A Nationwide Cross-Sectional Survey of Sleep-Related Problems in Japanese Visually Impaired Patients: Prevalence and Association with Health-Related Quality of Life

The Sleep Health of Individuals with Visual Impairments: A Scoping Review

PURPOSE

Amidst the global aging population and an increasing prevalence of visual impairment across all age groups, this study aims to investigate the current state of research on sleep health in visually impaired populations.

METHODS

A scoping review was conducted to synthesize the existing literature on sleep health and visual impairment. We employed conceptual mapping to identify key research topics, analyzing data from four databases: PubMed (n = 290), CINAHL (n = 81), Scopus (n = 117), and PsycInfo (n = 96). A total of 83 peer-reviewed articles, published from 1977 to August 2023, were included in the review.

RESULTS

Our analysis identified 11 distinct eye health conditions including blindness, glaucoma, diabetic retinopathy, low vision, cataract, retinitis pigmentosa, macular degeneration, optic neuropathy, visual field defects, ocular hypertension, and retinal vein occlusion. Additionally, 8 major sleep problems were recognized: abnormal sleep duration, daytime sleepiness, insomnia, Non-24-Hour Sleep Wake Disorder, sleep apnea, sleep disorders, sleep disturbances, and sleep disordered breathing. The dominant research themes were (1) poor sleep quality in individuals with visual impairments and ophthalmic diseases, (2) high prevalence of sleep issues in patients with ophthalmic diseases, (3) sleep apnea in patients with ophthalmic conditions, and (4) circadian rhythm disruptions in blind individuals.

CONCLUSION

This review highlights research gaps that, when addressed, could greatly enhance our comprehension of the interplay between visual impairment and sleep health. Bridging these gaps promises to lead to more holistic care strategies, potentially improving vision functioning and rehabilitation outcomes for individuals with visual impairments.

Association Between Vision-Related Functional Burden and Sleep Disorders in Adults Aged 20 and Over in the United States

Purpose

The impact of functional vision, rather than visual acuity, on sleep disorders is not well understood. This study estimated the relationship between vision-related functional burden and sleep disorders among a nationally representative sample in the United States.

Methods

Data from the National Health and Nutrition Examination Survey (NHANES) 2005-2008 were analyzed, which included a total of 10,914 US adults 20 years and older. Sleep disorders and vision-related functional burden were measured by the NHANES questionnaire sleep disorders section and vision section, respectively. Logistic regression was used to explore the association between vision-related functional burden and sleep disorders.

Results

A total of 9384 NHANES participants had complete functional vision and sleep disorders data. The mean age at baseline was 47.8 years, and the weighted prevalence of sleep disorders among adults with vision-related functional burden was 20.3%. After controlling for age, gender, race, smoking status, drinking frequency, general health condition, hypertension, diabetes, coronary heart disease, and depression, vision-related functional burden remained significantly associated with sleep disorders (adjusted odds ratio, 1.502; 95% confidence interval, 1.210-1.864; P < 0.001), whereas the association between presenting visual acuity and sleep disorders was not statistically significant.

Conclusions

Vision-related functional burden rather than impairment of visual acuity was related to the increased prevalence of sleep disorders in adults 20 years and older in the United States.

Translational Relevance

Our study provides insight into the relationship between functional vision and sleep disorders. It should be noted that individuals who report vision-related functional burden might be at risk of sleep disorders.

The Roles of Stress, Sleep, and Fatigue on Depression in People with Visual Impairments

The study aimed to investigate the mediating effect of fatigue and the moderating effect of sleep quality on stress and depressive symptoms among people with visual impairments. A total of 155 participants completed the online survey. The Perceived Stress Scale, the Fatigue Symptom Inventory, the Centre for Epidemiological Studies-Depression Inventory (CES-D), and the Pittsburgh Sleep Quality Index (PSQI) were used. Descriptive analysis, correlations, and moderated mediation modelling were conducted using R software. From the mediator variable (FSI) model (F = 22.427, R2 = 56.5, p < .001) and the dependent variable (CES-D) model (F = 35.912, R2 = 70.5, p < .001), after controlling for age, sex, employment, and education, sleep quality positively predicted fatigue levels (β = 2.422, p = .009), and fatigue positively predicted depressive symptoms (β = .152, p < .001). Sleep quality is an essential component of psychological well-being in people with visual impairments.

