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Smagula SF, Zhang G, Krafty RT, Ramos A, Sotres-Alvarez D, Rodakowski J, Gallo LC, Lamar M, Gujral S, Fischer D, Tarraf W, Mossavar-Rahmani Y, Redline S, Stone KL, Gonzalez HM, Patel SR. Sleep-wake behaviors associated with cognitive performance in middle-aged participants of the Hispanic Community Health Study/Study of Latinos. Sleep Health 2024:S2352-7218(24)00027-5. [PMID: 38693044 DOI: 10.1016/j.sleh.2024.02.002] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/26/2024] [Accepted: 02/20/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVES Many sleep-wake behaviors have been associated with cognition. We examined a panel of sleep-wake/activity characteristics to determine which are most robustly related to having low cognitive performance in midlife. Secondarily, we evaluate the predictive utility of sleep-wake measures to screen for low cognitive performance. METHODS The outcome was low cognitive performance defined as being >1 standard deviation below average age/sex/education internally normalized composite cognitive performance levels assessed in the Hispanic Community Health Study/Study of Latinos. Analyses included 1006 individuals who had sufficient sleep-wake measurements about 2years later (mean age=54.9, standard deviation= 5.1; 68.82% female). We evaluated associations of 31 sleep-wake variables with low cognitive performance using separate logistic regressions. RESULTS In individual models, the strongest sleep-wake correlates of low cognitive performance were measures of weaker and unstable 24-hour rhythms; greater 24-hour fragmentation; longer time-in-bed; and lower rhythm amplitude. One standard deviation worse on these sleep-wake factors was associated with ∼20%-30% greater odds of having low cognitive performance. In an internally cross-validated prediction model, the independent correlates of low cognitive performance were: lower Sleep Regularity Index scores; lower pseudo-F statistics (modellability of 24-hour rhythms); lower activity rhythm amplitude; and greater time in bed. Area under the curve was low/moderate (64%) indicating poor predictive utility. CONCLUSION The strongest sleep-wake behavioral correlates of low cognitive performance were measures of longer time-in-bed and irregular/weak rhythms. These sleep-wake assessments were not useful to identify previous low cognitive performance. Given their potential modifiability, experimental trials could test if targeting midlife time-in-bed and/or irregular rhythms influences cognition.
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Affiliation(s)
- Stephen F Smagula
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
| | - Gehui Zhang
- Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert T Krafty
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Alberto Ramos
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Daniela Sotres-Alvarez
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Juleen Rodakowski
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Linda C Gallo
- Department of Psychology, University of California San Diego, San Diego, California, USA
| | - Melissa Lamar
- Institute of Minority Health Research, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA; Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, Illinois, USA
| | - Swathi Gujral
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dorothee Fischer
- Department of Sleep and Human Factors Research, Institute for Aerospace Medicine, German Aerospace Center, Cologne, Germany
| | - Wassim Tarraf
- Institute of Gerontology, Wayne State University, Detroit, Michigan, USA
| | - Yasmin Mossavar-Rahmani
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, New York, New York, USA
| | - Susan Redline
- Division of Sleep Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Katie L Stone
- California Pacific Medical Center Research Institute, San Francisco, California, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Hector M Gonzalez
- Department of Neurosciences and the Shiley-Marcos Alzheimer's Disease Research Center, UC San Diego, San Diego, California, USA
| | - Sanjay R Patel
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Lau SCL, Zhang G, Rueschman M, Li X, Irwin MR, Krafty RT, McCall WV, Skidmore E, Patel SR, Redline S, Smagula SF. Sleep-wake behavioral characteristics associated with depression symptoms: findings from the Multi-Ethnic Study of Atherosclerosis. Sleep 2024; 47:zsae045. [PMID: 38394355 PMCID: PMC11009024 DOI: 10.1093/sleep/zsae045] [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: 10/04/2023] [Revised: 01/19/2024] [Indexed: 02/25/2024] Open
Abstract
STUDY OBJECTIVES To help prioritize target/groups for experimental intervention studies, we characterized cross-sectional associations between 24-hour sleep-wake measures and depression symptoms, and evaluated if similar sleep-wake-depression relationships existed in people with and without higher insomnia severity. METHODS Participants had ≥3 days of actigraphy data (n = 1884; mean age = 68.6/SD = 9.1; 54.1% female). We extracted 18 sleep, activity, timing, rhythmicity, and fragmentation measures from actigraphy. We used individual and multivariable regressions with the outcome of clinically significant depression symptoms (Center for Epidemiologic Studies Depression Scale ≥ 16). We conducted sensitivity analyses in people with higher insomnia severity (top quartile of the Women's Health Initiative Insomnia Rating Scale total score). RESULTS From separate models in the overall sample, the odds of having depression symptoms were higher with: later timing (e.g. activity onset time odds ratio [OR]/1 SD = 1.32; 95% confidence interval [CI]: 1.16 to 1.50), lower rhythmicity (e.g. pseudo-F OR/1 SD = 0.75; 95% CI: 0.66 to 0.85), less activity (e.g. amplitude OR/1 SD = 0.83; 95% CI: 0.72 to 0.95), and worse insomnia (OR/1 SD = 1.48, 95% CI: 1.31 to 1.68). In multivariable models conducted among people with lower insomnia severity, later timing, lower rhythmicity, and higher insomnia severity were independent correlates of depression. In people with higher insomnia symptom severity, measures of later timing were most strongly associated with depression symptoms. CONCLUSIONS These correlative observations suggest that experimental studies are warranted to test if: broadly promoting 24-hour sleep-wake functioning reduces depression even in people without severe insomnia, and if advancing timing leads to depression symptom reductions in people with insomnia.
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Affiliation(s)
- Stephen C L Lau
- Department of Occupational Therapy, School of Health and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO, USA
| | - Gehui Zhang
- Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael Rueschman
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Xiaoyu Li
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Michael R Irwin
- Norman Cousins Center for Psychoneuroimmunology, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - Robert T Krafty
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - William V McCall
- Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Elizabeth Skidmore
- Department of Occupational Therapy, School of Health and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sanjay R Patel
- Center for Sleep and Cardiovascular Outcomes Research, University of Pittsburgh, Pittsburgh, PA, USA
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Stephen F Smagula
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
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Smagula SF, Gasperetti CE, Buysse DJ, Irwin MR, Krafty RT, Lim SE, Reynolds CF, McCall WV, Harvey AG. Efficacy of the Transdiagnostic Intervention for Sleep and Circadian Dysfunction for Depression Symptoms and Sleep-Wake Disruption in Older and Younger Adults: Secondary Age-Stratified Analysis of a Randomized Controlled Trial. Am J Geriatr Psychiatry 2024; 32:478-488. [PMID: 38040569 PMCID: PMC10950538 DOI: 10.1016/j.jagp.2023.11.003] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE Perform a secondary analysis examining the efficacy of the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) for depression symptom responses, and explore changes in potential target mechanisms. DESIGN Secondary analysis of a randomized controlled trial with convenience age subsamples (younger (20-49 year; n = 52) versus and older (50-71 years; n = 35)). SETTING Community mental health clinics. PARTICIPANTS Eighty-seven adults with serious mental illness. INTERVENTION TranS-C versus treatment as usual (TAU). MEASUREMENTS Outcomes were depression symptoms (Quick Inventory of Depression Symptoms), insomnia symptoms (Insomnia Severity Index), and objective sleep-wake rhythm measures (interdaily stability and relative amplitude). RESULTS Depression response rates (≥50% symptom reductions) were higher in the TranS-C (35.0%) than the TAU (8.8%) group 6-months postintervention (χ2 = 10.3, p = 0.001). There was a medium effect of TranS-C versus TAU on depression symptoms 6-months postintervention (Cohen's d = -0.40, 95% confidence interval (CI): -0.81, 0.01). In both age groups, there were large treatment effects on insomnia symptoms post-treatment (Cohen's d >0.90). In the older subsample, there were additionally medium treatment effects on post-treatment interdaily stability (Cohen's d = 0.60, 95% CI: -0.11, 1.61). Post-treatment reductions in insomnia symptoms correlated with depression symptom reduction 6-months later in the younger subsample (Spearman rho = 0.59, n = 20, p = 0.008). In older adults, postintervention increases in interdaily stability correlated with depression symptom reductions 6-months later (Spearman rho = -0.52, n = 15, p = 0.049). CONCLUSION Confirmatory trials are needed, given the low age-specific sample sizes here, to determine if TranS -C's produces durable depression responses by increasing sleep-wake rhythm stability in older adults and improving insomnia symptoms in younger adults. BRIEF ARTICLE SUMMARY The authors evaluated preliminary efficacy of a behavioral intervention that targets sleep/sleep-wake rhythms, the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C), for depression symptoms in people with serious mental illness. TranS-C was associated with higher depression response rates than treatment as usual 6-months postintervention. The degree of depression symptom response 6-months later was related to the degree of treatment phase improvements in interdaily stability (in older adults) and reduction in insomnia severity (in younger adults). A pragmatic nonpharmacologic intervention, the Transdiagnostic Intervention for Sleep and Circadian Dysfunction, has preliminary efficacy for improving sleep-wake factors and depression symptoms.
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Affiliation(s)
- Stephen F Smagula
- Department of Psychiatry (SFS, DJB, SEL, CFR), School of Medicine, University of Pittsburgh, Pittsburgh, PA.
| | - Caitlin E Gasperetti
- Department of Child and Adolescent Psychiatry (CEG), Hassenfeld Children's Hospital at NYU Langone, New York, NY
| | - Daniel J Buysse
- Department of Psychiatry (SFS, DJB, SEL, CFR), School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Michael R Irwin
- Norman Cousins Center for Psychoneuroimmunology (MRI), Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA; Department of Psychiatry and Biobehavioral Sciences (MRI), University of California, Los Angeles, Los Angeles, CA
| | - Robert T Krafty
- Department of Biostatistics and Bioinformatics (RTK), Rollins School of Public Health, Emory University, Atlanta, GA
| | - Sarah E Lim
- Department of Psychiatry (SFS, DJB, SEL, CFR), School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Charles F Reynolds
- Department of Psychiatry (SFS, DJB, SEL, CFR), School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - William V McCall
- Department of Psychiatry and Health Behavior (WVMC), Medical College of Georgia, Augusta, GA
| | - Allison G Harvey
- Department of Psychology (AGH), University of California, Berkeley, CA
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Stahl ST, Kazan J, Lazzari T, Krafty RT, Reynolds CF, Rollman BL, Smagula SF, Gebara MA. Risk for Complicated Grief After the COVID-19 Death of a Marital Partner in Late Life. Am J Geriatr Psychiatry 2024; 32:386-391. [PMID: 37968160 PMCID: PMC10922502 DOI: 10.1016/j.jagp.2023.10.019] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/19/2023] [Accepted: 10/19/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVE To identify 1) complicated grief symptom clusters among acutely-bereaved older adults who have lost a spouse to COVID-19 and 2) if spousal death due to COVID-19 increased risk of developing probable PGD METHODS: Eighty adults participating in a randomized controlled trial for depression prevention (mean age [± SD] = 70.4 [6.6]) completed the Inventory of Complicated Grief, every 3 months over a maximum of 15 months. Twenty-four percent (n = 19) of participants lost a spouse to COVID-19; 76% (n = 61) lost a spouse to other causes of death. Adjusted linear regression examined the associations between COVID-19 bereavement and six symptom clusters: yearning and preoccupation, anger and bitterness, shock and disbelief, estrangement from others, hallucinations, and behavior change. RESULTS Compared to the non-COVID-19 group, the COVID-19 bereaved group reported greater shock and disbelief, hallucinations of the deceased, and estrangement from others. COVID-19 death was also associated with higher risk for probable prolonged grief disorder (PGD) at 12 months (odds ratio = 4.38, p = 0.027). CONCLUSIONS Older adults who have lost a spouse to COVID-19 present with specific symptoms of distress and may eventually require clinical care for PGD.
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Affiliation(s)
- Sarah T Stahl
- Department of Psychiatry (STS, JK, TL, CFR, SFS, MAG), University of Pittsburgh, Pittsburgh, PA.
| | - Joseph Kazan
- Department of Psychiatry (STS, JK, TL, CFR, SFS, MAG), University of Pittsburgh, Pittsburgh, PA
| | - Taylor Lazzari
- Department of Psychiatry (STS, JK, TL, CFR, SFS, MAG), University of Pittsburgh, Pittsburgh, PA
| | - Robert T Krafty
- Department of Biostatistics (RTK), Emory University, Atlanta, GA
| | - Charles F Reynolds
- Department of Psychiatry (STS, JK, TL, CFR, SFS, MAG), University of Pittsburgh, Pittsburgh, PA
| | - Bruce L Rollman
- Department of Medicine (BLR), University of Pittsburgh, Pittsburgh, PA
| | - Stephen F Smagula
- Department of Psychiatry (STS, JK, TL, CFR, SFS, MAG), University of Pittsburgh, Pittsburgh, PA
| | - Marie Anne Gebara
- Department of Psychiatry (STS, JK, TL, CFR, SFS, MAG), University of Pittsburgh, Pittsburgh, PA
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Yam D, Smagula SF. Open Questions Regarding the Efficacy, Mechanisms, and Moderators of Treatments for Circadian Sleep-Wake Disruption in People With Dementia. Am J Geriatr Psychiatry 2024:S1064-7481(24)00027-7. [PMID: 38331666 DOI: 10.1016/j.jagp.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/17/2024] [Indexed: 02/10/2024]
Affiliation(s)
- Dorothy Yam
- Medical Student, School of Medicine, University of Pittsburgh (DY), Pittsburgh, PA
| | - Stephen F Smagula
- Department of Psychiatry, School of Medicine, University of Pittsburgh (SFS), Pittsburgh, PA.
