Discrimination Predicts Suboptimal Adherence to CPAP Treatment and Mediates Black-White Differences in Use

BACKGROUND

Although racial and ethnic differences in CPAP adherence for OSA are widely established, no studies have examined the influence of perceived racial discrimination on CPAP usage, to our knowledge.

RESEARCH QUESTION

(1) Do Black adults with OSA report experiencing greater amounts of discrimination than non-Hispanic White adults? (2) Is discrimination associated with poorer CPAP adherence over time, independent of self-identified race? (3) Does discrimination mediate the relationship between self-identified Black race and CPAP usage?

STUDY DESIGN AND METHODS

In this prospective study, Black and non-Hispanic White adults with OSA initiating CPAP were enrolled from two sleep centers and completed questionnaires including sociodemographics, perceived discrimination, daytime sleepiness, insomnia symptoms, and depressive symptoms. Perceived discrimination was measured using the Everyday Discrimination Scale (EDS). Black and White group comparisons for baseline sociodemographic variables, sleep symptoms, and perceived discrimination were performed with Student t test or χ2/Fisher exact test, as appropriate. A linear regression model was completed with self-identified Black race and EDS total score as the primary independent variables of interest and mean daily CPAP usage at 30 and 90 days serving as the dependent outcomes. This regression modeling was repeated after adjusting for psychosocial variables known to be associated with CPAP usage. EDS total score was explored as a potential mediator of the association between self-identified Black race and mean daily CPAP adherence at 30 and 90 days.

RESULTS

The sample for this analysis consisted of 78 participants (31% female, 38% Black) with a mean age of 57 ± 14 years. Sixty percent of the Black adults reported they experienced racial discrimination at least a few times each year. Relative to White adults, Black adults were also more likely to indicate more than one reason for discrimination (27% vs 4%, P = .003). Adjusting for discrimination, self-identified Black race was associated with 1.4 (95% CI, -2.3 to -0.4 h; P = .006) and 1.6 (95% CI, -2.6 to -0.6 h; P = .003) fewer hours of mean daily CPAP usage at 30 and 90 days, respectively. In the fully adjusted model, a 1-unit change in the total discrimination score (more discrimination) was associated with a 0.08-h (95% CI, 0.01-0.15 h; P = .029) and 0.08-h (95% CI, 0.01-0.16 h; P = .045) change in mean daily CPAP usage at 30 and 90 days, respectively.

INTERPRETATION

Adults with OSA who encountered racial discrimination experienced greater decrement in CPAP usage than those who did not experience racial discrimination.

The Effect of Self-Reported Visual Impairment and Sleep on Cognitive Decline: Results of the Hispanic Community Health Study/Study of Latinos

BACKGROUND

Visual impairment could worsen sleep/wake disorders and cognitive decline.

OBJECTIVE

To examine interrelations among self-reported visual impairment, sleep, and cognitive decline in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Miami-site.

METHOD

HCHS/SOL Miami-site participants ages 45-74 years (n = 665) at Visit-1, who returned for cognitive test 7-years later (SOL-INCA). Participants completed the National Eye Institute Visual Functioning Questionnaire (NEI-VFQ), validated sleep questionnaires and test for obstructive sleep apnea (OSA) at Visit-1. We obtained verbal episodic learning and memory, verbal fluency, processing speed, and executive functioning at Visit-1 and at SOL-INCA. Processing speed/executive functioning were added to SOL-INCA. We examined global cognition and change using a regression-based reliable change index, adjusting for the time lapse between Visit-1 and SOL-INCA. We used regression models to test whether 1) persons with OSA, self-reported sleep duration, insomnia, and sleepiness have an increased risk for visual impairment, 2a) visual impairment is associated with worse cognitive function and/or decline, and 2b) sleep disorders attenuate these associations.

RESULT

Sleepiness (β= 0.04; p < 0.01) and insomnia (β= 0.04; p < 0.001) were cross-sectionally associated with visual impairment, adjusting for sociodemographic characteristics, behavioral factors, acculturation, and health conditions. Visual impairment was associated with lower global cognitive function at Visit-1 (β= -0.16; p < 0.001) and on average 7-years later (β= -0.18; p < 0.001). Visual impairment was also associated with a change in verbal fluency (β= -0.17; p < 0.01). OSA, self-reported sleep duration, insomnia, and sleepiness did not attenuate any of the associations.

CONCLUSION

Self-reported visual impairment was independently associated with worse cognitive function and decline.

Sex and racial/ethnic differences in sleep quality and its relationship with body weight status among US college students

Objective: To examine sex and racial/ethnic differences in sleep quality and the association between sleep quality and body weight status among US college students. Participants: A nationally representative sample (N = 324,767) of college students from 2011 to 2015. Methods: A secondary data analysis of cross-sectional data. Results: Women showed poorer sleep quality (nights per week getting enough sleep to feel rested) than men (4.00 versus 4.34 days; p < .001). In both men and women, compared with non-Hispanic whites, racial/ethnic minorities showed lower sleep quality (p < .001). Compared with normal weight participants, overweight participants had poorer sleep quality (p = .007) among men, and both overweight (p = .004) and obese participants (p < .001) had lower sleep quality among women. Conclusions: Understanding sex and racial/ethnic sleep differences and the association between sleep and body weight status is important for colleges to promote college students' healthy sleep.

Acculturation Associated with Sleep Duration, Sleep Quality, and Sleep Disorders at the US-Mexico Border

Sleep disparities exist among Hispanics/Latinos, although little work has characterized individuals at the United States (US)-Mexico border, particularly as it relates to acculturation. This study examined the association of Anglo and Mexican acculturation to various facets of sleep health among those of Mexican descent at the US-Mexico border. Data were collected from N = 100 adults of Mexican descent in the city of Nogales, Arizona (AZ). Surveys were presented in English or Spanish. Acculturation was assessed with the Acculturation Scale for Mexican-Americans (ARSMA-II). Insomnia was assessed with the Insomnia Severity Index (ISI), sleepiness was assessed with the Epworth Sleepiness Scale (ESS), sleep apnea risk was assessed with the Multivariable Apnea Prediction (MAP) index, weekday and weekend sleep duration and efficiency were assessed with the Sleep Timing Questionnaire, sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI), and sleep duration and sleep medication use were assessed with PSQI items. No associations were found between Mexican acculturation and any sleep outcomes in adjusted analyses. Anglo acculturation was associated with less weekend sleep duration and efficiency, worse insomnia severity and sleep quality, and more sleep apnea risk and sleep medication use. These results support the idea that sleep disparities may depend on the degree of acculturation, which should be considered in risk screening and interventions.

Parent-child relationship quality and sleep among adolescents: modification by race/ethnicity

BACKGROUND

Both parent-child relationship quality (PCRQ) and sleep are important for health and development, but few studies have examined links between PCRQ and adolescent sleep and potential interactions by race/ethnicity or sex.

METHODS

We used cross-sectional data from 6,019 participants (mean = 15.9 years; 50% male; 66% non-Hispanic White, 16% non-Hispanic Black, 5% Hispanic all races) from the National Longitudinal Study of Adolescent to Adult Health, a nationally representative sample of U.S. adolescents. Our exposure was current adolescent-rated PCRQ score. Outcomes were adolescents' reports of chronic insufficient sleep, sleep duration (mins), and frequency of insomnia symptoms (i.e., trouble falling or staying asleep "almost every day"/"every day" versus "never"/"just a few times"/"about once a week").

RESULTS

Adjusting for demographic characteristics, each 1-point increase in PCRQ score was associated with lower odds of insomnia symptoms (odds ratio [OR] = 0.92, 95% confidence interval [CI]: 0.90, 0.94), chronic insufficient sleep (OR = 0.93, 95% CI: 0.91, 0.95), and longer sleep duration (B = 2.56, 95% CI: 1.90, 3.22). After adjustment for depressive symptoms, the association with insomnia symptoms was no longer statistically significant. Race/ethnicity moderated the association between PCRQ and chronic insufficient sleep such that the magnitude of the association was greater in Hispanics vs. Whites and Blacks. There were no interactions of PCRQ with sex.

CONCLUSIONS

Among adolescents, better PCRQ was associated with better sleep, and this association varied by race/ethnicity for perceived chronic insufficient sleep. Longitudinal studies with objective and subjective sleep measures are needed to further understand these associations.

Parent Perspectives on Sleep and Sleep Habits Among Young Children Living With Economic Adversity

OBJECTIVE

To examine the perspectives of ethnically diverse, low-income parents of young children regarding sleep, sleep habits, and preferences for sleep promotion for themselves and their children.