Association between visual impairment and sleep duration in college students: A study conducted in UAE and Lebanon

Objective: To examine whether self-reported sleep duration and visual impairment were associated among College students. Participants: Students (n = 1002, age 17-35 years) from Lebanon and the United Arab Emirates. Methods: Students were asked to complete a validated questionnaire between October 2018 and May 2019. The questions were related to sociodemographics, lifestyle characteristics, visual impairment status, sleeping pattern, mobile-phone use and chronic conditions. Results: 18.3% of the respondents reported to suffer from visual impairment. Among them, 72.7% were females (p < .001), 65% admitted to frequently use mobile phones before sleeping (p < .001), 54.6% reported to sleep less than 7 h (p = .008) and 71.6% reported to suffer from sleep disturbances (p = .05). Visual impairment was associated with poor sleep quality (p < .001), mobile phone use before sleeping (p < .01) and daily stress (p < .05). Conclusion: Visual impairment in college students is associated with short sleep duration, mobile phone use before sleeping and stress level.

The impact of COVID-19 on the everyday life of blind and sighted individuals

The COVID-19 pandemic caused unexpected and unavoidable changes in daily life worldwide. Governments and communities found ways to mitigate the impact of these changes, but many solutions were inaccessible to people with visual impairments. This work aimed to investigate how blind individuals subjectively experienced the restrictions and isolation caused by the COVID-19 pandemic. To this end, a group of twenty-seven blind and seventeen sighted people took part in a survey addressing how COVID-19 impacted life practically and psychologically, how it affected their daily habits, and how it changed their experiences of themselves and others. Results demonstrated that both sighted and blind individuals had a hard time adapting to the new situation. However, while sighted people struggled more with personal and social aspects, the frustration of the blind population derived mostly from more practical and logistical issues. Likely as consequences, results showed that blind people engaged more in their inner life and experienced fear and anger as main emotions. This study suggests that changes in life associated with COVID-19 have been subjectively experienced differently based on the presence or not of blindness, and that tailored future interventions should be considered to take care of the different needs of blind individuals.

Relationship of night sleep duration with health lifestyle, depressive symptoms, internet addiction in Chinese High school Students

This study aimed to explore effects of night sleep duration and its relationships with health lifestyle, depressive symptoms and Internet addiction among high school students. In this study, we used multistage stratified random cluster sampling method. A total of 2149 adolescents aged 14-18 years old were recruited in the study. Associations among sleep duration and demographic characteristics, health lifestyle, depressive symptoms and Internet addiction among Chinese students were analyzed by univariate analysis and binary logistic regression analysis. Then, the structural equation model (SEM) was used to study the relationships between sleep duration and other variables. The mean sleep duration was (6.56 ± 1.15) hours. Approximately 16.0% of all participants had short sleep duration, and 20.5% had long sleep duration. Binary logistic regression analysis revealed that having more high sugar drinks and fried foods were positively associated with short sleep duration. Depressive symptoms not only directly had a negatively impact on sleep duration, but also had an indirect effect on sleep duration through Internet addiction. Sleep problems are common within the population of adolescents. Depressive symptoms was an important factor in the prevention of abnormal sleep duration, and interventions that target Internet addiction is key to reduce inadequate sleep.

The Impact of COVID-19 on Sleep Quality in People Living With Disabilities

Background: Research exploring the impact of the COVID-19 pandemic on sleep in people with disabilities has been scarce. This study provides a preliminary assessment of sleep in people with disabilities, across two timepoints during the pandemic, with a focus on those with visual impairment (VI).

Methods: Two online surveys were conducted between April 2020 and March 2021 to explore sleep quality using the Pittsburgh Sleep Quality Index (PSQI). A convenience sample of 602 participants completed the first survey and 160 completed the follow-up survey.

Results: Across both timepoints, participants with disabilities reported significantly poorer global sleep quality and higher levels of sleep disturbance, use of sleep medication and daytime dysfunction than those with no disabilities. Participants with VI reported significantly higher levels of sleep disturbance and use of sleep medication at both timepoints, poorer global sleep quality, sleep duration and latency at time 1, and daytime dysfunction at time 2, than those with no disabilities. Global sleep quality, sleep duration, sleep efficiency, and self-rated sleep quality deteriorated significantly in participants with no disabilities, but daytime dysfunction increased in all three groups. Disability and state anxiety were significant predictors of sleep quality across both surveys.