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Adhyapak N, Abboud MA, Rao PS, Kar A, Mignot E, Delucca G, Smagula SF, Krishnan V. Stability and Volatility of Human Rest-Activity Rhythms: Insights from Very Long Actograms (VLAs). medRxiv 2024:2024.01.22.24301243. [PMID: 38370763 PMCID: PMC10871462 DOI: 10.1101/2024.01.22.24301243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
Importance Wrist-worn activity monitors provide biomarkers of health by non-obtrusively measuring the timing and amount of rest and physical activity (rest-activity rhythms, RARs). The morphology and robustness of RARs vary by age, gender, and sociodemographic factors, and are perturbed in various chronic illnesses. However, these are cross-sectionally derived associations from recordings lasting 4-10 days, providing little insights into how RARs vary with time. Objective To describe how RAR parameters can vary or evolve with time (~months). Design Setting and Participants 48 very long actograms ("VLAs", ≥90 days in duration) were identified from subjects enrolled in the STAGES (Stanford Technology, Analytics and Genomics in Sleep) study, a prospective cross-sectional, multi-site assessment of individuals > 13 years of age that required diagnostic polysomnography to address a sleep complaint. A single 3-year long VLA (author GD) is also described. Exposures/Intervention None planned. Main Outcomes and Measures For each VLA, we assessed the following parameters in 14-day windows: circadian/ultradian spectrum, pseudo-F statistic ("F"), cosinor amplitude, intradaily variability, interdaily stability, acrophase and estimates of "sleep" and non-wearing. Results Included STAGES subjects (n = 48, 30 female) had a median age of 51, BMI of 29.4kg/m2, Epworth Sleepiness Scale score (ESS) of 10/24 and a median recording duration of 120 days. We observed marked within-subject undulations in all six RAR parameters, with many subjects displaying ultradian rhythms of activity that waxed and waned in intensity. When appraised at the group level (nomothetic), averaged RAR parameters remained remarkably stable over a ~4 month recording period. Cohort-level deficits in average RAR robustness associated with unemployment or high BMI (>29.4) also remained stable over time. Conclusions and Relevance Through an exemplary set of months-long wrist actigraphy recordings, this study quantitatively depicts the longitudinal stability and dynamic range of human rest-activity rhythms. We propose that continuous and long-term actigraphy may have broad potential as a holistic, transdiagnostic and ecologically valid monitoring biomarker of changes in chronobiological health. Prospective recordings from willing subjects will be necessary to precisely define contexts of use.
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Affiliation(s)
- Nandani Adhyapak
- Departments of Neurology, Neuroscience and Psychiatry & Behavioral Sciences Baylor College of Medicine, Houston, TX USA
| | - Mark A. Abboud
- Departments of Neurology, Neuroscience and Psychiatry & Behavioral Sciences Baylor College of Medicine, Houston, TX USA
| | - Pallavi S.K. Rao
- Departments of Neurology, Neuroscience and Psychiatry & Behavioral Sciences Baylor College of Medicine, Houston, TX USA
| | - Ananya Kar
- Departments of Neurology, Neuroscience and Psychiatry & Behavioral Sciences Baylor College of Medicine, Houston, TX USA
| | - Emmanuel Mignot
- Stanford Center for Sleep Science and Medicine Stanford Medicine, Palo Alto CA
| | | | - Stephen F. Smagula
- Departments of Psychiatry and Epidemiology University of Pittsburgh Medical Center, Pittsburgh PA USA
| | - Vaishnav Krishnan
- Departments of Neurology, Neuroscience and Psychiatry & Behavioral Sciences Baylor College of Medicine, Houston, TX USA
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Smagula SF. Association versus prediction and open question on what sleep-wake factors to target for dementia prevention: letter to the editor regarding "Earlier chronotype in midlife as a predictor of accelerated brain aging: a population-based longitudinal cohort study" by Kim et al. (https://doi.org/10.1093/sleep/zsad108). Sleep 2023; 46:zsad183. [PMID: 37506228 DOI: 10.1093/sleep/zsad183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023] Open
Affiliation(s)
- Stephen F Smagula
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh PA, USA
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Stahl ST, Skidmore E, Kringle E, Shih M, Baum C, Hammel J, Krafty R, Covassin N, Li J, Smagula SF. Rest-Activity Rhythm Characteristics Associated With Depression Symptoms in Stroke Survivors. Arch Phys Med Rehabil 2023; 104:1203-1208. [PMID: 36736806 PMCID: PMC10802795 DOI: 10.1016/j.apmr.2023.01.013] [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: 08/10/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To examine which 24-hour rest-activity rhythm (RAR) characteristics are associated with depression symptoms in stroke survivors. DESIGN Cross-sectional observational study examining associations of RAR characteristics with the presence of depression symptoms adjusting for age, sex, race, and medical comorbidity. SETTING Community setting. PARTICIPANTS Stroke survivors: (1) recruited locally (N women=35, N men=28) and (2) a nationally representative probability sample (the National Health and Nutrition Examination Survey [NHANES]; N women=156, N men=124). INTERVENTIONS None. MEASUREMENTS Objective RAR characteristics derived from accelerometer recordings including activity onset/offset times and non-parametric measures of RAR strength (relative amplitude), stability (interdaily stability), and fragmentation (intradaily variability). The presence of depression symptoms was categorized using Patient Health Questionnaire scores. RESULTS In both samples, the only RAR characteristic associated with depression symptoms was intradaily variability (fragmentation): local sample, odds ratio=1.96 [95% confidence interval=1.05-3.63]; NHANES sample, odds ratio=1.34, [95% confidence interval=1.01-1.78]). In the NHANES sample, which included both mild and moderate/severe depression, the association between 24-hour sleep-wake fragmentation and depression symptoms was driven by moderate-to-severe cases. CONCLUSIONS Stroke survivors with higher levels of RAR fragmentation were more likely to have depression symptoms in both samples. These findings have implications, given prior studies in general samples linking RAR fragmentation with future depression and dementia risk. Research is needed to establish the potential consequences, mechanisms, and modifiability of RAR fragmentation in stroke survivors.
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Affiliation(s)
- Sarah T Stahl
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Elizabeth Skidmore
- Department of Occupational Therapy, School of Health and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Emily Kringle
- Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Minmei Shih
- Department of Occupational Therapy, School of Health and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Carolyn Baum
- Program in Occupational Therapy, School of Medicine, Washington University, St. Louis, MO
| | - Joy Hammel
- Department of Occupational Therapy, College of Allied Health Sciences, University of Illinois at Chicago, Chicago, IL
| | - Robert Krafty
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Naima Covassin
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Jingen Li
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Stephen F Smagula
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.
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Smagula SF, Hasler BP, Schulz R, Graves JL, Reynolds CF, Aizenstein HJ, Buysse DJ, Krafty RT, Hall MH. Activity patterns related to depression symptoms in stressed dementia caregivers. Int Psychogeriatr 2023; 35:373-380. [PMID: 31658928 PMCID: PMC7188574 DOI: 10.1017/s1041610219001601] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Self-reported activity restriction is an established correlate of depression in dementia caregivers (dCGs). It is plausible that the daily distribution of objectively measured activity is also altered in dCGs with depression symptoms; if so, such activity characteristics could provide a passively measurable marker of depression or specific times to target preventive interventions. We therefore investigated how levels of activity throughout the day differed in dCGs with and without depression symptoms, then tested whether any such differences predicted changes in symptoms 6 months later. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS We examined 56 dCGs (mean age = 71, standard deviation (SD) = 6.7; 68% female) and used clustering to identify subgroups which had distinct depression symptom levels, leveraging baseline Center for Epidemiologic Studies of Depression Scale-Revised Edition and Patient Health Questionnaire-9 (PHQ-9) measures, as well as a PHQ-9 score from 6 months later. Using wrist activity (mean recording length = 12.9 days, minimum = 6 days), we calculated average hourly activity levels and then assessed when activity levels relate to depression symptoms and changes in symptoms 6 months later. RESULTS Clustering identified subgroups characterized by: (1) no/minimal symptoms (36%) and (2) depression symptoms (64%). After multiple comparison correction, the group of dCGs with depression symptoms was less active from 8 to 10 AM (Cohen's d ≤ -0.9). These morning activity levels predicted the degree of symptom change on the PHQ-9 6 months later (per SD unit β = -0.8, 95% confidence interval: -1.6, -0.1, p = 0.03) independent of self-reported activity restriction and other key factors. CONCLUSIONS These novel findings suggest that morning activity may protect dCGs from depression symptoms. Future studies should test whether helping dCGs get active in the morning influences the other features of depression in this population (i.e. insomnia, intrusive thoughts, and perceived activity restriction).
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Affiliation(s)
- Stephen F Smagula
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brant P Hasler
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Richard Schulz
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jessica L Graves
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Charles F Reynolds
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Howard J Aizenstein
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Daniel J Buysse
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert T Krafty
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Martica H Hall
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Smagula SF, Aizenstein HJ. Initial evidence regarding the neurobiological basis of psychological symptoms in dementia caregivers. Transl Psychiatry 2023; 13:169. [PMID: 37202392 DOI: 10.1038/s41398-023-02457-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 04/20/2023] [Accepted: 04/25/2023] [Indexed: 05/20/2023] Open
Abstract
Mood symptoms and disorders are common in dementia caregivers, who can be exposed to a myriad of potential stressors including their care recipient's neuropsychiatric symptoms. Existing evidence indicates that the effects of potentially stressful exposures on mental health depend on the caregiver's individual characteristics and responses. Specifically, prior studies indicate that risk factors measured on psychological (e.g., emotion-focused/behaviorally disengaged coping responses) and behavioral (e.g., sleep and activity restriction) levels of analysis may confer the effects of caregiving exposures on mental health. Theoretically, this process from caregiving stressors and other risk factors to mood symptoms is neurobiologically mediated. This article reviews recent studies that used brain imaging to identify neurobiological factors that are related to psychological outcomes in caregivers. Available observational data indicate that psychological outcomes in caregivers are related to differences in the structure/function of regions involved in socio-affective information processing (prefrontal), autobiographical memory (the posterior cingulate), and stress (amygdala). In addition, two small randomized controlled trials using repeated brain imaging showed that Mentalizing Imagery Therapy (a mindfulness program) increased prefrontal network connectivity and reduced mood symptoms. These studies raise the possibility that, in the future, brain imaging may be useful to detect the neurobiological basis of a given caregiver's mood vulnerability and guide the selection of interventions that are known to modify it. However, there remains a need for evidence on whether brain imaging improves on simpler/inexpensive measurement modalities like self-report for identifying vulnerable caregivers and matching them with efficacious interventions. In addition, to target interventions, more evidence is needed regarding the effects that both risk factors and interventions have on mood neurobiology (e.g., how persistent emotion-focused coping, sleep disruption, and mindfulness affect brain function).
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Affiliation(s)
- Stephen F Smagula
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Howard J Aizenstein
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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11
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Mayeli A, LaGoy AD, Smagula SF, Wilson JD, Zarbo C, Rocchetti M, Starace F, Zamparini M, Casiraghi L, Calza S, Rota M, D'Agostino A, de Girolamo G, Ferrarelli F. Shared and distinct abnormalities in sleep-wake patterns and their relationship with the negative symptoms of Schizophrenia Spectrum Disorder patients. Mol Psychiatry 2023; 28:2049-2057. [PMID: 37055512 DOI: 10.1038/s41380-023-02050-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 04/15/2023]
Abstract
Sleep and rest-activity-rhythm (RAR) abnormalities are commonly reported in schizophrenia spectrum disorder (SSD) patients. However, an in-depth characterization of sleep/RAR alterations in SSD, including patients in different treatment settings, and the relationship between these alterations and SSD clinical features (e.g., negative symptoms) is lacking. SSD (N = 137 altogether, N = 79 residential and N = 58 outpatients) and healthy control (HC) subjects (N = 113) were recruited for the DiAPAson project. Participants wore an ActiGraph for seven consecutive days to monitor habitual sleep-RAR patterns. Sleep/rest duration, activity (i.e., M10, calculated on the 10 most active hours), rhythm fragmentation within days (i.e., intra-daily variability, IV; beta, steepness of rest-active changes), and rhythm regularity across days (i.e., inter-daily stability, IS) were computed in each study participant. Negative symptoms were assessed in SSD patients with the Brief Negative Symptom Scale (BNSS). Both SSD groups showed lower M10 and longer sleep/rest duration vs. HC, while only residential patients had more fragmented and irregular rhythms than HC. Compared to outpatients, residential patients had lower M10 and higher beta, IV and IS. Furthermore, residential patients had worse BNSS scores relative to outpatients, and higher IS contributed to between-group differences in BNSS score severity. Altogether, residentials and outpatients SSD had both shared and unique abnormalities in Sleep/RAR measures vs. HC and relative to one another, which also contributed to the patients' negative symptom severity. Future work will help establish whether improving some of these measures may ameliorate the quality of life and clinical symptoms of SSD patients.
