Reliability of a sleep quality questionnaire for use in epidemiologic studies

Trends and disparities in sleep quality and duration in older adults in China from 2008 to 2018: A national observational study

Background

Poor sleep status as a common concern is a risk factor for many health problems among older people. China with an aging society lacks relevant nationwide data on the sleep status among older people. Therefore, the purpose of this study was to investigate trends and disparities in sleep quality and duration among older adults, and exploring influencing factors of poor sleep in China between 2008 and 2018.

Method

We used the four-waves data of the Chinese Longitudinal Healthy Longevity Survey (CLHLS) from 2008 to 2018. Sleep quality and average sleep hours per day was investigated by using questionnaires in the CLHLS. We categorized sleep duration as three groups including ≤5 h (short duration), 5-9 h (normal duration), or ≥9 h (long duration) per day. Multivariate logistic regression models were used to examine trends and risk factors of poor sleep quality, short sleep duration, and long sleep duration.

Results

The prevalence of poor sleep quality significantly increased from 34.87% in 2008 to 47.67% in 2018 (p < 0.05). Short sleep duration significantly increased from 5.29 to 8.37%, whereas long sleep duration decreased from 28.77 to 19.27%. Multivariate analysis showed that female sex, poor economic status, a greater number of chronic diseases, underweight, poor self-reported quality of life, and poor self-reported health were associated with poor sleep quality and short sleep duration (p < 0.05).

Conclusion

Our findings revealed that older adults had increased prevalence of poor sleep quality and short sleep duration from 2008 to 2018. More attention should be paid to the increased sleep problems among older adults and early interventions should be made to improve sleep quality and guarantee enough sleep time.

Postoperative poor sleep quality and its associated factors among adult patients: A multicenter cross-sectional study

Background

Sleep quality refers to a sense of being refreshed and rested after waking up from sleep. Postoperative patients were vulnerable to poor sleep quality due to having different contributing factors. The prevalence of poor sleep quality among postsurgical patients was left undisclosed in our study setting. Knowing the prevalence and contributing factors for poor sleep quality helps us to develop a strategic plan for prevention and management.

Method and materials

A multicenter cross-sectional study design was conducted on 424 postsurgical patients who were selected by a systematic random sampling method. Data was collected using the Pittsburgh Sleep Quality Index by a face-to-face interview. Data analysis was done using SPSS version 25. For categorical data, a chi-square test was done. Bivariable and multivariable analyses were performed to determine whether each of the independent variables is associated with the outcome variable.

Result

Based on this study result, the prevalence of poor sleep quality was 64.9%. Among the factors included in this study, variables which had an association with poor postoperative sleep quality were age range 25–54 years (AOR = 15.13), male gender (AOR = 4.81), educational level of secondary school (AOR = 6.29), patient income less than 2500 birr (AOR = 3.77), anxiety (AOR = 2.53), depression(AOR = 22.8), light exposure(AOR = 19.60), poor social support (AOR = 1.98), being emergency surgery (AOR = 2.46) and having a history of moderate to severe pain (AOR = 38.18, (95% CI).

Conclusion

Poor sleep quality among adult post-surgical patients was significantly high in Amhara regional comprehensive referral hospitals. Therefore; Clinicians need to prioritize postoperative sleep quality assessment and needs to minimize factors inducing postoperative sleep disturbances.

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The prevalence of postoperative poor sleep quality was 64.9%.

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Pain is associated with poor sleep qualities.

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Postoperative sleep quality was poorly managed.

Sleep Disorder Symptoms Among Adults in 8 States and the District of Columbia, 2017

Sleep disorder symptoms (trouble falling asleep or staying asleep, unintentionally falling asleep, snoring loudly, and episodes of having stopped breathing) among US adults (N = 59,108) from 8 states and the District of Columbia were analyzed by using data from the 2017 Behavioral Risk Factor Surveillance System. We conducted a multivariable logistic regression to assess the association between the 4 symptoms and sociodemographic characteristics, risk behaviors, and chronic conditions. The 4 symptoms were prevalent and more likely to be reported among adults with any chronic condition(s) than their counterparts without symptoms and among those who slept fewer than 7 hours compared with those who slept 7 to 9 hours.

