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Holingue C, Owusu JT, Tzuang M, Nyhuis CC, Yaffe K, Stone KL, Rebok GW, Ancoli-Israel S, Spira AP. Accelerometer-assessed sleep and decline in physical function in older men. Sleep Health 2024; 10:129-136. [PMID: 38143154 PMCID: PMC10922516 DOI: 10.1016/j.sleh.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 09/21/2023] [Accepted: 11/06/2023] [Indexed: 12/26/2023]
Abstract
OBJECTIVES Assess the prospective association of actigraphically measured sleep with self-report and objective measures of physical function among community-dwelling older men. METHODS Participants were (n = 1496) men aged ≥65 years from the Osteoporotic Fractures in Men Study and ancillary sleep study who were followed up at 4 years for physical function outcomes. Sleep predictors included baseline total sleep time (<6, 6-8 hours [reference], >8 hours), sleep efficiency (<80% or ≥80% [reference]), wake after sleep onset (<90 [reference] or ≥90 minutes), and sleep onset latency (<30 [reference] or ≥30 minutes), measured by wrist actigraphy. Outcomes included self-reported difficulties in mobility and instrumental activities of daily living and objective measures of physical performance (time to complete chair stands, gait speed, grip strength, best narrow walk pace). Multivariable regression models estimated associations between the sleep predictors and change in physical function at follow-up, adjusting for demographic and health-related variables. RESULTS Participants with short average baseline total sleep time (<6 hours) had significantly greater slowing in their walking speed from baseline to follow-up. Participants with long baseline sleep onset latency (≥30 minutes) had significant increases in mobility difficulties and time to complete chair stands. Sleep efficiency and wake after sleep onset were not significantly associated with any outcomes. No sleep predictors were associated with change in instrumental activities of daily living. CONCLUSIONS These findings add to the body of evidence showing links between poor sleep and subsequent declines in physical function. Further experimental research is needed to understand the mechanisms at play.
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Affiliation(s)
- Calliope Holingue
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - Jocelynn T Owusu
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Marian Tzuang
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Casandra C Nyhuis
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kristine Yaffe
- Departments of Psychiatry, Neurology, Epidemiology and Biostatistics, University of California, San Francisco, California, USA; San Francisco VA Medical Center, San Francisco, California, USA
| | - Katie L Stone
- California Pacific Medical Center Research Institute, San Francisco, California, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - George W Rebok
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Johns Hopkins Center on Aging and Health, Baltimore, Maryland, USA
| | - Sonia Ancoli-Israel
- Department of Psychiatry, University of California San Diego, San Diego, California, USA
| | - Adam P Spira
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Johns Hopkins Center on Aging and Health, Baltimore, Maryland, USA
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Nyhuis CC, Fernandez-Mendoza J. Insomnia nosology: a systematic review and critical appraisal of historical diagnostic categories and current phenotypes. J Sleep Res 2023; 32:e13910. [PMID: 37122153 DOI: 10.1111/jsr.13910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 05/02/2023]
Abstract
Insomnia nosology has significantly evolved since the Diagnostic and Statistical Manual (DSM)-III-R first distinguished between 'primary' and 'secondary' insomnia. Prior International Classification of Sleep Disorders (ICSD) nosology 'split' diagnostic phenotypes to address insomnia's heterogeneity and the DSM nosology 'lumped' them into primary insomnia, while both systems assumed causality for insomnia secondary to health conditions. In this systematic review, we discuss the historical phenotypes in prior insomnia nosology, present findings for currently proposed insomnia phenotypes based on more robust approaches, and critically appraise the most relevant ones. Electronic databases PsychINFO, PubMED, Web of Science, and references of eligible articles, were accessed to find diagnostic manuals, literature on insomnia phenotypes, including systematic reviews or meta-analysis, and assessments of the reliability or validity of insomnia diagnoses, identifying 184 articles. The data show that previous insomnia diagnoses lacked reliability and validity, leading current DSM-5-TR and ICSD-3 nosology to 'lump' phenotypes into a single diagnosis comorbid with health conditions. However, at least two new, robust insomnia phenotyping approaches were identified. One approach is multidimensional-multimethod and provides evidence for self-reported insomnia with objective short versus normal sleep duration linked to clinically relevant outcomes, while the other is multidimensional and provides evidence for two to five clusters (phenotypes) based on self-reported trait, state, and/or life-history data. Some approaches still need replication to better support whether their findings identify true phenotypes or simply different patterns of symptomatology. Regardless, these phenotyping efforts aim at improving insomnia nosology both as a classification system and as a mechanism to guide treatment.
