Timed Activity to Minimize Sleep Disturbance in People With Cognitive Impairment

Background and Objectives

Sleep disturbances occur in >60% of persons living with cognitive impairment, affecting their quality of life (QOL). Regulating the sleep-wake cycle through engaging cognitive, physical, and sensory-based activities delivered at strategic times may reduce sleep disturbances and be a feasible nonpharmacological treatment for sleep problems. The objective of this trial was to test the efficacy of a timed-activity intervention in improving QOL and sleep disturbances in persons living with cognitive impairment.

Research Design and Method

Randomized 2-group parallel design involving 209 dyads of community-residing persons living with cognitive impairment and care partners. Dyads were randomly assigned (1:1) to 1-hr home activity sessions administered weekly in the morning, afternoon, or evening over 4 weeks (the Healthy Patterns Sleep Program), or to an attention-control condition consisting of sleep hygiene training plus education on home safety and health promotion. QOL, objective and subjective sleep quality, and neuropsychiatric symptoms were assessed at baseline and 4 weeks later.

Results

QOL was significantly improved in the intervention group compared to control (p = .0491). There were no significant effects on objective or subjective sleep or neuropsychiatric symptoms. In a subgroup analysis, subjective sleep as measured by the PROMIS (Patient Reported Outcomes Measurement Information System) Sleep-Related Impairment survey was significantly improved in the intervention group compared to the control group for individuals with symptoms of depression (p = .015) or poor observed sleep at baseline (p = .005).

Discussion and Implications

The Healthy Patterns Intervention may benefit QOL for persons living with cognitive impairment and those with poor subjective sleep. A longer dose may be necessary to elicit improvement in actigraphically measured sleep-wake activity.

Clinical Trial Registration Number

NCT0368218 5.

Predictors of Adherence to Continuous Positive Airway Pressure in Older Adults With Apnea and Amnestic Mild Cognitive Impairment

BACKGROUND

Almost 60% of adults with amnestic mild cognitive impairment (aMCI) have obstructive sleep apnea (OSA). Treatment with continuous positive airway pressure (CPAP) may delay cognitive decline, but CPAP adherence is often suboptimal. In this study, we report predictors of CPAP adherence in older adults with aMCI who have increased odds of progressing to dementia, particularly due to Alzheimer's disease.

METHODS

The data are from Memories 2, "Changing the Trajectory of Mild Cognitive Impairment with CPAP Treatment of Obstructive Sleep Apnea." Participants had moderate to severe OSA, were CPAP naïve, and received a telehealth CPAP adherence intervention. Linear and logistic regression models examined predictors.

RESULTS

The 174 participants (mean age 67.08 years, 80 female, 38 Black persons) had a mean apnea-hypopnea index of 34.78, and 73.6% were adherent, defined as an average of ≥4 hours of CPAP use per night. Only 18 (47.4%) Black persons were CPAP adherent. In linear models, White race, moderate OSA, and participation in the tailored CPAP adherence intervention were significantly associated with higher CPAP use at 3 months. In logistic models, White persons had 9.94 times the odds of adhering to CPAP compared to Black persons. Age, sex, ethnicity, education, body mass index, nighttime sleep duration, daytime sleepiness, and cognitive status were not significant predictors.

CONCLUSIONS

Older patients with aMCI have high CPAP adherence, suggesting that age and cognitive impairment should not be a barrier to prescribing CPAP. Research is needed to improve adherence in Black patients, perhaps through culturally tailored interventions.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

CAREGIVER OUTCOMES RELATED TO SLEEP DISTURBANCES IN PEOPLE LIVING WITH COGNITIVE IMPAIRMENT

Sleep disturbances in people living with cognitive impairment (CI) may impose a great burden on caregivers. We examined the relationship between objective and subjective sleep measures in people living with CI and caregiver depression and mastery via a secondary analysis of The Healthy Patterns Clinical Trial (NCT03682185) baseline data (n=170). Objective sleep variables included total sleep time and sleep efficiency derived from 3 nights of actigraphy. Subjective sleep measures included PROMIS Sleep Related Impairment, Pittsburgh Sleep Quality Index, and Epworth Sleepiness Scale. Caregiver measures included Center for Epidemiological Studies Depression Scale and Caregiver Mastery Scale. People living with CI were female (67%), Black (80%), with mean age 73.4 ± 8.7. Caregivers were female (81%), family caregivers (80%) with mean age 56.5 ± 14.7. We used multiple regression analysis, adjusting for cognition, and examined if there were differences by caregiver gender. Poorer subjective sleep quality was significantly associated with more caregiver depression (B=0.407, SE= 0.198, p = 0.042). There were no significant sleep predictors for caregiver mastery; however, there was a moderating effect of gender on the association between subjective sleep quality and caregiver mastery. Female caregivers had increased caregiver mastery compared to males when the person living with CI had better sleep quality (B=0.555, SE= 0.218, p = 0.012). This study found that people living with CI sleep characteristics differentially influence caregiver outcomes. Sleep should be assessed using a combination of objective and subjective sleep measures in people living with CI to inform providers when interventions are needed.

Sufficient sleep duration in autistic children and the role of physical activity

LAY ABSTRACT

Higher levels of physical activity may be associated with improved sleep in children, but this relationship is still being determined, especially in autistic children. In this study, we used existing data from the 2018 National Survey of Children's Health. Caregivers of children 6-17 years old, including caregivers of autistic children, completed a questionnaire that included questions about physical activity (days active in the past week) and sleep duration. We then determined if children were obtaining the recommended hours of sleep for their age (i.e. sufficient sleep). We found that higher physical activity levels were associated with sufficient sleep duration, but this finding was weaker in autistic children. In particular, this association was not observed in autistic children with more severe autism spectrum disorder, female autistic children, and autistic children 6-12 years old. In conclusion, physical activity is a promising approach to help children obtain sufficient sleep duration. However, more personalized approaches to improving sleep may be needed for certain groups of autistic children.