Associations between health indicators and sleep duration of American adults: NHANES 2011-16

BACKGROUND

This study aimed to investigate associations between health indicators and sleep duration in the general population.

METHODS

This cross-sectional data from the National Health and Nutrition Examination Survey. Self-reported sleep duration was classified into short sleep (<7 h/day), regular sleep (7-8 h/day) and long sleep duration (>8 h/day). Health indicators included lifestyle indicators (smoking, alcohol use and physical inactivity), general health indicators (waist circumference and self-reported health condition) and chronic conditions [overweight/obesity, hypertension, diabetes, high cholesterol, chronic low back pain (CLBP) and oral health problems]. A series of multinomial logistic regression analysis were performed, controlling for confounders (age, sex, marital status, ethnic background, education level and poverty-to-income ratio).

RESULTS

Data of 12 835 participants were analyzed. The mean (SD) age of participants was 50.0 (±17.4) years, and 50.6% were women. After adjusting for all health indicators, current smoking (OR: 1.37; 95% CI: 1.17-1.61), a poor (OR: 1.52; 95% CI: 1.23-1.88) health condition, CLBP (OR: 1.40; 95% CI: 1.16-1.69) and oral health problems (OR: 1.28; 95% CI: 1.10-1.49) were associated with short sleep duration. No independent association with long sleep duration was observed in this study.

CONCLUSIONS

The results confirm that lifestyle indicators (current smoking and physical inactivity), general health indicators (self-reported health condition) and presence of some chronic conditions (CLBP and oral health problems) are associated with short sleep duration. The results did not confirm that any health indicator was associated with long sleep duration.

Sleep duration and napping in relation to colorectal and gastric cancer in the MCC-Spain study

Sleep duration is a novel and potentially modifiable risk factor for cancer. We evaluated the association of self-reported sleep duration and daytime napping with odds of colorectal and gastric cancer. We included 2008 incident colorectal cancer cases, 542 gastric cancer cases and 3622 frequency-matched population controls, recruited in the MCC-Spain case-control study (2008-2013). Sleep information, socio-demographic and lifestyle characteristics were obtained through personal interviews. Multivariable adjusted logistic regression models were used to estimate odds ratios (OR) with 95% confidence intervals (CI) for cancer, across categories of sleep duration (≤ 5, 6, 7, 8, ≥ 9 hours/day), daytime napping frequency (naps/week) and duration (minutes/nap). Compared to 7 hours of sleep, long sleep was associated with increased odds of colorectal (OR≥9 hours: 1.59; 95%CI 1.30-1.94) and gastric cancer (OR≥9 hours: 1.95; 1.37-2.76); short sleep was associated with increased odds of gastric cancer (OR≤5 hours: 1.32; 0.93-1.88). Frequent and long daytime naps increased the odds of colorectal (OR6-7 naps/week, ≥30 min: 1.32; 1.14-1.54) and gastric cancer (OR6-7 naps/week, ≥30 min: 1.56; 1.21-2.02). Effects of short sleep and frequent long naps were stronger among participants with night shift-work history. Sleep and circadian disruption may jointly play a role in the etiology of colorectal and gastric cancer.

REM sleep loss-induced elevated noradrenaline could predispose an individual to psychosomatic disorders: a review focused on proposal for prediction, prevention, and personalized treatment

