Understanding sleep quality in a national cohort of young adult cancer survivors: Results from the YACPRIME study

PURPOSE

A cancer diagnosis in young adulthood can negatively impact sleep quality. The present study describes sleep issues in young adults (YAs) and analyzes potential demographic and clinical characteristics related to sleep quality.

METHODS

Canadian YAs (n = 359) diagnosed with cancer between ages 15-39 participated in the study. Pittsburgh Sleep Quality Index (PSQI) items were examined to identify specific sleep issues that occurred 3+ times per week. Logistic regression was used to examine demographic, clinical, and symptom-related variables associated with poor sleep quality (defined as a PSQI global score >8) and sleep medication use.

RESULTS

Participants were predominantly female (87.5%) with an average age of 32 years. Of the sample, 52% had poor sleep quality, 55.5% took >30 min to fall asleep, 32.9% slept <7 h, and 54.6% reported a habitual sleep efficiency of <85%. YAs with poor sleep quality were 5.7 times more likely to report severe distress (p=<.001), as well as 1.8 times more likely to report poorer mental (p = .03) and physical functioning (p = .05). Nearly half (44%) of YAs used sleep medication to help them sleep. YAs who reported severe psychological distress were 2.4 times more likely to use sleeping medication (p = .01), whereas those with a household income ≥$100,000/year were half as likely to use medication to help with sleep (p = .04).

CONCLUSION

Psychological distress is associated with worse sleep quality and sleep medication use in YA cancer survivors. Sleep quality may be a possible target for future research and intervention to promote long-term function and recovery.

Recurrent prescription of sleep medication among primary care patients with type 2 diabetes: an observational study of real-world registry data

BACKGROUND

Little knowledge exists on the prevalence of recurrent sleep medication prescriptions among primary care patients with type 2 diabetes (T2D). Our aims were to examine the prevalence of recurrent sleep medication prescriptions and to elucidate the most often prescribed sleep medications in a Finnish primary care T2D population.

METHODS

The study examined 4,508 T2D patients who consulted a primary health care center between 2011 and 2019 in Rovaniemi, Finland. All the data were retrieved from patient records, and recurrent sleep medication was defined as two or more prescriptions within the study period. We used the Chi-square and Kruskal-Wallis tests to compare patients who did and did not have recurrent sleep medication prescriptions.

RESULTS

Altogether 28.1% of the T2D patients had been prescribed recurrent sleep medication. Benzodiazepine-like medication, melatonin, and mirtazapine were most often prescribed (to 56.9%, 44.4%, and 35.8%, respectively). Only 22.0% of the patients with recurrent sleep medication prescriptions had been diagnosed with a sleep disorder.

CONCLUSIONS

Recurrent sleep medication prescriptions are frequent among primary care T2D patients. It seems that sleep disorders are underdiagnosed in relation to this. Primary care clinicians should carefully estimate the need for sleep medication when treating T2D patients' sleep problems and emphasize the diagnostic patterns of sleep problems.

A study on road traffic noise exposure and prevalence of insomnia

The potential of the nocturnal traffic noise to affect the quality and the quantity of sleep makes it a serious threat to public health. The present study is an attempt to provide insights into the ways through which nocturnal traffic noise causes insomnia. A total of 4525 respondents participated in the study. Modelled nocturnal noise levels were used, and the assessment of insomnia-related symptoms was done using the Jenkins sleep problem scale. A directed acyclic graph was used to obtain the minimum set of confounders that need to be adjusted for obtaining unbiased estimates. DASS-21 item scale was used to evaluate the mental health of respondents. The study reported significant associations between traffic noise exposure and all insomnia-related symptoms. For the total study population, the highest risk occurred for difficulty in falling asleep symptom (OR = 1.45; 95% CI = 1.01 - 2.07). Based on the sensitivity analysis, respondents with bedrooms facing the road were found to have higher risks as compared to the overall sample with the highest risks occurring for difficulty in maintaining the sleep symptom (OR = 1.65; 95% CI = 1.08 - 2.51). Severity levels of mental disorders showed an increasing trend with the increasing noise levels. Females were found to have a higher risk as compared to males (OR = 1.75; 95% CI = 1.14 - 2.69). No significant association was found between traffic noise exposure and sleep medication usage. Future research on large populations can help in minimizing the impacts of nocturnal noise on public health.