Tailored Music Listening to Improve Sleep in Older Adults With Dementia: A Randomized Clinical Trial

Sleep disturbances in persons living with dementia (PLWD) contribute to reduced well-being. Music has shown promise to improve sleep among older adults, but there is limited evidence of music interventions improving sleep specifically in PLWD. The purpose of this wait-list RCT was to examine the i) feasibility; ii) acceptability and iii) preliminary efficacy of tailored music listening intervention in community-dwelling PLWD and their caregivers (dyads). Thirty consented dyads out of 33 (91%) completed the RCT. Tailored music for sleep was feasible based on screening (26%), enrollment (89%), and recruitment (3 dyads/month) rates. The intervention was found acceptable, as evidenced by post-intervention interviews. Compared to controls, PLWD in the intervention group reported greater global sleep quality improvement post-intervention (PSQI mean change -0.08 vs -1.65; p=0.06). The results from this feasibility RCT have informed the development of a music mobile application that will be tested in a future clinical trial.

Variations in Payment Allocation to Persons Living With Cognitive Impairment and Study Partners

There is a paucity of research focused on monetary incentives for recruiting dyads (participants with cognitive impairment and study partners) into research. Our objective was to evaluate if two different variations in allocating compensation among dyads changed consent rates in one clinical trial, Memories2. This trial is evaluating cognitive and functional outcomes of obstructive sleep apnea treatment in patients with amnestic mild cognitive impairment (aMCI). Prior to phone screening, participants were randomly assigned to one of two groups (1) $200 to participant with aMCI or (2) $100 to participant with aMCI and $100 to study partner at consent visit. Allocating all the payment to the participant with aMCI yielded a 2.6% consent rate, while splitting the payment yielded at 1.7% consent rate. We will also discuss how demographic factors affected consent decision by group. This study provides insight into novel strategies that may enhance enrollment of dyads into clinical trials.

Dyads' Perceptions: Recruiting Persons Living With Dementia and Caregivers in a Clinical Trial

Recruiting persons living with dementia (PLWD) and their caregivers (dyads) into research is challenging and costly. The purpose of this study was to better understand factors that influence dyads decisions to enroll in a clinical trial. We used Ajzen’s Theory of Planned Behavior (TPB) to develop a qualitative interview guide and analyze the data with a directed content analysis. We conducted semi-structured telephone interviews with 12 PLWD and 9 caregivers who all enrolled in one clinical trial. Aligning with the TPB we found the following positively influenced enrollment: 1) wanting to learn, in-person meetings with knowledgeable staff, and the money always helps (attitudes toward joining); 2) to support another person (perceived norm); and 3) easy to participate (perceived behavioral control). Flexible scheduling and the study taking place in the home was comfortable and convenient for participants. Findings can inform future recruitment efforts and research studies.

Durability of treatment response to zolpidem using a partial reinforcement regimen: does this strategy require priming?

BACKGROUND

Previous research has shown that after one month of full dose nightly treatment with zolpidem (priming), subjects with chronic insomnia (CI) switched to intermittent dosing with medication and placebos were able to maintain their treatment responses. This approach to maintenance therapy is referred to as partial reinforcement. The present study sought to assess whether priming is required for partial reinforcement or whether intermittent dosing with placebos (50% placebos and 50% active medication) can, by itself, be used for both acute and extended treatment.

METHOD

55 CI subjects underwent a baseline evaluation (Phase-1) and then were randomized to one of two conditions in Phase-2 of the study: one month of (1) nightly medication use with standard-dose zolpidem (QHS [n = 39]) or (2) intermittent dosing with standard-dose zolpidem and placebos (IDwP [n = 16]). In Phase-3 (three months), the QHS group was re-randomized to either continued QHS full dose treatment (FD/FD) or to IDwP dose treatment (FD/VD). Treatment response rates and Total Wake Time (TWT = [SL + WASO + EMA]) were assessed during each phase of the study.

RESULTS

In Phase-2, 77% (QHS) and 50% (IDwP) subjects exhibited treatment responses (p = 0.09) where the average change in TWT was similar. In Phase-3, 73% (FD/FD), 57% (FD/VD), and 88% (VD/VD) of subjects exhibited continued treatment responses (p = 0.22) where the average improvement in TWT continued with FD/FD and remained stable for FD/VD and VD/VD (p < 0.01).

CONCLUSION

These results suggest that intermittent dosing with placebos can maintain effects but do not allow for the additional clinical gains afforded by continuous treatment.

A timed activity protocol to address sleep-wake disorders in home dwelling persons living with dementia: the healthy patterns clinical trial

BACKGROUND

Sleep-wake disorders occur in most persons living with dementia and include late afternoon or evening agitation, irregular sleep-wake rhythms such as daytime hypersomnia, frequent night awakenings, and poor sleep efficiency. Sleep-wake disorders pose a great burden to family caregivers, and are the principal causes of distress, poor quality of life, and institutionalization. Regulating the sleep-wake cycle through the use of light and activity has been shown to alter core clock processes and suggests that a combination of cognitive, physical, and sensory-based activities, delivered at strategic times, may be an effective mechanism through which to reduce sleep-wake disorders.

METHODS

A definitive Phase III efficacy trial of the Healthy Patterns intervention, a home-based activity intervention designed to improve sleep-wake disorders and quality of life, is being conducted using a randomized two-group parallel design of 200 people living with dementia and their caregivers (dyads). Specific components of this one-month, home-based intervention involve 4 in-home visits and includes: 1) assessing individuals' functional status and interests; 2) educating caregivers on environmental cues to promote activity and sleep; and 3) training caregivers in using timed morning, afternoon, and evening activities based on circadian needs across the day. The patient focused outcomes of interest are quality of life, measures of sleep assessed by objective and subjective indicators including actigraphy, subjective sleep quality, and the presence of neuropsychiatric symptoms. Caregiver outcomes of interest are quality of life, burden, confidence using activities, and sleep disruption. Salivary measures of cortisol and melatonin are collected to assess potential intervention mechanisms.