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Affiliation(s)
- Casandra C Nyhuis
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Julio Fernandez-Mendoza
- Sleep Research and Treatment Center, Department of Psychiatry and Behavioral Health, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
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Ell J, Schiel JE, Feige B, Riemann D, Nyhuis CC, Fernandez-Mendoza J, Vetter C, Rutter MK, Kyle SD, Spiegelhalder K. Sleep health dimensions and shift work as longitudinal predictors of cognitive performance in the UK Biobank cohort. Sleep 2023:7099635. [PMID: 37004209 DOI: 10.1093/sleep/zsad093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Indexed: 04/03/2023] Open
Abstract
STUDY OBJECTIVES The long-term effects of sleep health and shift work on cognitive performance are unclear. In addition, research has been limited by small sample sizes and short follow-up periods. We conducted one of the largest examinations of the longitudinal influence of sleep health dimensions and shift work on cognitive performance in people of middle and old age using data from the UK Biobank. The hypothesis was that poor sleep health and shift work would predict lower cognitive performance. METHODS Self-reported sleep duration, daytime sleepiness, insomnia symptoms, chronotype and shift work status were assessed as predictors at baseline. Cognitive performance was operationalised by a touchscreen test battery at follow-up between 7.4 ± 2.2 and 9.0 ± 0.9 years after baseline assessment, depending on the specific task. Models were performed for each cognitive domain including relevant confounders (e.g., depression). The alpha level was set at p<0.01 for all analyses. RESULTS The study sample comprised 9,394 participants for the reasoning task, 30,072 for the reaction time task, 30,236 for the visual memory task, 2,019 for the numeric memory task and 9,476 for the prospective memory task. Shift work without night shifts (ß= -2.0x10- 1 ± 6.5x10- 2, p=0.002) and with night shifts (ß= -1.9x10- 1 ± 7.2x10- 2, p=0.010) predicted a significantly reduced performance in the reasoning task. Short sleep duration (ß= -2.4x10- 1 ± 7.9x10- 2, p=0.003) and shift work without night shifts (ß= -3.9x10- 1 ± 1.2x10- 1, p=0.002) predicted a significantly lower performance in the task probing prospective memory. CONCLUSIONS Our results suggest that, after controlling for confounding variables, shift work and short sleep duration are important predictors for cognitive performance in people of middle and old age. Further work is required to examine causal mechanisms of the observed associations.