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Affiliation(s)
- Ahmad Mayeli
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alice D LaGoy
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Stephen F Smagula
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - James D Wilson
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Cristina Zarbo
- Unit of Epidemiological Psychiatry and Evaluation, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - Matteo Rocchetti
- Department of Mental Health and Dependence, ASST of Pavia, Pavia, Italy
| | - Fabrizio Starace
- Department of Mental Health and Dependence, AUSL of Modena, Modena, Italy
| | - Manuel Zamparini
- Unit of Epidemiological Psychiatry and Evaluation, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - Letizia Casiraghi
- Department of Mental Health and Dependence, ASST of Pavia, Pavia, Italy
| | - Stefano Calza
- Unit of Biostatistics and Bioinformatics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Matteo Rota
- Unit of Biostatistics and Bioinformatics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | | | - Giovanni de Girolamo
- Unit of Epidemiological Psychiatry and Evaluation, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - Fabio Ferrarelli
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA.
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Abboud MA, Kamen JL, Bass JS, Lin L, Gavvala JR, Rao S, Smagula SF, Krishnan V. Actigraphic Correlates of Neuropsychiatric Symptoms in Adults with Focal Epilepsy. Epilepsia 2023. [PMID: 37029747 DOI: 10.1111/epi.17611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 04/09/2023]
Abstract
OBJECTIVES Disability in patients with epilepsy (PWE) is multifactorial: beyond seizure frequency/severity, PWE are prone to a range of neuropsychiatric, cognitive, and somatic comorbidities that significantly impact quality of life. Here, we explored how variations in seizure severity and the burden of self-reported somatic/neuropsychiatric symptoms correlate with disruptions to 24h activity patterns (rest-activity rhythms, RARs), determined through wrist accelerometry/actigraphy. METHODS Multiday wrist-actigraphy recordings were obtained from 59 adult patients with focal epilepsy (44% male, ages 18-72), who contemporaneously responded to validated psychometric instruments to measure anxiety, depression, sleepiness, and somatic symptoms. We conducted a similar in silico psychometric-actigraphic correlation in a publicly available dataset of 1747 Hispanic subjects (35% male, ages 18-65) from the Study of Latinos (SOL) Sueño Ancillary Study. RARs were analyzed via a sigmoidally-transformed cosine model (quantifying amplitude, steepness, acrophase and robustness) and non-parametric measures to estimate RAR stability, fragmentation, and sleep. RESULTS Compared with matched SOL subjects, RARs from PWE subjects featured a significantly lower amplitude, a wider rest phase and significantly more total daily sleep. Within PWE, similar RAR distortions were associated with seizure intractability and/or anticonvulsant polytherapy, whereas high anxiety, depression, and somatic symptom scores were associated with lower RAR robustness and acrophase delay. We applied the SOL dataset to train logistic regression models to dichotomously classify subjective anxiety, depression and sleepiness symptoms using demographic and RAR parameters. When tested on PWE, these models predicted prevalent anxiety and depression symptom burden (accuracy ~70%) but failed to predict subjective sleepiness. SIGNIFICANCE Together, these results demonstrate that RAR features may encode prevalent depression and anxiety symptoms in patients with focal epilepsy, potentially offering wearable-derived endpoints to adjunct clinical care and drug/device trials. With larger PWE-specific actigraphic-psychometric datasets, we may identify RAR signatures that may more precisely correlate with varying seizure frequency, the burden of anticonvulsant therapy and prevalent mood/anxiety symptoms.
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Affiliation(s)
- Mark A Abboud
- Departments of Neurology, 3Neuroscience and 4Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Jessica L Kamen
- Departments of Neurology, 3Neuroscience and 4Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - John S Bass
- Departments of Neurology, 3Neuroscience and 4Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Lu Lin
- Departments of Neurology, 3Neuroscience and 4Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Jay R Gavvala
- Departments of Neurology, 3Neuroscience and 4Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Sindhu Rao
- Departments of Neurology, 3Neuroscience and 4Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Stephen F Smagula
- Departments of Psychiatry and Epidemiology, University of Pittsburgh Medical Center, Pittsburg, PA, USA
| | - Vaishnav Krishnan
- Departments of Neurology, 3Neuroscience and 4Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
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Wescott DL, Franzen PL, Hasler BP, Miller MA, Soehner AM, Smagula SF, Wallace ML, Hall MH, Roecklein KA. Elusive hypersomnolence in seasonal affective disorder: actigraphic and self-reported sleep in and out of depressive episodes. Psychol Med 2023; 53:1313-1322. [PMID: 37010222 PMCID: PMC10071357 DOI: 10.1017/s003329172100283x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Hypersomnolence has been considered a prominent feature of seasonal affective disorder (SAD) despite mixed research findings. In the largest multi-season study conducted to date, we aimed to clarify the nature and extent of hypersomnolence in SAD using multiple measurements during winter depressive episodes and summer remission. METHODS Sleep measurements assessed in individuals with SAD and nonseasonal, never-depressed controls included actigraphy, daily sleep diaries, retrospective self-report questionnaires, and self-reported hypersomnia assessed via clinical interviews. To characterize hypersomnolence in SAD we (1) compared sleep between diagnostic groups and seasons, (2) examined correlates of self-reported hypersomnia in SAD, and (3) assessed agreement between commonly used measurement modalities. RESULTS In winter compared to summer, individuals with SAD (n = 64) reported sleeping 72 min longer based on clinical interviews (p < 0.001) and 23 min longer based on actigraphy (p = 0.011). Controls (n = 80) did not differ across seasons. There were no seasonal or group differences on total sleep time when assessed by sleep diaries or retrospective self-reports (p's > 0.05). Endorsement of winter hypersomnia in SAD participants was predicted by greater fatigue, total sleep time, time in bed, naps, and later sleep midpoints (p's < 0.05). CONCLUSION Despite a winter increase in total sleep time and year-round elevated daytime sleepiness, the average total sleep time (7 h) suggest hypersomnolence is a poor characterization of SAD. Importantly, self-reported hypersomnia captures multiple sleep disruptions, not solely lengthened sleep duration. We recommend using a multimodal assessment of hypersomnolence in mood disorders prior to sleep intervention.
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Affiliation(s)
| | - Peter L. Franzen
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Brant P. Hasler
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Megan A. Miller
- Rehabilitation Care Services, VA Puget Sound Healthcare System, Seattle, WA
| | - Adriane M. Soehner
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Stephen F. Smagula
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Meredith L. Wallace
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Statistics, University of Pittsburgh, Pittsburgh PA
| | - Martica H. Hall
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kathryn A. Roecklein
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA
- Center for the Neural Basis of Behavior, University of Pittsburgh, Pittsburgh, PA
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14
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Kazan J, Lyew T, Croswell E, Buysse DJ, Gebara MA, Karp JF, Krafty RT, Rashied AA, Reynolds CF, Rollman BL, Smagula SF, Stahl ST. A digital health intervention to stabilize the 24-hour rhythm of sleep, meals, and physical activity for reducing depression among older bereaved spouses: Protocol for a randomized controlled trial. Contemp Clin Trials 2023; 124:107016. [PMID: 36414207 PMCID: PMC9839623 DOI: 10.1016/j.cct.2022.107016] [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: 08/19/2022] [Revised: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Despite the high prevalence of depression and disruption to 24-h sleep-wake routines following the death of a spouse in late-life, no bereavement interventions have been developed to re-entrain a regular sleep-wake routine among older widow(er)s. We describe the rationale and methodology of the NIH-funded WELL Study (Widowed Elders' Lifestyle after Loss), a randomized controlled trial (RCT) comparing the efficacy of a digital health intervention (DHI) to enhanced usual care (EUC) arm for reducing depression symptoms in older spousally-bereaved adults. METHODS We will randomize approximately 200 recently bereaved (<12 months) adults aged 60+ years to one of two 12-week interventions: digital monitoring of the timing and regularity of sleep, meals, and physical activity plus weekly motivational health coaching; or enhanced usual care consisting of weekly telephone calls and similar assessment schedules. Participants will complete self-report and clinical assessments at baseline, post-intervention, and 3-, 6-, and 12-months post-intervention, and objective actigraphic assessments of their 24-h rest-activity rhythm (RAR) at baseline and 1-, 2-, and 3-months during the intervention. The primary outcome is change in depression symptoms burden (using the Hamilton Rating Scale for Depression) from pre- to post-intervention and over 12 months of follow-up. DISCUSSION WELL Study findings will inform the development of widely generalizable and scalable technology-based interventions to support bereaved spouses in community-based settings. Clinical http://Trials.gov Identifier: NCT04016896.
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Affiliation(s)
- Joseph Kazan
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thandi Lyew
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Emilee Croswell
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Daniel J Buysse
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marie Anne Gebara
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jordan F Karp
- Department of Psychiatry, University of Arizona, Tucson, AZ, USA
| | - Robert T Krafty
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Ammar A Rashied
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | | | - Bruce L Rollman
- Center for Behavioral Health, Media, & Technology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Stephen F Smagula
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sarah T Stahl
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA.
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15
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LaGoy AD, Mayeli A, Smagula SF, Ferrarelli F. Relationships between rest-activity rhythms, sleep, and clinical symptoms in individuals at clinical high risk for psychosis and healthy comparison subjects. J Psychiatr Res 2022; 155:465-470. [PMID: 36183600 PMCID: PMC10729940 DOI: 10.1016/j.jpsychires.2022.09.009] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 08/11/2022] [Accepted: 09/12/2022] [Indexed: 11/18/2022]
Abstract
Sleep-wake disturbances in individuals at clinical high risk (CHR) of psychosis may relate to increased symptom severity and contribute to disease progression. Here, we examined differences in rest-activity rhythms (RAR) measures, derived from actigraphy, and objective sleep outcomes, derived from electroencephalography (EEG), between 12 CHR and 16 healthy comparison (HC) individuals. Further, we examined the relationships between RAR disturbances, objective sleep outcomes and clinical psychosis symptoms (i.e., negative, positive, disorganized, general symptoms). Sleep-wake behaviors were monitored via actigraphy for 3-7 days (CHR: 5.7 ± 1.7 days; HC: 6.3 ± 1.2 days) prior to participants spending a night in the sleep laboratory, which was monitored with EEG. Separate regressions were used to examine the effect of clinical group on RAR measures and objective sleep outcomes after controlling for age and gender. CHR participants were found to be less active, specifically during the evening (17:00-20:00; β = 1.145, SE = 0.362, p = .004) and nighttime (21:00-24:00; β = 1.152, SE = 0.326, p = .002) relative to HC. Further, CHR participants had more fragmented sleep (wake after sleep onset: β = 0.888, SE = 0.395, p = .034) and more hyperarousal during sleep (NREM gamma activity: β = 1.087, SE = 0.348, p = .005), but these sleep disturbances were not related to reduced activity or clinical symptoms, whereas lower nighttime activity was related to more disorganized symptoms (ρ = -.640, p = .025). Thus, increasing activity through behavioral interventions may have additional beneficial effects on CHR clinical symptoms.
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Affiliation(s)
- Alice D LaGoy
- Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara Street, Pittsburgh, PA, 15213, USA; Department of Sports Medicine and Nutrition, University of Pittsburgh, 3600 Atwood Street, Pittsburgh, PA, 15260, USA
| | - Ahmad Mayeli
- Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara Street, Pittsburgh, PA, 15213, USA
| | - Stephen F Smagula
- Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara Street, Pittsburgh, PA, 15213, USA
| | - Fabio Ferrarelli
- Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara Street, Pittsburgh, PA, 15213, USA.
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Smagula SF, Zhang G, Gujral S, Covassin N, Li J, Taylor WD, Reynolds CF, Krafty RT. Association of 24-Hour Activity Pattern Phenotypes With Depression Symptoms and Cognitive Performance in Aging. JAMA Psychiatry 2022; 79:1023-1031. [PMID: 36044201 PMCID: PMC9434485 DOI: 10.1001/jamapsychiatry.2022.2573] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/08/2022] [Indexed: 11/14/2022]
Abstract
Importance Evidence regarding the nature and prevalence of 24-hour activity pattern phenotypes in older adults, especially those related to depression symptoms and cognition, is needed to guide the development of targeted mechanism research and behavioral interventions. Objectives To identify subgroups of older adults with similar 24-hour activity rhythm characteristics and characterize associated depression symptoms and cognitive performance. Design, Setting, and Participants From January to March 2022, a cross-sectional analysis of the 2011-2014 National Health and Nutrition Examination and Survey (NHANES) accelerometer study was conducted. The NHANES used a multistage probability sample that was designed to be representative of noninstitutionalized adults in the US. The main analysis included participants 65 years or older who had accelerometer and depression measures weighted to represent approximately 32 million older adults. Exposures Latent profile analysis identified subgroups with similar 24-hour activity pattern characteristics as measured using extended-cosine and nonparametric methods. Main Outcomes and Measures Covariate-adjusted sample-weighted regressions assessed associations of subgroup membership with (1) depression symptoms defined as 9-Item Patient Health Questionnaire (PHQ-9) scores of 10 or greater (PHQ-9) and (2) having at least psychometric mild cognitive impairment (p-MCI) defined as scoring less than 1 SD below the mean on a composite cognitive performance score. Results The actual clustering sample size was 1800 (weighted: mean [SD] age, 72.9 [7.3] years; 57% female participants). Clustering identified 4 subgroups: (1) 677 earlier rising/robust (37.6%), (2) 587 shorter active period/less modelable (32.6%), (3) 177 shorter active period/very weak (9.8%), and (4) 359 later settling/very weak (20.0%). The prevalence of a PHQ-9 score of 10 or greater differed significantly across groups (cluster 1, 3.5%; cluster 2, 4.7%; cluster 3, 7.5%; cluster 4, 9.0%; χ2 P = .004). The prevalence of having at least p-MCI differed significantly across groups (cluster 1, 7.2%; cluster 2, 12.0%; cluster 3, 21.0%; cluster 4, 18.0%; χ2 P < .001). Five of 9 depression symptoms differed significantly across subgroups. Conclusions and Relevance In this cross-sectional study, findings indicate that approximately 1 in 5 older adults in the US may be classified in a subgroup with weak activity patterns and later settling, and approximately 1 in 10 may be classified in a subgroup with weak patterns and shorter active duration. Future research is needed to investigate the biologic processes related to these behavioral phenotypes, including why earlier and robust activity patterns appear protective, and whether modifying disrupted patterns improves outcomes.