Historically and traditionally, it is known that sleep helps in maintaining healthy living. Its duration varies not only among individuals but also in the same individual depending on circumstances, suggesting it is a dynamic and personalized physiological process. It has been divided into rapid eye movement sleep (REMS) and non-REMS (NREMS). The former is unique that adult humans spend the least time in this stage, when although one is physically asleep, the brain behaves as if awake, the dream state. As NREMS is a pre-requisite for appearance of REMS, the latter can be considered a predictive readout of sleep quality and health. It plays a protective role against oxidative, stressful, and psychopathological insults. Several modern lifestyle activities compromise quality and quantity of sleep (including REMS) affecting fundamental physiological and psychopathosomatic processes in a personalized manner. REMS loss-induced elevated brain noradrenaline (NA) causes many associated symptoms, which are ameliorated by preventing NA action. Therefore, we propose that awareness about personalized sleep hygiene (including REMS) and maintaining optimum brain NA level should be of paramount significance for leading physical and mental well-being as well as healthy living. As sleep is a dynamic, multifactorial, homeostatically regulated process, for healthy living, we recommend addressing and treating sleep dysfunctions in a personalized manner by the health professionals, caregivers, family, and other supporting members in the society. We also recommend that maintaining sleep profile, optimum level of NA, and/or prevention of elevation of NA or its action in the brain must be seriously considered for ameliorating lifestyle and REMS disturbance-associated dysfunctions.

Self-reported prior night's sleep quantity on baseline symptom factors and computerized neurocognitive testing in high school athletes

Little is known regarding sleep and baseline concussion performance and symptoms in athletes. We explored the effects of self-reported prior night's sleep quantity on baseline symptoms and computerized neurocognitive testing in high school athletes. A retrospective analysis of 958 high school athletes between the ages of 13-19 years was completed on Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) performance. Participants were categorized into two groups based on self-reported prior night's sleep quantity: <8 h (n = 524; 55%) and ≥8 h (n = 434; 45%). Measures consisted of baseline total symptom score, symptom factors (vestibular-somatic, sleep-arousal, affective, and cognitive-sensory), and ImPACT composite scores (verbal and visual memory, visual-motor speed, reaction time, and impulse control). Significant differences were found on all baseline symptom factors (ps < .02) and total symptom scores (p < .001) with greater symptom reporting in the <8 h prior night's sleep group. No group differences were observed between duration and composite scores of verbal memory (p = .49), visual memory (p = .94), visual-motor speed (p = .38), reaction time (p = .50), or impulse control (p = .81). High school athletes who report <8 h of sleep the night prior to baseline concussion testing reported greater symptoms across all symptom factors. Clinicians should consider inadequate sleep the night prior to concussion testing to ensure accurate, valid assessments, especially on symptom reporting scales.

Clinical utility of the Epworth sleepiness scale

PURPOSE

The Epworth sleepiness scale (ESS) is a widely used tool which has been validated as a measure of sleepiness. However, the scores within individual patients referred for clinical sleep services vary considerably which may limit the clinical use of the ESS. We sought to determine the test-retest reliability of the ESS if scores were classified as either normal or sleepy.

METHODS

We measured the ESS in patients presenting to our sleep center at a clinical visit and again when a sleep study was done. Demographic and clinical information was extracted from the electronic medical record.

RESULTS

Average ESS scores were similar on 2 administrations, mean (SD) of 9.8 (5.4) and 10.2 (6.2). Bland-Altman analysis showed upper and lower limits of agreement of 7.5 and - 6.7, respectively. No demographic or clinical variables were identified which contributed to the intra-individual variability. Of the patients who presented with an initial ESS < 11, 80% had a second ESS < 11. Of the patients who presented with an initial ESS ≥ 11, 89% had a second ESS ≥ 11. Cohen's kappa for the two administrations of the ESS was 0.67 (95% CI of 0.51-0.83). Using previously published reports, we calculated Cohen's kappa for polysomnographic determination of the apnea-hypopnea index (AHI) with values ranging from 0.26 to 0.69.

CONCLUSIONS

Individual ESS scores varied considerably within individual patients, but with classification into either normal or sleepy, the test-retest reliability was substantial and in line with other clinical measures including polysomnographic determination of the AHI.

Comprehensive assessments of long-term sleep habits in epidemiological study: Validity and reliability of sleep factors questionnaire (SFQ) among Chinese women

OBJECTIVE

Epidemiological studies suggested that poor sleep is a potentially novel risk factor for several health outcomes currently; however, there are no validated questionnaires that can systematically measure sleep parameters within these studies. We evaluated the reliability and validity of 17-item sleep factors questionnaire (SFQ), which was developed to comprehensively assess long-term sleep habits for the Jiujiang Breast Cancer Study (JBCS), Jiujiang, China.