Conclusion: While sleep was consistently poorer in people with disabilities such as VI, it appears that the COVID-19 pandemic has had a greater impact on sleep in people with no disabilities. State anxiety and, to a lesser extent, disability, were significant predictors of sleep across both surveys, suggesting the need to address anxiety in interventions targeted toward improving sleep.

Light therapy for seasonal affective disorder in visual impairment and blindness - a pilot study

OBJECTIVE

Seasonal and non-seasonal depression are prevalent conditions in visual impairment (VI). We assessed the effects and side effects of light therapy in persons with severe VI/blindness who experienced recurrent depressive symptoms in winter corresponding to seasonal affective disorder (SAD) or subsyndromal SAD (sSAD).

RESULTS

We included 18 persons (11 with severe VI, 3 with light perception and 4 with no light perception) who met screening criteria for sSAD/SAD in a single-arm, assessor-blinded trial of 6 weeks light therapy. In the 12 persons who completed the 6 weeks of treatment, the post-treatment depression score was reduced (p < 0.001), and subjective wellbeing (p = 0.01) and sleep quality were improved (p = 0.03). In 6/12 participants (50%), the post-treatment depression score was below the cut-off set for remission. In four participants with VI, side effects (glare or transiently altered visual function) led to dropout or exclusion.

CONCLUSION

Light therapy was associated with a reduction in depressive symptoms in persons with severe VI/blindness. Eye safety remains a concern in persons with residual sight.

Sleep disruption considerations for Paralympic athletes competing at Tokyo 2020

The role of sleep is now recognized as an important component for success in athletic performance, and sleep is proposed to be one of the most effective recovery strategies available. Insufficient sleep is commonly reported among athletes while several factors have been put forward to explain why elite athletes might experience poor sleep. However, Paralympic athletes may be predisposed to a greater risk of poor sleep due to the associated complexities of some impairment types. In fact, clinical research has previously shown that individuals with disabilities have a higher prevalence of sleep disturbances when compared to their able-bodied counterparts. However, research and evidence-based practices regarding the sleep of elite Paralympic athletes are limited. Firstly, this narrative review aims to identify challenges associated with the Paralympic games to obtain optimal sleep. Secondly, identify the specific risk factors to sleep associated with particular impairment groups within the Paralympic population, and lastly to propose potential sleep-enhancing strategies that might be of relevance for Paralympic athletes. From this review, initial observations have identified that Paralympic athletes may have a heightened risk of sleep-related problems, and importantly highlighted the current lack of understanding within this population group. Furthermore, this review identified where further research is warranted to better understand how specific impairments impact sleep and, consequently, athletic performance. Additionally, this review highlighted that the forthcoming Tokyo games may offer a unique challenge for athletes trying to obtain optimal sleep, due to the anticipated thermal demands and the consequent irregular scheduling of events.

Movement behaviors, comorbidities, and health-related quality of life among adults with visual impairments

PURPOSE

The purpose of this study was to examine (a) discrete and integrative associations of physical activity (PA), sitting-time (ST), and sleep duration (SD) with health-related quality of life (HRQoL) among adults with visual impairments (VIs) and (b) the role that comorbidities play in the association between PA, ST, and SD and HRQoL among adults with VIs.

MATERIALS AND METHODS

This cross-sectional study utilized an online survey methodology. A sample of 195 adults with VIs were recruited from two VI-related listservs in the U.S. from June to September of 2019, and they completed a battery of self-reported measures.

RESULTS

Meeting SD, PA, and ST guidelines were positive predictors for HRQoL. The number of reported comorbidities was as a significant negative predictor for HRQoL. The number of comorbidities did not moderate the association between meeting movement guidelines and HRQoL. Adjusting for gender and number of comorbidities, analysis of covariance showed that individuals meeting all three guidelines had significantly higher HRQoL than those meeting none or SD guideline alone.

