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Musich M, Beversdorf DQ, McCrae CS, Curtis AF. Subjective-Objective Sleep Discrepancy in a Predominately White and Educated Older Adult Population: Examining the Associations with Cognition and Insomnia. J Gerontol B Psychol Sci Soc Sci 2024:gbae074. [PMID: 38679960 DOI: 10.1093/geronb/gbae074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Indexed: 05/01/2024] Open
Abstract
OBJECTIVES This study examined associations between various cognitive domains and sleep discrepancy (self-reported versus objectively measured sleep), and evaluated interactive associations with insomnia status (non-insomnia versus insomnia). METHOD Older adults (N=65, Mage=68.72, SD=5.06, 43 insomnia/22 non-insomnia) aged 60+ reported subjective sleep (7-days of sleep diaries), objective sleep assessment (one-night polysomnography, PSG, via Sleep ProfilerTM during the 7-day period), and completed cognitive tasks (NIH Toolbox-Cognition Battery) measuring attention and processing speed, working memory, inhibitory control, cognitive flexibility, and episodic memory. The sleep diary variable corresponding to same one-night of PSG was used to calculate the sleep discrepancy (diary minus PSG parameter) variables for total sleep time, sleep onset latency, wake after sleep onset, and sleep efficiency. Regression analyses determined independent and interactive (with insomnia status) associations between cognition and sleep discrepancy, controlling for age, sex, apnea-hypopnea index, and sleep medication usage. RESULTS Working memory interacted with insomnia status in associations with sleep discrepancy related to total sleep time and sleep efficiency. In those with insomnia, worse working memory was associated with shorter self-reported total sleep time (p=.008) and lower sleep efficiency (p=.04) than PSG measured. DISCUSSION In older adults with insomnia, worse working memory may be a contributing factor to sleep discrepancy. Future investigations of underlying neurophysiological factors and consideration of other objective sleep measures (actigraphy) are warranted. Prospective findings may help determine whether sleep discrepancy is a potential marker of future cognitive decline.
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Affiliation(s)
- Madison Musich
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, Missouri, USA
| | - David Q Beversdorf
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, Missouri, USA
- Department of Radiology and Neurology, University of Missouri-Columbia, Columbia, Missouri, USA
| | | | - Ashley F Curtis
- College of Nursing, University of South Florida, Tampa, Florida, USA
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2
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Miller MB, Freeman LK, Helle AC, Hall NA, DiBello AM, McCrae CS. Comparative feasibility and preliminary efficacy of CBT for insomnia among adults seeking and not seeking addiction treatment. J Sleep Res 2024; 33:e13969. [PMID: 37423902 DOI: 10.1111/jsr.13969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 05/02/2023] [Accepted: 06/06/2023] [Indexed: 07/11/2023]
Abstract
Two out of three adults seeking treatment for alcohol or other substance use disorders report co-occurring symptoms of insomnia. This study compared the feasibility, acceptability, and preliminary efficacy of cognitive behavioural therapy for insomnia (CBT-I) among adults seeking and not seeking treatment for substance use. Adults with alcohol or other substance use disorders (n = 22, 32% female, 82% White; Mage = 39.5) completed assessments at baseline, post-treatment, and at 6 week follow-up. Of those, 11 were and 11 were not enrolled in substance use treatment. All received CBT-I. Multiple imputation was used for missing data. Data were analysed using repeated measures analyses of variance. In the substance use treatment group, 6/11 completed post and 5/11 completed follow-up. In the non-treatment group, 9/11 completed post and 7/11 completed follow-up. Participants in both groups reported improvements in insomnia severity, sleep onset latency, and dysfunctional beliefs about sleep, with most effects evident at post and follow-up. There was a marginal group-by-time interaction in the change in frequency of substance use, with only participants not in substance use treatment reporting decreases at follow-up. Participants in substance use treatment reported significant reductions in substance-related problems and symptoms of post-traumatic stress disorder over time; however, they also reported more symptoms at baseline. CBT-I produces similar reductions in insomnia but is relatively less feasible among individuals in (versus not in) treatment for substance use disorder. This may be due to the more complex logistics of accessing CBT-I among those in treatment. We speculate that integrating CBT-I into treatment for addictions may improve feasibility in this population. clinicaltrials.gov NCT04198311.
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Affiliation(s)
- Mary Beth Miller
- Department of Psychiatry, University of Missouri, Columbia, Missouri, USA
| | - Lindsey K Freeman
- Department of Psychiatry, University of Missouri, Columbia, Missouri, USA
- Department of Psychological Sciences, University of Missouri, Columbia, Missouri, USA
| | - Ashley C Helle
- Department of Psychological Sciences, University of Missouri, Columbia, Missouri, USA
| | - Nicole A Hall
- Department of Psychology, University of Houston, Houston, Texas, USA
| | - Angelo M DiBello
- Center of Alcohol & Substance Use Studies, Rutgers University, Piscataway, New Jersey, USA
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3
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Rubi S, Monk JK, Shoemaker S, Miller C, Prabhu N, Flores LY, Bernard D, McCrae CS, Borsari B, Miller MB. Perpetuating and protective factors in insomnia across racial/ethnic groups of veterans. J Sleep Res 2024; 33:e14063. [PMID: 37778753 PMCID: PMC10947959 DOI: 10.1111/jsr.14063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/29/2023] [Accepted: 09/19/2023] [Indexed: 10/03/2023]
Abstract
Few studies have examined racial/ethnic differences in rates and correlates of insomnia among veterans. This study compared rates of insomnia and interest in sleep treatment among veterans of diverse racial/ethnic backgrounds. Consistent with the 3P model, we tested racial discrimination as a predictor of insomnia, with post-traumatic stress disorder symptoms and romantic partners as perpetuating and protective moderators of this association, respectively. A total of 325 veterans (N = 236 veterans of colour; 12% Asian, 36% Black, 14% Hispanic/Latine) completed questionnaires online from remote locations. Descriptive statistics were used to compare patterns across racial/ethnic groups. Linear regression was used to test moderators of the association between racial discrimination and insomnia severity. Overall, 68% of participants screened positive for insomnia: 90% of Asian; 79% of Hispanic/Latine; 65% of Black; and 58% of White participants. Of those, 74% reported interest in sleep treatment, and 76% of those with partners reported interest in including their partner in treatment. Racial discrimination and post-traumatic stress disorder were correlated with more severe insomnia, while romantic partners were correlated with less severe insomnia. Only post-traumatic stress disorder moderated the association between racial discrimination and insomnia severity. Rates of insomnia were highest among Asian and Hispanic/Latine participants, yet these groups were among the least likely to express interest in sleep treatment. Racial discrimination may exacerbate insomnia symptoms among veterans, but only among those who do not already have disturbed sleep in the context of post-traumatic stress disorder. Romantic partners may serve as a protective factor in insomnia, but do not seem to mitigate the impact of racial discrimination.