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Affiliation(s)
- Stephen F. Smagula
- Department of Psychiatry, School of Medicine, University of Pittsburgh Medical Center Western Psychiatric Hospital, Pittsburgh, Pennsylvania
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Gehui Zhang
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Swathi Gujral
- Department of Psychiatry, School of Medicine, University of Pittsburgh Medical Center Western Psychiatric Hospital, Pittsburgh, Pennsylvania
| | - Naima Covassin
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jingen Li
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Cardiovascular Medicine, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Warren D. Taylor
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Charles F. Reynolds
- Department of Psychiatry, School of Medicine, University of Pittsburgh Medical Center Western Psychiatric Hospital, Pittsburgh, Pennsylvania
| | - Robert T. Krafty
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Smagula SF, Biggs ML, Jacob ME, Rawlings AM, Odden MC, Arnold A, Newman AB, Buysse DJ. Associations of Modifiable Behavioral Risk Factor Combinations at 65 to 74 Years Old With Cognitive Health Span for 20 Years. Psychosom Med 2022; 84:785-792. [PMID: 35796682 PMCID: PMC9437131 DOI: 10.1097/psy.0000000000001100] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Behavioral risk factors for dementia tend to co-occur and interrelate, especially poor diet, physical inactivity, sleep disturbances, and depression. Having multiple of these modifiable behavioral risk factors (MBRFs) may predict a particularly shortened cognitive health span and therefore may signal high-risk status/high intervention need. METHODS These secondary analyses of data from the Cardiovascular Health Study included 3149 participants aged 65 to 74 years (mean [standard deviation {SD}] age = 69.5 [2.5] years; 59.6% female). MBRF exposures were self-reports regarding a) diet, b) activity, c) sleep, and d) depression symptoms. We primarily analyzed MBRF counts. For up to 26 years of follow-up, we assessed the a) number of remaining cognitively healthy life-years (CHLYs) and b) percentage of remaining life-years (LYs) that were CHLYs (%CHLY). We estimated CHLYs as time before a dementia diagnosis, cognitive screener scores indicating impairment, proxy report indicating significant cognitive decline, or dementia medication use. RESULTS Participants averaged a remaining 16 LYs (SD = 7 LYs), 12.2 CHLYs (SD = 6.6 CHLYs), and 78.1% of LYs being CHLYs (SD = 25.6 CHLYs). Compared with having no MBRFs, having one was associated with ~1 less LY and CHLY, but not a relatively lower %CHLY. In contrast, having 3+ MBRFs was associated with about 2 to 3 fewer LYs and CHLYs as well as about 6% lower %CHLY (95% confidence interval = -9.0 to -2.5 %CHLYs; p = .001). CONCLUSIONS MBRF-related reductions in the cognitive health span are most apparent when people have multiple MBRFs. Future research is needed to determine if/how behavioral risks converge mechanistically and if dementia prevention efficacy improves when targeting MBRF combinations.
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Affiliation(s)
- Stephen F. Smagula
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mary L. Biggs
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington, USA
| | - Mini E. Jacob
- Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases, University of Texas Health Sciences Center, San Antonio, Texas
| | | | - Michelle C. Odden
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA
| | - Alice Arnold
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington, USA
| | - Anne B. Newman
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daniel J. Buysse
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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18
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Allen HL, Gmelin T, Moored KD, Boudreau RM, Smagula SF, Cohen RW, Katz R, Stone K, Cauley JA, Glynn NW. Relationship Between Personality Measures and Perceived Mental Fatigability. J Aging Health 2022; 34:750-760. [PMID: 34821521 PMCID: PMC9130341 DOI: 10.1177/08982643211055032] [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] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Examine the association between personality measures and perceived mental fatigability. METHODS We performed a cross-sectional analysis in N=1670 men, age 84.3±4.1 years. Multivariable linear regression models were used to examine the covariate adjusted association between personality measures (conscientiousness, optimism, goal reengagement, and goal disengagement) and perceived mental fatigability (measured with the validated 10-item Pittsburgh Fatigability Scale, PFS). RESULTS One standard deviation lower conscientiousness (β=-0.91, p<.0001) and optimism (β=-0.63, p<.0001), and higher goal reengagement (β=0.51, p=.01) scores were independently associated with higher PFS Mental scores adjusted for age, cognitive function, self-reported health status, depressive symptoms, sleep disturbance, physical activity, and goal disengagement. DISCUSSION Lower conscientiousness, optimism, and higher goal reengagement were linked with more severe perceived mental fatigability in older men. Personality traits may potentially contribute to early risk assessment for fatigability in later life. Future work should be longitudinal in nature and include personality assessments to confirm the temporality of the relationships observed.
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Affiliation(s)
- Hannah L. Allen
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Theresa Gmelin
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Kyle D. Moored
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Robert M. Boudreau
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Stephen F. Smagula
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Rebecca W. Cohen
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Rain Katz
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Katie Stone
- California Pacific Medical Center Research Institute, San Francisco, CA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
| | - Jane A. Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Nancy W. Glynn
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
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19
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Wallace ML, Lee S, Stone KL, Hall MH, Smagula SF, Redline S, Ensrud K, Ancoli-Israel S, Buysse DJ. Actigraphy-derived sleep health profiles and mortality in older men and women. Sleep 2022; 45:6509372. [PMID: 35037946 PMCID: PMC8996026 DOI: 10.1093/sleep/zsac015] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/07/2021] [Indexed: 01/19/2023] Open
Abstract
STUDY OBJECTIVES To identify actigraphy sleep health profiles in older men (Osteoporotic Fractures in Men Study; N = 2640) and women (Study of Osteoporotic Fractures; N = 2430), and to determine whether profile predicts mortality. METHODS We applied a novel and flexible clustering approach (Multiple Coalesced Generalized Hyperbolic mixture modeling) to identify sleep health profiles based on actigraphy midpoint timing, midpoint variability, sleep interval length, maintenance, and napping/inactivity. Adjusted Cox models were used to determine whether profile predicts time to all-cause mortality. RESULTS We identified similar profiles in men and women: High Sleep Propensity [HSP] (20% of women; 39% of men; high napping and high maintenance); Adequate Sleep [AS] (74% of women; 31% of men; typical actigraphy levels); and Inadequate Sleep [IS] (6% of women; 30% of men; low maintenance and late/variable midpoint). In women, IS was associated with increased mortality risk (Hazard Ratio [HR] = 1.59 for IS vs. AS; 1.75 for IS vs. HSP). In men, AS and IS were associated with increased mortality risk (1.19 for IS vs. HSP; 1.22 for AS vs. HSP). CONCLUSIONS These findings suggest several considerations for sleep-related interventions in older adults. Low maintenance with late/variable midpoint is associated with increased mortality risk and may constitute a specific target for sleep health interventions. High napping/inactivity co-occurs with high sleep maintenance in some older adults. Although high napping/inactivity is typically considered a risk factor for deleterious health outcomes, our findings suggest that it may not increase risk when it occurs in combination with high sleep maintenance.
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Affiliation(s)
- Meredith L Wallace
- Corresponding author. Meredith L. Wallace, Department of Psychiatry, University of Pittsburgh, 3811 O’Hara Street, Pittsburgh, PA 15213, USA.
| | - Soomi Lee
- School of Aging Studies, College of Behavioral and Community Sciences, University of South Florida, Tampa, FL, USA
| | - Katie L Stone
- California Pacific Medical Center Research Institute, San Francisco, CA, USA
| | - Martica H Hall
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Stephen F Smagula
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Susan Redline
- Department of Medicine, Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kristine Ensrud
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA,Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA,Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Sonia Ancoli-Israel
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA
| | - Daniel J Buysse
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
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20
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Smagula SF, Stahl ST, Krafty RT, Buysse DJ. Initial proof of concept that a consumer wearable can be used for real-time rest-activity rhythm monitoring. Sleep 2021; 45:6472395. [PMID: 34931683 DOI: 10.1093/sleep/zsab288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Stephen F Smagula
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sarah T Stahl
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert T Krafty
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Daniel J Buysse
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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21
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Wallace ML, Yu L, Buysse DJ, Stone KL, Redline S, Smagula SF, Stefanick ML, Kritz-Silverstein D, Hall MH. Multidimensional sleep health domains in older men and women: an actigraphy factor analysis. Sleep 2021; 44:5904464. [PMID: 32918075 DOI: 10.1093/sleep/zsaa181] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/11/2020] [Indexed: 12/31/2022] Open
Abstract
The multidimensional sleep health framework emphasizes that sleep can be characterized across several domains, with implications for developing novel sleep treatments and improved prediction and health screening. However, empirical evidence regarding the domains and representative measures that exist in actigraphy-assessed sleep is lacking. We aimed to establish these domains and representative measures in older adults by examining the factor structure of 28 actigraphy-derived sleep measures from 2,841 older men from the Osteoporotic Fractures in Men Sleep Study and, separately, from 2,719 older women from the Study of Osteoporotic Fractures. Measures included means and standard deviations of actigraphy summary measures and estimates from extended cosine models of the raw actigraphy data. Exploratory factor analyses revealed the same five factors in both sexes: Timing (e.g. mean midpoint from sleep onset to wake-up), Efficiency (e.g. mean sleep efficiency), Duration (e.g. mean minutes from sleep onset to wake-up), Sleepiness/Wakefulness (e.g. mean minutes napping and amplitude of rhythm), and Regularity (e.g. standard deviation of the midpoint). Within each sex, confirmatory factor analyses confirmed the one-factor structure of each factor and the entire five-factor structure (Comparative Fit Index and Tucker-Lewis Index ≥ 0.95; Root Mean Square Error of Approximation 0.08-0.38). Correlation magnitudes among factors ranged from 0.01 to 0.34. These findings demonstrate the validity of conceptualizing actigraphy sleep as multidimensional, provide a framework for selecting sleep health domains and representative measures, and suggest targets for behavioral interventions. Similar analyses should be performed with additional measures of rhythmicity, other age ranges, and more racially/ethnically diverse samples.
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Affiliation(s)
| | - Lan Yu
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Daniel J Buysse
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Katie L Stone
- California Pacific Medical Center Research Institute, San Francisco, CA
| | - Susan Redline
- Departments of Medicine, Brigham and Women's Hospital and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Marcia L Stefanick
- Department of Medicine, Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA
| | - Donna Kritz-Silverstein
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA
| | - Martica H Hall
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
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22
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Smagula SF. Potential Implications of Evidence for Apathy's Brain Structural Basis. Am J Geriatr Psychiatry 2021; 29:333-335. [PMID: 33518463 DOI: 10.1016/j.jagp.2021.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 01/18/2021] [Accepted: 01/18/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Stephen F Smagula
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA.
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23
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Smagula SF, Capps CS, Krafty RT. Evaluating the timing of differences in activity related to depression symptoms across adulthood in the United States. J Affect Disord 2021; 284:64-68. [PMID: 33582433 PMCID: PMC7958982 DOI: 10.1016/j.jad.2021.01.069] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/04/2021] [Accepted: 01/29/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Relative activity deficits found in people with (verses without) depression symptoms/disorders may accumulate uniformly throughout the day, or they may tend to be expressed at specific times. Evidence for the latter would suggest times when behavioral approaches are most needed to reduce depression and its health consequences. METHODS We performed a secondary-data analysis of participants who contributed valid accelerometer data at the 2005-2006 National Health and Nutrition Examination Survey (n=4390). Participants were categorized according to the Patient Health Questionnaire-9 standard cut-point of ≥10 (i.e., people with versus without clinically significant depression symptoms). Average levels of accelerometer-measured activity in two-hour bins were the dependent variable in mixed models testing if the relationship between depression status and activity level differed by time of day; and if any such relations varied by age group (18-29 years, 30-44 years, 45-59 years, and 60+ years). RESULTS In adults over the age of 30, people with depression symptoms had generally lower levels of activity across the day, but these effects were most markedly pronounced in the morning hours. We found no differences in activity levels associated with prevalent depression symptoms among people 18-30 years of age. LIMITATIONS Core aspects of depression pathophysiology that produce these different activity patterns and confer their effects on mood were not measured. CONCLUSIONS In adults 30 years and older, efforts to ameliorate relative activity deficits associated with depression may benefit from considering the apparently outsized role of inactivity that occurs in the morning.
