndrome OSAS (24%), RLS and periodic limb movement PLM (18%), nightmares (13%), EDS (12%), sleepwalking (2%), possible rapid eye movement behavior disorders RED (2%), possible narcolepsy (1.4%). While the percentage of sleep disorders in CKD patients were as follows: insomnia (54%), followed by RLS (19%), PLM (12%), OSAS (16%), nightmares (15%), EDS (15%), sleepwalking (4%), possible RBD (3%), possible narcolepsy (1%). There was inverse correlation between sleep disorders and Hb, albumin and creatinine clearance; also there was positive correlation between sleep disorder and phosphorus. We concluded that the sleep disorders are common in CKD patients either on conservative management or on regular hemodialysis. Treatment of anemia, hyperphosphatemia and hypoalbuminemia may improve sleep disorders among those patients.

Is sleep quality related to cognition in individuals with heart failure?

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.

"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

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.

Reduced cerebral blood flow and white matter hyperintensities predict poor sleep in heart failure

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.

Patient experiences of recovery after heart valve replacement: suffering weakness, struggling to resume normality

Background

Heart valve disease is becoming a public health problem due to increasing life expectancy and new treatment methods. Patients are at risk of developing depression, anxiety or post-traumatic stress disorder after heart valve surgery. To better plan proper care, describing and understanding patients’ perception of recovery after heart valve replacement is essential. The objective was to describe the experience of recovery at home after heart valve replacement.

Methods

Qualitative interviews were conducted with 10 patients representing the population and these were later transcribed. The analysis was inspired by Ricoeur’s theory of interpretation, which consists of three levels: naive reading, structured analysis, and critical interpretation and discussion.

Results

The overall concept that emerged was suffering weakness and struggling to resume normality. Patients all struggled to resume normal living, both in regaining physical strength and in reestablishing balance in overall living. The overall concept can be interpreted in terms of the following themes: Disturbed network: Invaluable relatives, Contact with healthcare staff, Rehabilitation. Disturbed body: Stressful complications, Bodily attention, Physically affected, Physical capability. Recovery: Interrupted living, Suffering weakness, Gradual recovery, Achieving normality. Reflections: Thoughts about the procedure and Feeling sad and fragile.

Conclusion

The study presents the main themes of network, body, recovery and reflection for ten patients after heart valve replacement. These main themes can overall be summarized as suffering weakness and struggling to resume normality. Patients felt weak with a changed body, but after a long recovery process regained vitality and returned to their daily life.

Sleep-wake activity rhythm and health-related quality of life among patients with coronary artery disease and in a population-based sample--an actigraphy and questionnaire study

The aim of this study was to explore whether there are gender differences in sleep and health-related quality of life in patients with coronary artery disease (CAD) and a matched population-based sample and to see how subjectively rated sleep is associated with actigraphy. Secondly, to explore whether factors that predict patients' sleep quality could be identified. Fifty-seven patients with stable CAD and 47 participants from a population-based sample were included. All participants completed the Uppsala Sleep Inventory (USI), the Epworth Sleepiness Scale and the SF-36. Actigraphy recordings and a sleep diary were performed for seven 24-h periods. Multiple stepwise regression analysis showed that sleep duration, sleep onset latency, nocturnal awakenings, vitality (SF-36) and body mass index explained 60% of the sleep quality outcome (USI). Sleep duration, sleep efficiency and fragmentation index assessed with actigraphy and sleep diary accounted for 36% of the sleep quality outcome (diary). The result can form the basis for a non-pharmacological, self-care programme supported and led by nurses.

Sleep quality and sleepiness in persons with implantable cardioverter defibrillators: outcome from a clinical randomized longitudinal trial

BACKGROUND

Patients receiving an implantable cardioverter defibrillator (ICD) report various types and degree of sleep disruptions, but little is known regarding their characteristics, duration, and associated factors. The purposes of this study were: (1) to describe the effect of a psychoeducational intervention on sleep quality and daytime sleepiness, (2) to describe patterns of sleep over time, and (3) to identify predictors of poor sleep in an ICD population.

METHODS

A randomized longitudinal intervention trial was designed to test the effects of a psychoeducational intervention, which included a sleep education and counseling session in patients receiving their initial ICD. Patients (n=236; 75% men; mean age 58.4 [±11.2] from the PsychoEducationAl Intervention for ICD PatiEnts (PEACE) trial comprised the study population. Variables related to sleep were measured by the Pittsburgh Sleep Quality Inventory (PSQI) and Epworth Sleepiness Scale (ESS).

RESULTS

No psychoeducational intervention effects on sleep outcomes were observed. However, 67.2% of the patients reported poor sleep quality at baseline, and 56.8% had low sleep quality at 6 months based on PSQI scores>5; one-third (32.6%) were excessively sleepy based on ESS scores≥10 at 6 months. Anxiety, depression, physical function, pain intensity, and pain severity were all highly correlated to each other across time. Female gender was a significant covariate for the PSQI. New York Heart Association (NYHA) class was a significant covariate for sleepiness (Epworth).