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Affiliation(s)
- Sofia Rubi
- Department of Psychiatry, University of Missouri, School of Medicine, Columbia, Missouri, USA
| | - J. Kale Monk
- Department of Human Development and Family Science, University of Missouri College of Education & Human Development, Columbia, Missouri, USA
| | - Sydney Shoemaker
- Department of Psychiatry, University of Missouri, School of Medicine, Columbia, Missouri, USA
| | - Colten Miller
- Department of Psychiatry, University of Missouri, School of Medicine, Columbia, Missouri, USA
| | - Nivedita Prabhu
- Department of Psychiatry, University of Missouri, School of Medicine, Columbia, Missouri, USA
| | - Lisa Y. Flores
- Department of Psychological Sciences, University of Missouri College of Arts & Sciences, Columbia, Missouri, USA
| | - Donte Bernard
- Department of Psychological Sciences, University of Missouri College of Arts & Sciences, Columbia, Missouri, USA
| | | | - Brian Borsari
- Mental Health Service, San Francisco VA Health Care System, San Francisco, California, USA
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Mary Beth Miller
- Department of Psychiatry, University of Missouri, School of Medicine, Columbia, Missouri, USA
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Curtis AF, Jagannathan S, Musich M, Miller MB, McCrae CS. Mid-to-Late-Life Anxiety and Sleep during Initial Phase of COVID-19: Age- and Sex-Specific Insights to Inform Future Pandemic Healthcare. Brain Sci 2024; 14:346. [PMID: 38671998 PMCID: PMC11047835 DOI: 10.3390/brainsci14040346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/22/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024] Open
Abstract
This study examined associations between COVID-19-related anxiety and sleep in middle-aged and older adults and tested whether these varied by age or sex. In June/July 2020, middle-aged/older adults aged 50+ (n = 277, 45% women, Mage = 64.68 ± 7.83) in the United States completed measures of sleep and COVID-19-related anxiety. Multiple regressions examined whether anxiety was independently associated with or interacted with age or sex in its associations with sleep health, controlling for age, education, medical conditions, sleep/pain medication use, and COVID-19 status. Greater COVID-19 anxiety was associated with worse sleep quality and daytime dysfunction. COVID-19-related anxiety interacted with age (not sex) in associations with total sleep time and sleep efficiency. Greater anxiety was associated with shorter total sleep time and lower sleep efficiency in oldest-older adults (~73 years old) and youngest-older adults (~65 years old) but not middle-aged adults (~57 years old). In mid to late life, older adults may be most vulnerable to the impact of COVID-19-related anxiety on sleep health. Social and behavioral (e.g., knowledge on age-related vulnerability to COVID-19 risk/morbidity/mortality, uncertainty, and changes to daily routines) and physiological factors (sleep disruption and age-related autonomic dysfunction) may underlie these associations. Interventions that mitigate negative pandemic-related psychological and sleep outcomes may be particularly relevant for older adults.
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Affiliation(s)
- Ashley F. Curtis
- College of Nursing, University of South Florida, Tampa, FL 33612, USA
| | - Sadhika Jagannathan
- Department of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, WV 26506, USA;
| | - Madison Musich
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, MO 65211, USA;
| | - Mary Beth Miller
- Department of Psychiatry, University of Missouri-Columbia, Columbia, MO 65212, USA;
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Schotland H, Wickwire E, Aaronson RM, Dawson SC, Khosla S, Lee-Iannotti JK, Leu RM, Lewin DS, McCrae CS, Neubauer D, Ong JC, Heffron TM, Whittington C, Martin JL. Increasing access to evidence-based insomnia care in the United States: findings from an American Academy of Sleep Medicine stakeholder summit. J Clin Sleep Med 2024; 20:455-459. [PMID: 37942936 PMCID: PMC11019205 DOI: 10.5664/jcsm.10922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 11/10/2023]
Abstract
Challenges exist in access to high-quality care for insomnia disorder. After the recent publication of a clinical practice guideline on behavioral and psychological treatments for insomnia in adults, the American Academy of Sleep Medicine (AASM) hosted a 1-day virtual Insomnia Summit in September 2022 to discuss improving care for patients with insomnia disorder. Fifty participants representing a variety of organizations (eg, medical, psychological, and nursing associations; patient advocacy groups; and federal institutions) participated in the event. Videos highlighting patient perspectives on insomnia and an overview of current insomnia disorder treatment guidelines were followed by thematic sessions, each with 3 to 4 brief, topical presentations by content experts. Breakout groups were used to brainstorm and prioritize issues in each thematic area. Top barriers to care for insomnia disorder include limited access, limited awareness of treatment options, low perceived value of insomnia treatment, and an insufficient number of trained clinicians. Top facilitators of high-quality care include education and awareness, novel care models to increase access, expanding the insomnia patient care workforce, incorporating research into practice, and increasing reimbursement for psychotherapies. Priorities for the future include increasing awareness among patients and providers, increasing the number of skilled behavioral sleep medicine providers, increasing advocacy efforts to address insurance issues (eg, billing, reimbursement, and performance measures), and working collaboratively with multidisciplinary organizations to achieve common goals. These priorities highlight that goals set to improve accessible, high-quality care for insomnia disorder will require sustained, coordinated efforts to increase awareness, improve reimbursement, and grow the necessary skilled health care workforce. CITATION Schotland H, Wickwire E, Aaronson RM, et al. Increasing access to evidence-based insomnia care in the United States: findings from an American Academy of Sleep Medicine stakeholder summit. J Clin Sleep Med. 2024;20(3):455-459.
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Affiliation(s)
| | - Emerson Wickwire
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Spencer C. Dawson
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
| | - Seema Khosla
- North Dakota Center for Sleep, Fargo, North Dakota
| | - Joyce K. Lee-Iannotti
- Department of Internal Medicine, Department of Neurology, University of Arizona College of Medicine–Phoenix, Phoenix, Arizona
| | - Roberta M. Leu
- Division of Pulmonology and Sleep, Department of Pediatrics, Emory University, Atlanta, Georgia
- Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | - Christina S. McCrae
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri
| | - David Neubauer
- Sleep Disorders Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jason C. Ong
- Nox Health, Inc, Alpharetta, Georgia
- Center for Circadian and Sleep Medicine, Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Jennifer L. Martin
- VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, Los Angeles, California
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California
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Curtis AF, Nair N, Hayse B, McGovney K, Mikula C, Halder P, Craggs JG, Kiselica A, McCrae CS. Preliminary investigation of the interactive role of physiological arousal and insomnia complaints in gray matter volume alterations in chronic widespread pain. J Clin Sleep Med 2024; 20:293-302. [PMID: 37823586 PMCID: PMC10835766 DOI: 10.5664/jcsm.10860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 10/06/2023] [Accepted: 10/06/2023] [Indexed: 10/13/2023]
Abstract
STUDY OBJECTIVES Brain regions involved in insomnia and chronic pain are overlapping and diffuse. The interactive role of physiological arousal in associations between insomnia symptoms and neural regions is unknown. This preliminary study examined whether arousal interacted with sleep in associations with gray matter volume of frontal (dorsolateral prefrontal cortex, anterior cingulate cortex) and temporal (right/left hippocampus) regions in adults with chronic widespread pain and insomnia complaints. METHODS Forty-seven adults with chronic widespread pain and insomnia (mean age = 46.00, standard deviation = 13.88, 89% women) completed 14 daily diaries measuring sleep onset latency (SOL), wake time after sleep onset, and total sleep time (TST), as well as Holter monitor assessments of heart rate variability (measuring physiological arousal), and magnetic resonance imaging. Multiple regressions examined whether average SOL, wake time after sleep onset, or TST were independently or interactively (with arousal/heart rate variability) associated with dorsolateral prefrontal cortex, anterior cingulate cortex, and left/right hippocampus gray matter volumes. RESULTS Shorter TST was associated with lower right hippocampus volume. TST also interacted with arousal in its association with right hippocampal volume, Specifically, shorter TST was associated with lower volume at highest and average arousal levels. SOL interacted with arousal in its association with anterior cingulate cortex volume, such that, among individuals with lowest arousal, longer SOL was associated with lower volume. CONCLUSIONS Preliminary findings highlight the interactive roles of physiological arousal and insomnia symptoms in associations with neural structure in chronic widespread pain and insomnia. Individuals with the highest physiological arousal may be particularly vulnerable to the impact of shorter TST on hippocampal volume loss. Reducing SOL may only impact anterior cingulate cortex volume in those with lower physiological arousal. CITATION Curtis AF, Nair N, Hayse B, et al. Preliminary investigation of the interactive role of physiological arousal and insomnia complaints in gray matter volume alterations in chronic widespread pain. J Clin Sleep Med. 2024;20(2):293-302.
