Sleep Disturbances During the Menopausal Transition: The Role of Sleep Reactivity and Arousal Predisposition

BACKGROUND

Sleep disturbances are common during the menopausal transition and several factors can contribute to this increased incidence. This study examined the association between sleep reactivity, arousal predisposition, sleep disturbances, and menopause.

METHODS

Data for this study were derived from a longitudinal, population-based study on the natural history of insomnia. A total of 873 women (40-60 years) were divided into two groups according to their menopausal status at baseline: reproductive (n = 408) and postmenopausal (n = 465). Participants were evaluated annually throughout the five-year follow-up period. Four questionnaires were used to examine sleep quality, insomnia severity, sleep reactivity, and arousal predisposition. The data were analyzed using two approaches: cross-sectional with a multivariate analysis and binary regression, and longitudinal with a linear mixed models using menopausal groups (3) x time (5) design.

RESULTS

Cross-sectional analyses showed that postmenopausal women reported significantly more severe insomnia and poorer sleep quality than reproductive women. Sleep reactivity and arousal predisposition were significant predictors of sleep disturbances. Longitudinal analyses revealed increased sleep disturbances in the two years before and after the menopausal transition. Sleep reactivity and arousal predisposition did not moderate the temporal relationship between menopausal transition and sleep disturbances.

CONCLUSION

More sleep disturbances were reported during the menopausal transition, but those difficulties were not explained by sleep reactivity and arousal predisposition. These results suggest the involvement of other psychophysiological factors in the development of sleep disturbances during the menopause.

Natural history of excessive daytime sleepiness: a population-based 5-year longitudinal study

STUDY OBJECTIVES

To document the rates of persistent, remitted, and intermittent excessive daytime sleepiness (EDS) in a longitudinal 5-year community study of adults and to assess how changes in risk factors over time can predict improvement of daytime sleepiness (DS).

METHODS

Participants were recruited in 2007-2008 as part of a population-based epidemiological study implemented in Canada. They completed postal assessments at baseline and at each yearly follow-up. An Epworth Sleepiness Scale total score >10 indicated clinically significant EDS; a 4-point reduction between two consecutive evaluations defined DS improvement. Socio-demographic, lifestyle, health characteristics, and sleep-related measures (e.g. insomnia symptoms, sleep duration, sleep medication) were self-reported at each time point. Cox proportional-hazard models were used to predict EDS and DS remissions over 5 years.

RESULTS

Among the 2167 participants, 33% (n = 714) met criteria for EDS at baseline, of whom 33% had persistent EDS, 44% intermittent EDS, and 23% remitted EDS over the follow-up. Furthermore, 61.4% of 2167 initial participants had stable DS, 27.1% sustained DS improvement and 8.5% transient improvement over the follow-up. The main predictors of EDS remission or DS improvement were normal weight, taking less hypnotics, having hypertension, increased nighttime sleep duration, and decreased insomnia, and depressive symptoms.

CONCLUSIONS

EDS waxes and wanes over time with frequent periods of remission and is influenced by behavioral characteristics and changes in psychological, metabolic, and nighttime sleep patterns. Targeting these predictors in future interventions is crucial to reduce DS in the general adult population.

0512 Impact of a Patient Decision-Aid When Selecting Insomnia Treatments and Factors Associated with Decisional Conflict: Preliminary Findings from an Ongoing Pragmatic Clinical Trial

Introduction

Preferences play an important role in determining insomnia treatment outcomes, but the validity of patient choice is rarely assessed. Uninformed preferences can lead to decisional conflict, which can negatively impact on treatment initiation, adherence, and subsequent outcomes. The current study aims to evaluate the impact of integrating a patient decision-aid as part of a pragmatic clinical trial and to identify baseline covariates associated with clinically significant decisional conflict (CSDC).

Methods

Secondary analysis of an ongoing pragmatic clinical trial for a two-stage cognitive behavioral therapy for insomnia (CBT-I) intervention was undertaken. Participants were referred from primary care clinics in Quebec City, Canada. Upon enrolment, participants were guided by a decision-aid, outlining the risks and benefits of prospective treatment options, when selecting their preferred arm of treatment in Phase 1. Options included SHUTi, SHUTi combined with an existing medication or continuing usual treatment with medication alone. Participants also completed a battery of sleep and mental health measures at baseline. Prior to treatment initiation, the 4-item SURE (Sure of myself; Understand information; Risk-Benefit ratio; Encouragement) scale was administered to screen for CSDC. Relationships between CSDC and baseline covariates were explored using Pearson correlations.