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Affiliation(s)
- Stephen F Smagula
- Department of Psychiatry, School of Medicine, University of Pittsburgh, USA; Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, USA.
| | - Chandler S Capps
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, USA
| | - Robert T Krafty
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, USA
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24
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Smagula SF, Sofer T, Guo N, Prerau M, Purcell S, Mariani S, Yaffe K, Redline S, Stone KL. Spectral sleep electroencephalographic correlates of sleep efficiency, and discrepancies between actigraphy and self-reported measures, in older men. J Sleep Res 2021; 30:e13033. [PMID: 32198950 PMCID: PMC7607534 DOI: 10.1111/jsr.13033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 02/03/2020] [Revised: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 11/27/2022]
Abstract
Discrepancies between actigraphic and self-reported sleep measures are common. Studies of people with insomnia, in whom both sleep disturbances and discrepancy are common, suggest disturbances and discrepancy reflect differences in the sleeping brain's activity measurable using spectral electroencephalogram (EEG). Disentangling effects of discrepancy and disturbance on sleep EEG could help target research on the consequences and treatments of different sleep phenotypes. We therefore categorized participants in a cohort study including 2,850 men (average age = 76 years, standard deviation = 5.5) into four groups using median splits on actigraphic and self-reported sleep efficiency (SE). We compared spectral power between these groups in 1-Hz bins up to 24 Hz. Compared with the concordant-high SE group: (a) the group with high actigraphic and low self-reported SE had higher spectral power from 11-15 Hz across the night; (b) both groups with low actigraphic SE had higher power across the 15-24 Hz range, predominantly in early cycles, and greater slow frequency power in later cycles. These findings suggest that perceived wakefulness undetected by actigraphy may result from or drive activity corresponding to spindles. We also found, consistent with hyperarousal models, that low SE detectable via actigraphy was related to higher frequency power in the beta range; actigraph-measured inefficiency was also associated with later slow oscillations, potentially representing attempts to dissipate homeostatic drive elevated from earlier hyperarousal. These distinct spectral EEG markers (of low SE measured with actigraphy vs. low perceived SE that is not captured by actigraphy) may have different causes or consequences.
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Affiliation(s)
- Stephen F. Smagula
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tamar Sofer
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital, Harvard University, Boston, MA, USA
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Na Guo
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital, Harvard University, Boston, MA, USA
| | - Michael Prerau
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital, Harvard University, Boston, MA, USA
| | - Shaun Purcell
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital, Harvard University, Boston, MA, USA
| | - Sara Mariani
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital, Harvard University, Boston, MA, USA
| | - Kristine Yaffe
- San Francisco VA Health Care System, San Francisco, CA, USA
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital, Harvard University, Boston, MA, USA
- Division of Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Katie L. Stone
- California Pacific Medical Center Research Institute, San Francisco, CA, USA
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25
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Stahl ST, Neagoe I, Smagula SF, Posluszny D, Bovbjerg DH. Cancer Bereavement and Depression Symptoms in Older Spouses: The Possible Modifying Role of the Circadian Rest-Activity Rhythm. Clin Gerontol 2021; 44:126-132. [PMID: 32856562 PMCID: PMC7886956 DOI: 10.1080/07317115.2020.1812787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This study examines the associations of cancer death and aspects of the 24-h circadian rest-activity rhythm (RAR) on depression symptoms in older spouses. METHODS Participants included 46 adults aged 60-94 years (M = 73 years) who experienced the death of a spouse. We tested a multivariate model using cancer death (vs. non-cancer death) and RAR variables as correlates of depression symptoms while controlling for age, sex, physical illness burden, and preparedness for death. We also present a case example to describe the behavioral activity patterns of a participant bereaved by cancer. RESULTS Cancer death was associated with elevated levels of depression symptoms. However, the timing of the RAR moderated this association. Cancer bereavement was associated with depression symptoms when participants "settled-down" after 11:00 PM. The case example illustrates how intrusive thoughts about death quality impacts a widower's drive to stay busy with daily activities. CONCLUSIONS Settling down earlier in the evening is important for older spouses bereaved by cancer, in terms of fewer symptoms of depression. CLINICAL IMPLICATIONS Objectively specifying the activity patterns of older spouses bereaved by cancer is a promising avenue for interventions that aim to reduce depression symptoms.
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Affiliation(s)
- Sarah T Stahl
- Department of Psychiatry, University of Pittsburgh , Pittsburgh, Pennsylvania, USA
| | - Ioana Neagoe
- Department of Psychiatry, University of Pittsburgh , Pittsburgh, Pennsylvania, USA
| | - Stephen F Smagula
- Department of Psychiatry, University of Pittsburgh , Pittsburgh, Pennsylvania, USA
| | - Donna Posluszny
- Department of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania, USA
| | - Dana H Bovbjerg
- Department of Psychiatry, University of Pittsburgh , Pittsburgh, Pennsylvania, USA
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26
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Stahl ST, Smagula SF, Rodakowski J, Dew MA, Karp JF, Albert SM, Butters M, Gildengers A, Reynolds CF. Subjective Sleep Quality and Trajectories of Interleukin-6 in Older Adults. Am J Geriatr Psychiatry 2021; 29:204-208. [PMID: 32680764 PMCID: PMC7759575 DOI: 10.1016/j.jagp.2020.06.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/09/2020] [Accepted: 06/16/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND We aimed to identify trajectories of inflammation in older adults at elevated risk for syndromal depression and anxiety and to determine whether baseline physical, cognitive, and psychosocial factors could distinguish 15-month longitudinal trajectories. METHODS Older adults (N = 195, mean age (±SD) = 74.4 years (9.0) participating in three depression and anxiety prevention protocols completed a comprehensive battery of psychosocial assessments and provided blood samples for analysis of interleukin-6 (IL-6) every 3 months over a maximum of 15 months. Group-based trajectory modeling identified trajectories. Adjusted logistic regression examined associations between baseline factors and trajectory groups. RESULTS Two 15-month trajectories were identified: stable lower IL-6 levels (84%; mean (±SD) = 3.2 (2.1) pg/mL); and consistently higher IL-6 levels (16%; mean = 9.5 (7.4) pg/mL). Poor sleep quality predicted consistently higher levels of IL-6 (OR = 1.9, 95% CI = 1.03-3.55). CONCLUSION Poor sleep quality may represent a therapeutic target to reduce inflammation.
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Affiliation(s)
- Sarah T Stahl
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA.
| | | | - Juleen Rodakowski
- Department of Occupational Therapy, University of Pittsburgh, Pittsburgh, PA
| | - Mary Amanda Dew
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Jordan F Karp
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Steven M Albert
- Department of Behavioral and Community Health Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Meryl Butters
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Ariel Gildengers
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
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27
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Stahl ST, Rodakowski J, Smagula SF. Timing of Daily Activities over a 24-Hour Period and Affective Status among a National Cohort of Older Dementia Caregivers. J Aging Health 2020; 33:125-132. [PMID: 32975475 DOI: 10.1177/0898264320962363] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To examine the allocation of daily activities over a 24-hour period in caregivers (CGs) with and without a probable affective disorder. Methods: Participants were 192 older dementia CGs (mean age = 72.9 years, 70% female) who participated in the National Study of Caregiving. Time diary data were used to measure the duration and timing that caregivers were doing hygienic self-care, eating/drinking, household care, physical caregiving, medical caregiving, socializing, and television viewing. Affective status was assessed using the two-item Patient Health Questionnaire and the Generalized Anxiety Disorder screeners. Results: CGs were more likely to screen positive for depression/anxiety symptoms if they started hygienic self-care later (OR = 1.76, 95% CI = 1.10-2.83) and started medical caregiving later (OR = 2.34, 95% CI = 1.24-4.41). Hygienic self-care start times attenuated the effects of medical caregiving on the affective status. Discussion: Later timing of hygienic self-care may be an important behavioral response that contributes to affective disorder risk in dementia CGs.
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Affiliation(s)
- Sarah T Stahl
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Juleen Rodakowski
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Stephen F Smagula
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
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28
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Smagula SF, Karim HT, Ibrahim TS, Krafty RT, Stahl ST, Rodakowski J, Reynolds CF, Hall MH, Aizenstein HJ. Resting-State Function Connectivity Associated With Being a "Morning-Type" Dementia Caregiver and Having Lower Depression Symptom Severity. J Gerontol B Psychol Sci Soc Sci 2020; 76:1071-1076. [PMID: 32750139 DOI: 10.1093/geronb/gbaa115] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES A lack of "morningness" predicts greater depression symptom severity over time, including in a vulnerable group of older adults: family dementia caregivers (dCGs). Evidence regarding the neurobiological basis of these correlations is needed to guide future research towards biomarker-informed detection and prevention approaches. We therefore primarily aimed to identify simple resting-state biomarkers that correlated with a lack of "morningness" in dCGs. METHOD We examined 54 dCGs (mean age = 70, range: 61-84; 70% female) of whom 40% were definite "morning types" according to Composite Scale of Morningness (CSM). Using a 7 Tesla resting-state sequence, we compared the functional connectivity of nodes in networks previously implicated in depression (fronto-parietal, default mode, limbic, and salience) between caregivers who were and were not "morning types." RESULTS Correcting for voxel-wise comparisons, "morning-type" dCGs had less amygdala-posterior cingulate connectivity (Cohen's d = -1.3), which statistically mediated ~32% of the association between the degree of "morningness" and lower depression severity. Post hoc analyses of CSM items found significant correlations, with both amygdala-posterior cingulate FC and depression severity, for 4/6 items pertaining to difficulty, 2/5 items pertaining to preference, and 0/2 items pertaining to typical patterns. DISCUSSION Prior research shows that amygdala-posterior cingulate connectivity increases when allocating attention to peripheral aspects of negative emotional stimuli. As such, difficulty with morning activation may relate to the ongoing direction of focus around distressing content; in contrast, morning activity participation may serve to limit focus on distress. Replication and experimental studies are required to confirm these associations and their modifiability.
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Affiliation(s)
- Stephen F Smagula
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pennsylvania
| | - Helmet T Karim
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pennsylvania
| | - Tamer S Ibrahim
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pennsylvania
| | - Robert T Krafty
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pennsylvania
| | - Sarah T Stahl
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pennsylvania
| | - Juleen Rodakowski
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pennsylvania
| | - Charles F Reynolds
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pennsylvania
| | - Martica H Hall
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pennsylvania
| | - Howard J Aizenstein
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pennsylvania
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29
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Roecklein KA, Wescott DL, Smagula SF, Soehner AM, Franzen PL, Hasler BP. 0037 Melanopsin Driven Pupil Responses and Physical Activity: Stability of Activity from Day-to-Day in Winter in Seasonal Affective Disorder. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.036] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
The post-illumination pupil response (PIPR) is a measure of the responsivity of intrinsically photosensitive retinal ganglion cells (ipRGCs), and reflects the cell biology of the photoentrainment pathway projecting from the retina to the circadian clock. Adequate signaling from the ipRGCs in the retina to the circadian clock is necessary to result in robust circadian output which we hypothesize would increase inter-daily stability (IS), a non-parametric modeling technique that examines stability of rest activity rhythms across successive days.
Methods
Participants were aged 18–66 years and recruited from the greater Pittsburgh area during the Winter with Seasonal Affective Disorder who completed both actigraphy and pupillometry (n = 16). PIPR measures were collected after a 1 second red or blue light pulse, and are calculated as the Net difference between red and blue at multiple time frames: at 6 seconds post stimulus (PIPR 6), from 10–30 seconds post-stimulus (PIPR 20), or from 10–40 seconds post-stimulus (PIPR 30). Using actigraphy, inter-daily stability (IS) was calculated as the amount of overall variability in the recording that is accounted for by the typical 24-hour profile, and reflects stability of the mean 24-h profile day-to-day.
Results
Inter-daily stability (IS) was associated with Net PIPR 20 (Β = 0.561; p = .031) and Net PIPR 30 (Β = 0.551; p = .034; all Β’s are standardized), but not Net PIPR 6 (Β = 0.298; p = .304). Retinal irradiance was calculated for each participant based on age and pupil diameter, to account for age-related differences in transmission of the stimulus to the retina. All raw Net PIPR values were adjusted for calculated retinal irradiance, and gender and time since wake were included as covariates.
Conclusion
Inter-daily stability (IS) values indicate greater stability of 24-hour activity profiles across days. If reduced responsivity to entraining pulses of light is associated with day-to-day instability in activity rhythms, as shown here, we might expect that amplifying entraining light through environmental changes or bright light therapy would normalize inter-daily stability in SAD, or the reverse, stabilizing activity profiles across days could improve depression and/or normalize retinal ipRGC responsivity.
Support
NIMH K.A.R. MH103303
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Affiliation(s)
- K A Roecklein
- University of Pittsburgh Department of Psychology, Pittsburgh, PA
| | - D L Wescott
- University of Pittsburgh Department of Psychology, Pittsburgh, PA
| | - S F Smagula
- University of Pittsburgh Department of Psychiatry, Pittsburgh, PA
| | - A M Soehner
- University of Pittsburgh Department of Psychiatry, Pittsburgh, PA
| | - P L Franzen
- University of Pittsburgh Department of Psychiatry, Pittsburgh, PA
| | - B P Hasler
- University of Pittsburgh Department of Psychiatry, Pittsburgh, PA
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30
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Hartman AG, Smagula SF, Bendixen R. 0980 Sleep And Activity Rhythms In Children With Duchenne Muscular Dystrophy. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.976] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Duchenne muscular dystrophy (DMD) is a rare, progressive, neurological disorder with high rates of depression, anxiety, and attention issues. Rest-activity rhythm (RAR) disturbances are also associated with these co-morbidities in other populations. However, RAR patterns and timing have not been explored in DMD and could provide important information regarding mechanisms of sleep in which to intervene. To address this knowledge gap, we used wrist actigraphy to explore the timing of rest-activity rhythms in boys with and without DMD.
Methods
Boys aged 4-15 with DMD (n= 17) and age matched controls (n=17) wore an ActiGraph GT9X for ten consecutive days. We averaged activity counts each hour and computed Cohen’s d effect sizes and t-tests with Benjamini-Hochberg corrections. Extended cosine models were fit to derive RAR measures using custom R code.