METHODS

The participants included 100 women aged 18-74years, who were randomly selected from the JBCS project, and completed a SFQ at baseline and again 1year later, and 4 quarterly 30 consecutive days (a total of 120days) sleep diaries over this same year. Reliability was tested by comparing the 2 SFQs; validity by comparing the average measures between the SFQ and the 4 sleep diaries.

RESULTS

Validity analysis showed moderate correlation (γ=0.41) for sleep duration with the adjusted concordance correlation coefficient (CCC_adj) of 0.54; the weighted κ statistics indicated an excellent agreement for night/shift work and sleep medication use; fair-to-moderate for sleep quality, light at night (LAN), nighttime sleeping with light on, sleep noise and nap time; slight-to-fair for sleep quality and nighttime wakings frequency. Reliability analysis showed excellent correlation for night/shift work and sleep medication use; fair-to-moderate for LAN, nighttime wakings frequency, insomnia frequency, sleep noise and nap time; but slight-to-fair for insomnia frequency and nighttime sleeping with light on; the CCC_adj for sleep duration was 0.61.

CONCLUSIONS

The SFQ showed reasonable reliability and validity for sleep assessments in most domains.

Trends in Self-Reported Sleep Duration among US Adults from 1985 to 2012

STUDY OBJECTIVE

The trend in sleep duration in the United States population remains uncertain. Our objective was to examine changes in sleep duration from 1985 to 2012 among US adults.

DESIGN

Trend analysis.

SETTING

Civilian noninstitutional population of the United States.

PARTICIPANTS

324,242 US adults aged ≥ 18 y of the National Health Interview Survey (1985, 1990, and 2004-2012).

MEASUREMENTS AND RESULTS

Sleep duration was defined on the basis of the question "On average, how many hours of sleep do you get in a 24-h period?" The age-adjusted mean sleep duration was 7.40 h (standard error [SE] 0.01) in 1985, 7.29 h (SE 0.01) in 1990, 7.18 h (SE 0.01) in 2004, and 7.18 h (SE 0.01) in 2012 (P 2012 versus 1985 < 0.001; P trend 2004-2012 = 0.982). The age-adjusted percentage of adults sleeping ≤ 6 h was 22.3% (SE 0.3) in 1985, 24.4% (SE 0.3) in 1990, 28.6% (SE 0.3) in 2004, and 29.2% (SE 0.3) in 2012 (P 2012 versus 1985 < 0.001; P trend 2004-2012 = 0.050). In 2012, approximately 70.1 million US adults reported sleeping ≤ 6 h.

CONCLUSIONS

Since 1985, age-adjusted mean sleep duration has decreased slightly and the percentage of adults sleeping ≤ 6 h increased by 31%. Since 2004, however, mean sleep duration and the percentage of adults sleeping ≤ 6 h have changed little.

Habitual sleep duration and predicted 10-year cardiovascular risk using the pooled cohort risk equations among US adults

Background

The association between sleep duration and predicted cardiovascular risk has been poorly characterized. The objective of this study was to examine the association between self‐reported sleep duration and predicted 10‐year cardiovascular risk among US adults.

Methods and Results

Data from 7690 men and nonpregnant women who were aged 40 to 79 years, who were free of self‐reported heart disease and stroke, and who participated in a National Health and Nutrition Examination Survey from 2005 to 2012 were analyzed. Sleep duration was self‐reported. Predicted 10‐year cardiovascular risk was calculated using the pooled cohort equations. Among the included participants, 13.1% reported sleeping ≤5 hours, 24.4% reported sleeping 6 hours, 31.9% reported sleeping 7 hours, 25.2% reported sleeping 8 hours, 4.0% reported sleeping 9 hours, and 1.3% reported sleeping ≥10 hours. After adjustment for covariates, geometric mean–predicted 10‐year cardiovascular risk was 4.0%, 3.6%, 3.4%, 3.5%, 3.7%, and 3.7% among participants who reported sleeping ≤5, 6, 7, 8, 9, and ≥10 hours per night, respectively (P_{Wald chi‐square}<0.001). The age‐adjusted percentages of predicted cardiovascular risk ≥20% for the 6 intervals of sleep duration were 14.5%, 11.9%, 11.0%, 11.4%, 11.8%, and 16.3% (P_{Wald chi‐square}=0.022). After maximal adjustment, however, sleep duration was not significantly associated with cardiovascular risk ≥20% (P_{Wald chi‐square}=0.698).