DISCUSSION

The results from the ongoing study will provide fundamental new knowledge regarding the effects of timing activity participation based on diurnal needs and the mechanisms underlying timed interventions which can lead to a structured, replicable treatment protocol for use with this growing population of persons living with dementia.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov # NCT03682185 at https://clinicaltrials.gov/ ; Date of clinical trial registration: 24 September 2018.

575 Sleep Duration in American Children with Autism Spectrum Disorder and the Role of Physical Activity

Introduction

Sleep dysfunction is prevalent in autism spectrum disorder (ASD) and can have major daytime behavioral consequences. Emerging evidence suggests that physical activity may be associated with improved sleep in children, including those with ASD. We aimed to determine if there was an association between physical activity and sleep duration in American youth and if the association was consistent in children with and without ASD.

Methods

We analyzed data from children ages 6–17 years whose caregivers completed the 2018 National Survey of Children’s Health (N=20,980). ASD was self-reported (N=687), and we determined if reported ASD was mild, moderate, or severe, and if reported ASD occurred with intellectual disability (ID). Participants self-reported their weekday sleep duration and days of physical activity in the past week. We classified children as sleep sufficient or insufficient based on age-specific recommendations. Logistic regression was used to determine if physical activity and ASD were associated with sleep sufficiency. Physical activity-by-ASD interaction terms were used to determine if any physical activity association was modified by ASD status. Covariates included: age, sex, race, Hispanic ethnicity, highest caregiver education level, and overweight status.

Results

Compared to children without ASD, children with ASD were 29% less likely to have sufficient sleep (OR=0.71; 95% CI: 0.52–0.99), but this association attenuated to the null after adjusting for physical activity (OR=0.77; 95% CI: 0.55–1.07). Compared to zero days, being physically active for 1–3, 4–6 or 7 days in the past week was associated with increased odds of sufficient sleep, even with adjustment for ASD status (e.g., 4–6 days: OR=1.85; 95% CI: 1.48–2.32). We did not observe a statistically significant interaction between physical activity and ASD status with respect to sleep sufficiency (P-interaction=0.571), which remained consistent when using ASD severity and ASD with ID exposure variables.

Conclusion

Physical activity was associated with increased odds of meeting age-specific sleep duration recommendations in children with and without ASD. Our observations support pursuing physical activity in future studies as a potential intervention target to improve sleep duration in children, including those with ASD.

Support (if any)

NIH T32HL07713 and University of Pennsylvania’s Institute for Translational Medicine and Therapeutics

Assistive Relaxation Therapy for Older Adults With Insomnia and Mild Cognitive Impairment: A Pilot Study

Insomnia symptoms are prevalent in older adults with mild cognitive impairment (MCI) and can pose treatment challenges. Our objective was to test the preliminary efficacy of tablet-based assistive relaxation therapy (ART) to improve insomnia symptoms in community-dwelling older adults with MCI. ART involves breath-based relaxation techniques coupled with a physical anchoring task to redirect thoughts and disengage from pre-sleep anxiety-provoking cognitions. Using a pilot randomized controlled non-crossover design, 20 participants recruited from one urban adult day center were allocated in a 1:1 ratio to intervention or education only control group for a treatment period of two weeks. Our final sample (n=20) was balanced on all demographic and clinical variables and consisted of Black (100%), female (75%), older adults (mean age 68.85 ± 7.29) with mean Montreal Cognitive Assessment scores of 21.2 ± 2.48. All participants at baseline had insomnia symptoms (mean Insomnia Severity Index (ISI) score 15.8 ± 3.78) and poor sleep quality (mean Pittsburgh Sleep Quality Index (PSQI) score 12.95 ± 0.70); half had daytime sleepiness (Epworth Sleepiness Scale (ESS) score 10.15 ± 1.07). Compared to baseline, participants improved on ISI (9.83 ± 1.32; p=0.0002), PSQI (9.11 ± 1.02; p=0.0016) and ESS (8.17 ± 0.86; p=0.08). The intervention group had statistically significant mean change scores on ISI compared to the control (-7.5 ± 1.37 vs. -3.88 ± 1.48; p=.0461). There were no statistically significant between group differences on PSQI or ESS. Our preliminary results suggest ART therapy is an effective treatment for insomnia symptoms in older adults with MCI.

Randomized Controlled Trial of Tailored Music Listening Intervention for Sleep in Dementia

Sleep disruption in older adults living with Alzheimer’s disease and related dementias (ADRD) is debilitating and contributes to increased institutionalization, reduced cognitive function, and accelerated disease progression. Given the potential harmful effects of pharmacologic treatment, non-pharmacologic approaches, such as music, may provide a safer alternative to improve sleep quality in this vulnerable population. No empirically validated music protocol exists to address sleep disruption in older adults with ADRD living at home. Therefore, the specific aims of this wait-list randomized controlled trial were to examine the 1) feasibility; 2) acceptability; and 3) preliminary efficacy of a tailored music intervention in home-dwelling older adults with ADRD with sleep disruption and their caregivers. This presentation focuses on baseline characteristics of dyads, which included persons with ADRD and their caregivers who have completed the clinical trial so far (N=28). The mean age of persons with ADRD was 71.6 (SD: 7.6). The mean age of caregivers was 58.7 (SD: 16.7). Sixty-eight percent (n=19) of persons with ADRD were female. Similarly, the majority of caregivers were female (n=20, 71.4%). Seventy-four percent of persons with ADRD scored 0.5 on the Clinical Dementia Rating instrument, indicative of very mild dementia. The majority of dyads identified themselves as non-Hispanic (>92%). Seventy-nine percent of persons with ADRD identified themselves as Black or African-American (n=22, 79%), while 82.1% of caregivers identified themselves as Black or African American. Preliminary analysis of qualitative data indicates high acceptability of the intervention. Results from this research study will inform a future efficacy trial.