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Affiliation(s)
- Johanna Ell
- Department of Psychiatry and Psychotherapy, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Julian E Schiel
- Department of Psychiatry and Psychotherapy, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bernd Feige
- Department of Psychiatry and Psychotherapy, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dieter Riemann
- Department of Psychiatry and Psychotherapy, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Basics in NeuroModulation (NeuroModulBasics), Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Casandra C Nyhuis
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Julio Fernandez-Mendoza
- Sleep Research and Treatment Center, Department of Psychiatry and Behavioral Health, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Céline Vetter
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA
| | - Martin K Rutter
- Centre for Biological Timing, Faculty of Biology, Medicine and Health, University of Manchester, UK
- Diabetes, Endocrinology and Metabolism Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Simon D Kyle
- Sleep and Circadian Neuroscience Institute (SCNi), Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kai Spiegelhalder
- Department of Psychiatry and Psychotherapy, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Alfini AJ, Won J, Weiss LR, Nyhuis CC, Zipunnikov V, Spira AP, Liu-Ambrose T, Shackman AJ, Smith JC. Cardiorespiratory Fitness as a Moderator of Sleep-Related Associations with Hippocampal Volume and Cognition. Brain Sci 2022; 12:brainsci12101360. [PMID: 36291294 PMCID: PMC9599432 DOI: 10.3390/brainsci12101360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/23/2022] [Accepted: 10/03/2022] [Indexed: 11/16/2022] Open
Abstract
The objective of this study was to understand the associations of sleep and cardiorespiratory fitness with hippocampal volume and global cognition among older adults (n = 30, age = 65.8 years, female = 73.3%). Wrist actigraphy provided objective measures of nighttime sleep including sleep duration, average wake bout length (WBL; sleep disturbance), and wake-to-sleep transition probability (WTSP; sleep consolidation). Cardiorespiratory fitness was quantified via cycle exercise using a modified heart rate recovery approach. Magnetic resonance imaging was used to determine hippocampal volume and the Mini-Mental State Examination was used to assess global cognition. Fitness moderated associations of sleep with hippocampal volume and cognitive performance, whereby the association of WBL—an index of poor sleep—with hippocampal atrophy was stronger among less-fit individuals, and the association of sleep duration with cognitive performance was stronger among more-fit individuals. Across the fitness levels, a longer WBL was associated with lower cognitive performance, and a higher WTSP—an index of more consolidated sleep—was associated with greater hippocampal volume. Sleep and fitness were unrelated to the volume of an amygdala control region, suggesting a degree of neuroanatomical specificity. In conclusion, higher cardiorespiratory fitness may attenuate sleep disturbance-related hippocampal atrophy and magnify the cognitive benefits of good sleep. Prospective studies are needed to confirm these findings.
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Affiliation(s)
- Alfonso J. Alfini
- National Center on Sleep Disorders Research, Division of Lung Diseases, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD 20817, USA
| | - Junyeon Won
- Department of Kinesiology, University of Maryland School of Public Health, College Park, MD 20742, USA
| | - Lauren R. Weiss
- Department of Kinesiology, University of Maryland School of Public Health, College Park, MD 20742, USA
- Neuroscience and Cognitive Science Program, University of Maryland, College Park, MD 20742, USA
| | - Casandra C. Nyhuis
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Vadim Zipunnikov
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Adam P. Spira
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
- Center on Aging and Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Teresa Liu-Ambrose
- Department of Physical Therapy, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, Vancouver, BC V5Z 1M9, Canada
| | - Alexander J. Shackman
- Neuroscience and Cognitive Science Program, University of Maryland, College Park, MD 20742, USA
- Department of Psychology, University of Maryland, College Park, MD 20742, USA
- Maryland Neuroimaging Center, University of Maryland, College Park, MD 20742, USA
| | - J. Carson Smith
- Department of Kinesiology, University of Maryland School of Public Health, College Park, MD 20742, USA
- Neuroscience and Cognitive Science Program, University of Maryland, College Park, MD 20742, USA
- Maryland Neuroimaging Center, University of Maryland, College Park, MD 20742, USA
- Correspondence: ; Tel.: +1-301-405-0344
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Alfini AJ, Won J, Weiss LR, Nyhuis CC, Shackman AJ, Spira AP, Smith JC. Impact of exercise on older adults' mood is moderated by sleep and mediated by altered brain connectivity. Soc Cogn Affect Neurosci 2020; 15:1238-1251. [PMID: 33201227 PMCID: PMC7745152 DOI: 10.1093/scan/nsaa149] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/25/2020] [Accepted: 10/27/2020] [Indexed: 01/01/2023] Open
Abstract
Older adults comprise the fastest growing global demographic and are at increased risk of poor mental health outcomes. Although aerobic exercise and sleep are critical to the preservation of emotional well-being, few studies have examined their combined mood-enhancing effects, or the potential neural mechanisms underlying these effects. Here, we used a randomized crossover design to test the impact of acute exercise on mood and the intrinsic functional connectivity (iFC) of the cingulo-opercular network in physically healthy older adults. Wrist actigraphy provided objective indices of sleep. Results revealed that 30 min of moderate-intensity aerobic exercise acutely enhanced positive affect (PA) and reduced iFC between the cingulo-opercular network and the hippocampus. Both effects were magnified among older adults with greater sleep disturbance. Exercise-induced changes in hippocampal iFC mediated relations between sleep disturbance and exercise-induced increases in PA. These findings provide evidence that aerobic exercise enhances mood, that it does so by altering connectivity between the anterior insula-a key hub in the cingulo-opercular network-and the hippocampus and that lower sleep quality is a stronger predictor of these effects among older adults. These observations underscore the benefits of moderate-intensity exercise-a safe and scalable behavioral intervention-and provide new clues about the neural circuitry underlying the interactive effects of sleep and exercise on mood.