Results
An overall delay in RAR timing was found in the DMD group due to three specific, large effect-size differences in RAR patterns. Boys with DMD were: (1) less active at 8AM and 9AM (e.g., at 9AM: d=-0.82, p=0.02, FDR=0.14); (2) more active from 10PM-midnight (e.g., at 11PM: d=1.1, p=0.003, FDR=0.07) and (3) more active at 4AM (d=0.74, p=0.04, FDR=0.14). Extended-cosine modeling showed that, while amplitude of activity was similar across groups (d=-0.29, p= 0.41), boys with DMD had later morning activity onset (d= 0.70, p= 0.05), later peak activity timing (d= 0.86, p= 0.02), and later evening activity offset (d= 0.96, p= 0.01).
Conclusion
A significant delay in activity was evident in the DMD group compared with controls. Although the mechanism causing this shift is currently unknown, delayed chronotypes have been linked to poor health outcomes like depression and anxiety in other populations. Further research should explore the causes and consequences of the RAR timing delays we observed and inform future care.
Support
Foundation to Eradicate Duchenne, PI: Bendixen, 1/1/2017-12/31/2019.
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Affiliation(s)
| | | | - R Bendixen
- University of Pittsburgh, Pittsburgh, PA
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31
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Abstract
PURPOSE OF REVIEW This paper critically evaluates literature from the last three years on sleep in caregivers for older adults. Research is evaluated in four main areas: factors related to caregivers having sleep problems, sleep health in various types of caregivers, how caregivers' sleep and health inter-relate, and interventions to improve sleep. RECENT FINDINGS A range of both care recipients' and caregivers' characteristics have been associated with caregiver sleep quality measured subjectively and objectively. Care recipient factors associated with caregiver sleep quality include fall risk and sleep quality, while caregiver factors include stress, duration, intensity, provision of medical/nursing care tasks, and even particular serotonin genotypes (e.g. short allele carriers for 5-HTTLPR). While the greatest focus has been on dementia caregivers, recent work suggests groups such as end-of-life caregivers, former caregivers, and caregivers with multiple care roles (e.g. child, older adult, paid care) have sleep disturbances that vary by their unique contexts. Caregiver's sleep, particularly subjective assessments, relates to their mood and physiological well-being; and evidence suggests that sleep may be an important mediator linking care stressors with mental health. Factors such as mindfulness and sense of coherence may protect caregivers from sleep disturbances.
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Affiliation(s)
- Amanda N Leggett
- Department of Psychiatry, 4250 Plymouth Rd. University of Michigan, Ann Arbor, MI, USA, 734-232-0538
| | - Madelyn Morley
- School of Public Health, 1415 Washington Heights, University of Michigan, Ann Arbor, MI, USA 48109, 734-764-5425
| | - Stephen F Smagula
- Department of Psychiatry, School of Medicine, University of Pittsburgh 3811 O'Hara Street, Pittsburgh, PA, USA, 15213 412-246-6674
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32
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Smagula SF, Chahine L, Metti A, Rangarajan A, Aizenstein HJ, Tian Q, Rosano C. Regional Gray Matter Volume Links Rest-Activity Rhythm Fragmentation With Past Cognitive Decline. Am J Geriatr Psychiatry 2020; 28:248-251. [PMID: 31377045 PMCID: PMC6980463 DOI: 10.1016/j.jagp.2019.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/19/2019] [Accepted: 07/15/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVES We examined the extent to which measures of neurodegeneration and cerebrovascular disease explain the rest-activity rhythm (RAR)-cognition link. METHODS Seventy participants (mean age at MRI = 86, standard deviation (SD) = 2.6; 53% female) had cognitive, MRI, and accelerometer data. The slope of cognitive decline was defined applying a mixed model to 10 repeated Modified Mini Mental Status Test (3MS) measures over 14 years. Regional gray matter volume (GMV), white matter hyperintensities, and RARs were measured around year 12. RESULTS Past 3MS decline was related to RAR fragmentation (per SD β = -0.43, 95% confidence interval: -0.73, -0.14) and lower posterior parietal GMV (per standard deviation β = 0.47, 95% confidence interval: 0.14, 0.79). Higher RAR fragmentation was related to lower posterior parietal GMV (Pearson r = -0.39, n = 70, p = 0.0007), which attenuated the association of RAR fragmentation and past cognitive decline by 17%. CONCLUSIONS Longitudinal studies are warranted to understand the temporal relations and mechanisms linking RAR fragmentation and neurodegeneration.
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Affiliation(s)
- Stephen F Smagula
- Department of Psychiatry (SFS, AR, and HJA), School of Medicine, University of Pittsburgh, Pittsburgh, PA.
| | - Lana Chahine
- Department of Neurology (LC), School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Andrea Metti
- Department of Epidemiology (AM and CR), Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Anusha Rangarajan
- Department of Psychiatry (SFS, AR, and HJA), School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Howard J Aizenstein
- Department of Psychiatry (SFS, AR, and HJA), School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Qu Tian
- Intramural Research Program (QT), National Institute on Aging, Baltimore, MD
| | - Caterina Rosano
- Department of Epidemiology (AM and CR), Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
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33
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Smagula SF, Jia Y, Chang CCH, Cohen A, Ganguli M. Trajectories of daytime sleepiness and their associations with dementia incidence. J Sleep Res 2019; 29:e12952. [PMID: 31782578 DOI: 10.1111/jsr.12952] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/17/2019] [Accepted: 11/04/2019] [Indexed: 12/16/2022]
Abstract
Several studies have associated daytime sleepiness with risk of dementia, but it is unknown whether longstanding and emerging daytime sleepiness equally signal a risk of dementia, and whether other health factors explain these associations. In a prospective, population-based epidemiologic study, we (i) assessed associations of daytime sleepiness trajectories over 10 years with dementia incidence and (ii) examined whether selected health characteristics attenuated these associations. Using latent group-based trajectory analysis we categorized participants into three groups: (i) no daytime sleepiness (n = 959, 49.2%), (ii) emerging daytime sleepiness (n = 342, 17.5%) and (iii) persistent daytime sleepiness (n = 650, 33.3%). Compared with no daytime sleepiness, emerging and persistent daytime sleepiness were similarly associated with greater incident dementia risk (respective hazard ratios [95% confidence intervals] were 2.2 [1.3, 3.5] and 1.9 [1.2, 3.1]). Baseline blood pressure, body mass index, chronic disease diagnoses and symptoms of depression did not attenuate these associations. In contrast, lack of independence in instrumental activities of daily living attenuated the daytime sleepiness-dementia association by approximately 17%-21%. These findings suggest that persistent and emerging daytime sleepiness may signal a risk of dementia. However, the underlying mechanisms remain unclear. Further studies should investigate whether and how pathways to sleepiness, functional impairment and dementia pathophysiology interrelate and manifest together over time.
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Affiliation(s)
- Stephen F Smagula
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yichen Jia
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Chung-Chou H Chang
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ann Cohen
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mary Ganguli
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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34
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Smagula SF. New Evidence for a Biological Pathway to Mental Health Problems in Dementia Caregivers: Invited Commentary on the Article by Wells et al. (AMGP-1247). Am J Geriatr Psychiatry 2019; 27:1057-1059. [PMID: 31285154 PMCID: PMC6917029 DOI: 10.1016/j.jagp.2019.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/03/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Stephen F. Smagula
- Department of Psychiatry, School of Medicine, University
of Pittsburgh,Department of Epidemiology, Graduate School of Public
Health, University of Pittsburgh
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35
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Krafty RT, Fu H, Graves JL, Bruce SA, Hall MH, Smagula SF. Measuring Variability in Rest-Activity Rhythms from Actigraphy with Application to Characterizing Symptoms of Depression. Stat Biosci 2019; 11:314-333. [PMID: 31788133 PMCID: PMC6884363] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The twenty-four hour sleep-wake pattern known as the rest-activity rhythm (RAR) is associated with many aspects of health and well-being. Researchers have utilized a number of interpretable, person-specific RAR measures that can be estimated from actigraphy. Actigraphs are wearable devices that dynamically record acceleration and provide indirect measures of physical activity over time. One class of useful RAR measures are those that quantify variability around a mean circadian pattern. However, current parametric and nonparametric RAR measures used by applied researchers can only quantify variability from a limited or undefined number of rhythmic sources. The primary goal of this article is to consider a new measure of RAR variability: the log-power spectrum of stochastic error around a circadian mean. This functional measure quantifies the relative contributions of variability about a circadian mean from all possibly frequencies, including weekly, daily, and high-frequency sources of variation. It can be estimated through a two-stage procedure that smooths the log-periodogram of residuals after estimating a circadian mean. The development of this measure was motivated by a study of depression in older adults and revealed that slow, rhythmic variations in activity from a circadian pattern are correlated with depression symptoms.
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Affiliation(s)
| | - Haoyi Fu
- Department of Biostatistics, University of Pittsburgh
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36
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Bulkley MB, Trout J, Murphy B, Carbine K, Davies J, Smagula SF, Larson MJ, LeCheminanat J, Kay DB. 0273 Morning Versus Evening Exercise: Which is Better for Sleep Quality in Premenopausal Women? Sleep 2019. [DOI: 10.1093/sleep/zsz067.272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- M Brooks Bulkley
- Department of Psychology, Brigham Young University, Provo, UT, USA
| | - Jonathan Trout
- Department of Psychology, Brigham Young University, Provo, UT, USA
| | - Britta Murphy
- Department of Nutrition, Dietetics, and Food Sciences, Brigham Young University, Provo, UT, USA
| | - Kaylie Carbine
- Department of Psychology, Brigham Young University, Provo, UT, USA
| | - Jessica Davies
- Department of Nutrition, Dietetics, and Food Sciences, Brigham Young University, Provo, UT, USA
| | - Stephen F Smagula
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael J Larson
- Department of Psychology, Brigham Young University, Provo, UT, USA
| | - James LeCheminanat
- Department of Nutrition, Dietetics, and Food Sciences, Brigham Young University, Provo, UT, USA
| | - Daniel B Kay
- Department of Psychology, Brigham Young University, Provo, UT, USA
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37
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Smagula SF, Gujral S, Capps CS, Krafty RT. A Systematic Review of Evidence for a Role of Rest-Activity Rhythms in Dementia. Front Psychiatry 2019; 10:778. [PMID: 31736798 PMCID: PMC6832024 DOI: 10.3389/fpsyt.2019.00778] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 05/02/2019] [Accepted: 09/30/2019] [Indexed: 12/13/2022] Open
Abstract
Background: Rest-activity rhythm (RAR) disruption may be a risk factor for dementia that can be objectively measured with wearable accelerometers. It is possible that risk monitoring and preventive interventions could be developed targeting RARs. To evaluate whether current evidence supports these applications, we systematically reviewed published studies linking RARs with dementia, its course, and mechanisms. Methods: Entering pre-defined search terms in PsycINFO, MEDLINE, and PubMed databases returned 192 unique titles. We identified 32 articles that met our primary inclusion criteria, namely, that they examined objective RAR measures in the context of dementia, cognition, or brain biomarkers. Results: Cross-sectional studies consistently found that people with dementia had less stable (5/6 studies), more fragmented (4/6 studies), lower amplitude rhythms (5/5 studies), that had a worse fit to 24-h models (3/3 studies). Findings from studies relating RARs to cognitive test performance (rather than diagnostic status) were more nuanced. RAR fragmentation was associated with neurodegeneration biomarkers in 2/2 studies; and 1/1 study found 24-h model fit related to hippocampal hyperactivation. Although 2/2 studies found RARs related to markers of cerebrovascular disease, the specific RARs and cerebrovascular disease measures were not consistent. Longitudinal studies (3/3 articles) reported that lower amplitude and worse 24-h rhythm fit predicted future cognitive impairment and executive function. However, interventions aimed at modifying RARs had mixed effects (e.g., 0/4 studies demonstrated effects of morning light on 24-h model fit; evening light was associated with improved 24-h fit in 2/2 studies reporting); these effects may be more evident in subgroups. Conclusions: Consistent evidence shows that dementia is associated with disrupted RARs. Importantly, recent studies have shown that RAR disruption is associated with dementia biomarkers and, prospectively, with the risk of cognitive impairment. Interventions mostly tried using bright light to modify RARs in people who already have dementia; these studies produced modest effects on RARs and did not show modification of dementia's course. Altogether, these findings suggest studies are needed to understand how RARs relate to changes in brain health earlier in the disease process. Better understanding of the biopsychosocial mechanisms linking RARs with future dementia risk can help further target intervention development.
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Affiliation(s)
- Stephen F Smagula
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Swathi Gujral
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Veterans Administration, Veterans Integrated Service Network 4, Mental Illness Research, Education and Clinical Center of Excellence, Pittsburgh, PA, United States
| | - Chandler S Capps
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, PA, United States
| | - Robert T Krafty
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, PA, United States
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38
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Smagula SF, DuPont CM, Miller MA, Krafty RT, Hasler BP, Franzen PL, Roecklein KA. Rest-activity rhythms characteristics and seasonal changes in seasonal affective disorder. Chronobiol Int 2018; 35:1553-1559. [PMID: 30024782 DOI: 10.1080/07420528.2018.1496094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Identifying objectively measurable seasonal changes in 24-h activity patterns (rest-activity rhythms or RARs) that occur in seasonal affective disorder (SAD) could help guide research and practice towards new monitoring tools or prevention targets. We quantified RARs from actigraphy data using non-parametric and extended cosine based approaches, then compared RARs between people with SAD and healthy controls in the summer (n = 70) and winter seasons (n = 84). We also characterized the within-person seasonal RAR changes that occurred in the SAD (n = 19) and control (n = 26) participants who contributed repeated measures. Only controls had significant winter increases in RAR fragmentation (intra-daily variability; in controls mean winter-summer changes (log scale) = 0.05, 0.21 standard deviation, p = 0.03). In SAD participants only, estimated evening settling times (down-mesor) were an average of 30 min earlier in the winter compared with the summer (1-h standard deviation, p = 0.045). These RAR characteristics correlated with greater fatigue (Spearman r = 0.36) but not depression symptom severity. Additional research is needed to ascertain why healthy controls, but not people with SAD, appear to have increased RAR fragmentation in the winter. People with SAD lacked this increase in RAR fragmentation, and instead had earlier evening setting in the winter. Prospective and intervention studies with greater temporal resolution are warranted to ascertain how these seasonal behavioral differences relate to fatigue pathophysiology in SAD. Future research is needed to determine whether extending the winter active period, even in relatively fragmented bouts, could help reduce the fatigue symptoms common in SAD.
