Why Do They Fall? The Impact of Insomnia on Gait of Older Adults: A Case-Control Study

Insomnia Symptoms and Environmental Disruptors: A Preliminary Evaluation of Veterans in a Subacute Rehabilitation

OBJECTIVES

Evaluate insomnia symptoms and environmental disruptors at admission and discharge in a subacute rehabilitation care setting.

METHODS

Veterans (age ≥50) admitted to a Veterans Health Administration (VA) Hospital subacute rehabilitation between March and August 2022 completed baseline (N = 46) and follow up (N = 33) assessments with the Insomnia Severity Index (ISI), Sleep Need Questionnaire (SNQ), Epworth Sleepiness Scale (ESS), and an assessment of environmental sleep disruptors. Veterans were offered sleep resources after admission evaluations and outpatient referrals after discharge evaluations. Pearson correlation determined associations between length of stay (LOS), ISI, SNQ, and ESS scores at admission and discharge; chi-square and Wilcoxon Signed Rank Tests compared insomnia at admission and discharge.

RESULTS

One-half of participants reported clinically meaningful insomnia symptoms and sleep needs at baseline with no significant change at discharge. Almost all (89.1%) Veterans reported sleep was disturbed by environmental factors, primarily staff awakenings. LOS was correlated with ESS scores at discharge (r = .52, p = .002).

CONCLUSIONS

Environmental sleep disruption was common during a subacute rehabilitation admission and were not adequately addressed through sleep resources and treatment due to low uptake.

CLINICAL IMPLICATIONS

Providers should assess sleep at admission and lessen environmental sleep disruptors by reducing noise, light, and non-essential awakenings at night.

Wearable sensors for assessing disease severity and progression in Progressive Supranuclear Palsy

INTRODUCTION

Progressive supranuclear palsy (PSP) is an atypical parkinsonism characterized by prominent gait and postural impairment. The PSP rating scale (PSPrs) is a clinician-administered tool to evaluate disease severity and progression. More recently, digital technologies have been used to investigate gait parameters. Therefore, object of this study was to implement a protocol using wearable sensors evaluating disease severity and progression in PSP.

METHODS

Patients were evaluated with the PSPrs as well as with three wearable sensors located on the feet and lumbar area. Spearman coefficient was used to assess the relationship between PSPrs and quantitative measurements. Furthermore, sensor parameters were included in a multiple linear regression model to assess their ability in predicting the PSPrs total score and sub-scores. Finally, differences between baseline and three-month follow-up were calculated for PSPrs and each quantitative variable. The significance level in all analyses was set at ≤ 0.05.

RESULTS

Fifty-eight evaluations from thirty-five patients were analyzed. Quantitative measurements showed multiple significant correlations with the PSPrs scores (r between 0.3 and 0.7; p < 0.05). Linear regression models confirmed the relationships. After three months visit, significant worsening from baseline was observed for cadence, cycle duration and PSPrs item 25, while PSPrs item 10 showed a significant improvement.

CONCLUSION

We propose wearable sensors can provide an objective, sensitive quantitative evaluation and immediate notification of gait changes in PSP. Our protocol can be easily introduced in outpatient and research settings as a complementary tool to clinical measures as well as an informative tool on disease severity and progression in PSP.

Prevalence of sleep-related problems and risks in a community-dwelling older adult population: a cross-sectional survey-based study

Background

Despite evidence of adverse health consequences of inadequate restorative sleep for older adults, assessment of sleep quantity, quality, and use of sleep aids is not routinely done. We aimed to characterize sleep problems, sleep risks, and advice received about sleep in a community-dwelling older adult population, overall and in subgroups with health conditions and functional difficulties.