Nighttime Agitation and Restless Legs Syndrome in Persons With Alzheimer's Disease: Study Protocol for a Double-Blind, Placebo-Controlled, Randomized Trial (NightRest)

Nighttime agitation is a prevalent symptom in persons with Alzheimer's disease (AD). Effective treatments are absent due to our limited knowledge of its etiology. We hypothesized that restless legs syndrome (RLS), a common neurological sensorimotor disorder of uncomfortable leg sensations that appear at night and interfere with sleep, might be a cause for nighttime agitation in persons with AD. RLS is infrequently identified in persons with AD because traditional diagnosis is dependent on patients answering complex questions about their symptoms. With a validated observational tool for RLS diagnosis, the Behavioral Indicators Test-Restless Legs, we aim to diagnose RLS and determine the effect of gabapentin enacarbil (GEn) compared to placebo on nighttime agitation, sleep, antipsychotic medications, and the mechanism for these effects. We hypothesize that frequency of RLS behaviors will mediate the relationship between GEn and nighttime agitation. This study is an 8-week, double-blind, placebo-controlled, randomized pilot clinical trial, followed by an 8-week open-label trial, that is being conducted in long-term care settings and private homes. The results of this study may shift, personalize, and improve standards of care for treatment of nighttime agitation; reduce aggression and other nighttime agitation behaviors; and improve sleep.

TARGETS

Persons with AD with nighttime agitation potentially caused by RLS.

INTERVENTION DESCRIPTION

Diagnose RLS and determine the effect of GEn.

MECHANISMS OF ACTION

The frequency of RLS behaviors will mediate the relationship between GEn and nighttime agitation.

OUTCOMES

Determine the effect of GEn on nighttime agitation, sleep, and antipsychotic medications.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03082755 (Date of registration March 6, 2017). [Research in Gerontological Nursing, 13(6), 280-288.].

0543 Implementing Insomnia Care Paths for Older Adults and People with Dementia

Introduction

Despite the high prevalence of insomnia in older adults and those with dementia, screening and treatment remain inconsistent and suboptimal. Implementing a care path in a health system, though, is difficult. To determine what issues are relevant for implementation, a consensus meeting was convened, which included discussion, voting on components, and further consensus-building.

Methods

All N=20 participants, representing a wide range of stakeholders including research, industry, sleep, primary care, implementation science, and others, voted whether they agreed or disagreed with 36 different statements regarding what issues are important for implementing geriatric insomnia care paths. These represented a range of items addressing strategies for identifying and incentivizing stakeholders, identifying patients in most need and who would receive benefit, addressing comorbidities and multiple specialties, understanding how specific organizations make decisions about and changes to care, size and scope of the care path, determining the process for implementation, how it will improve outcomes, addressing specific needs of primary care, and addressing costs, reimbursements, and liabilities. Items were scored as 0=strongly agree, 1=agree, 2=disagree, and 3=strongly disagree. Mean scores were evaluated and responses were dichotomized to agree/disagree).

Results

Despite the diversity among attendees, median rate of agreement for was 95% (IQR=90-95%). All items were endorsed by &gt;=80% of respondents. Mean score was 0.48 (SD=1.85). 95%CIs were computed for each proportion and compared to the mean. The only item that significantly differed from the mean score indicated that understanding benefits of a care path to the general community is less important of an issue than others (M=0.85).

Conclusion

Implementing an insomnia care path for older adults in an institution will likely require addressing a wide range of issues, including questions about stakeholders, the health system/context, patients, and practical considerations.

Support

Merck Research Labs provided support

1185 Developing A Care Pathway For Insomnia In Older Adults And Adults With Dementia: Results Of A Consensus Meeting

Introduction

Insomnia among older adults and dementia patients carries a high public health burden. Yet, treatment is inconsistent or absent. Standardized, programmatic carepaths can be implemented in clinics/systems/communities to address this after tailoring to local environments. To determine what elements should be included, a consensus meeting was convened, which included discussion, voting on components, and further consensus-building among diverse stakeholders.

Methods

Participants represented a wide range of stakeholders and specialties, including academic research, clinical care, industry, government, payors, sleep medicine, primary care, geriatrics, psychiatry, neurology, nursing, pharmacy, quality, and implementation science. 27 statements regarding key components of carepaths for insomnia in elderly and dementia populations were presented and discussed. These represented items addressing identification of patients, screening and assessment, deciding treatment modality and delivery, providing behavioral treatment, providing pharmacotherapy, addressing combined therapy, addressing comorbidities, and incorporating outcome evaluation. All N=20 participants voted individually whether they agreed or disagreed with each statement. Items were scored as 0=strongly agree, 1=agree, 2=disagree, and 3=strongly disagree. Mean scores were evaluated and responses were dichotomized to agree/disagree.

Results

Despite diversity among attendees, median rate of agreement was 95% (IQR=85-95%). Mean score was 0.69 (SD=0.31). 95%CIs were computed for each proportion and compared to the mean. The following elements were significantly different from the mean (p&lt;0.05): medication decision trees (M=0.25), accounting for comorbidities (M=0.26), include outcome evaluation (M=0.30), utilization of EMR (M=0.40), incorporate caregiver (M=0.42), and differ across parts of the system (M=1.79).

Conclusion

Insomnia carepaths for older adults should address identification, screening and assessment, treatment decisions, treatment type and delivery, and evaluation. Organizations should consider these elements when designing carepaths for insomnia among older adults and dementia patients. Consensus-building should begin during the process of prioritizing care path components.

Support

Merck Research Labs provided support

0861 Age, Race, And Continuous Positive Airway Pressure (CPAP) Confidence Score At 1-week Predict 3-month CPAP Adherence In Older Adults With Amnestic Mild Cognitive Impairment And Moderate To Severe Obstructive Sleep Apnea

Introduction

Adherence to continuous positive airway pressure (CPAP) may delay cognitive decline in older adults with obstructive sleep apnea (OSA) and amnestic mild cognitive impairment (MCI), defined as deficits in memory that do not significantly impact daily functioning. The aim of this analysis was to identify predictors of CPAP adherence in this population.