Results

Of the 55 participants initially enrolled, 94.5% (n=52) of participants preferentially selected SHUTi, either as sole treatment (n=24) or in combination with an existing medication (n=28), over usual treatment with medication alone (n=3). Overall, CSDC was only reported by 5.5% (n=3) of the sample population, with no group differences observed, suggesting effective clarification of treatment options through the decision-aid. Interestingly, higher SURE scores (i.e. less decisional conflict) were negatively correlated with depressive symptoms (r= -0.295, n= 55, p= 0.029) and anxiety symptoms (r= -0.301, n= 55, p= 0.026). Correlations with age, insomnia symptoms, duration of insomnia and fatigue were not statistically significant.

Conclusion

The patient decision-aid appeared to resolve decisional conflict for 94.5% (n=52) of participants. Findings allude to the potential influence of emotional status on information processing pathways in an insomnia context, warranting further research.

Support

Research supported by a grant from the Canadian Institutes of Health Research (CIHR-IRSC:0441002152).

0536 Motivation at Pretreatment and its Correlates in a Trial of Digital CBT For Insomnia: Preliminary Findings

Introduction

Pretreatment motivation is a critical variable in any intervention seeking to modify behaviors. Lack of motivation may hamper the effects of cognitive-behavioral therapy for insomnia (CBT-I), especially when delivered online. This study aims to investigate baseline correlates of pretreatment motivation and its influence on treatment outcomes in the context of digitalized CBT-I.

Methods

This is a secondary analysis of an ongoing pragmatic trial conducted in primary care clinics of Québec City, Canada. The trial was designed to assess the efficacy of a stepped-care intervention for chronic insomnia in which participants received a digital CBT-I (SHUTi), alone or in addition to sleep medication they were already using. Pre-treatment motivation was measured using two items based on the perceived importance of improving sleep and readiness to change behaviors to improve sleep (Score range: 0 to 20; cronbach’s alpha 0.79). Baseline questionnaires included an extended version of Insomnia Severity Index (ISI), Fatigue Severity Scale (FFS), Generalized Anxiety Disorder (GAD-7) and Patient Health Questionnaire (PHQ-9). Treatment outcome was measured by a change in ISI scores (i.e. ISI post - ISI pre).

Results

A total of 28 participants were included in the analysis. All participants preferentially selected ISI either as monotherapy (n=13)or in combination with their usual sleep medication (n=15). Participants’ motivation before treatment was high (Mean: 18.04; SD: 1.93). We did not find any associations between motivation and ISI score change or incidence of dropout. However, baseline fatigue was positively correlated with pretreatment motivation (r = 0.51, p = 0.005) and more severe insomnia symptoms were also associated with higher motivation (r=0.43, p=0.03). Specifically, perceived importance was associated with both nighttime and daytime insomnia symptoms while readiness for behavioral change was only associated with daytime impairments on energy, mood and social activities (all p = 0.01). Baseline anxiety and depressive symptoms were not correlated with motivation.

Conclusion

Insomnia-related daytime impairments and elevated fatigue levels appear to be linked to pretreatment motivation, especially for behavioral changes. Further study with greater statistic power is warranted to understand the relationship between participants’ motivation and treatment adherence or outcomes.

Support

CIHR0083000212

0511 Patterns of Concomitant Over-the-Counter, Natural Product and Prescription Sleep Aid Use: A Population-Based Study

Introduction

Despite limited evidence, over-the-counter medications (OTC) and natural products (NP) are increasingly combined with prescribed medications (Rx) to manage insomnia symptoms. Self-medication patterns are expected to be heterogenous and may predispose individuals to inappropriate medication-taking behaviors, but little is known about the usage trajectories of sleep aids. This study investigates patterns of concomitant NP, OTC and Rx use in a Canadian population-based sample.

Methods

Data were derived from a longitudinal study on the natural history of insomnia. Participants were 3416 adults (62% female, Mage = 49.7, MInsomnia Severity Index= 8.4). Self-reported data for OTC, NP and Rx use in the last year (yes/no) was extracted at 0-, 6- and 12-month follow-up. A Latent Class Growth Curve Analysis was conducted to identify patterns of concomitant sleep aid use. Participants also completed a battery of clinical measures including the Ford Insomnia Response to Stress Test, Dysfunctional Beliefs and Attitudes about Sleep scale (16-item), Beck Depression Inventory, Insomnia Severity Index and the Pittsburgh Sleep Quality Index. Preliminary associations between class membership and baseline covariates were evaluated using the χ 2 test or a one-way ANOVA. Sampling weights were applied to all analyses, adjusting for partial non-response.