Sleep medication use and risk of fractures in breast cancer survivors

Purpose

Sleep problems are more common in breast cancer survivors than those without a cancer history. Our goal was to examine the risk of fractures among breast cancers survivors who used prescription sleep aids.

Methods

We conducted a retrospective cohort study of 21,346 adult women diagnosed with stage 0–III breast cancer between 2009 and 2016 and followed them through 2017. We examined person-year rates of fractures by sleep medication use and calculated adjusted hazard ratios (HR) and 95% confidence intervals (CI) with Cox proportional hazards models using time-dependent variables for sleep medications and covariate medications (antidepressants, anti-anxiety medications, and bisphosphonates) adjusted for demographics, comorbidities, and tumor characteristics and cancer treatments.

Results

The sleep medication use was common (40%) in breast cancer survivors and was associated with a 33% increased risk of fractures (adjusted HR = 1.33, 95% CI: 1.20–1.49). Further, in a sensitivity analysis based on new use of sleep medication, the fracture risk was even stronger (adjusted HR = 1.44, 95% CI: 1.26–1.64).

Conclusion

Given the high use of sleep medications and the high risk of fractures in breast cancer survivors, this study suggests that non-pharmacologic management of sleep problems might be considered as alternative therapy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-021-06392-4.

The effect of sleep medications on prospective and retrospective memory: a population-based study

Sleep medications, especially benzodiazepines, are known to cause motor and cognitive impairments as side-effects from their use. However, an evaluation of the effects of sleep medications in general on prospective and retrospective memory remains to be seen. Thus, the effects of the different types of sleep medicines were assessed using the total score and the 8 subscales of the Prospective and Retrospective Memory Questionnaire (PRMQ) in a representative sample from the Municipality of São Paulo. The effects of each type of medication on these same parameters were evaluated afterwards. Each analysis was performed controlling for different covariates to observe their degree of interference on the observed results. Impairment due to use of sleep aid medication was observed in 6 of the 8 subscales, as well in the overall score of the PRMQ when compared to non-users. Prospective subscales were particularly affected, even when controlling for highly interfering covariates such as depression and anxiety, and objective sleep variables related to sleep architecture and wakefulness in the night. Few effects were detected between the various types of medication even when controlling for covariates, suggesting that a sample with higher power is necessary to conduct a more detailed analysis. Using pharmacological aids to improve sleep may impair prospective and (to some extent) retrospective memory. Therefore, the relationship between sleep impairment, memory deficits and medication use must be considered by physicians.

Sleep medication use and incident dementia in a nationally representative sample of older adults in the US

BACKGROUND

Sleep difficulties are common among older adults, and clinical management of sleep difficulties commonly includes sleep medication (pharmacological and non-pharmacological). Our research examines sleep medication use and incident dementia over 8 years using nationally representative data from older adults ages 65 years and older in the United States.

METHODS

We used data collected from the National Health and Aging Trends Study (NHATS), a nationally-representative longitudinal study of Medicare beneficiaries. Routine sleep medication use (pharmacological and non-pharmacological) was defined as use "most nights" or "every night." Participants were screened for dementia with validated instruments that assessed memory, orientation, and executive function. We conduct prospective analyses to examine the relationship between routine sleep medication use and incident dementia using Cox proportional hazards modeling and estimated survival curves. Analyses controlled for age, sex, marital status, education, and chronic conditions.