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Affiliation(s)
- Ashley F. Curtis
- College of Nursing, University of South Florida, Tampa, Florida
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, Missouri
| | - Neetu Nair
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri
| | - Braden Hayse
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri
| | - Kevin McGovney
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, Missouri
| | - Cynthia Mikula
- Department of Health Psychology, University of Missouri-Columbia, Columbia, Missouri
| | - Puja Halder
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri
| | - Jason G. Craggs
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri
- Department of Physical Therapy, University of Missouri-Columbia, Columbia, Missouri
- Department of Psychiatry & Behavioral Neurosciences, University of South Florida, Tampa, FL
| | - Andrew Kiselica
- Department of Health Psychology, University of Missouri-Columbia, Columbia, Missouri
| | - Christina S. McCrae
- College of Nursing, University of South Florida, Tampa, Florida
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri
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7
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Stearns MA, McCrae CS, Curtis AF, Nair N, Hayse B, Nadorff DK, Wilkerson A. Adolescent sleep mediates maternal depressive problems and parenting behaviors: daughter and son differences in a majority Black and Hispanic sample. J Clin Sleep Med 2024. [PMID: 38189515 DOI: 10.5664/jcsm.10996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
STUDY OBJECTIVES Parents who experience depressive symptoms are less likely to use positive parenting behaviors, in part because of sad affect and inconsistency, which can lead to disengaged parenting. Their children also are more likely to get too little sleep, get too much sleep, or have trouble sleeping, leading to increased child irritability and defiance, which may make it more difficult for a parent to use clear rules and result in more harsh parenting behaviors. The current study examined whether adolescent sleep (too little, too much, trouble sleeping) mediated the relation between maternal depression and parenting behaviors (harsh parenting, positive parenting, clear rules). Further, child gender was examined as a moderator (i.e., moderated mediation). METHODS The sample (N=318) consisted of mothers reporting on adolescents aged 16-18 (M=16.89, SD=.429; 53.4% female) from the 10th wave of the Schools and Families Educating Children Study (SAFE). Measures included the Child Behavior Checklist (CBCL), Center for Epidemiologic Studies Depression Scale (CESD), and the Parenting Practices Questionnaire (PPQ). RESULTS Too little sleep mediated the relation between maternal depressive problems and clear rules in the overall sample (β = .05), and between maternal depressive problems and positive parenting (β = .11), clear rules (β = .13), and harsh parenting (β = .14) for only sons. Too much sleep mediated the relation between maternal depressive problems and harsh parenting in the overall sample (β = .03), but no mediation occurred for sons and daughters separately. Trouble sleeping did not serve as a mediator in the overall sample but mediated the relation between maternal depressive problems and clear rules for daughters (β = .03) and between maternal depressive problems and harsh parenting for sons (β = .09). CONCLUSIONS These results suggest that adolescent sleep difficulties may be one contributing factor to why mothers who are dealing with depressive symptoms have difficulty using clear rules/positive parenting and use more harsh parenting behaviors. In addition, several of these mediations differed for sons and daughters, indicating important gender differences which may help to better inform and design intervention programs for mothers experiencing depression.
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Affiliation(s)
| | | | | | - Neetu Nair
- Department of Psychiatry, University of Missouri, Columbia, MO
| | - Braden Hayse
- Department of Psychological Sciences, University of Missouri, Columbia, MO
| | | | - Allison Wilkerson
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
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Curtis AF, Costa AN, Musich M, Schmiedeler A, Jagannathan S, Connell M, Atkinson A, Miller MB, McCrae CS. Sex as a moderator of the sleep and cognition relationship in middle-aged and older adults: A preliminary investigation. Behav Sleep Med 2024; 22:14-27. [PMID: 36809223 DOI: 10.1080/15402002.2023.2177293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
OBJECTIVES Despite known sex differences in the prevalence of sleep disturbance and cognitive impairment, research investigating sex differences in sleep/cognition associations is limited. We examined sex as a moderator of associations between self-reported sleep and objective cognition in middle-aged/older adults. METHODS Adults aged 50+ (32 men/31 women, Mage = 63.6 ± 7.7) completed the Pittsburgh Sleep Quality Index (PSQI) and cognitive tasks: Stroop (processing speed, inhibition), Posner (spatial attentional orienting) and Sternberg (working memory). Multiple regressions examined whether PSQI metrics (global score, sleep quality ratings, sleep duration, sleep efficiency) were independently or interactively (with sex) associated with cognition, controlling for age and education. RESULTS Sex interacted with sleep quality ratings in its association with endogenous spatial attentional orienting (∆R2 = .10, p = .01). Worse ratings of sleep quality were associated with worse orienting in women (B = 22.73, SE = 9.53, p = .02), not men (p = .24). Sex interacted with sleep efficiency in its associations with processing speed (∆R2 = .06, p = .04). Lower sleep efficiency was associated with slower Stroop control trial performance in women (B = -15.91, SE = 7.57, p = .04), not men (p = .48). CONCLUSIONS Preliminary findings suggest middle-aged/older women are more vulnerable to associations between poor sleep quality and low sleep efficiency on spatial attentional orienting and processing speed, respectively. Future studies in larger samples investigating sex-specific prospective sleep and cognition associations are warranted.
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Affiliation(s)
- Ashley F Curtis
- College of Nursing, University of South Florida, Tampa, Florida, USA
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri, USA
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Amy N Costa
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Madison Musich
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Anthony Schmiedeler
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri, USA
- Department of Educational, School, and Counseling Psychology, University of Missouri-Columbia, Columbia, Missouri, USA
| | | | - Maggie Connell
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Angela Atkinson
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Mary Beth Miller
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri, USA
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9
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Costa AN, Coman A, Musich M, Park J, Beversdorf DQ, McCrae CS, Curtis AF. Sleep characteristics and pain in middle-aged and older adults: Sex-specific impact of physical and sitting activity. Sleep Med 2023; 111:180-190. [PMID: 37788556 DOI: 10.1016/j.sleep.2023.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/30/2023] [Accepted: 09/25/2023] [Indexed: 10/05/2023]
Abstract
OBJECTIVES The relationship between poor sleep health and worse pain is established. Physical activity has been successful in reducing chronic pain and improving sleep in aging adults. Despite known sex differences (more women than men experiencing chronic pain and insomnia), sex-specific patterns of interactive associations between physical activity, sleep, and pain remain unexplored. This study tested whether physical and sitting activity moderated associations between sleep characteristics and pain intensity, and whether sex further moderated these relationships. METHODS Participants aged 50+ (N = 170, Mage = 64.34, 72 women) completed an online survey measuring pre-sleep arousal (Pre-sleep Arousal Scale), sleep (Pittsburgh Sleep Quality Index), past month average pain intensity, and physical activity (International Physical Activity Questionnaire). Multiple regressions evaluated whether minutes of physical activity (total, vigorous, moderate, walking) or sitting activity, pre-sleep arousal, sleep, sex, or their interaction was associated with pain. Analyses controlled for education, difficulty walking, body mass index, total medical conditions, pain medication, and depressive/anxiety symptoms. RESULTS In women, vigorous activity interacted with total pre-sleep arousal and somatic pre-sleep arousal in its association with pain. Higher total arousal and somatic arousal were associated with worse pain intensity only for women who reported highest levels of vigorous activity. No such associations were observed for men or for other physical or sitting activity levels. CONCLUSIONS Vigorous physical activity may exacerbate the association between more pre-sleep arousal and worse pain in middle-aged and older women. Research should explore potential sex-specific mechanisms (e.g., inflammatory cytokines, arousal neural networks) underlying these results.