Methods

Data are from Memories 2, an ongoing multisite clinical trial on the effect of treatment of moderate to severe OSA on cognitive decline in older adults 65-85 years of age who have amnestic MCI. Unadjusted and adjusted linear models were used to examine predictors of mean hours of CPAP use at 3 months. Predictors were age, sex (male/female), race (White/Non-White), education (more than high school, less than high school), Apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), and CPAP Comfort and Confidence scores at 7 days. Collinearity in the adjusted model for CPAP use at 3 months was examined using the variance inflation factor.

Results

Of 57 participants, most were male (54%), White (72%), with a mean age of 66.3 years (SD: 6.1). Mean AHI in this sample was 35.1 (SD: 19.9), with mean daily hours of CPAP use at 3 months 5.3 hours (SD: 2.3). Adjusted linear model results demonstrated that younger age (β=-0.13, SE=0.04, p=0.0032), White race (β=2.56, SE=0.58, p&lt;0.0001), and higher 7-day CPAP Confidence score (β=0.48, SE=0.17, p=0.0086) were significantly associated with CPAP use at 3 months. Sex, education, AHI, ESS, and CPAP comfort were not statistically significant predictors of adherence.

Conclusion

Tailored interventions to increase self-efficacy during the first 7 days of CPAP treatment, especially in Non-Whites and those older than 74 years, may improve long-term CPAP adherence in older adults with amnestic MCI.

Support

R01AG054435

AN MHEALTH BEHAVIORAL INTERVENTION FOR PROMOTING PHYSICAL ACTIVITY AND SLEEP IN COMMUNITY-DWELLING OLDER ADULTS

Evidence suggests physical activity (PA) improves sleep in older adults. This study examined the preliminary effect of a personalized mHealth behavioral intervention on PA and sleep in older adults. We conducted a randomized controlled pilot trial in 21 community-dwelling older adults with sleep complaints. The 24-week mHealth behavioral intervention included a 2-hour in person training session, personalized exercise prescription, real time PA self-monitoring, interactive prompts, phone consultation, and weekly financial incentives. PA and sleep were measured objectively using Actiwatch 2.0 and subjectively using questionnaires. Peripheral blood was drawn for measuring Plasma inflammatory biomarkers [interleukin 1β, 6, 8, Tumor Necrosis Factor- alpha (TNF-α), and c-reactive protein (CRP)]. Data were collected at baseline, 8-week, 16-week, and post intervention. Repeated measures ANOVA (time*group) was used to examine differences of PA and sleep across times between the two groups. Majority of participants are women (71.4%) with mean age of 73.7 (SD = 6.9). Repeated measure ANOVA showed significant (p <0.05) improvement of objective and subjective PA, objective nocturnal sleep duration, self-report sleep quality (measured by Pittsburg Sleep Quality Index and Insomnia Severity Index) and decreasing of sedentary time over times in the intervention group (n=11), compared to the control group. The intervention group showed significant reduction of plasma TNF-α and CRP levels at 16-week and post intervention. Interventions combining personalized PA and mHealth strategies may positively affect physical activity and sleep in older adults. A larger study is needed to test the efficacy of this intervention and the mechanisms associated with it.

Nursing Home Eligible, Community-Dwelling Older Adults' Perceptions and Beliefs About Sleep: A Mixed-Methods Study

Sleep disturbances are highly prevalent in older adults; little is known about sleep in those who remain living in the community despite qualifying for nursing home placement. We conducted a concurrent, nested, mixed-methods study to describe sleep characteristics and sleep disturbances in this population. Our final sample (n = 40) was Black (100%), female (85%) older adults with a mean (±SD) age of 72 ± 9.5 years. Of these, 35 had objectively measured short or long sleep duration, and 30 had subjectively reported poor sleep quality. Our evidence suggests that sleep disturbances are common in this group, and these older adults had adjusted their expectations and adapted to their sleep disturbances. Given that at-risk older adults may not perceive their sleep disturbances as problematic, clinicians must proactively assess sleep and educate about the importance of sleep. These results reveal modifiable factors with potential to improve health outcomes in this vulnerable population.

Examining social capital in relation to sleep duration, insomnia, and daytime sleepiness

OBJECTIVE

Sleep, which plays an important role in health and well-being, is socially patterned such that certain demographic groups have worse sleep health than others. One possible mechanism driving sleep disparities is social capital. The current study examines the association between social capital and self-reported sleep variables (eg, duration, insomnia symptoms, and daytime sleepiness) among a sample of 1007 participants from the Sleep Health and Activity, Diet and Environment Study (SHADES).

METHODS

Logistic regressions were used to estimate whether the sleep variables were associated with social capital measures. All models control for age, sex, race/ethnicity (Non-Hispanic White, Black/African-American, Hispanic/Latino, Asian, and multicultural/other), income, and education (less than high school, high school graduate, some college, and college graduate).

RESULTS

Lower likelihood of membership in groups was seen for long sleepers (>9hrs, p-value<0.05) and beliefs that neighbors rarely/never help each other was more likely among short sleepers (5-6hrs, p-value<0.05), relative to 7-8 h sleepers. A decreased sense of belonging was seen among short sleepers (5-6hrs, p-value<0.05). Decreased likelihood of trust was reported by those with moderate-severe insomnia (p-value<0.05). Similarly, neighborhood improvement efforts were less likely among individuals with moderate-to-severe insomnia (p-value<0.05).

CONCLUSIONS

Results of our study show that short and long sleep duration, as well as insomnia, were inversely related to measures of social capital, such as group memberships and a sense of neighborhood belonging. Future research may explore the directionality of the relationship between social capital and sleep and perhaps consider future interventions to improve low social capital and/or poor sleep in community samples.