Conclusions

Mean‐predicted 10‐year cardiovascular risk was lowest among adults who reported sleeping 7 hours per night and increased as participants reported sleeping fewer and more hours.

Invited commentary: validity of case-control studies of sleep duration and breast cancer

The light-at-night theory of breast cancer causation states that a portion of the high breast cancer risk in the industrialized world, and of the rising risk in the developing word, is due to the introduction and increasing use of electricity to light the night. It is difficult to test this idea in human populations, partly because almost everyone in the modern world uses electric lighting after the sun sets. Specific hypotheses that have been tested include the notions that shift workers should be at higher risk, blind women should be at lower risk, and reported sleep duration should be inversely associated with risk. Girschik et al. (Am J Epidemiol. 2013;177(4):316-327) have tested the latter in a case-control study. Although the case-control design is useful for many questions, it is probably not useful for studies of sleep duration and health.

Self-reported sleep duration, sleep quality, and breast cancer risk in a population-based case-control study

Breast cancer is one of the most commonly diagnosed invasive cancers. Established risk factors account for only a small proportion of cases. Previous studies have found reductions in sleep duration and quality in the general population over time. There is evidence to suggest a link between poor sleep and an increased risk of breast cancer. In this study, we investigated the relationship between breast cancer and sleep duration and quality in Western Australian women. Data were obtained from a population-based case-control study conducted from 2009 to 2011. Participants completed a self-administered questionnaire that included questions on sleep. Odds ratios and 95% confidence intervals were calculated using unconditional logistic regression. Sensitivity analysis for potential selection and misclassification bias was also conducted. We found no association between self-reported sleep duration on workdays and risk of breast cancer (for <6 hours, odds ratio (OR) = 1.05 (95% CI: 0.82, 1.33); for 6-7 hours, OR = 0.96 (95% CI: 0.80, 1.16); and for >8 hours, OR = 1.10 (95% CI: 0.87, 1.39), compared with the reference category of 7-8 hours' sleep). In addition, we found no association between sleep duration on nonworkdays, subjective sleep quality, or combined duration and quality and risk of breast cancer. This study does not provide evidence to support an association between self-reported sleep duration or quality and the risk of breast cancer.

Validation of self-reported sleep against actigraphy

BACKGROUND

Self-report remains the most practical and cost-effective method for epidemiologic sleep studies involving large population-based samples. Several validated questionnaires have been developed to assess sleep, but these tools are lengthy to administer and may be impractical for epidemiologic studies. We examined whether a 3-item sleep questionnaire, similar to those typically used in epidemiologic studies, closely corresponded with objective measures of sleep as assessed using actigraphy monitoring.

METHODS

Eligible participants were Western Australian women aged 18 to 80 years. Participants completed a sleep questionnaire, wore a wrist actigraph for 7 nights, and completed a brief daily sleep log. Objective actigraphy measurements for 56 participants were summarized by mean and mode and compared with the subjective reports, using weighted kappa and delta.

RESULTS

Data collected from the questionnaire showed poor agreement with objectively measured sleep, with kappas ranging from -0.19 to 0.14.

CONCLUSIONS

Our results indicate that sleep questions typically used in epidemiologic studies do not closely correspond with objective measures of sleep as assessed using actigraphy. The findings have implications for studies that have used such sleep questions. A means of appropriately measuring sleep as a risk factor in epidemiologic studies remains to be determined.