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Affiliation(s)
- Amy N Costa
- Department of Psychology, University of South Florida, Tampa, FL, USA; Department of Psychological Sciences, University of Missouri-Columbia, Columbia, MO, USA
| | - Adriana Coman
- Department of Biological Chemistry, Grinnell College, Grinnell, IA, USA
| | - Madison Musich
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, MO, USA
| | - Jeeeun Park
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, MO, USA; Department of Biological Sciences, University of Missouri-Columbia, Columbia, MO, USA
| | - David Q Beversdorf
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, MO, USA; Department of Neurology, University of Missouri-Columbia, Columbia, MO, USA; Department of Radiology, University of Missouri-Columbia, Columbia, MO, USA
| | | | - Ashley F Curtis
- College of Nursing, University of South Florida, Tampa, FL, USA.
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Miller MB, Carpenter RW, Freeman LK, Dunsiger S, McGeary JE, Borsari B, McCrae CS, Arnedt JT, Korte P, Merrill JE, Carey KB, Metrik J. Effect of Cognitive Behavioral Therapy for Insomnia on Alcohol Treatment Outcomes Among US Veterans: A Randomized Clinical Trial. JAMA Psychiatry 2023; 80:905-913. [PMID: 37342036 PMCID: PMC10285676 DOI: 10.1001/jamapsychiatry.2023.1971] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 04/06/2023] [Indexed: 06/22/2023]
Abstract
Importance Three of 4 adults in treatment for alcohol use disorder (AUD) report symptoms of insomnia. Yet the first-line treatment for insomnia (cognitive behavioral therapy for insomnia, CBT-I) is often delayed until abstinence is established. Objective To test the feasibility, acceptability, and preliminary efficacy of CBT-I among veterans early in their AUD treatment and to examine improvement in insomnia as a mechanism for improvement in alcohol use outcomes. Design, Setting, and Participants For this randomized clinical trial, participants were recruited through the Addictions Treatment Program at a Veterans Health Administration hospital between 2019 and 2022. Patients in treatment for AUD were eligible if they met criteria for insomnia disorder and reported alcohol use in the past 2 months at baseline. Follow-up visits occurred posttreatment and at 6 weeks. Interventions Participants were randomly assigned to receive 5 weekly sessions of CBT-I or a single session about sleep hygiene (control). Participants were asked to complete sleep diaries for 7 days at each assessment. Main Outcomes and Measures Primary outcomes included posttreatment insomnia severity (assessed using the Insomnia Severity Index) and follow-up frequency of any drinking and heavy drinking (4 drinks for women, ≥5 drinks for men; number of days via Timeline Followback) and alcohol-related problems (Short Inventory of Problems). Posttreatment insomnia severity was tested as a mediator of CBT-I effects on alcohol use outcomes at the 6-week follow-up. Results The study cohort included 67 veterans with a mean (SD) age of 46.3 years (11.8); 61 (91%) were male and 6 (9%) female. The CBT-I group included 32 participants, and the sleep hygiene control group 35 participants. Of those randomized, 59 (88%) provided posttreatment or follow-up data (31 CBT-I, 28 sleep hygiene). Relative to sleep hygiene, CBT-I participants reported greater decreases in insomnia severity at posttreatment (group × time interaction: -3.70; 95% CI, -6.79 to -0.61) and follow-up (-3.34; 95% CI, -6.46 to -0.23) and greater improvements in sleep efficiency (posttreatment, 8.31; 95% CI, 1.35 to 15.26; follow-up, 18.03; 95% CI, 10.46 to 25.60). They also reported greater decreases in alcohol problems at follow-up (group × time interaction: -0.84; 95% CI, -1.66 to -0.02), and this effect was mediated by posttreatment change in insomnia severity. No group differences emerged for abstinence or heavy-drinking frequency. Conclusions and Relevance In this randomized clinical trial, CBT-I outperformed sleep hygiene in reducing insomnia symptoms and alcohol-related problems over time but had no effect on frequency of heavy drinking. CBT-I should be considered a first-line treatment for insomnia, regardless of abstinence. Trial Registration ClinicalTrials.gov Identifier: NCT03806491.
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Affiliation(s)
| | | | | | - Shira Dunsiger
- Brown University School of Public Health, Providence, Rhode Island
| | - John E. McGeary
- Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
| | - Brian Borsari
- San Francisco VA Health Care System, San Francisco, California
- University of California, San Francisco
| | | | | | - Paul Korte
- Harry S. Truman Memorial Veterans’ Hospital, Columbia, Missouri
| | | | - Kate B. Carey
- Brown University School of Public Health, Providence, Rhode Island
| | - Jane Metrik
- Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
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11
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McCrae CS, Curtis AF, Stearns MA, Nair N, Golzy M, Shenker JI, Beversdorf DQ, Cottle A, Rowe MA. Development and Initial Evaluation of Web-Based Cognitive Behavioral Therapy for Insomnia in Rural Family Caregivers of People With Dementia (NiteCAPP): Mixed Methods Study. JMIR Aging 2023; 6:e45859. [PMID: 37616032 PMCID: PMC10485710 DOI: 10.2196/45859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 06/12/2023] [Accepted: 07/04/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Informal caregivers of people with dementia frequently experience chronic insomnia, contributing to stress and poor health outcomes. Rural caregivers are particularly vulnerable but have limited access to cognitive behavioral therapy for insomnia (CBT-I), a recommended frontline treatment for chronic insomnia. Web-based delivery promises to improve insomnia, particularly for rural caregivers who have limited access to traditional in-person treatments. Our team translated an efficacious 4-session standard CBT-I content protocol into digital format to create NiteCAPP. OBJECTIVE This study aimed to (1) adapt NiteCAPP for dementia caregivers to create NiteCAPP CARES, a tailored digital format with standard CBT-I content plus caregiver-focused modifications; (2) conduct usability testing and evaluate acceptability of NiteCAPP CARES' content and features; and (3) pilot-test the adapted intervention to evaluate feasibility and preliminary effects on sleep and related health outcomes. METHODS We followed Medical Research Council recommendations for evaluating complex medical interventions to explore user needs and adapt and validate content using a stepwise approach: (1) a rural dementia caregiver (n=5) and primary care provider (n=5) advisory panel gave feedback that was used to adapt NiteCAPP; (2) caregiver (n=5) and primary care provider (n=7) focus groups reviewed the newly adapted NiteCAPP CARES and provided feedback that guided further adaptations; and (3) NiteCAPP CARES was pilot-tested in caregivers (n=5) for feasibility and to establish preliminary effects. Self-report usability measures were collected following intervention. Before and after treatment, 14 daily electronic sleep diaries and questionnaires were collected to evaluate arousal, health, mood, burden, subjective cognition, and interpersonal processes. RESULTS The stepped approach provided user and expert feedback on satisfaction, usefulness, and content, resulting in a new digital CBT-I tailored for rural dementia caregivers: NiteCAPP CARES. The advisory panel recommended streamlining content, eliminating jargon, and including caregiver-focused content. Focus groups gave NiteCAPP CARES high usefulness ratings (mean score 4.4, SD 0.79, scored from 1=least to 5=most favorable; score range 4.2-4.8). Multiple features were evaluated positively, including the intervention's comprehensive and engaging information, caregiver focus, good layout, easy-to-access intervention material, and easy-to-understand sleep graphs. Suggestions for improvement included the provision of day and night viewing options, collapsible text, font size options, tabbed access to videos, and a glossary of terms. Pilot-test users rated usefulness (mean score 4.3, SD 0.83; range 4.1-4.5) and satisfaction (mean score 8.4, SD 1.41, scored from 1=least to 10=most satisfied; range 7.4-9.0) highly. Preliminary effects on caregiver sleep, arousal, health, mood, burden, cognition, and interpersonal processes (all P<.05) were promising. CONCLUSIONS Adaptations made to standard digital CBT-I created a feasible, tailored digital intervention for rural dementia caregivers. Important next steps include further examination of feasibility and efficacy in a randomized controlled trial with an active control condition, a multisite effectiveness trial, and eventual broad dissemination. TRIAL REGISTRATION ClinicalTrials.gov NCT04632628; https://clinicaltrials.gov/ct2/show/NCT04632628.