METHOD

We recruited a sample of mothers who had a 15- to 60-month-old child enrolled in the Special Supplemental Nutritional Program for Women, Infants and Children in a Northeastern U.S. city. We used a convergent mixed-methods design to conduct semistructured interviews and questionnaires to measure parent sleep quality (Pittsburgh Sleep Quality Index), sleep apnea (Berlin Apnea Questionnaire), mood (Centers for Epidemiological Studies of Depression), children's sleep (Children's Sleep Habits Questionnaire), and behavior (Child Behavior Checklist).

RESULTS

Thirty-two mothers (M age = 30.97 [SD 6.34] years; n = 21 [65%] African American) and children (N = 14 [44% female]; M age =38 [SD 12.63] months) participated. Children's average sleep duration was 10 hr, which is below the recommendation for this age group; overall sleep difficulty was high despite most mothers reporting that their children had normal sleep. Five children had abnormal Child Behavior Checklist scores, suggesting internalizing and externalizing behaviors. More than half of the mothers had poor sleep quality and 24 (75%) were at high risk for sleep apnea. Mothers viewed sleep as important for themselves and their children and identified both effective and ineffective practices to promote sleep, including practices learned from their own families.

CONCLUSIONS

Ethnically diverse mothers who are living with economic adversity value sleep for themselves and their children. The high value placed on sleep, despite misconceptions about normal sleep, suggest opportunities to promote sleep interventions. The content and delivery methods should be tailored to their knowledge, preferences, and cultural practices.

Confirmatory factor analysis of the Insomnia Severity Index (ISI) and invariance across race: a pooled analysis of MsFLASH data

OBJECTIVE

Women's sleep at menopause is widely reported to be problematic. The Insomnia Severity Index (ISI) is a commonly used tool for quantifying sleep problems in clinical and research settings, but psychometric properties in postmenopausal women have not been reported. Our study aim was to examine the factor structure of the ISI in a large and diverse sample of midlife women with hot flashes.

METHODS

Baseline data were from 899 women enrolled in one of the three clinical trials using similar entry criteria conducted by the Menopause Strategies Finding Lasting Answers to Symptoms and Health research network. We conducted confirmatory factor analyses for the total sample and within strata defined by race/ethnicity (black and white women).

RESULTS

The ISI had two factors in the total sample. The two-factor structure was consistent across black and white women, with the exception of one item "difficulty falling asleep."

CONCLUSIONS

The ISI in midlife women with hot flashes is composed of two factors that capture dimensions of the insomnia severity and daytime impact. The instrument is a psychometrically sound scale appropriate for use in research and clinical practice to capture the severity and daytime impact of insomnia symptoms in diverse samples of midlife women with hot flashes. An abbreviated screening of two items could be considered to determine if further evaluation is needed of sleep complaints.

A Narrative Review of the Literature on Insufficient Sleep, Insomnia, and Health Correlates in American Indian/Alaska Native Populations

Insufficient sleep and insomnia promote chronic disease in the general population and may combine with social and economic factors to increase rates of chronic health conditions among AI/AN people. Given that insufficient sleep and insomnia can be addressed via behavioral interventions, it is critical to understand the prevalence and correlates of these disorders among AI/AN individuals in order to elucidate the mechanisms associated with health disparities and provide guidance for subsequent treatment research and practice. We reviewed the available literature on insufficient sleep and insomnia in the AI/AN population. PubMed, PsycINFO, Google Scholar, and ProQuest were searched between June 12th and October 28th of 2018. Prevalence of insufficient sleep ranged from 15% to 40%; insomnia prevalence ranged from 25% to 33%. Insufficient sleep was associated with unhealthy diet, low physical activity levels, higher BMI, worse self-reported health, increased risk for diabetes mellitus, cardiovascular disease, frequent mental distress, smoking, binge drinking, depression, and chronic pain. Insomnia was associated with depression, childhood abuse, PTSD, anxiety, alcohol use, low social support, and low trait-resilience levels. Research on evidence-based treatment and implementation practices targeting insufficient sleep and insomnia was lacking, and only one study described the development/validation of a measure of insufficient sleep among AI/AN people. There is a need for rigorous sleep research including testing and implementation of evidence-based treatment for insufficient sleep and insomnia in this population in an effort to help eliminate health disparities. We present recommendations for research and clinical practice based on the current review.

Neighborhood deprivation predicts infant sleep quality

OBJECTIVES

The current study examined the relationship between neighborhood deprivation and infant sleep at 3 months of age.

METHODS

Neighborhood and sleep data were collected from 80 African American infants and their caregivers. A composite neighborhood deprivation score was created using census data. Infant sleep was measured via 7 nights of actigraphy monitoring when infants were 3 months of age. Current analyses considered the average number of infant night wakings as an index of sleep quality. Multilevel models were used, in which children (level 1) were nested within census tracts (level 2).

RESULTS

Controlling for level 1 covariates, greater neighborhood deprivation (b = 0.07, P < .01), was associated with poorer infant sleep, as characterized by a greater number of wakings during the nighttime sleep period.

CONCLUSIONS

Findings suggest that infants who reside in communities marked by higher deprivation experience poorer quality sleep, even after controlling for family-level factors.

Associations between polysomnography and actigraphy-based sleep indices and glycemic control among those with and without type 2 diabetes: the Multi-Ethnic Study of Atherosclerosis

Study Objectives

To examine the associations of sleep measures with hemoglobin A1c (HbA1c) among individuals with and without type 2 diabetes.

Methods

Data were from 2049 Multi-Ethnic Study of Atherosclerosis participants taking part in a sleep ancillary study. Cross-sectional linear regression models examined associations of actigraphy estimates of sleep (sleep duration, variability, and maintenance efficiency) and polysomnography measures (obstructive sleep apnea [OSA] and hypoxemia) with HbA1c, stratified by diabetes status. Primary models were adjusted for demographics, lifestyle behaviors, and obesity.

Results

Among individuals with diabetes (20 per cent population), those who slept <5 hr/night had greater HbA1c than those who slept 7-8 hr/night (7.44 vs. 6.98 per cent, ptrend = 0.04), with no attenuation of associations after adjusting for OSA/hypoxemia. In women with diabetes, but not men, those in the lowest quartile of sleep maintenance efficiency had greater HbA1c than those in the highest quartile of sleep maintenance efficiency (7.60 vs. 6.97 per cent, ptrend < 0.01). Among those without diabetes, individuals with severe OSA or in the highest quartile of hypoxemia had significantly greater HbA1c than those without OSA or who were in the lowest quartile of hypoxemia (5.76 vs. 5.66 per cent, ptrend = 0.01; 5.75 vs. 5.66 per cent, ptrend < 0.01, respectively). Associations did not meaningfully differ by race/ethnicity.

Conclusions

Among individuals with diabetes, HbA1c was significantly higher in men and women with short sleep duration and in women with poor sleep maintenance efficiency, suggesting a role for behavioral sleep interventions in the management of diabetes. Among individuals without diabetes, untreated severe OSA/hypoxemia may adversely influence HbA1c.

Mediterranean diet pattern and sleep duration and insomnia symptoms in the Multi-Ethnic Study of Atherosclerosis

Sleep duration and sleep quality are important predictors of risk for cardiovascular disease (CVD). One potential link between sleep health and CVD is through lifestyle factors such as diet. To clarify the association between diet and sleep, we assessed the associations of sleep duration and insomnia symptoms with current Mediterranean-style diet (aMed) and with historical changes in aMed score. Actigraphy-measured sleep duration and self-reported insomnia symptoms categorized as insomnia with short sleep (<6 hr/night), insomnia without short sleep, no insomnia with short sleep, and no insomnia or short sleep were obtained from 2068 individuals who also had dietary intake data. A 10-point aMed score, derived from a self-report food frequency questionnaire, was collected concurrently with the sleep assessment and 10 years before. Compared with individuals who currently reported a low aMed score, those with a moderate-high aMed score were more likely to sleep 6-7 vs. <6 hr/night (p < 0.01) and less likely to report insomnia symptoms occurring with short sleep (vs. no insomnia or short sleep alone; p < 0.05). An increase in aMed score over the preceding 10 years was not associated with sleep duration or insomnia symptoms. However, compared with those with decreasing aMed score, individuals with an unchanging score reported fewer insomnia symptoms (p ≤ 0.01). These results suggest that a Mediterranean-style diet is associated with adequate sleep duration, less insomnia symptoms, and less likely to have insomnia accompanied by short sleep. Further research should identify possible mediators through which diet may promote adequate sleep duration and reduce the risk of insomnia.