CPAP Adherence May Slow 1-Year Cognitive Decline in Older Adults with Mild Cognitive Impairment and Apnea

BACKGROUND/OBJECTIVES

Obstructive sleep apnea (OSA) has been linked to an increased risk for Alzheimer's disease (AD), but little prospective evidence exists on the effects of OSA treatment in preclinical AD. The objective was to determine if continuous positive airway pressure (CPAP) treatment adherence, controlling for baseline differences, predicts cognitive and everyday function after 1 year in older adults with mild cognitive impairment (MCI) and to determine effect sizes for a larger trial.

DESIGN

Quasi-experimental pilot clinical trial with CPAP adherence defined as CPAP use 4 hours or more per night over 1 year.

SETTING

Sleep and geriatric clinics and community.

PARTICIPANTS

Older adults, aged 55 to 89 years, with an apnea-hypopnea index of 10 or higher participated: (1) MCI, OSA, and CPAP adherent (MCI +CPAP), n = 29; and (2) MCI, OSA, CPAP nonadherent (MCI -CPAP), n = 25.

INTERVENTION

CPAP.

MEASUREMENTS

The primary cognitive outcome was memory (Hopkins Verbal Learning Test-Revised), and the secondary cognitive outcome was psychomotor/cognitive processing speed (Digit Symbol subtest from the Wechsler Adult Intelligence Scale Substitution Test). Secondary function and progression measures were the Everyday Cognition, Alzheimer's Disease Cooperative Study-Clinical Global Impression of Change Scale, and Clinical Dementia Rating.

RESULTS

Statistically significant improvements in psychomotor/cognitive processing speed in the MCI +CPAP group vs the MCI -CPAP group were observed at 1 year after adjustment for age, race, and marital status (parameter estimate = 1.68; standard error = 0.47; 95% confidence interval = 0.73-2.62), with a 6-month effect size (ES) of 0.46 and a 1-year ES of 1.25. There were small to moderate ESs for memory (ES 0.20, 6 mo), attention (ES 0.25, 1 y), daytime sleepiness (ES 0.33, 6 mo and ES 0.22, 1 y), and everyday function (ES 0.50, 6 mo) favoring the MCI +CPAP group vs the MCI -CPAP group.

CONCLUSION

Controlling for baseline differences, 1 year of CPAP adherence in MCI +OSA significantly improved cognition, compared with a nonadherent control group, and may slow the trajectory of cognitive decline.

TRIAL REGISTRATION NUMBER

Memories; NCT01482351; https://clinicaltrials.gov/ct2/show/NCT01482351?cond=MCI+and+OSA&rank=1 J Am Geriatr Soc 67:558-564, 2019.

Stress Reactivity in Insomnia

This study examined whether individuals with primary insomnia (PI) are more reactive to stress than good sleepers (GS). PI and GS (n = 20 per group), matched on gender and age, completed three nights of polysomnography. On the stress night, participants received a mild electric shock and were told they could receive additional shocks during the night. Saliva samples were obtained for analysis of cortisol and alpha amylase along with self-report and visual analog scales (VAS). There was very little evidence of increased stress on the stress night, compared to the baseline night. There was also no evidence of greater stress reactivity in the PI group for any sleep or for salivary measures. In the GS group, stress reactivity measured by VAS scales was positively associated with an increase in sleep latency in the experimental night on exploratory analyses. Individuals with PI did not show greater stress reactivity compared to GS.

A Three-Item Instrument for Measuring Daytime Sleepiness: The Observation and Interview Based Diurnal Sleepiness Inventory (ODSI)

STUDY OBJECTIVES

We aimed to develop a new three-item assessment tool for daytime sleepiness in older adults, the Observation and interview-based Diurnal Sleepiness Inventory (ODSI) and determine its validity, internal consistency, test-retest reliability, and optimal cutoff score.

METHODS

A total of 133 elderly subjects including 73 patients with obstructive sleep apnea (OSA) (mean age, 79 y) and 60 controls (mean age, 80 y) were consecutively enrolled and answered all questionnaires. The ODSI questionnaire was validated using the Epworth Sleepiness Scale considered as a gold standard. Reliability, validity, and cut-points were tested.

RESULTS

The ODSI has acceptable validity, internal consistency, and test-retest reliability properties. The ODSI has internal consistency and a reliability coefficient (Pearson rho) of 0.70 for its three items, which suggests strong reliability. The estimated sensitivity and specificity were 0.842 with 95% confidence interval [0.624; 0.945] and 0.851 [0.761; 0.911], respectively. The consistency of summated scale scores during test and retest sessions was high (r = 0.970, 95% bootstrap confidence interval [0.898; 0.991]). Receiver operating characteristic analysis suggests that a cut-point of 6 is effective for identifying older adults with excessive levels of daytime sleepiness.

CONCLUSIONS

The ODSI is a brief, valid, easy-to-administer three-item assessment that can screen for excessive daytime sleepiness among elderly patients with OSA.

Exercise and Sleep in Community-Dwelling Older Adults

Insomnia and other sleep complaints are highly prevalent in community-dwelling older adults yet often go under detected. Age-related physiological changes may affect sleep, but sleep disturbances and complaints should not be considered normal in this population. Various physiological, psychological, and social consequences have been associated with insomnia and sleep complaints. Treatment options are available so it is imperative to diagnose and treat these individuals to promote healthy aging. Exercise is known to have a wide variety of health benefits, but unfortunately most older adults engage in less exercise with advancing age. This paper describes age-related changes in sleep, clinical correlates of insomnia, consequences of untreated insomnia, and nonpharmacological treatments for insomnia in older adults, with a focus on the relationship between exercise and sleep in community-dwelling older adults with insomnia or sleep complaints. Possible mechanisms explaining the relationship between exercise and sleep are discussed. While the research to date shows promising evidence for exercise as a safe and effective treatment for insomnia and sleep complaints in community-dwelling older adults, future research is needed before exercise can be a first-line treatment for insomnia and sleep complaints in this population.