CONCLUSIONS

The results demonstrate the discrete and integrative HRQoL-related benefits of meeting three movement behavior guidelines for adults with VIs. The existence of comorbid conditions did not moderate this relationship.Implications for rehabilitationAdults with visual impairments (VIs) tend to report poorer health-related quality of life (HRQoL) than those without VIs.In our sample, participants who met all three of the physical activity (PA), sitting-time, and sleep guidelines had significantly higher HRQoL than those meeting none or the sleep guideline alone.Mechanisms to disseminate movement guidelines and associated benefits are needed to promote guideline adherence to adults with VIs.Rehabilitation professionals should design and implement multi-behavior programs to promote adherence to PA, screen-time, and sleep duration guidelines to enhance HRQoL among adults with VIs, including those experiencing comorbid conditions.

Prevalence and associated factors of circadian rhythm sleep-wake disorders and insomnia among visually impaired Japanese individuals

BACKGROUND

Although earlier studies have demonstrated that circadian rhythm sleep-wake disorders (CRSWD) are more prevalent in visually impaired individuals, the actual prevalence of CRSWD and insomnia among the visually impaired Japanese population remains unclear. The aim of this cross-sectional, telephone-based study was to estimate the prevalence of CRSWD and insomnia, and explore factors associated with CRSWD and insomnia among visually impaired Japanese individuals.

METHODS

A nationwide telephone survey was conducted among visually-impaired individuals through local branches of the Japan Federation of the Blind. In total, 157 visually impaired individuals were eligible for this study. Demographic information and information about visual impairments, lifestyle, and sleep patterns were assessed using questionnaires and subsequent telephone interviews. CRSWD and insomnia were defined according to the International Classification of Sleep Disorders-Third Edition criteria.

RESULTS

The prevalence of CRSWD in visually impaired individuals was 33.1%. Among those with CRSWD, a non-24-h/irregular sleep-wake rhythm type was the most frequently observed (26.8%), followed by an advanced sleep-wake phase type and a delayed sleep-wake phase type (3.8 and 2.5%, respectively). Furthermore, 28.7% of the visually impaired individuals were found to have insomnia. In the visually impaired individuals, the absence of light perception, unemployment, living alone, and use of hypnotics were significantly associated with CRSWD, whereas only the use of hypnotics was extracted as a marginally associated factor of insomnia.

CONCLUSIONS

CRSWD and insomnia were highly prevalent in visually impaired Japanese individuals. The presence of CRSWD among the visually impaired individuals was associated with a lack of light perception and/or social zeitgebers.

Prevalence and risk factors of sleep disorders in visually impaired athletes

OBJECTIVE

The present study clarified the prevalence and risk factors of sleep disorders in visually impaired athletes.

METHODS

A cross-sectional questionnaire survey was conducted with 99 visually impaired athletes engaged in the following Paralympic sport events: track and field (marathon), goalball, swimming, blind soccer, and judo. Eighty-one respondents (male: 72.8%; average age: 32.5 ± 12.0 years) who completed the survey were chosen for analyses. Survey items were attributes [age, gender, body mass index, and condition of visual impairment (athletic classification and causing time of disability)], lifestyle habits (bedtime, wake-up time, drinking alcohol, meals, and use of electronics after lights out), competition activities (sports time per week, morning and evening practices, and competition stressors), psychological distress, and sleep disorders [recorded using the Pittsburgh Sleep Quality Index (PSQI)]. First, the prevalence of the respondents having sleep disorders (scored 5.5 points or more in the PSQI) was investigated. Then, the relations between attributes, lifestyle habits, competition activities, psychological distress, and sleep disorders were explored using logistic regression analysis.

RESULTS

Twenty-six respondents (32.1%) had sleep disorders. Results of multivariate logistic regression analysis showed that "interpersonal relationship stressors" and "wake-up time" were independently related to sleep disorders.

CONCLUSIONS

Approximately one-third of visually impaired athletes were shown to have sleep disorders. High interpersonal relationship stressors and late wake-up time may be risk factors of their sleep disorders.

Effects of primary glaucoma on sleep quality and daytime sleepiness of patients residing at an equatorial latitude

AIM

To investigate the impact of primary glaucoma on sleep quality and daytime sleepiness of patients.