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Affiliation(s)
- Christina S McCrae
- Department of Psychiatry, University of Missouri, Columbia, MO, United States
- College of Nursing, University of South Florida, Tampa, FL, United States
| | - Ashley F Curtis
- College of Nursing, University of South Florida, Tampa, FL, United States
| | - Melanie A Stearns
- College of Nursing, University of South Florida, Tampa, FL, United States
| | - Neetu Nair
- Department of Psychiatry, University of Missouri, Columbia, MO, United States
| | - Mojgan Golzy
- Department of Family and Community Medicine, University of Missouri, Columbia, MO, United States
| | - Joel I Shenker
- Department of Neurology, University of Missouri, Columbia, MO, United States
| | - David Q Beversdorf
- Department of Neurology, University of Missouri, Columbia, MO, United States
- Departments of Radiology, University of Missouri, Columbia, MO, United States
- Department of Psychological Sciences, University of Missouri, Columbia, MO, United States
- The Thompson Center for Autism and Neurodevelopmental Disorders, University of Missouri, Columbia, MO, United States
| | | | - Meredeth A Rowe
- College of Nursing, University of South Florida, Tampa, FL, United States
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12
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Miller MB, Monk JK, Flores LY, Everson AT, Martinez LD, Massey K, Blanke EM, Dorimé-Williams ML, Williams MS, McCrae CS, Borsari B. Impact of discrimination and coping on Veterans' willingness to seek treatment for physical and mental health problems. Psychol Addict Behav 2023; 37:209-221. [PMID: 35787102 DOI: 10.1037/adb0000861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE This study aimed to provide insight into health disparities among Veterans by (a) documenting the prevalence of physical and mental health problems in a racially diverse sample of Veterans, (b) comparing Veterans' willingness to seek treatment for various physical and mental health conditions, and (c) examining the impact of discrimination and coping on willingness to seek treatment. METHOD Veterans reported on current physical and mental health symptoms and the importance of treatment for various health conditions. Patterns were examined in the full sample (N = 334, 32% female) and the subsample who reported hazardous alcohol use in the past year (n = 116, 33% female). Linear regression was used to test alternative coping as a moderator of the association between experiences with discrimination and willingness to seek treatment among Veterans of color (n = 242, 37% female). RESULTS Participants reported greater willingness to seek treatment for physical than mental health conditions. Sleep problems (75%) and substance use (74%) were the most prevalent health behaviors, but they were rated lowest in treatment importance. Among Veterans of color, everyday experiences with discrimination were generally associated with less willingness to seek physical or mental health treatment, but often only among those who denied use of coping strategies. CONCLUSIONS Veterans are least willing to seek treatment for the health conditions that are most prevalent in their communities. Coping strategies may mitigate the negative association between discriminatory experiences and willingness to seek treatment among Veterans of color. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
| | | | | | | | | | - Kenya Massey
- Department of Educational Leadership & Policy Analysis
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13
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Miller MB, Freeman LK, Aranda A, Shoemaker S, Sisk D, Rubi S, Everson AT, Flores LY, Williams MS, Dorimé-Williams ML, McCrae CS, Borsari B. Prevalence and correlates of alcohol-induced blackout in a diverse sample of veterans. Alcohol Clin Exp Res (Hoboken) 2023; 47:395-405. [PMID: 36533546 PMCID: PMC9992316 DOI: 10.1111/acer.15002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/16/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Alcohol-induced blackouts have been associated concurrently and prospectively with alcohol-related harm. Although rates of heavy drinking among military samples tend to be comparable or higher than rates among civilian samples, the prevalence and correlates of blackout in the military population are understudied. METHODS Veterans (N = 241, 29% female, 39% Black) reported on their alcohol consumption and mental health as part of a larger health-related study among veterans. In this secondary analysis, we tested theoretically and empirically informed predictors (gender, drinking quantity, and other drug use) and consequences [depression, posttraumatic stress disorder (PTSD)] of alcohol-induced blackout. Given the diversity of the sample, potential roles of racial/ethnic discrimination and drinking to cope in alcohol-induced blackout were also tested. RESULTS Past-year prevalence of alcohol-induced blackout was 53% among veterans who drank alcohol and 68% among those who screened positive for hazardous drinking. Everyday experience of racial discrimination was the strongest concurrent predictor of alcohol-induced blackout. Drinking quantity and use of other drugs were significant correlates only in bivariate models. Controlling for gender, race, drinking quantity, other drug use, and discrimination, blackout frequency was significantly associated with symptoms of depression, but not symptoms of PTSD. Both blackout and racial discrimination were associated with drinking to cope. CONCLUSIONS The prevalence and correlates of alcohol-induced blackout among veterans are largely consistent with those documented in civilian and young adult populations. Among racially diverse groups, racial discrimination may be more strongly associated with mental health symptoms than alcohol consumption or acute alcohol consequences such as blackout.
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Affiliation(s)
- Mary Beth Miller
- Department of Psychiatry, University of Missouri, School of Medicine, 1 Hospital Dr DC067.00, Columbia, MO 65212, USA
- Department of Psychological Sciences, University of Missouri, College of Arts & Sciences, 210 McAlester Hall, Columbia, MO 65211, USA
| | - Lindsey K. Freeman
- Department of Psychiatry, University of Missouri, School of Medicine, 1 Hospital Dr DC067.00, Columbia, MO 65212, USA
- Department of Psychological Sciences, University of Missouri, College of Arts & Sciences, 210 McAlester Hall, Columbia, MO 65211, USA
| | - Amaya Aranda
- Department of Psychiatry, University of Missouri, School of Medicine, 1 Hospital Dr DC067.00, Columbia, MO 65212, USA
- Department of Psychological Sciences, University of Missouri, College of Arts & Sciences, 210 McAlester Hall, Columbia, MO 65211, USA
| | - Sydney Shoemaker
- Department of Psychiatry, University of Missouri, School of Medicine, 1 Hospital Dr DC067.00, Columbia, MO 65212, USA
| | - Delaney Sisk
- Department of Psychiatry, University of Missouri, School of Medicine, 1 Hospital Dr DC067.00, Columbia, MO 65212, USA
| | - Sofia Rubi
- Department of Psychiatry, University of Missouri, School of Medicine, 1 Hospital Dr DC067.00, Columbia, MO 65212, USA
| | - Adam T. Everson
- Department of Psychiatry, University of Missouri, School of Medicine, 1 Hospital Dr DC067.00, Columbia, MO 65212, USA
| | - Lisa Y. Flores
- Department of Psychological Sciences, University of Missouri, College of Arts & Sciences, 210 McAlester Hall, Columbia, MO 65211, USA
| | - Michael S. Williams
- Department of Educational Leadership & Policy Analysis, University of Missouri, College of Education, 202 Hill Hall, Columbia, MO 65211, USA
| | - Marjorie L. Dorimé-Williams
- Department of Educational Leadership & Policy Analysis, University of Missouri, College of Education, 202 Hill Hall, Columbia, MO 65211, USA
| | | | - Brian Borsari
- Mental Health Service, San Francisco VA Health Care System, San Francisco, CA
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA
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14
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Costa AN, Curtis AF, Musich M, Guandique AA, McCrae CS. Self-reported cognition in older adults with insomnia: Associations with sleep and domain specific cognition. J Sleep Res 2023; 32:e13751. [PMID: 36217906 DOI: 10.1111/jsr.13751] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 08/01/2022] [Accepted: 09/21/2022] [Indexed: 02/03/2023]
Abstract
Poor subjective evaluation of cognition and sleep are associated with cognitive decline in older adults. Relationships among self-reported cognition, sleep, and cognitive domains remain unclear. We evaluated the interactive associations of objective cognition and subjective sleep with self-reported cognition in older adults with insomnia. Fifty-one older adults (Mage = 69.19, SD = 7.95) with insomnia completed 14 days of self-reported cognition ratings (0-very poor, 100-very good), sleep (total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO), sleep efficiency), and daily cognitive tasks: Letter series (reasoning), word list delayed recall (verbal memory), Symbol Digit Modalities Test (SDMT) (attention/processing speed), and number copy (processing speed). Multiple regressions for each cognitive task determined whether average objective cognition or sleep were independently/interactively associated with average self-reported cognition, controlling for age, education, and depression. The interaction between SDMT performance and TST was associated with self-reported cognition. Specifically, the relationship between scores and self-reported cognition was congruent in those with the shortest TST. Similarly, the interactions between SDMT and WASO, as well as sleep efficiency, were associated with self-reported. Specifically, the relationship between scores and self-reported cognition was congruent in those with longest and average WASO, as well as shortest and average sleep efficiency. The findings suggest, in an older adult population with insomnia, a congruent association exists between attention/processing speed and self-reported cognition in those with worse subjective sleep (shorter TST, longer WASO, and lower SE). Insomnia symptoms should be taken into consideration when examining the relationship between objective cognition and self-reported cognition.