Physical neighborhood and social environment, beliefs about sleep, sleep hygiene behaviors, and sleep quality among African Americans

OBJECTIVES

African Americans (AAs) have a higher prevalence of sleep disorders than other racial/ethnic groups. However, little is known about the relationships among individual and neighborhood factors related to sleep quality in AAs. The purposes of this study were to (1) describe beliefs about sleep, sleep hygiene behaviors, and sleep quality among AAs; and (2) examine the relationships among sociodemographic characteristics, neighborhood environment, beliefs about sleep, sleep hygiene behaviors, and sleep quality.

METHODS

We conducted a cross-sectional study of 252 AA men and women in the Greater New Haven, CT, USA community. We assessed their sociodemographic characteristics, neighborhood environment, beliefs about sleep, sleep hygiene, and sleep quality with the following measures, respectively: the Neighborhood Environment Scale, the brief version of Dysfunctional Beliefs and Attitudes about Sleep, the Sleep Hygiene Practice Scale, the Pittsburgh Sleep Quality Index. We performed descriptive statistics, correlations and multiple hierarchical regression.

RESULTS

About 72% of the participants (mean age: 53.88 ± 14.17 years, 77.8% women) reported experiencing sleep disturbance. People with poor sleep quality were more likely to report poorer neighborhood social environment (social cohesion), poorer overall neighborhood environment, more dysfunctional beliefs toward sleep, and poorer sleep hygiene than those who had good sleep quality. In the final multivariate model that controlled for a number of chronic comorbid conditions, neighborhood environment, beliefs about sleep, and sleep hygiene behaviors were significantly associated with sleep quality.

CONCLUSIONS

Future efforts are needed to improve sleep among AAs by considering both the individual's belief about sleep, sleep hygiene behaviors and neighborhood factors.

Discrimination and Sleep Difficulties during Adolescence: The Mediating Roles of Loneliness and Perceived Stress

Irregular and insufficient sleep place youth at risk for adverse psychological and physical health outcomes. Recent research indicates that discrimination constitutes a type of stressor that interferes with adolescent sleep; however, the mechanisms through which discrimination affects sleep are not well understood. This study examined whether ethnic and non-ethnic (i.e., gender, age, and height/weight) discrimination were associated with adolescents' sleep duration, variability, and quality, and whether loneliness and perceived stress mediated these associations. An ethnically-diverse sample (42% Latino, 29% European American, 23% Asian) of adolescents (N = 316; M age = 16.40 years, 57% girls) reported on their experiences of discrimination, perceived stress, and loneliness. Sleep duration and variability were assessed by actigraphy and sleep quality through self-reports. Ethnic discrimination was related to shorter sleep duration and both ethnic and non-ethnic discrimination were associated with worse sleep quality. Loneliness and perceived stress partially mediated the relation between discrimination and sleep quality. Discriminatory experiences can heighten feelings of loneliness and stress, which, in turn, may contribute to diminished sleep quality during adolescence.

Pathways linking racial/ethnic discrimination and sleep among U.S.-born and foreign-born Latinxs

This study examined the association between racial/ethnic discrimination and sleep through psychological distress and body mass index (BMI), and determined whether the aforementioned associations vary between U.S. and foreign-born Latinxs. Participants were 1332 Latinx adults enrolled in the Texas City Stress and Health Study. Multistage sampling methods were used to select participants. A model linking racial/ethnic discrimination with sleep disturbances through direct and indirect (i.e., psychological distress and BMI) paths demonstrated good fit. Greater racial/ethnic discrimination was associated with greater psychological distress and higher BMI. Psychological distress and BMI were also significant predictors of sleep disturbances. The indirect path from racial/ethnic discrimination to sleep disturbances via psychological distress was significant. A model with parameters constrained to be equal between U.S.-born and foreign-born Latinxs suggested associations were comparable between these groups. Our study demonstrated the relevance of racial/ethnic discrimination to sleep disturbances, particularly its association via psychological distress among Latinxs.

Poor sleep moderates the relationship between daytime napping and inflammation in Black and White men

OBJECTIVES

To test whether napping was associated with 2 inflammatory markers with known relationships to cardiovascular disease: high-sensitivity C-reactive protein (hsCRP) and interleukin-6 (IL-6). Because IL-6 is known to impact central inflammatory processes that relate to sleep regulation, including subjective fatigue, we tested whether this relationship was moderated by sleep duration, sleep efficiency, and self-reported sleep quality.

DESIGN

Cross-sectional.

PARTICIPANTS

A community sample of Black and White men (N=253) completed a week of actigraphy and diary measures of sleep and napping and provided a fasting blood sample.

MEASUREMENTS/ANALYSIS

Napping was measured as the proportion of days with at least 30 minutes napped and the average minutes napped per day. Linear regressions adjusted for race, socioeconomic status, employment, body mass index, smoking, medications that affect sleep or inflammation, working the nightshift, and day-sleeping status, followed by interaction terms between napping and sleep duration, efficiency, and quality, respectively.

RESULTS

There were no significant main effects of actigraphy- or diary-measured napping on IL-6 or hsCRP. Moderation analyses indicated elevated IL-6 values among men who napped more days (by actigraphy) and demonstrated short sleep duration (P=.03). Moderation analyses also indicated elevated IL-6 among men who demonstrated greater average minutes napped (by actigraphy) and short sleep duration (P<.001), low efficiency (P=.03), and poor quality (P=.03). Moderation analyses involving diary napping or hsCRP were not significant.

CONCLUSIONS

Actigraphy-assessed daytime napping is related to higher IL-6 in men who demonstrate worse sleep characteristics. Daytime napping may pose additional risk for inflammation beyond the known risk conferred by short sleep.

A latent genetic subtype of major depression identified by whole-exome genotyping data in a Mexican-American cohort

Identifying data-driven subtypes of major depressive disorder (MDD) is an important topic of psychiatric research. Currently, MDD subtypes are based on clinically defined depression symptom patterns. Although a few data-driven attempts have been made to identify more homogenous subgroups within MDD, other studies have not focused on using human genetic data for MDD subtyping. Here we used a computational strategy to identify MDD subtypes based on single-nucleotide polymorphism genotyping data from MDD cases and controls using Hamming distance and cluster analysis. We examined a cohort of Mexican-American participants from Los Angeles, including MDD patients (n=203) and healthy controls (n=196). The results in cluster trees indicate that a significant latent subtype exists in the Mexican-American MDD group. The individuals in this hidden subtype have increased common genetic substrates related to major depression and they also have more anxiety and less middle insomnia, depersonalization and derealisation, and paranoid symptoms. Advances in this line of research to validate this strategy in other patient groups of different ethnicities will have the potential to eventually be translated to clinical practice, with the tantalising possibility that in the future it may be possible to refine MDD diagnosis based on genetic data.

Neighborhood Factors as Predictors of Poor Sleep in the Sueño Ancillary Study of the Hispanic Community Health Study/Study of Latinos

Study Objectives

To evaluate whether an adverse neighborhood environment has higher prevalence of poor sleep in a US Hispanic/Latino population.

Methods

A cross-sectional analysis was performed in 2156 US Hispanic/Latino participants aged 18-64 years from the Sueño ancillary study of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). Participants completed surveys of neighborhood environment including perceived safety, violence and noise, the Insomnia Severity Index (ISI), and 7 days of wrist actigraphy.

Results

In age and sex-adjusted analyses, short sleep, low sleep efficiency, and late sleep midpoint were all more prevalent among those living in an unsafe neighborhood. After adjustment for background, site, nativity, income, employment, depressive symptoms, and sleep apnea, the absolute risk of sleeping <6 hours was 7.7 (95% CI [0.9, 14.6]) percentage points greater in those living in an unsafe compared to a safe neighborhood. There were no differences in the prevalence of insomnia by level of safety or violence. Insomnia was more prevalent among those living in a noisy neighborhood. In adjusted analysis, the absolute risk of insomnia was 4.4 (95% CI [0.4, 8.4]) percentage points greater in those living in noisy compared to non-noisy neighborhoods.

Conclusion

Using validated measures of sleep duration and insomnia, we have demonstrated the existence of a higher prevalence of short sleep and insomnia by adverse neighborhood factors. An adverse neighborhood environment is an established risk factor for a variety of poor health outcomes. Our findings suggest negative effects on sleep may represent one pathway by which neighborhood environment influences health.

Alterations in serum melatonin and sleep in individuals in a sub-arctic region from winter to spring

METHODS

In a sub-arctic region at 69 degrees N, seven individuals with self-reported insomnia during the 'dark period' and seven without, were followed with repeated measures of melatonin and questioned on ten different sleep variables, from the beginning of January to the vernal equinox in March.