METHODS

Prospective cross-sectional study with consecutive sampling in South-East Asian population was performed. Validated questionnaires: the Pittsburg Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) were administered prospectively. Subjects with non-glaucomatous optic neuropathy or concomitant retinal pathology were excluded. Glaucoma severity was based on HVF 24-2 perimetry. Binocular single vision was represented based on the better eye. Frequency of and predictive factors for poor sleep quality and excessive daytime sleepiness were compared.

RESULTS

A total of 79 primary open angle glaucoma (POAG), 27 primary angle-closure glaucoma (PACG) patients, and 89 controls were recruited. PACG patients had higher median PSQI scores (P=0.004) and poorer sleep quality (P<0.001). Compared to controls, PACG patients were 3.34 times more likely to have poor sleep quality (P=0.008), which remained significant after adjustment for demographics (P=0.016) and predictive variables (P=0.013). PACG patients have poorer sleep quality when visual acuity (VA) was 6/15 or worse (P=0.009). Univariate and multivariate analysis of predictive variables for poor sleep quality and daytime sleepiness did not find statistical significance.

CONCLUSION

PACG patients have poorer sleep quality but not daytime sleepiness. This is important in South-East Asian population with heavy disease burden. Evaluations on sleep disturbances can be considered to provide more holistic care.

Visual impairment, low vision acuity, and the mediating effect of sleep indicators among older adults in India

Little is known about the prevalence and association between visual impairment, low vision acuity, and sleep indicators (sleep duration and sleep problem) in the Indian context. We investigate this association for Indian older adults (50+ ages). Using cross-sectional data from WHO-Study on global AGEing and adult health (WHO-SAGE) 2007–2008, a sample of 6560 ( Mage = 61.81, SD = 9.00) was selected for analysis. Self-reported visual impairment and performance-based low vision acuity were used as outcome variables, whereas sleep duration, problem in sleep, and medical condition with socio-demographic were used as covariates. Multivariate logistic regression analyses were conducted. In a fully adjusted model (including all covariates), vision impairment was associated with short sleep duration (<6 hr) and sleep problem, separately and together for both genders. Low vision was positively associated with short sleep duration and sleep problem, separately and together for males, whereas only long sleep (⩾9 hr) is associated with low vision acuity for females in fully adjusted model. Results suggest that sleep apnea including short sleep duration and sleep problem is the underestimated cause of visual impairment and vision acuity. Healthcare providers should consider sleep parameters (sleep duration and sleep problem) along with sleep apnea in the treatment of visual impaired older adults.

The association between visual impairment and fatigue: a systematic review and meta-analysis of observational studies

PURPOSE

The aim was to compare fatigue levels between patients with visual impairment and controls with normal sight and to examine the association between fatigue and vision loss severity.

METHODS

A systematic literature search was performed using databases of PubMed, Embase, PsycINFO and Cochrane to identify observational studies with outcomes related to fatigue (e.g. vitality subscale of the Short-Form 36, Fatigue Assessment Scale). A meta-analysis was performed using standardised mean differences (SMDs) and odds ratios (OR) to quantitatively summarise the association between visual impairment and fatigue. Sources of heterogeneity were explored by subgroup and sensitivity analyses. Study quality was assessed with the Newcastle-Ottawa scale.

RESULTS

After reviewing 4477 studies, 22 studies with a total of 40 004 participants were included, of which 18 contributed to meta-analysis. Among these, eight were assessed as moderate quality studies and 10 as high quality studies. Pooled analysis involving 2500 patients and 8395 controls showed higher fatigue severity levels (S.M.D. = -0.36, 95% CI -0.50 to -0.22, 14 studies) among visually impaired patients compared to normally sighted controls. This effect size was small and persisted in sensitivity analyses that involved study quality, fatigue assessment tools and visual acuity data. Furthermore, pooled analysis of four studies including 2615 patients and 5438 controls showed a significant association between visual impairment and fatigue (OR = 2.61, 95% CI 1.69 to 4.04). Secondary meta-analysis of four studies showed no significant difference in fatigue severity (S.M.D. = 0.01, 95% CI -0.37 to 0.39) between patients with moderate visual impairment and patients with severe visual impairment or blindness.