CONCLUSIONS

Low sleep quality and daytime sleepiness are found at time of insertion and over time in patients with ICD. Female gender, higher NYHA class, as well as two latent factors encompassing increased anxiety, depressive symptoms, and decreased physical function and increased pain, were significant predictors of poor sleep quality and sleepiness over time. These data help identify those at higher risk for sleep problems after ICD.

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.

A preliminary investigation of symptom pattern and prevalence before and up to 6 months after implantation of a left ventricular assist device

Despite increased use of left ventricular assist devices (LVAD) in patients with advanced or end-stage heart failure; little is known about the reoccurrence of common heart failure symptoms (e.g., fatigue) after LVAD implantation. The objective of this study was to investigate the prevalence and pattern of selected heart failure symptoms and identify changes in symptom patterns before and up to 6 months after LVAD implantation. We used self-report questionnaires to collect data from patients (n = 12) and measure symptoms at baseline, 1 and 2 weeks, and 1, 3, and 6 months after LVAD. We found that high levels of fatigue, anxiety, depression, and sleep disturbance were prevalent during these periods. However, we did not find any significant changes in symptom pattern over time. The preliminary findings set the starting point for large-scale studies fundamental to advances in symptom-management research in LVAD and for other patients living with 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.

Quality of sleep and day-time sleepiness in chronic hemodialysis: a study of 400 patients

OBJECTIVE

Impaired sleep has potential health consequences in chronic hemodialysis patients. To date, this issue has not been examined in studies involving a large number of subjects. This study aimed to identify factors associated with poor sleep quality and excessive day-time sleepiness (EDS) in dialysis patients.

MATERIAL AND METHODS

This cross-sectional observational study involved 400 patients (59% male) from three hemodialysis centers (SD-HEMOFOR). Quality of sleep was evaluated by the Pittsburgh Sleep Quality Index (PSQI), EDS by the Epworth Sleepiness Scale (ESS), risk of obstructive sleep apnea (OSA) by the Berlin questionnaire and comorbidity severity by the Charlson Comorbidity Index (CCI).

RESULTS

Poor sleep quality (PSQI >5) was found in 227 individuals (57%) and was associated with older age (p = 0.001), diabetes (p = 0.03), heart failure (p < 0.005), hypoalbuminemia (p = 0.01), low transferrin saturation (TSAT) (p = 0.009), higher CCI score (p = 0.01) and depression (p < 0.005). Independent factors were older age, heart failure, low TSAT and depressive symptoms. Day-time somnolence was present in 108 patients (27%) and was independently associated with stroke [odds ratio (OR) = 2.84, CI 1.03-7.76), lower hemoglobin concentration (OR = 2.45, CI 0.95-3.03) and high risk of OSA (OR = 1.65, CI 1.03-2.63). High risk of OSA (n = 120; 30%), was associated with hypertension (p < 0.001), overweight/obesity (p = 0.001), older age (p = 0.003) and symptoms of depression (p = 0.01).

CONCLUSIONS

Poor sleep quality and EDS were prevalent on chronic hemodialysis. Heart failure, low TSAT and depressive symptoms were independently associated with poor sleep quality. Stroke, anemia and high risk of OSA were independently associated with EDS. These results provide new insight into possible treatment strategies.

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.

Excessive daytime sleepiness is associated with poor medication adherence in adults with heart failure

BACKGROUND

A relationship between excessive daytime sleepiness (EDS) and poor treatment adherence has been suspected but not confirmed. We hypothesized that medication adherence would be poorer in adults with heart failure (HF) and EDS and that cognitive status would be the mechanism of effect.

METHODS AND RESULTS

A sample of 280 adults with chronic HF were enrolled into a prospective cohort comparison study. We identified a cohort with EDS and a control group without EDS and further divided both groups into those with and without mild cognitive decline. Data on medication adherence were obtained at baseline and 3 and 6 months by using the Basel Assessment of Adherence Scale. Regression analysis was used to clarify the contribution of EDS and cognition to medication adherence and to assess relationships over 6 months after adjusting for age, enrollment site, gender, race, functional class, depression, and premorbid intellect. At baseline, 62% of subjects were nonadherent to their medication regime. Nonadherence was significantly more common in those with EDS, regardless of cognitive status (P = .035). The odds of nonadherence increased by 11% for each unit increase in EDS (adjusted odds ratio 1.11; 95% confidence interval 1.05-1.19; P = .001). In longitudinal models, there was a 10% increase in the odds of nonadherence for each unit increase in EDS (P = .008). The only cognition measure significantly associated with medication adherence was attention (P = .047).

CONCLUSIONS

Adults with HF and EDS are more likely to have problems adhering to their medication regimen than those without EDS, regardless of their cognitive status. Identifying and correcting factors that interfere with sleep may improve medication adherence.