RESULTS

The distribution of melatonin over a 24-hour period (five time points) indicated an increase in melatonin levels in both groups in the middle of January and a decrease at the time of year when the sun first rises over the horizon (23rd-24th of January). Moreover, an indication of a delayed phase shift of melatonin secretion was found during the dark period, which returned to "normal" secretion during the night at the equinox in March. Individuals with sleep problems had a slower return to "normal" melatonin secretion than those without sleep problems. A positive correlation between morning tiredness and morning levels of melatonin was found among individuals with sleep disturbances, but not in controls.

CONCLUSION

This study indicates changes in the internal circadian rhythm in humans at the end of the annual dark period of winter when there is a rapid increase in the number of hours of sunlight. For vulnerable individuals, the disturbance in sleep, and in particlar morning tiredness, lasts at least until the vernal equinox in March.

Sleep of M&#257;ori and non-M&#257;ori of Advanced Age

AIM

To estimate prevalence and identify predictors and outcomes of reporting sleep problems in M&#257;ori and non-M&#257;ori of advanced age.

METHOD

Participants were 251 M&#257;ori, and 398 non-M&#257;ori adults (79-90 years) from Te Pu&#257;waitanga o Ng&#257; Tapuwae Kia Ora Tonu. Life and Living in Advanced Age: A Cohort Study in New Zealand. Multiple logistic regression identified predictors of reporting a current sleep problem and investigated relationships between current sleep problems and physical and mental health.

RESULTS

26.3% of M&#257;ori and 31.7% of non-M&#257;ori reported a current sleep problem. Reporting a current sleep problem was associated with ethnicity (non-M&#257;ori, adjusted OR=0.52, 95% CI=0.30-0.90), and reporting a past sleep problem (adjusted OR=2.67, 95% CI=1.25-5.72). Sleep problems were related to poorer physical and mental health, and falling.

CONCLUSION

Sleep problems are commonly reported and associated with poorer health. Early recognition and management of sleep problems could improve physical and mental health.

Association between Sleep Duration, Insomnia Symptoms and Bone Mineral Density in Older Boston Puerto Rican Adults

Objective

To examine the association between sleep patterns (sleep duration and insomnia symptoms) and total and regional bone mineral density (BMD) among older Boston Puerto Rican adults.

Materials/Methods

We conducted a cross-sectional study including 750 Puerto Rican adults, aged 47–79 y living in Massachusetts. BMD at 3 hip sites and the lumbar spine were measured using dual-energy X-ray absorptiometry. Sleep duration (≤5 h, 6 h, 7 h, 8 h, or ≥9 h/d) and insomnia symptoms (difficulty initiating sleep, difficulty maintaining sleep, early-morning awaking, and non-restorative sleep) were assessed by a questionnaire. Multivariable regression was used to examine sex-specific associations between sleep duration, insomnia symptoms and BMD adjusting for standard confounders and covariates.

Results

Men who slept ≥9h/d had significantly lower femoral neck BMD, relative to those reporting 8 h/d sleep, after adjusting for age, education level, smoking, physical activity, depressive symptomatology, comorbidity and serum vitamin D concentration. This association was attenuated and lost significance after further adjustment for urinary cortisol and serum inflammation biomarkers. In contrast, the association between sleep duration and BMD was not significant in women. Further, we did not find any significant associations between insomnia symptoms and BMD in men or women.

Conclusions

Our study does not support the hypothesis that shorter sleep duration and insomnia symptoms are associated with lower BMD levels in older adults. However, our results should be interpreted with caution. Future studies with larger sample size, objective assessment of sleep pattern, and prospective design are needed before a conclusion regarding sleep and BMD can be reached.

Factors associated with clinically significant insomnia among pregnant low-income Latinas

BACKGROUND

Poor sleep, common during pregnancy, is associated with negative health risks. The study aimed to identify predictors of clinically significant insomnia among pregnant Latinas.

METHODS

A total of 1289 pregnant Latinas recruited from obstetric clinics completed the Insomnia Severity Index (ISI) and questions about demographics and sleep.

RESULTS

Clinically significant insomnia (ISI≥10) was present among 17% of participants. Significant correlates of clinically significant insomnia were higher scores on the Edinburgh Postnatal Depression Scale (EPDS) after removing the sleep item (47% of women with EPDS≥9 and 9% with EPDS<9), completing measures in English (rather than Spanish: 26% versus 13%), and income but not pregnancy week, age, highest education level, or marital status. The highest percentage of clinically significant insomnia (59%) was experienced by women with EPDS≥9 who completed measures in English. The lowest percentage of clinically significant insomnia (6.2%) was experienced by women with EPDS<9 who completed measures in Spanish.

CONCLUSIONS

In this sample of low-income, mostly Spanish-speaking pregnant Latinas, rates of clinically significant insomnia appear to be higher than rates among nonpregnant Latinas. Rates of clinically significant insomnia are particularly high among Latinas with elevated depressive symptom severity, a known risk for insomnia. Acculturation, as indicated by completing measures in English, may be another risk specific to Latinas, possibly owing to loss of some ethnicity-specific protective factors (e.g., social support, strong family ties, and group identity). It will be important to directly test this explanation in future research.

Chronic exposure to everyday discrimination and sleep in a multiethnic sample of middle-aged women

OBJECTIVE

Researchers have suggested that poor sleep may play a role in the association between discrimination and health, but studies linking experiences of discrimination to sleep are limited. The authors examined associations between reports of everyday discrimination over 4 years (chronic everyday discrimination) and subjective and objective indicators of poor sleep.

METHOD

Participants were 368 African American, Caucasian, and Chinese women from the Study of Women's Health Across the Nation Sleep Study. Everyday discrimination was assessed each year from baseline through the third follow-up exam via questionnaire with the Everyday Discrimination Scale (intraclass correlation coefficient over 4 years = .90). Subjective sleep complaints were measured beginning in Year 5 with the Pittsburgh Sleep Quality Index. Objective indices of sleep continuity, duration, and architecture were assessed via in-home polysomnography, beginning in Year 5.

RESULTS

In linear regression analyses adjusted for age, race/ethnicity, and financial strain, chronic everyday discrimination was associated with more subjective sleep complaints (Estimate = 1.52, p < .001) and polysomnography-assessed wakefulness after sleep onset (Estimate = .19, p < .02), a marker of sleep continuity. Findings did not differ by race/ethnicity and remained significant after adjusting for menopausal status, body mass index, medication use, and depressive symptoms.

CONCLUSION

Experiences of chronic everyday discrimination are independently associated with both subjective and objective indices of poor sleep. Findings add to the growing literature linking discrimination to key markers of biobehavioral health.

Sleep-related behaviors and beliefs associated with race/ethnicity in women

Explore how social factors influence sleep, especially sleep-related beliefs and behaviors. Sleep complaints, sleep hygiene behaviors, and beliefs about sleep were studied in 65 black/African American and white/European American women. Differences were found for snoring and discrepancy between sleep duration and need. Sleep behaviors differed across groups for napping, methods for coping with sleep difficulties, and nonsleep behaviors in bed. Beliefs also distinguished groups, with differences in motivation for sleep and beliefs about sleep being important for health and functioning. These findings have important public health implications in terms of developing effective sleep education interventions that include consideration of cultural aspects.

Association of sleep duration with untreated diabetes in Japanese men

OBJECTIVE

We assessed the cross-sectional association between sleep duration and untreated diabetes in Japanese men.

METHODS

Participants included 20,744 men aged 30-64 years who first visited the general hospital in Tokyo for routine health assessments during 2003-2007. Untreated diabetes was defined as not being under diabetes treatment and fasting blood glucose of ≥126 mg/dL or hemoglobin A(1c) of ≥6.5%. Sleep duration (≤5, 6, 7, or ≥8 h) and confounders were assessed using a questionnaire. Logistic regression was used to calculate odds ratios (ORs) for diabetes after adjustment for confounders.

RESULTS

The prevalence of untreated diabetes was 3.4% in all men. The prevalence of untreated diabetes by sleep duration was as follows: ≤5 h: 3.5%; 6 h: 3.3%; 7 h: 3.2%; and ≥8 h: 5.1%. Men who reported sleeping for ≤5 h (OR: 1.52, 95% confidential interval [CI]: 1.22-1.90) and ≥8 h (OR: 1.39, 95% CI: 1.05-1.85) were significantly more likely to have untreated diabetes compared with those who reported sleeping for 7 h. In stratified analyses by obesity (body mass index ≥25.0 kg/m(2)), the association between long sleep duration (≥8 h) and untreated diabetes remained significant only in obese men.

CONCLUSION

Short sleep duration was significantly associated with untreated diabetes in both nonobese and obese men. Regarding long sleep duration, a significant association was observed in obese men only.

