Actigraphic and Sleep Diary Measures in Veterans With Traumatic Brain Injury: Discrepancy in Selected Sleep Parameters

A randomized clinical trial for a self-guided sleep intervention following moderate-severe traumatic brain injury: Study protocol

BACKGROUND

Individuals with a history of moderate-severe traumatic brain injury (TBI) experience a significantly higher prevalence of insomnia compared to the general population. While individuals living with TBI have been shown to benefit from traditional insomnia interventions (e.g., face-to-face [F2F]), such as Cognitive Behavioral Therapy for Insomnia (CBTI), many barriers exist that limit access to F2F evidence-based treatments. Although computerized CBT-I (CCBT-I) is efficacious in terms of reducing insomnia symptoms, individuals with moderate-severe TBI may require support to engage in such treatment. Here we describe the rationale, design, and methods of a randomized controlled trial (RCT) assessing the efficacy of a guided CCBT-I program for reducing insomnia symptoms for participants with a history of moderate-severe TBI.

METHODS

This is an RCT of a guided CCBT-I intervention for individuals with a history of moderate-severe TBI and insomnia. The primary outcome is self-reported insomnia severity, pre- to post-intervention. Exploratory outcomes include changes in sleep misperception following CCBT-I and describing the nature of guidance needed by the Study Clinician during the intervention.

CONCLUSION

This study represents an innovative approach to facilitating broader engagement with an evidence-based online treatment for insomnia among those with a history of moderate-severe TBI. Findings will provide evidence for the level and nature of support needed to implement guided CCBT-I. Should findings be positive, this study would provide support for a strategy by which to deliver guided CCBT-I to individuals with a history of moderate-severe TBI.

Sleep Quality Drives Next Day Pain and Fatigue in Adults With Inflammatory Bowel Disease: A Short Report

BACKGROUND AND AIMS

Poor sleep is prevalent in inflammatory bowel disease [IBD] and is associated with increased symptom severity and decreased quality of life. To date, research is mostly cross-sectional, limiting the ability to examine the causal direction between sleep and IBD symptoms. This short report aims to assess the temporal associations among sleep quality, pain, fatigue, and physical activity in adults with IBD.

METHODS

Adult IBD patients [N = 18] completed a structured electronic diary two times per day [morning and evening] over 14 consecutive days. Morning diary items assessed sleep [sleep quality, wake after sleep onset, number of awakenings] and evening diary items assessed daytime IBD symptoms [abdominal pain, fatigue]. An actigraph measured daily step count [physical activity]. Generalised estimating equation models evaluated the lagged temporal associations between sleep ratings and next day pain, fatigue, and physical activity as well as reverse lagged temporal associations between daytime symptoms and physical activity and subsequent sleep ratings.

RESULTS

Poor self-reported sleep quality predicted increased next day abdominal pain and fatigue scores. Increased time awake during the night predicted decreased next day physical activity. In the reverse analyses, only the relationship between daytime abdominal pain and wake after sleep onset was significant.

CONCLUSIONS

Poor sleep appears to drive IBD-related outcomes, such as pain and fatigue. These findings are a first step in demonstrating the key role of sleep in the IBD patient experience, potentially resulting in a treatment target for intervention. Future research is needed to confirm results in a larger sample.

Actigraphic and nursing sleep log measures in moderate-to-severe traumatic brain injury: Identifying discrepancies in total sleep time

BACKGROUND

Sleep disturbances are common in patients with traumatic brain injury (TBI). In an inpatient rehabilitation setting, clinicians often use information from sleep logs filled out by trained nurses to identify and treat sleep disturbances. However, there are limited data related to accuracy of sleep logs, and patient-reported sleep diaries are poor predictors of total sleep time, which raises concern about the accuracy of sleep logs filled out by a third party.

OBJECTIVE

To examine the reliability of sleep logs for participants with TBI by comparing total sleep time determined by sleep logs versus actigraphy.

DESIGN

Prospective, cross-sectional study.

SETTING

Free-standing, academic inpatient rehabilitation facility.