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Affiliation(s)
- Amy N Costa
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Ashley F Curtis
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, Missouri, USA.,Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Madison Musich
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Alan A Guandique
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Christina S McCrae
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri, USA
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15
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Costa AN, Nowakowski LM, McCrae CS, Cowan N, Curtis AF. Discrepancies in Objective and Subjective Cognition in Middle-Aged and Older Adults: Does Personality Matter? Gerontol Geriatr Med 2023; 9:23337214221146663. [PMID: 36644685 PMCID: PMC9837265 DOI: 10.1177/23337214221146663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/21/2022] [Accepted: 12/04/2022] [Indexed: 01/13/2023] Open
Abstract
Associations between subjective cognition and current objective functioning are inconclusive. Given known associations between personality and cognition, this study tested whether personality moderates associations between subjective memory and objective cognition in middle-aged and older adults. Participants (N = 62, M age = 63.8, SD = 7.7, 33 men) completed assessments of personality (Big Five Inventory-10), subjective memory (Cognitive Failures Questionnaire [CFQ-memory]), and objective cognition (processing speed, attention, inhibition [Stroop], working memory [Sternberg], set-shifting [Wisconsin Card Sorting Task]). Multiple regressions and simple slopes analyses examined whether personality moderates associations between subjective memory and objective cognition, controlling for age, number of medical conditions, and household income. Extraversion moderated associations between processing speed and CFQ-memory. Agreeableness moderated associations between set-shifting and CFQ-memory. Among individuals with higher extraversion and lower agreeableness, objectively worse cognition was associated with the fewest memory complaints. Findings suggest personality may impact the discrepancies between subjective memory and objective cognition in mid-to-late life.
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Affiliation(s)
| | | | | | | | - Ashley F. Curtis
- University of Missouri, Columbia, USA,University of South Florida, Tampa, USA,Ashley F. Curtis, College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd, MDC Box 22, Tampa, FL, 33612, USA.
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16
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Chan WS, McCrae CS, Ng ASY. Is Cognitive Behavioral Therapy for Insomnia Effective for Improving Sleep Duration in Individuals with Insomnia? A Meta-Analysis of Randomized Controlled Trials. Ann Behav Med 2022; 57:428-441. [DOI: 10.1093/abm/kaac061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Abstract
Background
Accumulating evidence suggests that sleep duration is a critical determinant of physical and mental health. Half of the individuals with chronic insomnia report less than optimal sleep duration. Cognitive behavioral therapy for insomnia (CBT-I) is an effective treatment for reducing sleep difficulties in individuals with chronic insomnia. However, its effectiveness for increasing sleep duration is less well-established and a synthesis of these findings is lacking.
Purpose
To provide a synthesis of findings from randomized controlled trials (RCTs) on the effect of CBT-I on subjective and objective total sleep time (TST).
Methods
A systematic search was performed on articles published from 2004 to 05/30/2021. A total of 43 RCTs were included in the meta-analysis. Publication biases were examined. Meta-regressions were conducted to examine if any sample or treatment characteristics moderated the effect sizes across trials.
Results
We found a small average effect of CBT-I on diary-assessed TST at post-treatment, equivalent to an approximately 30-min increase. Age significantly moderated the effects of CBT-I on diary-measured and polysomnography-measured TST; older ages were associated with smaller effect sizes. Contrarily, a negative, medium effect size was found for actigraphy-assessed TST, equivalent to an approximately 30-min decrease. Publication biases were found for diary data at follow-up assessments suggesting that positive findings were favored.
Conclusions
CBT-I resulted in improvements in TST measured by sleep diaries and polysomnography (in adults). These improvements were not corroborated by actigraphy findings. Theoretical and clinical implications were discussed.
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Affiliation(s)
- Wai Sze Chan
- Department of Psychology, The University of Hong Kong , Hong Kong , China
| | | | - Albe Sin-Ying Ng
- Department of Psychology, The University of Hong Kong , Hong Kong , China
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17
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Freeman LK, Miller MB, Simenson A, Sparrow E, Costa AN, Musich M, McCrae CS, Curtis AF. Sex differences in associations between alcohol use and sleep in mid-to-late life. Sleep Med 2022; 100:298-303. [PMID: 36152525 DOI: 10.1016/j.sleep.2022.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/18/2022] [Accepted: 08/24/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To examine associations between alcohol use and sleep in middled-aged/older adults and to test sex as a moderator of this relationship. METHODS Participants were 183 adults (46% female) ages 50 and above who consumed alcohol in the past year. Linear regressions tested sex as a moderator of associations between alcohol use and sleep parameters. Alcohol use was measured using the Alcohol Use Disorders Identification Test (AUDIT). Overall sleep health and sleep quality were assessed using the Pittsburgh Sleep Quality Index (PSQI), and pre-sleep arousal was assessed using the Pre-Sleep Arousal Scale. RESULTS Overall, 11% of participants screened positive for hazardous drinking (AUDIT scores of 7+/8+ for women/men), and 59% reported poor overall sleep health (scores >5 on the PSQI). Alcohol use was not associated with overall sleep health (B = -0.25, p = .08) or pre-sleep arousal (B = 0.15, p = .64). However, contrary to hypotheses, more hazardous drinking was associated with better subjective sleep quality, only among women (B = -0.08, p = .009). Alcohol use was not associated with sleep quality among men (B = 0.01, p = .58). Associations remained significant when controlling for age, symptoms of anxiety and depression, body mass index, use of sleep medication, number of medical conditions, and chronic pain. CONCLUSIONS Among middle-aged and older adults, alcohol use is more strongly associated with sleep patterns among women than men, when assessed concurrently (i.e., at the same time point). Findings support the need for further consideration of sex differences in associations between alcohol use and sleep.