Association of short sleep duration with obesity, diabetes, fatty liver and behavioral factors in Japanese men

OBJECTIVE

Sleep is one of the major means to maintain health. The association of short sleep duration with obesity, diabetes, fatty liver and behavioral factors requires further exploration.

METHODS

A total of 8157 Japanese men who underwent health evaluations were divided into 3 groups by sleep duration <5 hours, 5~<7 hours and ≥7 hours. Poor sleep was self-reported, being defined as difficulty of getting to sleep or awakening easily. The age-adjusted and age and poor sleep-adjusted odds ratios of the 3 groups for obesity, diabetes, fatty liver, mental stress, poor sleep, regular exercise and late dinner time were investigated.

RESULTS

Compared to the sleep duration 5~<7 hours group, the age-adjusted odds ratios of the <5 hours group were significantly higher for obesity (1.42), diabetes (1.63), mental stress (1.75), poor sleep (1.85), late dinner time (1.47), and significantly lower for regular exercise (0.61); while those of the ≥7 hours group were significantly lower for obesity (0.73), fatty liver (0.82), mental stress (0.73), poor sleep (0.69), late dinner time (0.45), and significantly higher for regular exercise (1.27). Above significances still existed after adjustment for age and poor sleep.

CONCLUSION

Short sleep duration is associated with obesity, diabetes, fatty liver and multiple behavioral factors. The optimal sleep duration for health promotion and effective actions for obtaining optimal sleep, including modifications of behavioral and environmental factors, should be one of the major concerns of public health.

Gender and ethnic differences in prevalence of self-reported insomnia among patients with obstructive sleep apnea

BACKGROUND

Insomnia and obstructive sleep apnea (OSA) are the two most common sleep disorders. Studies have shown that complaints of insomnia are prevalent among sleep clinic patients evaluated for OSA. Less is known about the gender and ethnic variations in this association.

OBJECTIVES

This paper aims to study the influence of gender and ethnicity in the prevalence of insomnia in patients with OSA and explore the association between these two disorders with an emphasis on psychophysiologic insomnia.

METHODS AND MEASUREMENTS

We reviewed case files, including self-reported questionnaires and polysomnography studies of 300 OSA patients [apnea-hypopnea index (AHI) of >10] from three ethnic groups--Caucasian, Hispanic, and African American, 50 patients each, male and female, seen at a tertiary care county hospital adult sleep center. Self-reported insomnia was classified as sleep onset insomnia, sleep maintenance insomnia, or insomnia with early morning awakening. Psychophysiologic insomnia was documented if the patient reported two of the following five symptoms: racing thoughts when trying to sleep, increased muscle tension when trying to sleep, fear of being unable to sleep, fear of being unable to fall back to sleep after waking up, and lying in bed worrying. Fischer exact tests for each contingency table were run using SPSS.

RESULTS

Among OSA patients, women were older, had higher body mass index, and lower AHI at the time of diagnosis, compared to men. Insomnia was more prevalent among patients with OSA (84%) than the reported 30% among general adult population. Sleep onset insomnia was reported more frequently by women (62%) than men (53%) (p = 0.03). Similarly self-reported psychophysiologic insomnia also showed a female preponderance (53% vs. 45%, p = 0.03). Caucasian women had the highest rate of self-reported sleep maintenance insomnia (80%). Hispanic women are more likely to complain of symptoms suggestive of psychophysiologic insomnia (58%).

CONCLUSIONS

There is a higher prevalence of insomnia in OSA patients. Ethnicity and gender possibly exhibit a complex and significant influence on the reported subtype of insomnia. Further larger studies may help confirm, as well as clarify, mechanisms that underlie the ethnic and gender differences that we have noted.

Napping, nighttime sleep, and cardiovascular risk factors in mid-life adults

STUDY OBJECTIVES

To evaluate the relations between sleep characteristics and cardiovascular risk factors and napping behavior, and to assess whether daytime napping leads to subsequent better or worse sleep.

METHODS

The sample consisted of 224 (African American, Caucasian, and Asian) middle-aged men and women. Sleep measures included nine nights of actigraphy and sleep diaries, sleep questionnaires, and one night of polysomnography to measure sleep disordered breathing.

RESULTS

More frequent napping was associated with shorter nighttime sleep duration averaged across the nine nights of actigraphy (especially among African Americans), more daytime sleepiness, more pain and fatigue by diary, and increased body mass index and waist circumference. Shorter nighttime sleep duration was associated with taking a nap during the next day and taking a nap was associated with less efficient sleep the next night.

CONCLUSIONS

Napping in middle-aged men and women is associated with overall less nighttime sleep in African Americans and lower sleep efficiency as measured by actigraphy, and increased BMI and central adiposity. These findings point to the importance of measuring of napping in understanding associations of sleep with cardiovascular risk.

Prevalence and correlates of insomnia and its impact on quality of life in Chinese schizophrenia patients

STUDY OBJECTIVES

This study aimed to determine the prevalence and the sociodemographic and clinical correlates of insomnia in Chinese schizophrenia outpatients and its impact on patients' quality of life (QOL).

DESIGN

Two hundred fifty-five clinically stable schizophrenia outpatients were randomly selected in Hong Kong and their counterparts matched according to sex, age, age at onset, and length of illness were recruited in Beijing, China. All subjects at both sites were interviewed by the same investigator using standardized assessment instruments.

SETTING

Hong Kong and Beijing, China.

PATIENTS OR PARTICIPANTS

Clinically stable schizophrenia outpatients.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

In the combined Beijing-Hong Kong sample the frequency of at least one type of insomnia over the previous 12 months was 36.0%; the rates of difficulty initiating sleep (DIS), difficulty maintaining sleep (DMS), and early morning awakening (EMA) were 21.2%, 23.6%, and 11.9%, respectively. Poor sleep was significantly associated with advanced age, older age at onset, fewer psychiatric admissions, severity of positive symptoms, anxiety, extrapyramidal symptoms (EPS) and depressive symptoms, less frequent use of atypical antipsychotic medications (AP), and more frequent use of benzodiazepines (BZD) and hypnotics. Poor sleepers had significantly poorer QOL in all domains than patients without insomnia. After controlling for the potential confounding effects of sociodemographic and clinical factors, a significant difference remained between the 2 groups with regard to the physical QOL domain. A multiple logistic regression analysis found that advanced age, fewer psychiatric admissions, severity of depressive symptoms and use of hypnotics were significant contributors to poor sleep.

CONCLUSION

Insomnia is independently associated with poor QOL. More attention should be paid in clinical practice to the high rate of insomnia in Chinese schizophrenia patients.

Insomnia did not predict incident hypertension in older adults in the cardiovascular health study

STUDY OBJECTIVE

We hypothesized that the sleep complaints of insomnia predict incident hypertension, particularly in African Americans. The purpose of this study was to analyze insomnia complaints as predictors of incident hypertension in the Cardiovascular Health Study (CHS), stratifying by gender and allowing for race and sleep variable interaction.

DESIGN

This is a prospective cohort study over a 6-year period of follow-up.

SETTING

This is a community-based study of participants in Forsyth County, North Carolina; Pittsburgh, Pennsylvania; Sacramento County, California; and Washington County, Maryland.

PARTICIPANTS

The study analyzed data from 1419 older individuals (baseline mean age 73.4 +/- 4.4 years) from the Cardiovascular Health Study who were not hypertensive at baseline.

INTERVENTIONS

none.

MEASUREMENTS

We constructed relative risks of incident hypertension over a 6-year period for insomnia complaints singly and in combination.

RESULTS

Difficulty falling asleep, singly or in combination with other sleep complaints, predicted a statistically significant reduction of risk for incident hypertension for non-African American men in 6 years of follow-up. Insomnia complaints did not predict incident hypertension in 6 years of follow-up in women or in African Americans, although there may not have been enough power to show a significant association for African Americans.

CONCLUSIONS

Insomnia did not predict hypertension in this older cohort which was free of hypertension at baseline. Difficulty falling asleep was associated with reduced risk of hypertension in non-African American men.

Race and financial strain are independent correlates of sleep in midlife women: the SWAN sleep study

STUDY OBJECTIVES

To examine racial differences in sleep in a large cohort of midlife women and to evaluate whether indices of socioeconomic status (SES) are associated with racial differences in sleep.

DESIGN

Cross-sectional study.

SETTING

Participants' homes.

PARTICIPANTS

Caucasian (n=171), African American (n=138) and Chinese women (n=59).

INTERVENTIONS

None.