RESULTS

Among respondents at baseline (n = 6373), most participants (21%) were age 70-74 years of age. Participants were 59% female and the sample comprised non-Hispanic White (71%). At baseline, 15% of our study sample reported using sleep medication routinely, which is representative of 4.6 million older adults in the US. Covariate adjusted proportional hazard models revealed that routinely using sleep medication was associated with incident dementia (HR = 1.30, 95%CI: 1.10 to 1.53, p < 0.01).

CONCLUSIONS

Our study observed, in a nationally representative study of older adults in the US across 8 years of data that 15% of older adults report routinely using sleep medication, yet routine use of sleeping medication was associated with incident dementia across the follow-up interval. Future research may examine behavioral approaches to improving sleep among older adults.

Traffic noise, noise annoyance and psychotropic medication use

BACKGROUND

Road-traffic noise can induce stress, which may contribute to mental health disorders. Mental health problems have not received much attention in noise research. People perceive noise differently, which may affect the extent to which noise contributes to poor mental health at the individual level. This paper aims to assess the relationships between outdoor traffic noise and noise annoyance and the use of psychotropic medication.

METHODS

We conducted a survey to assess noise annoyance and psychotropic medication among residents of the Helsinki Capital Region of Finland. We also assessed the associations of annoyance and road-traffic noise with sleep disorders, anxiety and depression. Respondents were randomly sampled from the Finnish Population registry, and data was collected using a self-administered questionnaire. Outdoor traffic noise was modelled using the Nordic prediction model. Associations between annoyance and modelled façade-noise levels with mental health outcome indicators were assessed using a binary logistic regression while controlling for socioeconomic, lifestyle and exposure-related factors.

RESULTS

A total of 7321 respondents returned completed questionnaires. Among the study respondents, 15%, 7% and 7% used sleep medication, anxiolytic and antidepressant medications, respectively, in the year preceding the study. Noise annoyance was associated with anxiolytic drug use, OR = 1.41 (95% CI: 1.02-1.95), but not with sedative or antidepressant use. There was suggestive association between modelled noise at levels higher than 60 dB and anxiolytic or antidepressant use. In respondents whose bedroom windows faced the street, modelled noise was definitively associated with antidepressant use. Noise sensitivity did not modify the effect of noise but was associated with an increased use of psychotropic medication.

CONCLUSION

We observed suggestive associations between high levels of road-traffic noise and psychotropic medication use. Noise sensitivity was associated with psychotropic medication use.

Arousability and Fall Risk During Forced Awakenings From Nocturnal Sleep Among Healthy Males Following Administration of Zolpidem 10 mg and Doxepin 6 mg: A Randomized, Placebo-Controlled, Four-Way Crossover Trial

Study Objectives

To examine and compare the arousability threshold and fall risk upon awakening of doxepin (6 mg) versus zolpidem (10 mg).

Methods

A total of 52 healthy adult males were included in a double-blind, placebo-controlled, four-way crossover study. The experimental procedure included four nights with polysomnography in the lab (zolpidem, doxepin, and their respective placebo conditions). Arousability was measured using an auditory awakening threshold delivered at the peak-plasma concentration for the active hypnotics and at matched times for the respective placebo conditions. Fall risk during the night was measured following awakening using the Berg Balance Scale and the Tandem Walk Task.

Results

Both arousability and fall risk were lower in the doxepin condition compared to the zolpidem condition. Furthermore, arousability and fall risk for doxepin did not differ significantly from the placebo conditions. A significantly greater proportion of participants in the zolpidem condition (63.5%) did not wake until receiving the loudest tone (110 dB) as compared to the doxepin (17.6%) and placebo conditions (17.3%, 5.8%).

Conclusions

Results suggest that zolpidem has greater risks for balance and awakening threshold compared with low-dose doxepin. Future prospective studies should extend results to clinical samples with population-level risk of injury and arousability.