Results

Analyses revealed a 6-class solution; each class reflected a preferential agent(s) choice, which remained stable over 12-months: Minimal Use (74.5%), Rx-Dominant (11.3%), NP-Dominant (6.3%), OTC-Dominant (4.3%), Rx-NP-Dominant (2.4%), and Rx-OTC-Dominant (1.1%). Classes with prominent prescribed agent use were older [F(5, 207.6) =27.2, p<0.001], more likely to seek help [χ 2(5, n=2977) =653.1, p< 0.001] and consume alcohol [χ 2(5, n=2968) =49.2, p< 0.001]. Clinically, these individuals reported greater stress reactivity [F(5, 2966) =48.4, p< 0.001], depressive symptoms [F(5,197.4) =32.0, p<0.001], dysfunctional sleep beliefs [F(5, 2987) =54.3, p< 0.001], insomnia severity [F(5, 2983) =88.4, p< 0.001] and poorer sleep quality [F(5, 203.8) =124.2, p< 0.001].

Conclusion

A majority of adults used agents minimally. Stability of medication-taking patterns suggests that individuals adopt less sporadic approaches when combining sleep aids than previously assumed. Clinical profiles and sleep aid choice could pre-empt vulnerabilities to inappropriate self-medication.

Support

Research supported by a grant from the Canadian Institutes of Health Research (MOP#115103)

Cardiovascular autonomic dysfunction in insomnia patients with objective short sleep duration

Two phenotypes have been proposed: insomnia with objective near-normal sleep duration, related to increased psychological symptoms, and insomnia with objective short sleep duration, associated with cardiometabolic morbidity. Reduced heart rate variability has also been implicated in the pathophysiology of cardiometabolic disease; however, there are little data on whether cardiovascular function differs between patients with objective short sleep duration and near-normal sleep duration. Participants (Mage  = 49.9 ± 11.3 years; 62.8% female) were 180 adults with chronic insomnia (Mduration  = 15.7 ± 13.6). Objective sleep duration was based on total sleep time averaged across two consecutive nights of polysomnography and subjective sleep duration was based on 2-week sleep diaries. The sample was divided into two groups, with sleep duration shorter (polysomnography-total sleep time: n = 46; sleep diary: n = 95) or equal/longer (polysomnography-total sleep time: n = 134; sleep diary: n = 85) than 6 hr. Electrocardiogram data derived from polysomnography were used to obtain heart rate and heart rate variability during stage 2 (N2) and rapid eye movement sleep. Heart rate variability measures included absolute and normalized high-frequency component, an index of parasympathetic activation, and the ratio of low- to high-frequency (LF/HF ratio), an index of sympathovagal balance. After controlling for covariates (e.g., co-morbidity), patients with objective short sleep duration had reduced high-frequency (p < .05) and elevated low-frequency/high-frequency ratio (p = .036) and heart rate (p = .051) compared with patients with near-normal sleep duration. No differences were observed between phenotypes when subjective sleep duration was used. Insomnia patients with objective short sleep duration showed significantly dampened parasympathetic activation and increased sympathovagal imbalance relative to their counterparts with near-normal sleep duration. These findings highlight the importance of treating insomnia, as treatment may reduce the risk of cardiovascular disease.

Monthly fluctuations of insomnia symptoms in a population-based sample

STUDY OBJECTIVES

To document the monthly changes in sleep/insomnia status over a 12-month period; to determine the optimal time intervals to reliably capture new incident cases and recurrent episodes of insomnia and the likelihood of its persistence over time.

DESIGN

Participants were 100 adults (mean age = 49.9 years; 66% women) randomly selected from a larger population-based sample enrolled in a longitudinal study of the natural history of insomnia. They completed 12 monthly telephone interviews assessing insomnia, use of sleep aids, stressful life events, and physical and mental health problems in the previous month. A total of 1,125 interviews of a potential 1,200 were completed. Based on data collected at each assessment, participants were classified into one of three subgroups: good sleepers, insomnia symptoms, and insomnia syndrome.

RESULTS

At baseline, 42 participants were classified as good sleepers, 34 met criteria for insomnia symptoms, and 24 for an insomnia syndrome. There were significant fluctuations of insomnia over time, with 66% of the participants changing sleep status at least once over the 12 monthly assessments (51.5% for good sleepers, 59.5% for insomnia syndrome, and 93.4% for insomnia symptoms). Changes of status were more frequent among individuals with insomnia symptoms at baseline (mean = 3.46, SD = 2.36) than among those initially classified as good sleepers (mean = 2.12, SD = 2.70). Among the subgroup with insomnia symptoms at baseline, 88.3% reported improved sleep (i.e., became good sleepers) at least once over the 12 monthly assessments compared to 27.7% whose sleep worsened (i.e., met criteria for an insomnia syndrome) during the same period. Among individuals classified as good sleepers at baseline, risks of developing insomnia symptoms and syndrome over the subsequent months were, respectively, 48.6% and 14.5%. Monthly assessment over an interval of 6 months was found most reliable to estimate incidence rates, while an interval of 3 months proved the most reliable for defining chronic insomnia.