PARTICIPANTS

Thirty individuals (n = 30) participated in the study. Inclusion criteria were (1) diagnosis of moderate-to-severe TBI; (2) age ≥ 18 years at the time of TBI; and (3) participating in inpatient rehabilitation with no prior inpatient rehabilitation admissions.

INTERVENTIONS

Actigraph monitoring using ActiGraph GT9X Link devices was initiated within 72 hours of admission and continued for 7 consecutive days. Sleep logs were concurrently filled out by trained nurses.

MAIN OUTCOME MEASURES

Sleep parameter correspondence between actigraphy and sleep logs in moderate-to-severe TBI.

RESULTS

Only 51.4% of participants' sleep logs and actigraph total sleep time measurements were within 1 hour of each other, and only 23.8% were within 30 minutes. On average, sleep logs overestimated actigraphy-determined total sleep time by 60 minutes compared to actigraphic measurement.

CONCLUSIONS

For those with moderate-to-severe TBI undergoing inpatient rehabilitation, sleep logs are poor predictors of sleep time because they overestimate total sleep time compared to actigraphy. Therefore, clinicians should use caution when using sleep log data to make decisions regarding treatment for sleep disturbances in TBI.

Comparing polysomnography, actigraphy, and sleep diary in the home environment: The Study of Women's Health Across the Nation (SWAN) Sleep Study

Study Objectives

Polysomnography (PSG) is considered the "gold standard" for assessing sleep, but cost and burden limit its use. Although wrist actigraphy and self-report diaries are feasible alternatives to PSG, few studies have compared all three modalities concurrently across multiple nights in the home to assess their relative validity across multiple sleep outcomes. This study compared sleep duration and continuity measured by PSG, actigraphy, and sleep diaries and examined moderation by race/ethnicity.

Methods

Participants from the Study of Women's Health Across the Nation (SWAN) Sleep Study included 323 White (n = 147), African American (n = 120), and Chinese (n = 56) middle-aged community-dwelling women (mean age: 51 years, range: 48-57). PSG, wrist actigraphy (AW-64; Philips Respironics, McMurray, PA), and sleep diaries were collected concurrently in participants' homes over three consecutive nights. Multivariable repeated-measures linear models compared time in bed (TIB), total sleep time (TST), sleep efficiency (SE), sleep latency (SL), and wake after sleep onset (WASO) across modalities.

Results

Actigraphy and PSG produced similar estimates of sleep duration and efficiency. Diaries yielded higher estimates of TIB, TST, and SE versus PSG and actigraphy, and lower estimates of SL and WASO versus PSG. Diary SL was shorter than PSG SL only among White women, and diary WASO was lower than PSG and actigraphy WASO among African American versus White women.

Conclusions

Given concordance with PSG, actigraphy may be preferred as an alternative to PSG for measuring sleep in the home. Future research should consider racial/ethnic differences in diary-reported sleep continuity.

Injury, Sleep, and Functional Outcome in Hospital Patients With Traumatic Brain Injury

PROBLEM

Uninterrupted nighttime sleep is associated with better cognition and functional outcomes in healthy adults, but the relationship between sleep and functional outcome in individuals hospitalized with severe traumatic brain injury (TBI) remains to be clarified.

OBJECTIVE

The aims of this study were to (1) describe nighttime rest-activity variables-wake bouts (counts), total wake time (minutes), and sleep efficiency (SE) (percentage; time asleep/time in bed)-in people on a neuroscience step-down unit (NSDU) post-TBI and (2) describe the association between injury and nighttime rest-activity on post-TBI functional outcome (using Functional Independence Measure [FIM] at discharge from inpatient care).

METHODS

This study is a cross-sectional, descriptive pilot study. We recruited participants from the NSDU (n = 17 [age: mean (SD), 63.4 (17.9)]; 82% male, 94% white) who wore wrist actigraphy (source of nighttime rest-activity variables) for up to 5 nights. For injury variables, we used Glasgow Coma Scale (GCS) score and Injury Severity Score (ISS). We used Spearman ρ and regression to measure associations.