Road traffic noise and registry based use of sleep medication

BACKGROUND

Road traffic noise has been associated with adverse health effects including sleep disturbances. Use of sleep medication as an indicator of sleeping problems has rarely been explored in studies of the effects of traffic noise. Furthermore, using registry data on sleep medications provides an opportunity to study the effects of noise on sleep where attribution of sleep problems to noise is not possible.

METHODS

We used questionnaire data from the population-based study Health and Environment in Oslo (HELMILO) (2009-10) (n = 13,019). Individual data on sleep medications was obtained from the Norwegian Prescription Database (NorPD). Noise levels (L _night) were modeled for the most exposed façade of the building at each participant's home address. Logistic regression models adjusted for potential confounders were used to analyze the association between traffic noise and sleep medication use both for one whole year and for the summer season. The results were reported as changes in the effect estimate per 5 decibel (dB) increase in noise level.

RESULTS

We observed no association between traffic noise and sleep medication use during one year [odds ratio (OR) = 1.00; 95% confidence interval (CI): 0.96, 1.04]. For sleep medication use in the summer season, there was a positive, however non-significant association (OR = 1.04; 95% CI: 0.99, 1.10). Among individuals sleeping with the bedroom window open, the association increased slightly and was borderline statistically significant (OR = 1.06; 95% CI: 1.00, 1.12).

CONCLUSIONS

We found no evidence of an association between traffic noise and sleep medication use during one year. However, for the summer season, there was some suggestive evidence of an association. These findings indicate that season may play a role in the association between traffic noise and sleep, possibly because indoor traffic noise levels are likely to be higher during summer due to more frequent window opening. More studies are, however, necessary in order to confirm this.

Sleep and cognitive performance: cross-sectional associations in the UK Biobank

OBJECTIVE

The relationship between insomnia symptoms and cognitive performance is unclear, particularly at the population level. We conducted the largest examination of this association to date through analysis of the UK Biobank, a large population-based sample of adults aged 40-69 years. We also sought to determine associations between cognitive performance and self-reported chronotype, sleep medication use and sleep duration.

METHODS

This cross-sectional, population-based study involved 477,529 participants, comprising 133,314 patients with frequent insomnia symptoms (age: 57.4 ± 7.7 years; 62.1% female) and 344,215 controls without insomnia symptoms (age: 56.1 ± 8.2 years; 52.0% female). Cognitive performance was assessed by a touchscreen test battery probing reasoning, basic reaction time, numeric memory, visual memory, and prospective memory. Adjusted models included relevant demographic, clinical, and sleep variables.

RESULTS

Frequent insomnia symptoms were associated with cognitive impairment in unadjusted models; however, these effects were reversed after full adjustment, leaving those with frequent insomnia symptoms showing statistically better cognitive performance over those without. Relative to intermediate chronotype, evening chronotype was associated with superior task performance, while morning chronotype was associated with the poorest performance. Sleep medication use and both long (>9 h) and short (<7 h) sleep durations were associated with impaired performance.

CONCLUSIONS

Our results suggest that after adjustment for potential confounding variables, frequent insomnia symptoms may be associated with a small statistical advantage, which is unlikely to be clinically meaningful, on simple neurocognitive tasks. Further work is required to examine the mechanistic underpinnings of an apparent evening chronotype advantage in cognitive performance and the impairment associated with morning chronotype, sleep medication use, and sleep duration extremes.

Age- and gender-specific associations between insomnia and falls in Boston Puerto Rican adults

PURPOSE

This study evaluated the age- and gender-specific associations between insomnia and falls in community-dwelling Puerto Rican adults, independently of multiple covariates.

METHODS

Cross-sectional data were collected from 954 Puerto Ricans, aged 46-79 years, in Boston, Massachusetts. In-person interviews were conducted to collect information on sociodemographics and lifestyle, mental status, medication use, comorbidities, sleep duration, insomnia symptoms, and falls and fractures. Blood and urine samples, and bone density measures were collected to assess C-reactive protein, serum interleukin-6, urinary cortisol, and bone mineral density.