MEASUREMENTS

Sleep quality was assessed with the Pittsburgh Sleep Quality Index. Polysomnographically assessed sleep duration, continuity, architecture, and NREM electroencephalograhic (EEG) power were calculated over multiple nights. Sleep disordered breathing and periodic leg movements were measured on a separate night. Linear regression analysis was used to model the independent and synergistic effects of race and SES on sleep after adjusting for other factors that impact sleep in midlife women. Indices of SES were self-reported educational attainment and financial strain.

RESULTS

Sleep was worse in African American women than Caucasian participants as measured by self-report, visual sleep stage scoring, and NREM EEG power. Slow wave sleep differences were also observed between Chinese and Caucasian participants. Racial differences persisted after adjustment for indices of SES. Although educational attainment was unrelated to sleep, financial strain was associated with decreased sleep quality and lower sleep efficiency. Financial strain-by-race interactions were not statistically significant, suggesting that financial strain has additive effects on sleep, independent of race.

CONCLUSIONS

Independent relationships between race and financial strain with sleep were observed despite statistical adjustment for other factors that might account for these relationships. Results do not suggest that assessed indices of SES moderate the race-sleep relationship, perhaps due to too few women of low SES in the study.

Sleep disturbance during the menopausal transition in a multi-ethnic community sample of women

STUDY OBJECTIVES

Examine age-adjusted odds and racial/ethnic differences in self-reported difficulties falling and staying asleep and early morning awakening in midlife women to determine whether difficulty sleeping increased with progression through the menopausal transition.

DESIGN

Longitudinal analysis.

SETTING

Community-based.

PARTICIPANTS

3,045 Caucasian, African American, Chinese, Japanese, and Hispanic women, aged 42-52 years and pre- or early peri-menopausal at baseline, participating in the Study of Women's Health Across the Nation (SWAN).

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Self-reported number of nights of difficulty falling asleep, staying asleep, and early morning awakening during the previous 2 weeks were obtained at baseline and 7 annual assessments. Random effects logistic regression was used to model associations between each of the 3 sleep measures and the menopausal transition, defined by bleeding patterns, vasomotor symptoms (VMS), and estradiol (E2) and follicle stimulating hormone (FSH) serum levels. Adjusted odds ratios (ORs) for difficulty falling asleep and staying asleep increased through the menopausal transition, but decreased for early morning awakening from late perimenopause to postmenopause. Naturally and surgically postmenopausal women using hormones, compared with those who were not, generally had lower ORs for disturbed sleep. More frequent VMS were associated with higher ORs of each sleep difficulty. Decreasing E2 levels were associated with higher ORs of trouble falling and staying asleep, and increasing FSH levels were associated with higher ORs of trouble staying asleep. Racial/ethnic differences were found for staying asleep and early morning awakening.

CONCLUSIONS

Progression through the menopausal transition as indicated by 3 menopausal characteristics--symptoms, bleeding-defined stages, and endogenous hormone levels--is associated with self-reported sleep disturbances.

Influence of race and socioeconomic status on sleep: Pittsburgh SleepSCORE project

OBJECTIVE

To examine the independent and interactive effects of race and socioeconomic status (SES) on objective indices and self-reports of sleep.

METHODS

The sleep of 187 adults (41% black; mean age = 59.5 +/- 7.2 years) was examined. Nine nights of actigraphy and two nights of inhome polysomnography (PSG) were used to assess average sleep duration, continuity, and architecture; self-report was used to assess sleep quality. Psychosocial factors, health behaviors, and environmental factors were also measured.

RESULTS

Blacks had shorter sleep duration and lower sleep efficiency, as measured by actigraphy and PSG, and they spent less time proportionately in Stage 3-4 sleep, compared with others (p < .01). Lower SES was associated with longer actigraphy-measured latency, more wake after sleep onset as measured by PSG, and poorer sleep quality on the Pittsburgh Sleep Quality Index (p < .05).

CONCLUSIONS

Blacks and perhaps individuals in lower SES groups may be at risk for sleep disturbances and associated health consequences.

Prevalence and consequences of insomnia in New Zealand: disparities between Maori and non-Maori

OBJECTIVE

To investigate the prevalence of self-reported insomnia symptoms among Maori (Indigenous people) and non-Maori adults in the general population of New Zealand. To explore the consequences for health and quality of life experienced by those who report common insomnia complaints and sleeping problems.

METHODS

In 2001, a two-page questionnaire was mailed to a stratified random sample of 4,000 adults aged 20-59 years nationwide. Participants were selected from the New Zealand electoral roll. The sample design aimed for equal numbers of Maori and non-Maori participants, men and women, and participants in each decade of age (72.5% response rate).

RESULTS

Population prevalence estimates indicate that self-reported insomnia symptoms and sleeping problems are higher among Maori than non-Maori. Multiple logistic regression analyses showed that self-reported insomnia symptoms and/or sleeping problems are significantly associated with reporting poor or fair health and quality of life outcomes.

CONCLUSIONS

Approximately one-quarter of adults in New Zealand may suffer from a chronic sleep problem, highlighting insomnia as a major public health issue in New Zealand.

IMPLICATIONS

Significant differences in the prevalence of insomnia symptoms and current sleeping problems with respect to ethnicity have implications in the purchase and development of treatment services, with greater need for these services among Maori than non-Maori.

The sleep of African Americans: a comparative review

Researchers have not thoroughly assessed the sleep of African Americans (AAs) despite the recent increased attention to ethnic research. This article reviews the sleep and epidemiological literatures to assess AA sleep. Although the limited data were sometimes inconsistent, they suggest that AAs sleep worse than Caucasian Americans. AAs take longer to fall asleep, report poorer sleep quality, have more light and less deep sleep, and nap more often and longer. AAs have a higher prevalence of sleep-disordered breathing and exhibit more risk factors for poor sleep. These differences are concentrated in young- and middle-age adults. There are no sleep disorders treatment data for AAs. These data support further research into ethnic differences in both normal and disturbed sleep.

Use of hypnotics in Sámi and non-Sámi populations in northern Norway

OBJECTIVES

Our knowledge of the impact of indigenous culture on drug consumption is scarce. Based on the Sámi Health Study, we compare the use of hypnotics among the Sámi and non-Sámi people, living in the same area at 70 degrees N in northern Norway.

STUDY DESIGN

Cross-sectional survey based on a cardiovascular screening, including questionnaires and a clinical examination.

METHODS

A total of 16 323 men and women born 1925 - 1967 in counties with a mixed Sámi and non-Sámi population responded to a questionnaire delivered at attendance of a health study. The response rate was 60%. The main analyses were restricted to 12 378 subjects with information on all relevant variables, including ethnicity and use of hypnotics.

RESULTS

The prevalence of insomnia and use of hypnotics was significantly lower in the Sámi compared to the non-Sámi population in northern Norway (p < 0.0001). Regardless of ethnicity and age, prevalence of use of hypnotics in women was twice that of men. People who consulted modern, or traditional healers had a higher prevalence of use of hypnotics compared to those who did not.

CONCLUSIONS

The stronger the Sámi affiliation, the lower the prevalence of use of hypnotics. In general, insomnia is less frequently stated in the Sámi than in the non-Sámi study population. This may reflect a different attitude to sleep as a phenomenon among the Sámi.

The influence of age, gender, ethnicity, and insomnia on Epworth sleepiness scores: A normative US population

BACKGROUND AND PURPOSE

This study explored the distribution of Epworth Sleepiness Scale (ESS) scores in a randomly sampled, community population and provided percentile scores that will assist in decision-making in both research and clinical settings.

PATIENTS AND METHODS

Participants included 703 individuals between the ages of 20 and 98, with 116 people with insomnia (PWI) and 587 people not having insomnia (PNI). Analyses produced main effects for sleep status and ethnicity.

RESULTS

PWI had higher ESS scores than PNI and African-Americans had higher ESS scores than Caucasians, although effect sizes were small. Gender, age group, and season did not impact ESS scores. Receiver operating characteristic (ROC) curve analysis proved the ESS to discriminate poorly between PWI and PNI.

CONCLUSIONS

This study found higher percentages of 'sleepy' individuals than previous studies. PWI did have slightly elevated scores on the ESS, but this elevation was not necessarily predictive of an insomnia diagnosis. Results support a continuum of sleepiness/alertness among PWI.

Ethnic Differences in Symptoms of Insomnia Among Adolescents

SUBJECT OBJECTIVE

To provide data on the prevalence of symptoms of disturbed sleep, particularly insomnia, and to ascertain whether there are differentials attributable to ethnic culture or ethnic status.

DESIGN

Data were collected from youths (aged 11-17 years) and adult caregivers from a community-based sample of households using personal interviews and questionnaires.

SETTING

Managed-care subscriber populations in metropolitan area of over 4.5 million.