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Affiliation(s)
- Stephen F Smagula
- a Department of Psychiatry, School of Medicine , University of Pittsburgh , Pittsburgh , PA , USA.,b Department of Epidemiology, Graduate School of Public Health , University of Pittsburgh , Pittsburgh , PA , USA
| | - Caitlin M DuPont
- c Department of Psychology , University of Pittsburgh , Pittsburgh , PA , USA
| | - Megan A Miller
- c Department of Psychology , University of Pittsburgh , Pittsburgh , PA , USA.,d Mental Health Service Line , VA Puget Sound Healthcare System , Seattle , WA , USA
| | - Robert T Krafty
- e Department of Biostatistics, Graduate School of Public Health , University of Pittsburgh , Pittsburgh , PA , USA
| | - Brant P Hasler
- a Department of Psychiatry, School of Medicine , University of Pittsburgh , Pittsburgh , PA , USA
| | - Peter L Franzen
- a Department of Psychiatry, School of Medicine , University of Pittsburgh , Pittsburgh , PA , USA
| | - Kathryn A Roecklein
- c Department of Psychology , University of Pittsburgh , Pittsburgh , PA , USA
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39
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Smagula SF, Krafty RT, Thayer JF, Buysse DJ, Hall MH. Rest-activity rhythm profiles associated with manic-hypomanic and depressive symptoms. J Psychiatr Res 2018; 102:238-244. [PMID: 29705489 PMCID: PMC6005763 DOI: 10.1016/j.jpsychires.2018.04.015] [Citation(s) in RCA: 17] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 04/05/2018] [Accepted: 04/18/2018] [Indexed: 11/23/2022]
Abstract
Rest-activity rhythm (RAR) disturbances are associated with mood disorders. But there remains a need to identify the particular RAR profiles associated with psychiatric symptom dimensions. Establishing such profiles would support the development of tools that track the 24-h sleep-wake phenotypes signaling clinical heterogeneity. We used data-driven clustering to identify RAR profiles in 145 adults aged 36-82 years (mean = 60, standard deviation = 9). Then we evaluated psychiatric symptom dimensions (including positive and negative affect, depressive, manic-hypomanic, panic-agoraphobic, and substance use symptoms) associated with these empirically-derived RAR profiles. Clustering identified three sub-groups characterized, on average, by: (1) earlier and more robust RARs ("earlier/robust," n = 55, 38%); (2) later and irregular RARs ("later/irregular," n = 31, 21%); and (3) later RARs and a narrower active period ("later/narrower," n = 59, 41%). Compared with the "earlier/robust" group: the "later/irregular" group had higher levels of lifetime manic-hypomanic symptoms (β (standard error) = 0.80 (0.22) higher standardized symptom units, p = 0.0004) and lifetime depression symptoms (β (standard error) = 0.73 (0.21) higher standardized symptom units, p = 0.0009); the "later/narrower" group had more lifetime depression symptoms (β (standard error) = 0.48 (0.18) higher standardized symptom units, p = 0.0076). These associations persisted after adjustments for sleep continuity and duration, suggesting that RARs are distinct behavioral correlates of clinical heterogeneity. Longitudinal studies are needed to confirm whether RAR characteristics contribute to the risk of manic and/or depressive episodes, and whether they reflect the consequences of psychiatric disturbance (e.g., on quality of life or disability). Opportunities to monitor or intervene on objectively-assessed RARs could facilitate better mental health related outcomes.
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Affiliation(s)
- Stephen F Smagula
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Robert T Krafty
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Julian F Thayer
- Department of Psychology, The Ohio State University, Columbus, OH, USA
| | - Daniel J Buysse
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Martica H Hall
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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40
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Smagula SF, Karim HT, Rangarajan A, Santos FP, Wood SC, Santini T, Jakicic JM, Reynolds CF, Cameron JL, Vallejo AN, Butters MA, Rosano C, Ibrahim TS, Erickson KI, Aizenstein HJ. Association of Hippocampal Substructure Resting-State Functional Connectivity with Memory Performance in Older Adults. Am J Geriatr Psychiatry 2018; 26:690-699. [PMID: 29628321 PMCID: PMC5993618 DOI: 10.1016/j.jagp.2018.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 02/28/2018] [Accepted: 03/06/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Hippocampal hyperactivation marks preclinical dementia pathophysiology, potentially due to differences in the connectivity of specific medial temporal lobe structures. Our aims were to characterize the resting-state functional connectivity of medial temporal lobe sub-structures in older adults, and evaluate whether specific substructural (rather than global) functional connectivity relates to memory function. METHODS In 15 adults (mean age: 69 years), we evaluated the resting state functional connectivity of medial temporal lobe substructures: dentate/Cornu Ammonis (CA) 4, CA1, CA2/3, subiculum, the molecular layer, entorhinal cortex, and parahippocampus. We used 7-Tesla susceptibility weighted imaging and magnetization-prepared rapid gradient echo sequences to segment substructures of the hippocampus, which were used as structural seeds for examining functional connectivity in a resting BOLD sequence. We then assessed correlations between functional connectivity with memory performance (short and long delay free recall on the California Verbal Learning Test [CVLT]). RESULTS All the seed regions had significant connectivity within the temporal lobe (including the fusiform, temporal, and lingual gyri). The left CA1 was the only seed with significant functional connectivity to the amygdala. The left entorhinal cortex was the only seed to have significant functional connectivity with frontal cortex (anterior cingulate and superior frontal gyrus). Only higher left dentate-left lingual connectivity was associated with poorer CVLT performance (Spearman r = -0.81, p = 0.0003, Benjamini-Hochberg false discovery rate: 0.01) after multiple comparison correction. CONCLUSIONS Rather than global hyper-connectivity of the medial temporal lobe, left dentate-lingual connectivity may provide a specific assay of medial temporal lobe hyper-connectivity relevant to memory in aging.
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Affiliation(s)
- Stephen F Smagula
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA; Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA.
| | - Helmet T Karim
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Anusha Rangarajan
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA
| | | | - Sossena C Wood
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA
| | - Tales Santini
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA
| | - John M Jakicic
- Department of Health and Physical Activity, University of Pittsburgh, Pittsburgh, PA
| | - Charles F Reynolds
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Judy L Cameron
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Abbe N Vallejo
- Department of Pediatrics and Immunology, University of Pittsburgh, Pittsburgh, PA
| | - Meryl A Butters
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Caterina Rosano
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Tamer S Ibrahim
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA
| | - Kirk I Erickson
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA
| | - Howard J Aizenstein
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA
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Li J, Blackwell T, McPhillips M, Smagula SF, Pack A, Ancoli-Israe S, Gooneratne N, Stone K. 0699 Daytime Physical Activity and Subsequent Changes in Sleep in Older Men: The MrOS Study. Sleep 2018. [DOI: 10.1093/sleep/zsy061.698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- J Li
- University of Pennsylvania, Philadelphia, PA
| | - T Blackwell
- California Pacific Medical Center, San Francisco, CA
| | | | | | - A Pack
- University of Pennsylvania, Philadelphia, PA
| | | | | | - K Stone
- California Pacific Medical Center, San Francisco, CA
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Affiliation(s)
- Timothy M. Hughes
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Samuel N. Lockhart
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Stephen F. Smagula
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Wallace ML, Stone K, Smagula SF, Hall MH, Simsek B, Kado DM, Redline S, Vo TN, Buysse DJ. Which Sleep Health Characteristics Predict All-Cause Mortality in Older Men? An Application of Flexible Multivariable Approaches. Sleep 2018; 41:4642232. [PMID: 29165696 PMCID: PMC5806578 DOI: 10.1093/sleep/zsx189] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [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] [Indexed: 12/22/2022] Open
Abstract
Study Objectives Sleep is multidimensional, with domains including duration, timing, continuity, regularity, rhythmicity, quality, and sleepiness/alertness. Individual sleep characteristics representing these domains are known to predict health outcomes. However, most studies consider sleep characteristics in isolation, resulting in an incomplete understanding of which sleep characteristics are the strongest predictors of health outcomes. We applied three multivariable approaches to robustly determine which sleep characteristics increase mortality risk in the osteoporotic fractures in men sleep study. Methods In total, 2,887 men (mean 76.3 years) completed relevant assessments and were followed for up to 11 years. One actigraphy or self-reported sleep characteristic was selected to represent each of seven sleep domains. Multivariable Cox models, survival trees, and random survival forests were applied to determine which sleep characteristics increase mortality risk. Results Rhythmicity (actigraphy pseudo-F statistic) and continuity (actigraphy minutes awake after sleep onset) were the most robust sleep predictors across models. In a multivariable Cox model, lower rhythmicity (hazard ratio, HR [95%CI] =1.12 [1.04, 1.22]) and lower continuity (1.16 [1.08, 1.24]) were the strongest sleep predictors. In the random survival forest, rhythmicity and continuity were the most important individual sleep characteristics (ranked as the sixth and eighth most important among 43 possible sleep and non-sleep predictors); moreover, the predictive importance of all sleep information considered simultaneously followed only age, cognition, and cardiovascular disease. Conclusions Research within a multidimensional sleep health framework can jumpstart future research on causal pathways linking sleep and health, new interventions that target specific sleep health profiles, and improved sleep screening for adverse health outcomes.
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Affiliation(s)
| | - Katie Stone
- California Pacific Medical Center, Research Institute, San Francisco, CA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
| | | | - Martica H Hall
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Burcin Simsek
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Deborah M Kado
- Department of Family Medicine & Public Health, University of California, La Jolla, San Diego, CA
| | - Susan Redline
- Departments of Medicine, Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Tien N Vo
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
| | - Daniel J Buysse
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
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Gebara MA, Kasckow J, Smagula SF, DiNapoli EA, Karp JF, Lenze EJ, Mulsant BH, Reynolds CF. The role of late life depressive symptoms on the trajectories of insomnia symptoms during antidepressant treatment. J Psychiatr Res 2018; 96:162-166. [PMID: 29069615 PMCID: PMC5698156 DOI: 10.1016/j.jpsychires.2017.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 09/13/2017] [Accepted: 10/13/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Sleep disturbances are common in late life depression; however, changes in insomnia symptoms during antidepressant treatment need to be characterized further. The objective of this study was two-fold: 1) to describe longitudinal trajectories of insomnia symptoms in older adults receiving antidepressant treatment and 2) to examine whether baseline depressive symptoms were associated with trajectories of sleep over time. METHODS Data was obtained from 680 older adults (aged ≥ 60) with major depression who participated in one of two protocolized open-label antidepressant treatment clinical trials (Maintenance Therapies in Late Life Depression [MTLD-3]; Incomplete Response in Late Life Depression: Getting to Remission [IRL-GRey]). Depression (total score minus sleep items) and sleep (sum of sleep items) outcomes were derived from the Hamilton Depression Rating Scale in the MLTD-3 and Montgomery-Asberg Depression Rating Scale in the IRL-GRey. RESULTS Both datasets identified 5 possible trajectories of insomnia symptoms with about half of the older adults having clinically significant baseline sleep disturbances and minimal improvement following a course of antidepressant treatment (i.e., sub-optimal sleep trajectory). Furthermore, across both datasets, worse baseline depression severity was associated with sub-optimal sleep trajectories. CONCLUSION In older adults receiving antidepressant treatment, those with clinically significant baseline sleep disturbances and greater depression severity may require adjunctive sleep-focused treatment to ameliorate sleep symptoms.