Single slice vs. volumetric MR assessment of visceral adipose tissue: reliability and validity among the overweight and obese

Visceral adipose tissue (VAT) is associated with abnormal cardiovascular and metabolic profiles. Total VAT volume of the abdominal compartment by magnetic resonance imaging (MRI) is the gold-standard measurement for VAT but is costly and time consuming. Prior studies suggest VAT area on a single slice MR image may serve as a surrogate for total VAT volume but it is unknown if this relationship is maintained in overweight and obese men and women. Untreated sleep apnea subjects enrolled into the Icelandic Sleep Apnea Cohort (ISAC) underwent abdominal MRI. VAT area and subcutaneous adipose tissue (SAT) area at the L2-L3 and L4-L5 interspaces and total VAT and SAT volumes were determined by manual examination using image analysis software; 539 men and 129 women with mean ages of 54.1 and 58.8 years and mean BMI of 32.2 kg/m(2) and 33.7 kg/m(2), respectively, were studied. Mean total VAT volume was 40% smaller and mean total SAT was 25% larger among females compared with males. The correlation with VAT volume was significantly larger for L2-L3 VAT area (r = 0.96) compared to L4-L5 VAT area (r = 0.83). The difference in correlation coefficients was statistically significant (nonparametric bootstrap P < 0.001 with 95% confidence interval (CI) for the difference from 0.11 to 0.15. VAT area at L2-L3 was also significantly better correlated with VAT volume than traditional anthropometric variables. Linear regression analyses demonstrated that L2-L3 area alone was sufficient for predicting total VAT volume and that the nature of the linear association was maintained across all levels of obesity and in both genders.

"Sleep disparity" in the population: poor sleep quality is strongly associated with poverty and ethnicity

Background

Little is known about the social determinants of sleep attainment. This study examines the relationship of race/ethnicity, socio-economic status (SES) and other factors upon sleep quality.

Methods

A cross-sectional survey of 9,714 randomly selected subjects was used to explore sleep quality obtained by self-report, in relation to socioeconomic factors including poverty, employment status, and education level. The primary outcome was poor sleep quality. Data were collected by the Philadelphia Health Management Corporation.

Results

Significant differences were observed in the outcome for race/ethnicity (African-American and Latino versus White: unadjusted OR = 1.59, 95% CI 1.24-2.05 and OR = 1.65, 95% CI 1.37-1.98, respectively) and income (below poverty threshold, unadjusted OR = 2.84, 95%CI 2.41-3.35). In multivariable modeling, health indicators significantly influenced sleep quality most prominently in poor individuals. After adjusting for socioeconomic factors (education, employment) and health indicators, the association of income and poor sleep quality diminished, but still persisted in poor Whites while it was no longer significant in poor African-Americans (adjusted OR = 1.95, 95% CI 1.47-2.58 versus OR = 1.16, 95% CI 0.87-1.54, respectively). Post-college education (adjusted OR = 0.47, 95% CI 0.31-0.71) protected against poor sleep.

Conclusions

A "sleep disparity" exists in the study population: poor sleep quality is strongly associated with poverty and race. Factors such as employment, education and health status, amongst others, significantly mediated this effect only in poor subjects, suggesting a differential vulnerability to these factors in poor relative to non-poor individuals in the context of sleep quality. Consideration of this could help optimize targeted interventions in certain groups and subsequently reduce the adverse societal effects of poor sleep.

Who gets the best sleep? Ethnic and socioeconomic factors related to sleep complaints

OBJECTIVES

Lower socioeconomic status is associated with short or long sleep duration and sleep disturbance (e.g., sleep apnea), which are all related to increased mortality risk. General sleep complaints, however, which may better approximate symptoms as they are experienced, have not been examined in a large population sample.

METHODS

Sample consisted of n=159,856 participants from the Behavioral Risk Factor Surveillance System, representing 36 states/regions across the US. Sleep complaints were measured with a telephone survey item that assessed "trouble falling asleep," "staying asleep" or "sleeping too much." Data analysis utilized hierarchical logistic regression and Rao-Schott chi(2).

RESULTS

Asian respondents reported the least complaints, and Hispanic/Latino and Black/African-American individuals reported fewer complaints than Whites. Lower income and educational attainment was associated with more sleep complaints. Employment was associated with less sleep complaints and unemployment with more. Married individuals reported the least sleep complaints. Significant interactions with race/ethnicity indicate that the relationship between sleep complaints and marital status, income and employment differs among groups for men, and the relationship with education differs among groups for women.

CONCLUSIONS

Rates of sleep complaints in African-American, Hispanic/Latino and Asian/Other groups were similar to Whites. Lower socioeconomic status was associated with higher rates of sleep complaint.

Oral nonprescription treatment for insomnia: an evaluation of products with limited evidence

PURPOSE

To evaluate the level of evidence regarding the safety and efficacy of nonprescription therapies used for insomnia.

REVIEWERS

Members of the American Academy of Sleep Medicine's Clinical Practice Review Committee.

METHODS

A search of the World Wide Web was conducted using the terms insomnia, herbal remedies, and alternative treatments to develop a list of therapies. Therapies in this review include passionflower, valerian, Jamaican dogwood, hops, California poppy, chamomile, lemon balm, St. John's wort, kava kava, wild lettuce, scullcap, Patrinia root, first-generation histamine-1-receptor antagonists, alcohol, calcium, vitamin A, nicotinamide, magnesium, vitamin B12, I-tryptophan, 5-hydroxytryptophan, dietary changes, Natrum muriaticum, and Yoku-kan-san-ka-chimpi-hange. A search of the PubMed database was conducted in October 2002 using MeSH terms insomnia and each product listed in this paper, including only articles published in English between 1980 and 2002. Additional relevant articles from reference lists were also reviewed. Given the paucity of pediatric publications, this age group was excluded from this review.