Methods

This cross-sectional study used weighted self-report data for 5074 Kaiser Permanente Northern California members aged 65-79y who responded to a 2017 or 2020 Member Health Survey. We estimated usual amount of sleep (< 6, 6 to < 7, ≥7 hours) and prevalence of sleep problems (frequent insomnia, frequent daytime fatigue, poor quality sleep, and potential sleep apnea (OSA) symptoms (frequent very loud snoring, apnea episodes)) for older adults overall, by self-rated health, and in subgroups reporting hypertension, diabetes, heart disease, frequent problems with balance/walking, and frequent memory problems. We also estimated percentages who regularly used sleep aids and had discussed sleep adequacy with a healthcare professional in the past year.

Results

Approximately 30% of older adults usually got less than the recommended ≥7 hours sleep per day, and 9% experienced frequent daytime fatigue, 13% frequent insomnia, 18% frequent insomnia/poor quality sleep, and 8% potential OSA symptoms. Prevalence of frequent insomnia was higher among women than men (16% vs. 11%). Higher percentages of those in fair/poor health and those with frequent balance/walking and memory problems reported sleeping < 6 hours per day and having all four types of sleep problems. Nearly 20% of all older adults (22% of women vs. 17% of men) and 45% of those with frequent insomnia (no sex difference) reported regular sleep aid use. Only 10% of older adults reported discussing sleep with a healthcare professional whereas > 20% reported discussing diet and exercise.

Conclusions

Large percentages of older adults experience sleep problems or get less sleep than recommended for optimal sleep health. Older patients should routinely be assessed on multiple components of sleep health (sleep hygiene, quantity, quality, problems, and sleep aid use) and educated about sleep hygiene and the importance of getting adequate restorative sleep for their overall health and wellbeing.

Specific Sleep Health Domains as Predictors of Executive Function in Older Adults

OBJECTIVES

Sleep health and executive function are multifaceted constructs that decline with age. Some evidence suggests that poor sleep health may underlie declines in executive function, but this relationship is not consistently found in cognitively normal older adults. The authors systematically investigated distinct sleep health domain associations with specific aspects of executive function.

METHODS

Community-dwelling older adults completed clinical interviews, comprehensive neuropsychological assessments, and subjective sleep measures. Four sleep health domains were investigated: satisfaction/quality, sleep efficiency, sleep duration, and daytime sleepiness/fatigue. Hierarchical multiple regression analyses, adjusting for significant covariates, examined whether the sleep health domains differentially predicted executive function.

RESULTS

Separate analyses found that greater sleep efficiency was associated with better response inhibition, while greater daytime sleepiness/fatigue was associated with worse cognitive flexibility. Categorical differences in sleep duration indicated that average durations, compared with short and long durations, had better executive function performance across measures. Sleep satisfaction/quality was not statistically associated with executive function.

CONCLUSIONS

These findings have implications for sleep assessment and its intervention. Routine screening of sleep duration, efficiency, and daytime fatigue may be particularly useful in identifying those at greater risk of executive dysfunction. Targeting specific problems in sleep may serve to improve cognitive control and efficiency in older adults. Future research is warranted to establish the optimal hours of sleep duration for cognitive health.

Efficacy and Safety of Daridorexant in Older and Younger Adults with Insomnia Disorder: A Secondary Analysis of a Randomised Placebo-Controlled Trial

Background and Objective

The dual orexin receptor antagonist daridorexant, studied in two phase III trials, dose-dependently improved objective and subjective sleep variables and daytime functioning in adults with insomnia. Because treatment of insomnia in older adults is challenging and has limited options, the purpose of the current analysis was to further analyse the phase III trial studying the higher doses of daridorexant, those that showed efficacy (daridorexant 50 mg, daridorexant 25 mg and placebo, nightly for 3 months), and compare the safety and efficacy of daridorexant in patients aged ≥ 65 (‘older adults’) to those aged < 65 years (‘younger adults’).

Methods

Analyses by age (≥ 65 years, n = 364; < 65 years, n = 566) were performed on data from the randomised, double-blind, placebo-controlled Trial 1 in adult patients with insomnia (NCT03545191). Efficacy endpoints included a change from baseline at month 1 and month 3 in polysomnography-measured wake after sleep onset (WASO) and latency to persistent sleep (LPS), self-reported total sleep time (sTST) and daytime functioning assessed using the validated Insomnia Daytime Symptoms and Impacts Questionnaire (IDSIQ). Safety endpoints included adverse events and the Visual Analog Scale for morning sleepiness.