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Affiliation(s)
- Alfonso J Alfini
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Junyeon Won
- Department of Kinesiology, University of Maryland School of Public Health, College Park, MD 20742, USA
| | - Lauren R Weiss
- Department of Kinesiology, University of Maryland School of Public Health, College Park, MD 20742, USA
- Neuroscience and Cognitive Science Program, University of Maryland, College Park, MD 20742, USA
| | - Casandra C Nyhuis
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Alexander J Shackman
- Neuroscience and Cognitive Science Program, University of Maryland, College Park, MD 20742, USA
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Adam P Spira
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
- Center on Aging and Health, Johns Hopkins School of Medicine and Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - J Carson Smith
- Department of Kinesiology, University of Maryland School of Public Health, College Park, MD 20742, USA
- Neuroscience and Cognitive Science Program, University of Maryland, College Park, MD 20742, USA
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Won J, Alfini AJ, Weiss LR, Nyhuis CC, Spira AP, Callow DD, Carson Smith J. Caudate Volume Mediates the Interaction between Total Sleep Time and Executive Function after Acute Exercise in Healthy Older Adults. Brain Plast 2019; 5:69-82. [PMID: 31970061 PMCID: PMC6971824 DOI: 10.3233/bpl-190087] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Although both exercise and sleep are significant lifestyle factors in cognitive aging, the interaction of these two factors with respect to cognition remains to be determined. Also, little is known regarding the role of the basal ganglia (BG) in cognitive aging despite its involvement in both sleep and executive function. The primary objective of this study was to investigate the interaction between sleep and acute exercise on executive function performance, and secondarily, to assess if BG volume mediates this interaction. Thirty healthy older adults (65.8±7.3 years) completed 30 minutes of seated rest or moderate-intensity cycling exercise on different days. Structural MRI was used to assess the volumes of BG components including caudate, putamen, and globus pallidus shortly after the experimental conditions. Approximately 90 minutes after each condition, the Stroop task was administered to measure executive function. To examine sleep, participants wore a wrist actigraph for 8.0±3.6 days prior to the first experimental session. Results revealed that while longer total sleep time (TST) was associated with shorter Stroop response time (RT), shorter TST was associated with longer RT after exercise, compared to rest, for both congruent (p = 0.029) and incongruent (p = 0.022) trials. Longer TST was correlated with greater caudate volume, and greater caudate volume was associated with exercise-related improvement in Stroop incongruent RT. Ultimately, we found that the association between longer sleep duration and faster processing speed after acute exercise was mediated by greater caudate volume. These findings suggest that TST is an important factor for acute exercise-induced cognitive improvements in older adults, and that our study is a first step in understanding the interactive effects of these important lifestyle factors in cognitive aging that might simultaneously be addressed to promote healthy cognitive aging. Future studies should examine the interactive effects of sleep and chronic exercise on cognitive function, and whether BG volume might also mediate this interaction.