CONCLUSIONS

Current moderate to high quality evidence suggest that patients with visual impairment experience more severe fatigue symptoms than persons with normal sight. However, a limited number of available studies indicates that fatigue is not associated with severity of vision loss. Future studies are required to determine which factors and underlying mechanisms may explain the association between visual impairment and fatigue. Discussing fatigue at an early stage and developing intervention options for vision-related fatigue should be considered within the field of low vision rehabilitation.

Circadian Rhythm Disturbances in the Blind

PURPOSE OF REVIEW

Sleep timing, quantity, and quality are controlled by homeostatic and circadian systems. Circadian clock systems are present in all cells and organs and their timing is determined by a transcriptional-translational feedback loop of circadian genes. Individual cellular clocks are synchronized by the central body clock, situated in the suprachiasmatic nucleus, which communicates with them through humoral and neural signals including melatonin. The circadian system controls both the circadian period: (i.e., the length of the intrinsic clock), but also the circadian phase (i.e., the clock timing). An important determinant of the circadian system is light exposure. In most humans, the circadian period is slightly longer than 24 h and without regular resetting it tends to drift, leading to progressively later bedtimes and wake times and a tendency to cycle though periods of normal and abnormal sleep. Blind patients are thus at an increased risk of abnormal circadian function. The purpose of this article is to review recent research and clinical management of circadian rhythm disorders in blind patients.

RECENT FINDINGS

Blind patients can present delayed and advanced sleep phase disorders but the most common abnormality in totally blind patients without light perception is non-24-hour sleep-wake disorder (N24SWD). This is rare in the general population but may affect up to 50% of blind patients without light perception. The diagnosis of a circadian rhythm disorder in the blind is complex. New screening tools have been developed but actigraphy and repeated melatonin profiles over 24 h remain essential. Circadian disorders in the blind are frequent, especially in the patients without light perception. They require accurate diagnosis in order to target treatment. Determining the precise nature of a sleep disorder in blind patients with a suspected circadian rhythm abnormality is complex and requires a detailed clinical history with sleep diaries and the use of actigraphy and melatonin profiles.

Preserved sleep microstructure in blind individuals

The loss of vision, particularly when it occurs early in life, is associated with compensatory cortical plasticity not only in the visual cortical areas, but throughout the entire brain. The absence of visual input to the retina can also induce changes in entrainment of the circadian rhythm, as light is the primary zeitgeber of the master biological clock found in the suprachiasmatic nucleus of the hypothalamus. In addition, a greater number of sleep disturbances is often reported in blind individuals. Here, we examined various electroencephalographic microstructural components of sleep, both during rapid-eye-movement (REM) sleep and non-REM (NREM) sleep, between blind individuals, including both of early and late onset, and normal-sighted controls. During wakefulness, occipital alpha oscillations were lower, or absent in blind individuals. During sleep, differences were observed across electrode derivations between the early and late blind samples, which may reflect altered cortical networking in early blindness. Despite these differences in power spectra density, the electroencephalography microstructure of sleep, including sleep spindles, slow wave activity, and sawtooth waves, remained present in the absence of vision.

Association between Visual Impairment and Low Vision and Sleep Duration and Quality among Older Adults in South Africa

This study aims to estimate the association between visual impairment and low vision and sleep duration and poor sleep quality in a national sample of older adults in South Africa. A national population-based cross-sectional Study of Global Ageing and Adults Health (SAGE) wave 1 was conducted in 2008 with a sample of 3840 individuals aged 50 years or older in South Africa. The interviewer-administered questionnaire assessed socio-demographic characteristics, health variables, sleep duration, quality, visual impairment, and vision. Results indicate that 10.0% of the sample reported short sleep duration (≤5 h), 46.6% long sleep (≥9 h), 9.3% poor sleep quality, 8.4% self-reported and visual impairment (near and/or far vision); and 43.2% measured low vision (near and/or far vision) (0.01-0.25 decimal) and 7.5% low vision (0.01-0.125 decimal). In fully adjusted logistic regression models, self-reported visual impairment was associated with short sleep duration and poor sleep quality, separately and together. Low vision was only associated with long sleep duration and poor sleep quality in unadjusted models. Self-reported visual impairment was related to both short sleep duration and poor sleep quality. Population data on sleep patterns may want to include visual impairment measures.