CONCLUSIONS

Monthly assessment of insomnia and sleep patterns revealed significant variability over the course of a 12-month period. These findings highlight the importance for future epidemiological studies of conducting repeated assessment at shorter than the typical yearly interval in order to reliably capture the natural course of insomnia over time.

Prevalence, clinical characteristics, and risk factors for insomnia in the context of breast cancer

STUDY OBJECTIVES

To estimate the prevalence of insomnia, describe clinical characteristics of sleep difficulties, assess the influence of cancer on the insomnia course, and identify potential risk factors involved in the development of insomnia among women who had received radiotherapy for non metastatic breast cancer.

DESIGN

A sample of 300 consecutive women who had been treated with radiotherapy for non metastatic breast cancer first completed an insomnia screening questionnaire. Participants who reported sleep difficulties were subsequently interviewed over the phone to evaluate further the nature, severity, duration, and course of their insomnia.

SETTING

N/A.

PATIENTS OR PARTICIPANTS

N/A.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

Nineteen percent (n=56) of the participants met diagnostic criteria for an insomnia syndrome. In most cases (95%), insomnia was chronic. The onset of insomnia followed the breast cancer diagnosis in 33% of the patients and 58% of the patients reported that cancer either caused or aggravated their sleep difficulties. Factors associated with an increased risk for insomnia were sick leave, unemployment, widowhood, lumpectomy, chemotherapy, and a less severe cancer stage at diagnosis. Among women with insomnia symptoms, the risk to meet diagnostic criteria for an insomnia syndrome was higher in those who were separated and had a university degree.

CONCLUSIONS

Insomnia is a prevalent and often chronic problem in breast cancer patients. Although it is not always a direct consequence of cancer, pre-existing sleep difficulties are often aggravated by cancer. It is therefore important to better screen breast cancer patients with insomnia and offer them an appropriate treatment.

Decision making in migraine patients taking sumatriptan: an exploratory study

Until recently, much of the medical and psychological literature has examined and conceptualized the taking of medication from the viewpoint of adherence to or compliance with recommendations from health professionals. However, some authors have argued that medication taking is mostly determined by patient decision making. In order to investigate the factors and processes influencing the patient's decision to take or not take abortive therapy for migraines, 20 migraineurs (according to International Headache Society criteria) were asked, using a semistandardized interview, what factors influenced their decision to take or not take sumatriptan when they had a migraine. Qualitative analysis revealed a 2-stage decision-making process. First, the patient collects information from interoceptive and environmental cues (symptom monitoring) to predict whether the headache that is beginning will become a migraine. Then, if the patient decides it is a migraine, he or she weighs various factors to decide whether to take sumatriptan. These results are consistent with the current cognitive psychology literature on decision-making processes and could lead to significant improvements in understanding the process by which patients make decisions about taking sumatriptan and, ultimately, could lead to better patient education and more effective headache control. They also open a whole new field in the empirical investigation of medication-taking behavior.

Evaluating anxiety and depression in HIV-infected patients

Because there is a large overlap between HIV manifestations and somatic symptoms of anxiety and depression, it is crucial to use measures that do not contain somatic items to validly and reliably assess these psychological states in HIV-infected patients. The purpose of this study was to assess the psychometric properties of the Hospital Anxiety and Depression Scale (HADS), a questionnaire that does not include any somatic items, in HIV-seropositive individuals. Because the study was conducted among French Canadian individuals, the quality of the translation was 1st subjectively and empirically assessed. Then, the psychometric properties of the HADS were evaluated in 162 HIV-seropositive patients, who, in addition to the HADS, also completed the Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory. The French Canadian version used was found to be subjectively and empirically equivalent to the original English version. Moreover, results of this study demonstrated a bifactorial structure with factors corresponding to the HADS subscales, an excellent internal consistency and test-retest reliability, a very good convergent validity, and an acceptable discriminant validity. Strikingly, in contrast to the BDI, HADS scores were found to be unconfounded by the presence of HIV symptomatology. The HADS appears to represent the best currently available self-report scale to reliably and validly assess anxiety and depression in HIV-infected patients. The HADS is simple and brief to administer (14 items) and may therefore be easily implemented in routine HIV care.