RESULTS

Glasgow Coma Scale mean (SD) score was 8.8 (4.9), ISS mean (SD) score was 23.6 (6.7), and FIM mean (SD) score was 48 (14.5). Averages of nighttime rest-activity variables (8 PM-7 AM) were as follows: SE, 73% (SD, 16); wake bouts, 41 counts (SD, 18); total wake time, 74 minutes (SD, 47). Correlations showed significance between FIM and GCS (P = .005) and between SE and GCS (P = .015). GCS was the only statistically significant variable associated with FIM (P = .013); we eliminated other variables from the model as nonsignificant (P > .10). Sleep efficiency and FIM association was nonsignificant (P = .40). In a separate model (ISS, GCS, and SE [dependent variable]), GCS was significant (P = .04), but ISS was not (P = .25).

CONCLUSION

Patients with severe TBI on the NSDU have poor actigraphic sleep at night. GCS has a stronger association to functional outcome than nighttime rest-activity variables.

Unraveling the Biopsychosocial Factors of Fatigue and Sleep Problems After Traumatic Brain Injury: Protocol for a Multicenter Longitudinal Cohort Study

Background

Fatigue and sleep problems are common after a traumatic brain injury (TBI) and are experienced as highly distressing symptoms, playing a significant role in the recovery trajectory, and they can drastically impact the quality of life and societal participation of the patient and their family and friends. However, the etiology and development of these symptoms are still uncertain.

Objective

The aim of this study is to examine the development of fatigue and sleep problems following moderate to severe TBI and to explore the changes in underlying biological (pain, brain damage), psychological (emotional state), and social (support family, participation) factors across time.

Methods

This study is a longitudinal multicenter observational cohort study with 4 measurement points (3, 6, 12, and 18 months postinjury) including subjective questionnaires and cognitive tasks, preceded by 7 nights of actigraphy combined with a sleep diary. Recruitment of 137 moderate to severe TBI patients presenting at emergency and neurology departments or rehabilitation centers across the Netherlands is anticipated. The evolution of fatigue and sleep problems following TBI and their association with possible underlying biological (pain, brain damage), psychological (emotional state), and social (support family, participation) factors will be examined.

Results

Recruitment of participants for this longitudinal cohort study started in October 2017, and the enrollment of participants is ongoing. The first results are expected at the end of 2020.

Conclusions

To the authors’ knowledge, this is the first study that examines the development of both post-TBI fatigue and sleep longitudinally within a biopsychosocial model in moderate to severe TBI using both subjective and objective measures. Identification of modifiable factors such as mood and psychosocial stressors may give direction to the development of interventions for fatigue and sleep problems post-TBI.

Trial Registration

Netherlands Trial Register NTR7162; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=7162 (Archived by WebCite at http://www.webcitation.org/6z3mvNLuy)

International Registered Report Identifier (IRRID)

RR1-10.2196/11295

Agreement between clinician-rated versus patient-reported outcomes in Huntington disease

BACKGROUND

Clinician-rated measures of functioning are often used as primary endpoints in clinical trials and other behavioral research in Huntington disease. As study costs for clinician-rated assessments are not always feasible, there is a question of whether patient self-report of commonly used clinician-rated measures may serve as acceptable alternatives in low risk behavioral trials.

AIM

The purpose of this paper was to determine the level of agreement between self-report and clinician-ratings of commonly used functional assessment measures in Huntington disease.

DESIGN

486 participants with premanifest or manifest Huntington disease were examined. Total Functional Capacity, Functional Assessment, and Independence Scale assessments from the Unified Huntington Disease Rating scale were completed by clinicians; a self-report version was also completed by individuals with Huntington disease. Cronbach's α was used to examine internal consistency, one-way analysis of variance was used to examine group differences, and paired t tests, kappa agreement coefficients, and intra-class correlations were calculated to determine agreement between raters.

RESULTS

Internal consistency for self-reported ratings of functional capacity and ability were good. There were significant differences between those with premanifest, early-, and late-stage disease; those with later-stage disease reported less ability and independence than the other clinical groups. Although self-report ratings were not a perfect match with associated clinician-rated measures, differences were small. Cutoffs for achieving specified levels of agreement are provided.

CONCLUSIONS

Depending on the acceptable margin of error in a study, self-reported administration of these functional assessments may be appropriate when clinician-related assessments are not feasible.