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Affiliation(s)
- Junyeon Won
- Department of Kinesiology, University of Maryland, College Park, MD, USA
| | - Alfonso J Alfini
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Lauren R Weiss
- Department of Kinesiology, University of Maryland, College Park, MD, USA.,Program in Neuroscience and Cognitive Science, University of Maryland, College Park, MD, USA
| | - Casandra C Nyhuis
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Adam P Spira
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.,Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Center on Aging and Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Daniel D Callow
- Department of Kinesiology, University of Maryland, College Park, MD, USA.,Program in Neuroscience and Cognitive Science, University of Maryland, College Park, MD, USA
| | - J Carson Smith
- Department of Kinesiology, University of Maryland, College Park, MD, USA.,Program in Neuroscience and Cognitive Science, University of Maryland, College Park, MD, USA
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Fernandez F, Nyhuis CC, Anand P, Demara BI, Ruby NF, Spanò G, Clark C, Edgin JO. Young children with Down syndrome show normal development of circadian rhythms, but poor sleep efficiency: a cross-sectional study across the first 60 months of life. Sleep Med 2017; 33:134-144. [PMID: 28449894 PMCID: PMC5423393 DOI: 10.1016/j.sleep.2016.12.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 12/19/2016] [Accepted: 12/20/2016] [Indexed: 11/23/2022]
Abstract
Objectives To evaluate sleep consolidation and circadian activity rhythms in infants and toddlers with Down syndrome (DS) under light and socially entrained conditions within a familiar setting. Given previous human and animal data suggesting intact circadian regulation of melatonin across the day and night, it was hypothesized that behavioral indices of circadian rhythmicity would likewise be intact in the sample with DS. Methods A cross-sectional study of 66 infants and young children with DS, aged 5–67 months, and 43 typically developing age-matched controls. Sleep and measures of circadian robustness or timing were quantified using continuous in-home actigraphy recordings performed over seven days. Circadian robustness was quantified via time series analysis of rest-activity patterns. Phase markers of circadian timing were calculated alongside these values. Sleep efficiency was also estimated based on the actigraphy recordings. Results This study provided further evidence that general sleep quality is poor in infants and toddlers with DS, a population that has sleep apnea prevalence as high as 50% during the preschool years. Despite poor sleep quality, circadian rhythm and phase were preserved in children with DS and displayed similar developmental trajectories in cross-sectional comparisons with a typically developing (TD) cohort. In line with past work, lower sleep efficiency scores were quantified in the group with DS relative to TD children. Infants born with DS exhibited the worst sleep fragmentation; however, in both groups, sleep efficiency and consolidation increased across age. Three circadian phase markers showed that 35% of the recruitment sample with DS was phase-advanced to an earlier morning schedule, suggesting significant within-group variability in the timing of their daily activity rhythms. Conclusions Circadian rhythms of wake and sleep are robust in children born with DS. The present results suggest that sleep fragmentation and any resultant cognitive deficits are likely not confounded by corresponding deficits in circadian rhythms. Circadian activity rhythms are robust in young children with Down syndrome. Early morning activity is phase-advanced in a subgroup. Infants with Down syndrome show significant sleep fragmentation. Sleep efficiency improves with age in children with Down syndrome, but still lags the trajectory seen in typical development.
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Affiliation(s)
- Fabian Fernandez
- Departments of Psychology and Neurology, BIO5 Institute, University of Arizona, Tucson, USA; Evelyn F. McKnight Brain Institute, University of Arizona, Tucson, USA.
| | - Casandra C Nyhuis
- Department of Psychology, University of Arizona, Tucson, USA; Sonoran University Center for Excellence in Developmental Disabilities, University of Arizona, Tucson, USA
| | - Payal Anand
- Department of Psychology, University of Arizona, Tucson, USA; Sonoran University Center for Excellence in Developmental Disabilities, University of Arizona, Tucson, USA
| | - Bianca I Demara
- Department of Psychology, University of Arizona, Tucson, USA; Sonoran University Center for Excellence in Developmental Disabilities, University of Arizona, Tucson, USA
| | - Norman F Ruby
- Biology Department, Stanford University, Stanford, USA
| | - Goffredina Spanò
- Department of Psychology, University of Arizona, Tucson, USA; Sonoran University Center for Excellence in Developmental Disabilities, University of Arizona, Tucson, USA
| | - Caron Clark
- Department of Educational Psychology, University of Nebraska-Lincoln, Lincoln, USA
| | - Jamie O Edgin
- Department of Psychology, University of Arizona, Tucson, USA; Sonoran University Center for Excellence in Developmental Disabilities, University of Arizona, Tucson, USA
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