RESULTS

Multivariate robust Poisson regressions suggested that adults with insomnia had a 32 % increased likelihood of having falls (PR 1.32, p < 0.05), after adjustment for multiple covariates. Age and gender modified the effect of insomnia on risk of falls. Insomnia was significantly associated with higher risk of falls in adults of 60 years or older (PR 1.49, p < 0.05) and in women (PR 1.36, p < 0.05), but not in adults younger than 60 years or in men. Insomnia was not associated with recurrent falls or fractures.

CONCLUSIONS

Age and gender need to be taken into account when considering treatment of insomnia in preventing geriatric falls. Well-designed evidence-based interventions to treat insomnia and improve sleep quality may reduce the risk of falls in this population.

Factors related to the mobility of hospitalized older adults: A prospective cohort study

A low ambulation rate is common even among acutely ill hospitalized older adults. This prospective observational study conducted among 769 older adults (≥70) hospitalized in acute-care units tested the relationship of satisfaction with hospital environment, sleep-medication consumption, and in-hospital caloric intake to mobility levels during hospitalization on 3 consecutive hospitalization days. Approximately 20% of the patients did not walk, 30% walked only in their room, and 50% mobilized outside their room. A multinomial-logistic regression, controlling for potential intervening factors, showed that sleep-medication avoidance (AOR = 1.99; p < 0.01) and higher caloric intake (AOR = 9.69; p < 0.001) differentiated patients walking outside the room from non-walking patients. Satisfaction with the physical environment was lower in the non-mobile group than in the other two. Results suggest that hospital environment, sleep-medication consumption, and caloric intake during hospitalization need to be addressed in attempts to improve in-hospital mobility in older adults.

Use of sleep medications and risk of cancer: a matched case-control study

BACKGROUND

Previous research suggests a possible link between sleep-medication use and mortality, especially cancer deaths, but findings are mixed, and large population-based studies are lacking.

METHODS

Data from the Finnish Public Sector study were linked to the Finnish Cancer Register and the Drug Prescription Register of Finland. A total of 5053 cancer cases (mean age of 57.4 years) diagnosed in 2002-2011, and their 24,388 controls free of cancer and matched for sex, age, socioeconomic status, employer, and geographical area, were identified. The use of sleep medications was defined as purchases of prescribed sleep medications.

RESULTS

Both quantity and duration of prior sleep-medication use during the seven years studied were associated with increased odds of having cancer. Compared with participants not using sleep medications, the odds ratio was 1.18-fold (95% confidence interval (CI): 1.01-1.39) for those who used >100 defined daily doses per year and 1.16-fold (95% CI: 1.01-1.34) for those who had such a medication for >3 years. Site-specific analyses showed a more pronounced association of quantity and duration of sleep-medication use with subsequent cancer of the respiratory system (odds ratio for >100 defined daily doses per year vs. no use: 3.47; 95% CI: 1.97-6.11). No associations were found with other cancer sites.

CONCLUSION

In this register-based study, sleep-medication use was associated with an increased cancer incidence of the respiratory system. Further studies are needed to examine potential carcinogenic mechanisms associated with hypnotic medications.

Age-related changes in slow wave activity rise time and NREM sleep EEG with and without zolpidem in healthy young and older adults

OBJECTIVE

Whether there are age-related changes in slow wave activity (SWA) rise time, a marker of homeostatic sleep drive, is unknown. Additionally, although sleep medication use is highest among older adults, the quantitative electroencephalographic (EEG) profile of the most commonly prescribed sleep medication, zolpidem, in older adults is also unknown. We therefore quantified age-related and regional brain differences in sleep EEG with and without zolpidem.

METHODS

Thirteen healthy young adults aged 21.9 ± 2.2 years and 12 healthy older adults aged 67.4 ± 4.2 years participated in a randomized, double-blind, within-subject study that compared placebo to 5 mg zolpidem.