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Affiliation(s)
- Lindsey K Freeman
- Department of Psychological Sciences, University of Missouri, 210 McAlester Hall, Columbia, MO, 65211, USA
| | - Mary Beth Miller
- Department of Psychological Sciences, University of Missouri, 210 McAlester Hall, Columbia, MO, 65211, USA; Department of Psychiatry, University of Missouri, 1 Hospital Dr, Columbia, MO, 65212, USA
| | - Angelynn Simenson
- Department of Psychiatry, University of Missouri, 1 Hospital Dr, Columbia, MO, 65212, USA
| | - Emilie Sparrow
- Department of Psychological Sciences, University of Missouri, 210 McAlester Hall, Columbia, MO, 65211, USA
| | - Amy N Costa
- Department of Psychological Sciences, University of Missouri, 210 McAlester Hall, Columbia, MO, 65211, USA
| | - Madison Musich
- Department of Psychological Sciences, University of Missouri, 210 McAlester Hall, Columbia, MO, 65211, USA
| | - Christina S McCrae
- Department of Psychological Sciences, University of Missouri, 210 McAlester Hall, Columbia, MO, 65211, USA; Department of Psychiatry, University of Missouri, 1 Hospital Dr, Columbia, MO, 65212, USA
| | - Ashley F Curtis
- Department of Psychological Sciences, University of Missouri, 210 McAlester Hall, Columbia, MO, 65211, USA; Department of Psychiatry, University of Missouri, 1 Hospital Dr, Columbia, MO, 65212, USA.
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18
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McGovney KD, Curtis AF, McCrae CS. Actigraphic Physical Activity, Pain Intensity, and Polysomnographic Sleep in Fibromyalgia. Behav Sleep Med 2022:1-14. [PMID: 35856908 DOI: 10.1080/15402002.2022.2102009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Fibromyalgia involves chronic pain and disrupted physical activity and sleep. Research examining the relationship between pre-bedtime physical activity, pain, and objective sleep is limited. This study examined whether objectively measured physical activity levels (via actigraphy), pain intensity, or their interaction are associated with polysomnographic sleep outcomes. METHODS Adults with fibromyalgia and insomnia complaints (n = 134, mean age = 52 yrs, SD = 12 yrs, 94% female) completed 14 days of biaxial, wrist worn actigraphy, pain ratings, and a single night of polysomnography (PSG). Average activity for intervals 9:00-12:00, 12:00-15:00, 15:00-18:00, 18:00-21:00 was computed. Multiple regressions examined whether average activity, average evening pain, or their interaction were associated with PSG outcomes: sleep onset latency (SOL), wake after sleep onset (WASO), sleep efficiency, %stage1, %stage2, %stage3, and %rapid eye movement. Analyses controlled for age, body mass index, average bedtime, time in bed, and sleep/pain medication use. RESULTS Greater morning actigraphic physical activity from 9:00 to 12:00 was independently associated with greater %stage 1 sleep (B = 0.01, SE = 0.00, p < .01). Greater afternoon activity from 12:00 to 15:00 independently predicted a higher WASO (p < .001). Associations between afternoon physical activity from 12:00 to 15:00 and greater %stage 1 (p < .001) were significant for at higher (~71/100), average (~52/100), but not lowest (~32/100) pain. CONCLUSION Greater morning and afternoon activity is associated with greater PSG sleep fragmentation and greater %stage 1 sleep in individuals with fibromyalgia and insomnia complaints, and the relationship between higher physical activity and greater %stage 1 is stronger for individuals with higher pain. Further studies examining causal pathways between physical activity, activity pacing, and sleep are warranted in fibromyalgia.
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Affiliation(s)
- Kevin D McGovney
- Department of Psychological Sciences, University of Missouri, Columbia, Missouri, USA
| | - Ashley F Curtis
- Department of Psychological Sciences, University of Missouri, Columbia, Missouri, USA.,Department of Psychiatry, University of Missouri, Columbia, Missouri, USA
| | - Christina S McCrae
- Department of Psychiatry, University of Missouri, Columbia, Missouri, USA
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19
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McCrae CS, Curtis AF, Cottle A, Beversdorf DB, Shenker J, Mooney BP, Popescu M, Rantz M, Groer M, Stein P, Golzy M, Stearns MA, Simenson A, Nair N, Rowe MA. Impact of Web-Based Cognitive Behavioral Therapy for Insomnia on Stress, Health, Mood, Cognitive, Inflammatory, and Neurodegenerative Outcomes in Rural Dementia Caregivers: Protocol for the NiteCAPP CARES and NiteCAPP SHARES Randomized Controlled Trial. JMIR Res Protoc 2022; 11:e37874. [PMID: 35700020 PMCID: PMC9240954 DOI: 10.2196/37874] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/11/2022] [Accepted: 04/26/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Chronic insomnia affects up to 63% of family dementia caregivers. Research suggests that chronic insomnia prompts changes in central stress processing that have downstream negative effects on health and mood, as well as on cognitive, inflammatory, and neurodegenerative functioning. We hypothesize that cognitive behavioral therapy for insomnia (CBT-I) will reverse those downstream effects by improving insomnia and restoring healthy central stress processing. Rural caregivers are particularly vulnerable, but they have limited access to CBT-I; therefore, we developed an accessible digital version using community input (NiteCAPP CARES). OBJECTIVE This trial will evaluate the acceptability, feasibility, and short-term and long-term effects of NiteCAPP CARES on the sleep and stress mechanisms underlying poor caregiver health and functioning. METHODS Dyads (n=100) consisting of caregivers with chronic insomnia and their coresiding persons with dementia will be recruited from Columbia and surrounding areas in Missouri, United States. Participant dyads will be randomized to 4 weeks (plus 4 bimonthly booster sessions) of NiteCAPP CARES or a web-based sleep hygiene control (NiteCAPP SHARES). Participants will be assessed at baseline, after treatment, and 6- and 12-month follow-ups. The following assessments will be completed by caregivers: 1 week of actigraphy and daily diaries measuring sleep, Insomnia Severity Index, arousal (heart rate variability), inflammation (blood-derived biomarkers: interleukin-6 and C-reactive protein), neurodegeneration (blood-derived biomarkers: plasma amyloid beta [Aβ40 and Aβ42], total tau, and phosphorylated tau [p-tau181 and p-tau217]), cognition (Joggle battery, NIH Toolbox for Assessment of Neurological and Behavioral Function, and Cognitive Failures Questionnaire), stress and burden, health, and mood (depression and anxiety). Persons with dementia will complete 1 week of actigraphy at each time point. RESULTS Recruitment procedures started in February 2022. All data are expected to be collected by 2026. Full trial results are planned to be published by 2027. Secondary analyses of baseline data will be subsequently published. CONCLUSIONS This randomized controlled trial tests NiteCAPP CARES, a web-based CBT-I for rural caregivers. The knowledge obtained will address not only what outcomes improve but also how and why they improve and for how long, which will help us to modify NiteCAPP CARES to optimize treatment potency and support future pragmatic testing and dissemination. TRIAL REGISTRATION ClinicalTrials.gov NCT04896775; https://clinicaltrials.gov/ct2/show/NCT04896775. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/37874.