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Affiliation(s)
- Marie Anne Gebara
- VISN 4 Mental Illness Research, Education and Clinical Center (MIRECC), VA Pittsburgh Health Care System, Pittsburgh, PA, USA; Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - John Kasckow
- Beckley Health Care System, Behavioral Health, Beckley, WV
| | - Stephen F. Smagula
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Elizabeth A. DiNapoli
- VISN 4 Mental Illness Research, Education and Clinical Center (MIRECC), VA Pittsburgh Health Care System, Pittsburgh, PA
| | - Jordan F. Karp
- VISN 4 Mental Illness Research, Education and Clinical Center (MIRECC), VA Pittsburgh Health Care System, Pittsburgh, PA,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Eric J. Lenze
- Department of Psychiatry, Washington University School of Medicine, St Louis, MO
| | | | - Charles F. Reynolds
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
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45
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Smagula SF, Karim HT, Lenze EJ, Butters MA, Wu GF, Mulsant BH, Reynolds CF, Aizenstein HJ. Gray matter regions statistically mediating the cross-sectional association of eotaxin and set-shifting among older adults with major depressive disorder. Int J Geriatr Psychiatry 2017; 32:1226-1232. [PMID: 27645461 PMCID: PMC5846473 DOI: 10.1002/gps.4585] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/29/2016] [Accepted: 08/30/2016] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Eotaxin is a chemokine that exerts negative effects on neurogenesis. We recently showed that peripheral eotaxin levels correlate with both lower gray matter volume and poorer executive performance in older adults with major depressive disorder. These findings suggest that the relationship between eotaxin and set-shifting may be accounted for by lower gray matter volume in specific regions. Prior studies have identified specific gray matter regions that correlate with set-shifting performance, but have not examined whether these specific gray matter regions mediate the cross-sectional association between eotaxin and set-shifting. METHOD In 27 older adults (mean age: 68 ± 5.2 years) with major depressive disorder, we performed a whole brain (voxel-wise) analysis testing whether/where gray matter density statistically mediates the cross-sectional association of eotaxin and set-shifting performance. RESULTS We found the association between eotaxin and set-shifting performance was fully statistically mediated by lower gray matter density in left middle cingulate, right pre-/post-central, lingual, inferior/superior frontal, cuneus, and middle temporal regions. CONCLUSION The regions identified above may be both susceptible to a potential neurodegenerative effect of eotaxin, and critical to preserving set-shifting function. Longitudinal and intervention studies are needed to further evaluate whether targeting eotaxin levels will prevent neurodegeneration and executive impairment in older adults with depression. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Stephen F. Smagula
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Helmet T. Karim
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Eric J. Lenze
- Healthy Mind Lab, Department of Psychiatry, Washington University School of Medicine, St Louis, MO, USA
| | - Meryl A. Butters
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gregory F. Wu
- Department of Neurology, Washington University School of Medicine, St Louis, MO, USA
| | - Benoit H. Mulsant
- Centre for Addiction and Mental Health, and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Charles F. Reynolds
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA,Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Howard J. Aizenstein
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
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46
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Furihata R, Hall MH, Stone KL, Ancoli-Israel S, Smagula SF, Cauley JA, Kaneita Y, Uchiyama M, Buysse DJ. An Aggregate Measure of Sleep Health Is Associated With Prevalent and Incident Clinically Significant Depression Symptoms Among Community-Dwelling Older Women. Sleep 2017; 40:2731735. [PMID: 28364417 DOI: 10.1093/sleep/zsw075] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Objectives Sleep can be characterized along multiple dimensions. We investigated whether an aggregate measure of sleep health was associated with prevalent and incident clinically significant depression symptoms in a cohort of older women. Methods Participants were older women (mean age 80.1 years) who completed baseline (n = 6485) and follow-up (n = 3806) visits, approximately 6 years apart, in the Study of Osteoporotic Fractures (SOF). Self-reported sleep over the past 12 months was categorized as "good" or "poor" across 5 dimensions: satisfaction with sleep duration, daytime sleepiness, mid-sleep time, sleep onset latency, and sleep duration. An aggregate measure of sleep health was calculated by summing the number of "poor" dimensions. Clinically significant depression symptoms were defined as a score ≥6 on the Geriatric Depression Scale. Relationships between sleep health and depression symptoms were evaluated with multivariate logistic regression, adjusting for health measures and medications. Results Individual sleep health dimensions of sleep satisfaction, daytime sleepiness, mid-sleep time, and sleep onset latency were significantly associated with prevalent depression symptoms (odds ratios [OR] = 1.26-2.69). Sleep satisfaction, daytime sleepiness, and sleep onset latency were significantly associated with incident depression symptoms (OR = 1.32-1.79). The number of "poor" sleep health dimensions was associated in a gradient fashion with greater odds of prevalent (OR = 1.62-5.41) and incident (OR = 1.47-3.15) depression symptoms. Conclusion An aggregate, multidimensional measure of sleep health was associated with both prevalent and incident clinically-significant depression symptoms in a gradient fashion. Future studies are warranted to extend these findings in different populations and with different health outcomes.
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Affiliation(s)
- Ryuji Furihata
- Department of Psychiatry, Nihon University School of Medicine, Tokyo, Japan
| | - Martica H Hall
- Sleep and Chronobiology Center, Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Katie L Stone
- San Francisco Coordinating Center, San Francisco, CA.,California Pacific Medical Center, Research Institute, San Francisco, CA
| | - Sonia Ancoli-Israel
- Departments of Psychiatry and Medicine, University of California, San Diego, La Jolla, CA
| | - Stephen F Smagula
- Sleep and Chronobiology Center, Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Jane A Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Yoshitaka Kaneita
- Department of Public Health and Epidemiology, Faculty of Medicine, Oita University, Oita, Japan
| | - Makoto Uchiyama
- Department of Psychiatry, Nihon University School of Medicine, Tokyo, Japan
| | - Daniel J Buysse
- Sleep and Chronobiology Center, Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA
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47
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Smagula SF, Beach S, Rosso AL, Newman AB, Schulz R. Brain Structural Markers and Caregiving Characteristics as Interacting Correlates of Caregiving Strain. Am J Geriatr Psychiatry 2017; 25:582-591. [PMID: 28336265 PMCID: PMC5584683 DOI: 10.1016/j.jagp.2017.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 02/05/2017] [Accepted: 02/16/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the association between brain structural markers and caregiving strain among older informal caregivers. DESIGN A secondary data analysis combining data from the Caregiver Health Effects Study (1993-1994) and the Cardiovascular Health Study MRI examination (1992-1994). SETTING Four United States communities. PARTICIPANTS Co-residing spousal caregivers (N = 237; mean age: 76.2 years, SD: 2.2 years). MEASUREMENTS Visually rated ventricular and white matter (WM) grades from magnetic resonance imaging, caregiving strain defined as "emotional or physical strain associated with providing care" for any of 12 activities of daily living (ADLs) and instrumental activities of daily living (IADLs), plus measures of caregiving characteristics and caregiver's health. RESULTS Overall, 56% of caregivers reported strain. We detected an interaction where strain was very common (>82%) among caregivers who helped with four or more IADLs, regardless of WM grades, and among caregivers with the worst WM grades (WM grades ≥4), regardless of the number of IADLs they helped with. Among caregivers helping with fewer than four IADLs, having WM grade 4 or greater was associated with a 55% higher prevalence ratio for reporting strain. This association remained statistically significant but was most markedly attenuated by adjustments for: care recipient's memory and behavioral problems, caregiver's depression symptoms, and caregiver's ADL impairment. CONCLUSIONS Caregiving strain is very common among older informal caregivers who provide help with many IADLs, and among caregivers who help with fewer IADLs, but have manifest signs of white matter pathology. Modern quantitative-neuroimaging studies are needed to evaluate whether more subtle variability in brain structure confers caregiving strain and the related health consequences.
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Affiliation(s)
- Stephen F. Smagula
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Scott Beach
- University Center for Social and Urban Research (UCSUR), University of Pittsburgh, PA, USA
| | - Andrea L. Rosso
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA, USA
| | - Anne B. Newman
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA, USA
| | - Richard Schulz
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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48
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Smagula SF, Lotrich F, Aizenstein HJ, Diniz BS, Krystek J, Wu GF, Mulsant BH, Butters MA, Reynolds CF, Lenze EJ. Immunological biomarkers associated with brain structure and executive function in late-life depression: exploratory pilot study. Int J Geriatr Psychiatry 2017; 32:692-699. [PMID: 27282141 PMCID: PMC5772975 DOI: 10.1002/gps.4512] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/27/2016] [Accepted: 05/02/2016] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Several immunological biomarkers are altered in late-life major depressive disorder (LLD). Immunological alterations could contribute to LLD's consequences, but little is known about the relations between specific immunological biomarkers and brain health in LLD. We performed an exploratory pilot study to identify, from several candidates, the specific immunological biomarkers related to important aspects of brain health that are altered in LLD (brain structure and executive function). METHODS Adults (n = 31) were at least 60 years old and had major depressive disorder. A multiplex immunoassay assessed 13 immunological biomarkers, and we examined their associations with structural MRI (grey matter volume and white matter hyperintensity volume (WMH)) and executive function (Color-Word Interference and Trail-Making tests) measures. RESULTS Vascular endothelial growth factor (VEGF) and the chemokine eotaxin had significant negative associations with grey matter volume (VEGF: n = 31, r = -0.65; eotaxin: n = 29, r = -0.44). Tumor necrosis factor alpha (TNF-α) had a significant positive relationship with WMHs (n = 30, r = 0.52); interferon-γ (IFN-γ) and macrophage inflammatory protein-1α (MIP-1α) were also significantly associated with WMHs (IFN-γ: n = 31, r = 0.48; MIP-1α: n = 29, r = 0.45). Only eotaxin was associated with executive function (set-shifting performance as measured with the Trail-making test: n = 33, r = -0.43). CONCLUSIONS Immunological markers are associated with brain structure in LLD. We found the immunological correlates of grey and white matter differ. Prospective studies are needed to evaluate whether these immunological correlates of brain health increase the risk of LLD's consequences. Eotaxin, which correlated with both grey matter volume and set-shifting performance, may be particularly relevant to neurodegeneration and cognition in LLD. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Stephen F. Smagula
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Francis Lotrich
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Howard J. Aizenstein
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Breno S. Diniz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jeffrey Krystek
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gregory F. Wu
- Department of Neurology, Washington University School of Medicine, St Louis, MO, USA
| | - Benoit H. Mulsant
- Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Meryl A. Butters
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Charles F. Reynolds
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA,Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eric J. Lenze
- Healthy Mind Lab, Department of Psychiatry, Washington University School of Medicine, St Louis, MO, USA
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49
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Smagula SF, Harrison S, Cauley JA, Ancoli-Israel S, Cawthon PM, Cummings S, Stone KL. Determinants of Change in Objectively Assessed Sleep Duration Among Older Men. Am J Epidemiol 2017; 185:933-940. [PMID: 28453606 DOI: 10.1093/aje/kwx014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 05/11/2016] [Indexed: 12/22/2022] Open
Abstract
We examined potential risk factors for changes in objectively assessed sleep duration within a large sample of community-dwelling older men. Participants (n = 1,055; mean baseline age = 74.6 (standard deviation (SD), 4.7) years) had repeated ActiGraph assessments (ActiGraph LLC, Pensacola, Florida) taken at the baseline (2003-2005) and follow-up (2009-2012) waves of the Outcomes of Sleep Disorders in Older Men Study (an ancillary study to the Osteoporotic Fractures in Men (MrOS) Study conducted in 6 US communities). Among men with a baseline nighttime sleep duration of 5-8 hours, we assessed the odds of becoming a short-duration (<5 hours) or long-duration (>8 hours) sleeper at follow-up. The odds of becoming a short-duration sleeper were higher among men with peripheral vascular disease (adjusted odds ratio (aOR) = 6.54, 95% confidence interval (CI): 2.30, 18.55) and ≥1 impairment in Instrumental Activities of Daily Living (IADL) (aOR = 2.57, 95% CI: 0.97, 6.78). The odds of becoming a long-duration sleeper were higher among those with greater baseline age (per SD increment, aOR = 1.49, 95% CI: 1.12, 2.00), depression symptoms (aOR = 3.13, 95% CI: 1.05, 9.36), and worse global cognitive performance (per SD increment of Modified Mini-Mental State Examination score, aOR = 0.74, 95% CI: 0.58, 0.94). Peripheral vascular disease and IADL impairment, but not chronological age, may be involved in the etiology of short sleep duration in older men. The risk factors for long-duration sleep suggest that deteriorating brain health predicts elongated sleep duration in older men.
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50
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Smagula SF, Krafty RT, Taylor BJ, Martire LM, Schulz R, Hall MH. Rest-activity rhythm and sleep characteristics associated with depression symptom severity in strained dementia caregivers. J Sleep Res 2017; 26:718-725. [PMID: 28488270 DOI: 10.1111/jsr.12549] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 03/22/2017] [Indexed: 12/01/2022]
Abstract
Depression is associated with disturbances to sleep and the 24-h sleep-wake pattern (known as the rest-activity rhythm: RAR). However, there remains a need to identify the specific sleep/RAR correlates of depression symptom severity in population subgroups, such as strained dementia caregivers, who are at elevated risk for major depressive disorder. We assessed the cross-sectional associations of sleep/RARs with non-sleep depression symptom severity among 57 (mean age: 74 years, standard deviation: 7.4) strained dementia caregivers who were currently without clinical depression. We derived sleep measures from polysomnography and actigraphy, modelled RARs using a sigmoidally transformed cosine curve and measured non-sleep depression symptom severity using the Hamilton Depression Rating Scale (HRDS) with sleep items removed. The following sleep-wake measures were associated with greater depression symptom severity (absolute Spearman's correlations ranged from 0.23 to 0.32): more time awake after sleep onset (WASO), higher RAR middle level (mesor), relatively shorter active periods (alpha), earlier evening settling time (down-mesor) and less steep RARs (beta). In multivariable analysis, high WASO and low RAR beta were associated independently with depression symptom severity. Predicted non-sleep HDRS means (95% confidence intervals) in caregivers with and without these characteristics were: normal WASO/beta = 3.7 (2.3-5.0), high WASO/normal beta = 5.5 (3.5-7.6), normal WASO/low beta = 6.3 (3.6-8.9) and high WASO/low beta = 8.1 (5.3-10.9). Thus, in our sample of strained caregivers, greater sleep fragmentation (WASO) and less sustained/sharply segregated resting and active periods (low RAR beta) correlate uniquely with depression symptom severity. Longitudinal studies are needed to establish whether these independent sleep-wake correlates of depression symptoms explain heightened depression risk in dementia caregivers.
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Affiliation(s)
- Stephen F Smagula
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert T Krafty
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Briana J Taylor
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lynn M Martire
- Department of Human Development and Family Studies, Pennsylvania State University, State College, PA, USA
| | - Richard Schulz
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,University Center for Social and Urban Research, University of Pittsburgh, Pittsburgh, PA, USA
| | - Martica H Hall
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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