Results

At baseline, mean [standard deviation] WASO was numerically greater (110 [39] vs 92 [38] min) in older than younger adults, while LPS was comparable (~ 65 min). Mean baseline IDSIQ total and all domain scores were numerically lower (i.e. better) in older adults. Daridorexant caused similar reductions in WASO and LPS, and similar increases in sTST, from baseline, in both age groups; improvements were numerically greater with daridorexant 50 mg than 25 mg. At month 3, daridorexant 50 mg, compared with placebo, decreased WASO by a least-squares mean of 19.6 (95% confidence interval 9.7, 29.5) in older patients versus 17.4 min (10.7, 24.0) in younger patients and decreased LPS by a least-squares mean of 14.9 (7.5, 22.3) in older patients versus 9.7 min (3.7, 15.7) in younger patients. Daridorexant 50 mg increased sTST from baseline to month 3 by a least-squares mean of 59.9 (49.6, 70.3) in older patients versus 57.1 min (48.9, 65.3) in younger patients. Daridorexant 50 mg progressively improved IDSIQ total and domain scores from week 1 onwards similarly in both groups; daridorexant 25 mg improved IDSIQ scores, but only in younger adults. In both age groups, in comparison with placebo, the overall incidence of adverse events was comparable, and there were fewer falls on daridorexant. Daridorexant improved Visual Analog Scale morning sleepiness in both groups; daridorexant 50 mg increased the mean (standard deviation) Visual Analog Scale morning sleepiness score by 15.9 (20.7) in older adults and by 14.9 (18.7) in younger adults from baseline to month 3. In older adults, there was one case of sleep paralysis, and no cases of narcolepsy, cataplexy, or complex sleep behaviour.

Conclusions

In older patients with insomnia, as in younger patients, the efficacy of daridorexant is maximal on night-time and daytime variables at the higher dose of 50 mg. Older patients particularly require this dose to improve daytime functioning. Older patients are not at an increased risk of adverse events or residual effects the next morning after night-time administration of daridorexant, even at 50 mg. The dose of daridorexant does not need to be decreased for older patients.

Clinical Trial Registration

ClinicalTrials.gov (NCT03545191) [first posted: 4 June, 4 2018], https://clinicaltrials.gov/ct2/show/NCT03545191.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40266-022-00977-4.

The burden of chronic insomnia (difficulty in falling/staying asleep or not getting enough sleep) increases with age yet treatment options in older patients are limited. In older patients, because of a risk of side effects, guidelines suggest caution when prescribing sleep medications and, for some drugs, recommend starting at a lower dose. Daridorexant was approved in 2022 for the treatment of insomnia in adults following positive results in two trials that showed daridorexant significantly improved night-time sleep and daytime functioning over 3 months of treatment in adults with insomnia. Approximately 40% of patients taking part in these trials were aged 65 years or older. This current analysis compared the safety and benefits of daridorexant in older adults (aged at least 65 years) and younger adults (aged less than 65 years) in the trial that administered the highest two doses of daridorexant, 25 and 50 mg. The results showed that the benefits of daridorexant were comparable in both age groups over 3 months; compared with placebo, daridorexant improved night-time sleep (reduced time awake during the night, reduced time to fall asleep and increased total sleep time) and daytime functioning—patients had less daytime sleepiness and a better mood and feeling of alertness. In older patients, the benefits, particularly for daytime functioning, were greatest at the higher 50-mg dose, without any increase in side effects. Both doses of daridorexant were equally well tolerated in the two age groups, indicating that treatment with daridorexant at 50 mg can be safely started in older patients.