PARTICIPANTS

The sample consisted of 4175 youths and their caregivers (35.4% European American, 35.4% African American, 20.5% Mexican American, and 8.7% Other American).

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

The overall prevalence of DSM-IV insomnia-like syndrome in the past month was 4.7%. Females were more likely to report this syndrome, as were lower-income youths. Prevalence for European American youths was 5.3%, 5.2% for African American, and 3.5% Mexican American youths (p > .05). There also were some ethnic differences across symptoms of sleep disturbance that constitute insomnia.

CONCLUSION

For most comparisons, subsequent multivariate analyses indicate no significant ethnic difference, supporting the hypothesis that observed ethnic differences are due primarily to the effects of status differences (e.g., age, gender, socioeconomic status, etc.). Insomnia clearly is a major public health problem, with prevalences comparable to mood, anxiety and disruptive behavior disorders among adolescents.

Impact of Insomnia on Individual Health Dissatisfaction in Japan, South Korea, and Taiwan

STUDY OBJECTIVES

This study assessed the impact of insomnia on individual health dissatisfaction in Japan, South Korea, and Taiwan.

DESIGN

Cross-sectional surveys with a face-to-face interview were conducted in Japan (n = 1414), South Korea (n = 1007), and Taiwan (n = 785). Participants completed a questionnaire on general health dissatisfaction and insomnia symptoms. Insomnia was defined as having at least one of three types of insomnia symptoms (i.e., difficulty initiating sleep, difficulty maintaining sleep, and early-morning awakening). Information on sociodemographic characteristics (i.e., sex, age, education level, and household income) was also collected.

SETTING

N/A.

PARTICIPANTS

A nationwide sample of subjects aged 20 years or older

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

The age-adjusted prevalence of insomnia "lasting more than 2 weeks" was 4.0% in Japan, 9.9% in South Korea, and 10.3% in Taiwan. Insomnia was an independent contributor to health dissatisfaction after adjusting for sociodemographic characteristics in the three countries, with odds ratios of 2.54 (95% CI, [1.51-4.28]) in Japan, 2.15 (95% CI [1.33-3.48]) in South Korea, and 2.31 (95%CI [1.37-3.89]) in Taiwan. A multivariate logistic analysis showed that the sociodemographic characteristics that significantly influenced health dissatisfaction varied among nations-including older age and low education level in Japan and female gender and middle-income level in South Korea. No independent variables were selected in Taiwan.

CONCLUSION

Insomnia is closely linked to health dissatisfaction in the three Asian countries, with variation according to social and demographic factors.

Sleep duration and caffeine consumption in a French middle-aged working population

OBJECTIVE/BACKGROUND

To explore the association between sleep duration and daily caffeine intake in a working population. Caffeine acutely disrupts sleep in the laboratory, but the inter-relations between sleep and caffeine intake in daily life are ill-known.

METHODS

Questionnaire and diary based survey of 1498 persons from the GAZEL cohort of employees of the National Electricity and Gas Company (EDF-GDF) working in various locations in the Paris and South-West France areas. We analyzed total sleep time, our primary measure, and time in bed, both by sleep logs. We assessed daily intake of caffeine, consumption of alcohol and tobacco, use of hypnotics, and daytime somnolence, all by questionnaire.

RESULTS

Multiple linear regression analysis did not find a significant relationship between total sleep time and daily caffeine intake less than 8 cups of coffee per day, after controlling for age, gender, alcohol intake, smoking status, and use of hypnotics. By contrast, time in bed was reduced as caffeine intake increased (beta=-0.125; P<0.001). Higher caffeine intake was not related to a higher daytime somnolence.

CONCLUSION

Despite the well-known acute effects of caffeine on sleep, habitual use of up to 7 cups of coffee (or 600 mg of caffeine equivalent) per day was not associated with decreased duration of sleep.

Sleep-related nighttime crying (yonaki) in Japan: a community-based study

OBJECTIVE

To examine factors associated with the phenomenon of yonaki, or sleep-related nighttime crying (SRNC), in Japanese children

METHODS

A cross-sectional design incorporating parental self-report was used to investigate relationships between developmental, psychologic, and constitutional/physiological factors in the incidence of SRNC. Participants were the parents of 170 infants, 174 toddlers, and 137 children at a well-infant clinic in Tokyo, Japan.

RESULTS

The lifetime incidence rates of SRNC were 18.8% (infants), 64.9% (toddlers), and 59.9% (children). At all ages, children were most likely to cosleep with their parents; however, infants with reported SRNC were found to cosleep more frequently, whereas infants without SRNC were more likely to sleep in separate, child-dedicated beds. Toddlers with frequent SRNC were more likely to have irregular bedtimes and to have nonparental day care than were those without SRNC. Preschoolers who typically slept 9.5 to 10.5 hours per night were less likely to report SRNC than were children with longer or shorter nighttime sleep durations. In all groups, children with frequent SRNC were more likely to suffer from chronic eczema, and toddlers and preschoolers with SRNC exhibited bruxism more frequently.

CONCLUSIONS

The traditional Japanese arrangement of cosleeping represents an environment in which parents are readily accessible to children during waking episodes. Physical proximity to the parents in infancy, but not at other ages, is associated with SRNC. The higher incidence of bruxism, chronic eczema, and day care use among children with frequent SRNC supports the hypothesis that nighttime anxiety may promote SRNC.

Evaluation of insomnia and daytime napping in Iranian Alzheimer disease patients: relationship with severity of dementia and comparison with normal adults

OBJECTIVE

Alzheimer disease (AD) is among the most common and disabling diseases in adulthood, and it has been largely neglected in traditional societies like Iran. Exacerbation of AD symptoms creates many severe problems, especially in traditional Iranian extended families. One of these problems is insomnia, which can very significantly affect patients' family members because of disturbing insomnia-related behaviors.

METHODS

The authors studied 53 patients with probable AD who had been interviewed for dementia and depression in the Neurology Clinic of Roozbeh Psychiatric Hospital (Tehran University of Medical Sciences). Excluding patients with overlapping multi-infarct dementia, 35 AD patients (22 men, 13 women) and 21 adults without dementia were studied as a comparison group (11 men, 10 women).

RESULTS

There was a significant relationship between duration of informant-reported symptoms and severity of dementia with daytime napping and more daytime napping among AD patients than in the comparison group. There was also a significant relationship between cognitive decline and daytime napping in the comparison group. Our study showed a relationship between insomnia and aggression, between daytime napping and paranoid delusions; and between onset of insomnia and anxiety. The comparison group showed a significant relationship between depression and daytime napping.

CONCLUSIONS

Daytime napping and insomnia are very common among Iranian AD patients, much more so than in normal adults. There is also a significant relationship among psychiatric symptoms, daytime napping, and insomnia, but it seems that daytime napping and insomnia in depressed AD patients are caused more by the progress of AD than by depression.

Who Reports Insomnia? Relationships with Age, Sex, Ethnicity, and Socioeconomic Deprivation

STUDY OBJECTIVES

To investigate the prevalence of self-reported insomnia symptoms among Mâori (indigenous people) and non-Mâori adults in the general population of New Zealand. To explore the possible links between insomnia symptoms and ethnicity, gender, age, employment status and socio-economic deprivation.

DESIGN

Mail-out survey to a stratified random sample of 4,000 people aged 20 to 59 years, selected from the electoral roll.

SETTING

Nationwide survey of New Zealand adults (72.5% response rate).

PARTICIPANTS

The sample design aimed for equal numbers of Mâori and non-Mâori participants, men and women, and participants in each decade of age.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

Population prevalence estimates indicated that self-reported insomnia symptoms and sleeping problems were higher among Mâori than non-Mâori. Multiple logistic regression analyses identified unemployment and socioeconomic deprivation as being strongly associated to all insomnia symptoms and to reporting a sleeping problem lasting more than 6 months.

CONCLUSIONS

Socioeconomic factors and ethnicity are significant independent predictors of reported insomnia symptoms. This finding has important implications for the provision of treatment services to those most in need.

Prevalence and risk factors of insomnia in community-dwelling Chinese elderly: a Taiwanese urban area survey

OBJECTIVE

To determine the prevalence of and risk factors for self-reported sleep complaints in the elderly.

METHOD

A cross-sectional interview study was conducted in a total of 2045 non-institutionalized older individuals aged 65 years or above of an urban community of Taiwan.