RESULTS

Older adults showed a smaller rise in SWA and zolpidem increased age-related differences in SWA rise time such that age differences were observed earlier after latency to persistent sleep. Age-related differences in EEG power differed by brain region. Older, but not young, adults showed zolpidem-dependent reductions in theta and alpha frequencies. Zolpidem decreased stage 1 in older adults and did not alter other age-related sleep architecture parameters.

CONCLUSIONS

SWA findings provide additional support for reduced homeostatic sleep drive or reduced ability to respond to sleep drive with age. Consequences of reduced power in theta and alpha frequencies in older adults remain to be elucidated.

Over-the-counter and prescription sleep medication and incident stroke: the REasons for Geographic and Racial Differences in Stroke study

BACKGROUND

Preliminary evidence suggests sleep medications are associated with risk of vascular events; however, the long-term vascular consequences are understudied. This study investigated the relation between sleep medication use and incident stroke.

METHODS

Within the REasons for Geographic And Racial Differences in Stroke study, 21,678 black participants and white participants (≥45 years) with no history of stroke were studied. Participants were recruited from 2003 to 2007. From 2008 to 2010, participants self reported their prescription and over-the-counter sleep medication use over the past month. Suspected stroke events were identified by telephone contact at 6-month intervals and associated medical records were retrieved and physician-adjudicated. Proportional hazards analysis was used to estimate hazard ratios for incident stroke associated with sleep medication use (0, 1-14, and 15+ days per month) controlling for sociodemographics, stroke risk factors, mental health symptoms, and sleep apnea risk.

RESULTS

At the sleep assessment, 9.6% of the sample used prescription sleep medication and 11.1% used over-the-counter sleep aids. Over an average follow-up of 3.3 ± 1.0 years, 297 stroke events occurred. Over-the-counter sleep medication use was associated with increased risk of incident stroke in a frequency-response relationship (P = .014), with a 46% increased risk for 1-14 days of use per month (hazards ratio [HR] = 1.46; 95% confidence interval [CI], .99-2.15) and a 65% increased risk for 15+ days (HR = 1.65; 95% CI, .96-2.85). There was no significant association with prescription sleep medications (P = .80).

CONCLUSIONS

Over-the-counter sleep medication use may independently increase the risk of stroke beyond other risk factors in middle-aged to older individuals with no history of stroke.

Sleep quality of benzodiazepine users in nursing homes: a comparative study with nonusers

OBJECTIVES

We aim to describe subjective sleep quality among long-term users of benzodiazepines (BZDs) in Belgian nursing homes, to compare it to nonusers, and to investigate determinants of poor sleep quality.

METHODS

All mentally competent residents from 10 nursing homes were screened and compiled in a group of long-term BZD users or in a group of nonusers based on the medication chart. We collected demographic, functional, and medication characteristics and global and specific sleep parameters using the Pittsburgh Sleep Quality Index (PSQI). Linear regression was used to investigate which parameters were associated with sleep quality.

RESULTS

Of the 300 residents, 178 (59%) were long-term BZD users and 122 were nonusers. The 2 groups did not differ in demographic and functional characteristics (mean age, 85.5 y; range, 57-100; 75% women). The users reported significantly more difficulties with falling asleep, had more midnight awakenings, felt less rested in the morning, and had a poorer self-perceived sleep quality compared to nonusers. Sleep duration and time to fall asleep did not differ. The self-perceived sleep quality was mainly determined by difficulties during initiation of sleep. After controlling for demographic, medication, and functional characteristics, BZD use remained strongly associated with poor sleep (r=0.173; P=.003), and a study centre effect (differences among nursing homes) was observed (r=0.229; P<.001).

CONCLUSION

Our findings do not support long-term effectiveness of BZDs; long-term users slept more poorly than nonusers and were even more outspoken in users of long-acting BZDs. In future longitudinal comparative studies of sleep quality, unexplained variability needs further assessment with medical, psychologic, and institutional parameters.