Gait Speed and Sleep Duration Is Associated with Increased Risk of MCI in Older Community-Dwelling Adults

This study aimed to examine the linear and nonlinear associations between sleep duration and gait speed and the risk of developing mild cognitive impairment (MCI) in community-dwelling older adults. Participants were 233 older adults who met the study inclusion criteria. The MCI diagnosis was based on medical evaluations through a clinical interview conducted by a dementia specialist. Self-reported sleep duration was evaluated using the Pittsburgh Sleep Quality Index. The usual gait speed was calculated from the time taken to walk along a 4 m walkway. Multivariate logistic regression analysis was used to calculate the odds ratio (OR) and the 95% confidence interval (95% CI) of developing MCI in relation to sleep duration and gait speed. Generalized additive models were used to examine the dose−response relationships between sleep duration, gait speed, and the risk of developing MCI. Slower gait speed (OR: 1.84, 95%; CI: 1.00−3.13) and poor sleep duration (OR: 1.76, 95%; CI: 1.00−3.35) were associated with the risk of developing MCI, compared with their optimal status. In addition, the combination of poor sleep and slower gait was associated with a higher risk of developing MCI than optimal sleep duration and gait speed (OR: 3.13, 95%; CI: 1.93−5.14). Furthermore, gait speed and sleep duration were non-linearly associated with the risk of developing MCI. These results highlight the complex interplay and synergism between sleep duration and gait abilities on the risk of developing MCI in older adults. In addition, our results suggest that slower gait speed (<1.0 m/s) and short (<330 min) and long (>480 min) sleep duration may be linked to MCI risks through underlying pathways.

Static postural stability and neuropsychological performance after awakening from REM and NREM sleep in patients with chronic insomnia: a randomized, crossover, overnight polysomnography study

STUDY OBJECTIVES

Chronic insomnia disorder (CID) is a common sleep disorder, with a prevalence ranging from 6% to 10% worldwide. Individuals with CID experience more fragmented sleep than healthy controls do. They awaken frequently during the night and have a higher risk of injury from falling. Awakening from different sleep stages may have different effects on postural stability and waking performance. However, limited research has been conducted on this topic.

METHODS

This prospective randomized crossover study was conducted between January 2015 and January 2017. We included 20 adults aged 20-65 years who fulfilled diagnosis criteria for CID. Participants underwent two overnight polysomnography studies with an interval of at least 7 days. They were awakened during either rapid eye movement (REM) sleep or N1/N2 sleep alternatively. We compared measurements of static postural stability, vigilance scores, and neuropsychological tests between REM and N1/N2 sleep awakening.

RESULTS

Polysomnography parameters between the two nights were comparable. Participants who were awakened from REM sleep had worse static postural stability than those with N1/N2 awakening. Compared with N1/N2 awakening, larger mean sway areas of center of pressure (COP; p = 0.0413) and longer COP mean distances (p = 0.0139) were found in REM sleep awakening. There were no statistically significant differences in vigilance scores or neuropsychological tests between the two nights.

CONCLUSIONS

REM sleep awakening was associated with worse static postural stability than was N1/N2 awakening. No statistically significant differences were found in waking performance in alertness or in neuropsychological tests between N1/N2 and REM sleep awakening.

The Association Between Gait Speed and Sleep Problems Among Chinese Adults Aged 50 and Greater

Objective

The relationship between sleep problems and walking speed has been less explored. The present cross-sectional study was to investigate the association between sleep quality and sleep duration and gait speed in Chinese adults.

Methods

A total of 13,367 participants were recruited in this cross-sectional study, retrieving the data from the Global Aging and Adult Health Survey (SAGE). Gait speed was measured using the 4-m walking test. Age, sex, education years, smoking status, alcohol consumption, physical activity, chronic disease, sleep problems were self-reported by participants. To explore the association between sleep problems and gait speed, multivariate linear regression models were employed.

Results

In the adjusted model, poor sleep quality and longer sleep duration were significantly associated with slower normal walking speed in Chinese adults (p &lt; 0.001). Moreover, there were negatively significant associations between normal gait speed and sleep quality in male adults (p &lt; 0.01).

Conclusion

The findings suggest that slower normal walking speed was associated with poor sleep quality and longer sleep duration (&gt;8 h) in Chinese male adults.