RESULTS

The prevalence of one-month insomnia was 6% overall with a higher rate in elderly women (8%) than men (4.5%). Frequent use of hypnotics over the past month was 8.4%. Among specific sleep complaints, poor sleep quality was the most commonly reported symptom, followed by difficulty falling asleep and difficulty maintaining sleep or early morning awakenings. Increasing age did not correlate with an increased rate of insomnia and female gender was not an independent risk factor. Factors associated with insomnia for both genders were nocturnal micturation (OR = 20.6) and regular use of hypnotics (OR = 3.2). Pulmonary disease (OR = 2.7), not married (OR = 2.3), excessive daytime sleepiness (OR = 2.4), and mental illness (OR = 8.6) were risk factors for men while lack of education (OR = 1.8) and body pain (OR = 2.6) were risk factors for women. Depression (OR = 2.2) was strongly associated with insomnia in the elderly women as well.

CONCLUSIONS

There was a low insomnia prevalence rate in the urban elderly community. Identified insomniacs required treatment of physical and mental problems, particularly in gender-specific risk factors. For those who complained of putative poor sleep quality symptom, early intervention may halt their progress of sleep disturbance and avoid unnecessary benzodiazepine use. Future longitudinal studies to investigate causes of insomnia, as well as its detrimental effects on mood and health, are warranted.

Répercussions diurnes de l’insomnie dans la population générale française

Insomnia is a frequent symptom in the general population; numerous studies have proven this. In the past years, classifications have gradually given more emphasis to daytime repercussions of insomnia and to their consequences on social and cognitive functioning. They are now integrated in the definition of insomnia and are used to quantify its severity. If the daytime consequences of insomnia are well known at the clinical level, there are few epidemiological data on this matter. The aim of this study was to assess the daytime repercussions of insomnia complaints in the general population of France. A representative sample (n=5,622) aged 15 or older was surveyed by telephone with the help of the sleep-EVAL expert system, a computer program specially designed to evaluate sleep disorders and to manage epidemiological investigations. Interviews have been completed for 80.8% of the solicited subjects (n=5,622). The variables considered comprised insomnia and its daytime repercussions on cognitive functioning, affective tone, daytime sleepiness and diurnal fatigue. Insomnia was found in 18.6% of the sample. The prevalence was higher in women (22.4%) than in men (14.5%, p<0.001) with a relative risk of 1.7 (95% confidence interval 1.5 to 2) and was twice more frequent for subjects 65 years of age or older compared to subjects younger than 45 years. Approximately 30% of subjects reporting insomnia had difficulties initiating sleep. Nearly 75% of insomnia complainers reported having a disrupted sleep or waking up too early in the morning and about 40% said they had a non-restorative sleep. Repercussions on daytime functioning were reported by most insomnia subjects (67%). Repercussions on cognitive functioning changed according age, number of insomnia symptoms and the use of a psychotropic medication. A decreased efficiency was more likely to be reported by subjects between 15 and 44 years of age (OR: 2.9), those using a psychotropic (OR: 1.5), those reporting at least three insomnia symptoms (OR: 1.4) and women (OR: 1.4). The highest probability of the appearance of concentration difficulties was found in subjects younger than 65 Years, having a depressive disorder and using a psychotropic (15-44 years: OR 19.1; 45-64 years: OR 46.6). Difficulties maintaining attention were 15 times higher in subjects aged between 45 and 64 who were using a psychotropic and had also a depressive disorder. Memory difficulties were three times more likely to be reported by subjects using a psychotropic. At the affective level, irritability was 10 times more likely to be reported by subjects younger than 65 Years who were also using a psychotropic and had a depressive disorder. Independent of the presence of a mental disorder and the use of a psychotropic, subjects between 15 and 44 Years were five times more likely to be irritable following a bad sleep. Feeling depressed after a bad night's sleep was 18 times more likely to occur in subjects aged between 45 and 64 who were using a psychotropic and had a depressive disorder. Feeling anxious after a bad night's sleep was seven times more likely to occur in subjects with a depressive disorder. Daytime sleepiness was reported by approximately 20% of insomnia subjects. This rate was relatively comparable among gender, age groups, presence/absence of a mental disorder and use or not of a psychotropic. However, taking into account the interaction between age, use of a psychotropic and the presence of a mental disorder, subjects younger than 65 years, using a psychotropic and having a depressive disorder were at least 10 times more likely to report daytime sleepiness. Subjects who were suffering the most diurnal symptoms of insomnia were those younger than 65 years. Several factors can be evoked to explain this fact. These subjects were, for the most part, likelier to have a stricter sleep/wake schedule because of constraints imposed by work, studies, child care, etc. Subjects older than 65 Years were generally retired and therefore less prone to sleepiness and to cognitive difficulties. Insomnia consequences were limited due to their inactivity. Complementary studies should be undertaken to describe the daytime repercussions of insomnia for this specific age group of the general population and to measure these repercussions.

Population study on the prevalence of insomnia and insomnia-related factors among Japanese women

BACKGROUND

To identify the effect of certain factors on insomnia in the general population.

METHODS

A self-reported questionnaire survey was conducted among 648 Japanese women living in the residential area of a city. Age of participants ranged from 20 to 80 s.

RESULTS

The crude prevalence of insomnia was 8.8%. Multivariate logistic regression analysis with control for many confounding variables revealed that experiencing a major life event (OR=4.4, 95% CI=1.7-11.4, P<0.01), depressive state (OR=1.2, 95% CI=1.1-1.3, P<0.01), and 'relatively poor or poor' self-rated health (OR=3.2, 95% CI=1.0-10.1, P<0.05) were risk factors for insomnia. By contrast, there was no dose-response relationship between the distance of our subjects from a major road and prevalence of insomnia.

CONCLUSIONS

The authors assume that depressive state by a major life event is closely associated with insomnia and that relatively poor self-rated health is also associated with stressful event and psychological distress. Although the noise from vehicles such as cars or motorcycles can affect the quality of sleep for subjects who live near a major road, in general the prevalence of insomnia did not increase significantly in this study.

Sleep duration, insomnia and behavioral problems among Chinese adolescents

This study examined the associations among sleep duration, insomnia, and behavioral problems in a sample of 1359 Chinese adolescents. Participants completed a self-administrated questionnaire that included questions on sleep duration and insomnia symptoms and the Youth Self-Report of Child Behavior Checklist. It was found that adolescents who complained of insomnia reported sleep duration only half an hour shorter than did those without insomnia. Sleep duration did not differ among adolescents reporting three different types of insomnia (difficulty initiating sleep, difficulty maintaining sleep, and early morning awakening). Adolescents with insomnia reported more behavioral problems than did those without complaints of insomnia. After adjustment for age and sex, sleep duration of less than 7 h a day was significantly associated with most behavioral problems in those without complaints of insomnia but with only a few behavioral problems in adolescents reporting insomnia. Results suggest that sleep duration in adolescents with insomnia is short, but not as short as reported in previous clinical studies. Insomnia and short sleep duration are associated with a wide range of behavioral and emotional problems in adolescents.

Gender differences in insomnia--a study in the Hong Kong Chinese population

OBJECTIVE

To study the epidemiology of insomnia in the adult Chinese population in Hong Kong and to examine the potential gender-related demographic and lifestyle factors in insomnia.

METHODS

A population study via random telephone survey with a structured questionnaire was carried out for noninstitutionalized Chinese adults aged 18-65 by trained lay interviewers. The questionnaire included demographic data, sleep habits and problems, insomnia symptoms and lifestyle questions.

RESULTS

A total of 9851 subjects (46.4% male; 53.6% female) were included in the final analysis. The overall prevalence of Hong Kong Chinese as suffering from insomnia during the preceding month (with a frequency of sleep disturbance of at least three times per week) was 11.9% (95% CI 11.2-12.6), including difficulty in initiating sleep (DIS) (4.5%; 95% CI 4.1-5.0), difficulty in maintaining sleep (DMS) (6.9%; 95% CI 6.4-7.5) and early morning awakening (EMA) (4.0%; 95% CI 3.6-4.4). Females were about 1.6 times at higher risk for insomnia than males. The prevalence of insomnia was also shown to increase with age. Multivariate analysis showed that unemployment, lower economic status, alcohol consumption, regular medication and psychiatric disturbance were all associated with higher risks of insomnia in both sexes. Furthermore, lower education level and being retired was associated with a higher risk of insomnia in males, but being a housewife, divorced/widowed, and complaining of a nocturnal noisy environment were associated with a higher risk of insomnia in females. Among all these factors, psychiatric disturbance was the most influential risk factor for insomnia in both sexes. The reasons for gender differences of insomnia may include their differences in the prevalence of psychiatric morbidities, symptom endorsement, gonadal steroids, sociocultural factors and coping strategies.

CONCLUSIONS

Overall, 11.9% of the Hong Kong Chinese adult population complained of frequent insomnia in the preceding month. There was a higher prevalence of insomnia in females. Although there were common risk factors for insomnia in both sexes, there existed gender-specific risk factors.