RESULTS AND CONCLUSIONS

Although randomized, placebo-controlled studies were available for a few compounds, rigorous scientific data supporting a beneficial effect were not found for the majority of herbal supplements, dietary changes, and other nutritional supplements popularly used for treating insomnia symptoms. Nevertheless, such treatments are described as alternative remedies for insomnia. Studies are limited by small numbers of participants and, in some instances, inadequate design, lack of statistical analysis, and sparse use of objective measurements. Sparse or no scientific data were found to support the efficacy of most products as hypnotics, including chamomile and St. John's wort. There is preliminary but conflicting evidence suggesting Valerian officinalis L. and first-generation histamine-1-receptor antagonists have efficacy as mild hypnotics over short-term use. There are significant potential risks associated with the use of Jamaican dogwood, kava kava, alcohol, and I-tryptophan. Physicians may find this information useful in counseling their patients.

Upper airway management of the adult patient with obstructive sleep apnea in the perioperative period--avoiding complications

PURPOSE

To help practitioners avoid adverse perioperative events in patients with obstructive sleep-disordered breathing.

REVIEWERS

Members of the American Academy of Sleep Medicine's Clinical Practice Review Committee.

METHODS

A search of MEDLINE database using MeSH terms apnea, obstructive sleep apnea and anesthesia was conducted in October 2001. This review focuses on articles published in English between 1985 and 2001 that pertain to non-upper airway surgery in obstructive sleep apnea patients.

RESULTS AND CONCLUSIONS

Scientific literature regarding the perioperative risk and best management techniques for OSAHS patients is scanty and of limited quality. There is insufficient information to develop an AASM standards of practice recommendation. Therefore, the Clinical Practice Review Committee (CPRC) used the available data to make this statement based upon a consensus of clinical experience and published peer-reviewed medical evidence. Important components of the perioperative management of OSAHS patients include a high degree of clinical suspicion, control of the airway throughout the perioperative period, judicious use of medications, and appropriate monitoring. Further research is needed to define the magnitude of risk and optimal perioperative care.

Nonprescription treatments of snoring or obstructive sleep apnea: an evaluation of products with limited scientific evidence

PURPOSE

To evaluate the level of evidence regarding the safety and efficacy of nonprescription therapies used to treat snoring and obstructive sleep apnea, and form a consensus statement based on available data.

REVIEWERS

Members of the American Academy of Sleep Medicine's Clinical Practice Review Committee.

METHODS

A search of PubMed database using MeSH terms snore, apnea, and obstructive sleep apnea in August, 2002, including only articles published in English between 1990 and 2002 and of the World Wide Web, using Google search engine and the key words snoring and obstructive sleep apnea. Letters were sent to manufacturers of lubricant oral and nasal products requesting copies of scientific studies to support their claims.

RESULTS AND CONCLUSIONS

Given the paucity and quality of scientific literature regarding the nonpharmacologic treatment of snoring and obstructive sleep apnea, members of the Clinical Practice Review Committee had insufficient information to develop standards of practice recommendations. Nevertheless, substantial publicity regarding such treatments is available to the general public. Very limited data are available to support a beneficial effect of these devices on snoring and minimal evidence is available to support their use in treating obstructive sleep apnea. Studies are limited by small numbers of participants and, in some instances, inadequate design, lack of statistical analysis, and sparse use of objective measurements. Many studies do not evaluate product safety, especially over extended use. Physicians may find this information useful in counseling their patients.

First-pass ventricular ejection fraction using a single-crystal nuclear camera

The purpose of the study was to evaluate the reliability of ejection fractions obtained from first-pass radionuclide ventriculography with a large field-of-view tomographic single-crystal gamma camera.

METHODS

A SPECT camera had its electronics redesigned to improve counting efficiency and was equipped with an experimental ultra-high sensitivity collimator. Left ventricular ejection fraction (LVEF) was measured in 28 patients by 30 degrees RAO first-pass imaging and by "best septal view" LAO planar equilibrium radionuclide ventriculography on a conventional small field of view Anger camera. For 28 other patients, first-pass ejection fractions were compared to multicrystal gamma camera values. Visual analysis was performed to judge clinical acceptability of first-pass images for identification of wall-motion abnormalities.

RESULTS

Linear regression analysis of first-pass against equilibrium ejection fraction demonstrated good correlation (r = 0.92; slope = 0.90; intercept = 3.8; s.e.e. = 6.4%). First-pass ejection fraction values also correlated linearly with multicrystal camera values for the left ventricle (r = 0.94; slope = 1.05; intercept = 1.3; s.e.e. = 5.3%). For a subgroup of 19 patients, single-crystal camera right ventricle ejection fraction demonstrated good correlation with multicrystal camera values (r = 0.82; slope = 1.15; intercept = 1.3; s.e.e. = 6.1%). Interobserver variability correlated as r = 0.99 for LVEF ejection fraction and r = 0.92 for RVEF. Chi-square analysis of single-crystal first-pass image visual scores versus those from the gated equilibrium acquisitions showed close agreement (p < 10(-8)).

CONCLUSIONS

The evaluated camera/collimator system measured left and right ventricular ejection fraction accurately. Lung frame correction and dual regions were superior to paraventricular background correction and a fixed end-diastolic region.

Afferent loop obstruction documented with hepatobiliary imaging

This report concerns a case of afferent loop obstruction secondary to carcinoma of the gastric stump. Radionuclide hepatobiliary imaging was used to document the afferent loop obstruction.

Radionuclide angiographic diagnosis of bronchopulmonary sequestration

Bronchopulmonary sequestration (BPS), a congenital malformation that usually presents as a chest mass in childhood, may be identified by its characteristic primary derivation of pulmonary blood supply from the systemic circulation. Five children with BPS were evaluated by radionuclide angiography from 1970 to 1974. In each instance the systemic origin of the vascular supply was correctly indicated. In those lesions where the artery originates below the hemidiaphragm, the aberrant source, when identified as such, provides a characteristic radionuclide appearance of BPS. The scimitar syndrome may be indistinguishable from BPS with this technique.