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Affiliation(s)
| | | | | | | | - Joel Shenker
- University of Missouri, Columbia, MO, United States
| | | | | | | | - Maureen Groer
- University of South Florida, Tampa, FL, United States
| | | | - Mojgan Golzy
- University of Missouri, Columbia, MO, United States
| | | | | | - Neetu Nair
- University of Missouri, Columbia, MO, United States
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20
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Abstract
STUDY OBJECTIVES Subjective memory complaints and objective cognitive dysfunction are common in aging populations, however research investigating the associations between them is inconclusive. Given the high prevalence of sleep complaints in middle-aged/older adults, this research tested whether objective cognition interacted with sleep parameters in its associations with subjective cognition. METHODS Cognitively healthy adults aged 50+ completed the Pittsburgh Sleep Quality Index, Cognitive Failures Questionnaire (CFQ) and cognitive tasks: Stroop, Sternberg, and Posner cueing. Multiple regression and simple slope analyses examined whether objective cognition interacted with sleep parameters in its associations with subjective memory. RESULTS Stroop performance and sleep (efficiency and disturbances) had interactive associations with CFQ-memory. Specifically, better Stroop performance (faster reaction time, RT-control trials) was associated with more memory complaints at worst and average, but not best sleep efficiency. Additionally, faster RT was associated with more memory complaints only for worst sleep disturbance. Similarly, Sternberg performance and sleep (efficiency and disturbances) had interactive associations with CFQ-memory. Specifically, higher proportion correct was associated with more memory complaints only at worst sleep efficiency and sleep disturbance. Finally, Posner performance and sleep disturbance had an interactive association with CFQ-memory. Faster exogenous orienting was associated with more memory complaints only for worst sleep disturbance. CONCLUSIONS Objective cognition interacts with sleep efficiency and sleep disturbances in its associations with subjective memory in mid-to-late life. Findings suggest sleep fragmentation plays a role in the discrepant relationship between objective and subjective cognition. Future studies should investigate this relationship in aging populations with sleep disorders and/or cognitive impairments.
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Affiliation(s)
- Amy N Costa
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, MO
| | | | - Nelson Cowan
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, MO
| | - Ashley F Curtis
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, MO.,Department of Psychiatry, University of Missouri-Columbia, Columbia, MO
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21
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Miller MB, Flores LY, Dorimé-Williams ML, Williams MS, Martinez LD, Freeman LK, Everson AT, Hall NA, Monk JK, McCrae CS, Borsari B. Motives for and Barriers to Research Participation Among Racially and Ethnically Diverse Veterans. Mil Med 2022; 188:usac127. [PMID: 35584195 PMCID: PMC10363000 DOI: 10.1093/milmed/usac127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 03/09/2022] [Accepted: 04/26/2022] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Veterans in general-and especially those who identify as Veterans of color-are underrepresented in health-related treatment research. This contributes to health inequity by hindering the development of evidence-based treatment recommendations for people of color. This project utilized culturally centered research procedures to identify health-related research priorities and examine motives for and barriers to research participation in a diverse sample of Veterans. MATERIALS AND METHODS Veterans (N = 330, 32% female; 36% Black, 28% White, 15% Latinx, 12% Asian, 4% Multiracial) reported their experiences with and perspectives on health-related research online from remote locations. Linear regression was used to test associations between discrimination and motives/barriers for research. All procedures were approved by the Institutional Review Board (#2033562). RESULTS Participants identified psychological concerns, particularly PTSD, as research priorities for Veterans in their communities, but also prioritized physical problems (e.g., brain injury) and social concerns (e.g., homelessness, access to care). Perceptions of, motives for, and barriers to research were similar across racial/ethnic groups. The most common motive was contributing to research that seems important, and the most common barrier was not knowing about research opportunities. Every-day experiences with discrimination (e.g., people acting as if they are afraid of you because of your race/ethnicity) were associated with more barriers to research among Black participants. CONCLUSIONS Experiences of racial/ethnic discrimination are associated with different research-related outcomes across racial/ethnic groups. Efforts to engage diverse populations should prioritize access to (not willingness to participate in) health-related research.
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Affiliation(s)
- Mary Beth Miller
- Department of Psychiatry, University of Missouri, Columbia, MO 65212, USA
- Department of Psychological Sciences, University of Missouri, Columbia, MO 65211, USA
| | - Lisa Y Flores
- Department of Psychological Sciences, University of Missouri, Columbia, MO 65211, USA
| | | | - Michael S Williams
- Department of Educational Leadership & Policy Analysis, University of Missouri, Columbia, MO 65211, USA
| | - Leticia D Martinez
- Department of Psychiatry, University of Missouri, Columbia, MO 65212, USA
| | - Lindsey K Freeman
- Department of Psychological Sciences, University of Missouri, Columbia, MO 65211, USA
| | - Adam T Everson
- Department of Psychiatry, University of Missouri, Columbia, MO 65212, USA
| | - Nicole A Hall
- Department of Psychiatry, University of Missouri, Columbia, MO 65212, USA
| | - J Kale Monk
- Human Development and Family Science, University of Missouri, Columbia, MO 65211, USA
| | - Christina S McCrae
- Department of Psychiatry, University of Missouri, Columbia, MO 65212, USA
- Department of Psychological Sciences, University of Missouri, Columbia, MO 65211, USA
| | - Brian Borsari
- Mental Health Service, San Francisco VA Health Care System, San Francisco, CA 94121, USA
- Department of Psychiatry and Behavioral Sciences, UCSF, San Francisco, CA 94143, USA
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22
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Miller MB, Curtis AF, Hall NA, Freeman LK, Everson AT, Martinez LD, Park CJ, McCrae CS. Daily associations between modifiable sleep behaviors and nighttime sleep among young adult drinkers with insomnia. J Clin Sleep Med 2022; 18:703-712. [PMID: 34605392 PMCID: PMC8883105 DOI: 10.5664/jcsm.9706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Empirical evidence linking individual sleep hygiene practices to subsequent sleep parameters is limited, particularly at the daily level. This study compared the strength of daily, within-person associations between these modifiable sleep behaviors and nighttime sleep in young adult drinkers with insomnia. METHODS Young adults (ages 18-30 years; n = 56) who met diagnostic criteria for insomnia and reported past-month binge drinking wore wrist actigraphy and completed online sleep diaries for 8.5 days (standard deviation = 2.3; 477 reports). Diaries assessed engagement in 11 sleep hygiene recommendations. Multilevel models tested daily associations between sleep behaviors and 3 outcomes: sleep quality, self-reported sleep efficiency, and actigraphy-measured sleep efficiency. RESULTS Participants self-reported better sleep quality/efficiency on days that they slept in a comfortable environment, limited naps to 30 minutes, and maintained a consistent wake time. They self-reported worse sleep quality and efficiency on nights that they avoided alcohol use before bedtime. No sleep behaviors were significantly associated with actigraphy-measured sleep efficiency after correcting for inflation in type I error. CONCLUSIONS The sleep hygiene recommendations most strongly associated with sleep at the daily level were consistent with stimulus control. Creating a comfortable sleep environment also emerged as an important correlate of daily sleep. Heavy drinkers with insomnia may perceive better sleep if they drink before bedtime; however, this finding may be unique to this population. CITATION Miller MB, Curtis AF, Hall NA, et al. Daily associations between modifiable sleep behaviors and nighttime sleep among young adult drinkers with insomnia. J Clin Sleep Med. 2022;18(3):703-712.
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Affiliation(s)
- Mary Beth Miller
- Address correspondence to: Mary Beth Miller, PhD, One Hospital Drive DC067.00, Columbia, MO 65212; Tel: (573) 882-1813; Fax: (573) 884-1070;
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23
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Roth AJ, Curtis AF, Rowe MA, McCrae CS. Using Telehealth to Deliver Cognitive Behavioral Treatment of Insomnia to a Caregiver of a Person With Alzheimer's Disease. J Cogn Psychother 2022; 36:3-23. [PMID: 35121676 DOI: 10.1891/jcpsy-d-20-00055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cognitive behavioral therapy for Insomnia (CBT-I) is the gold standard treatment for insomnia. There is limited access to qualified providers to deliver CBT-I; moreover, there are patient populations who struggle with access to insomnia care due to limited time and resources. This includes caregivers for persons with Alzheimer's disease, for whom sleep disturbance is a common concern. Utilizing telehealth to deliver CBT-I may be particularly important for vulnerable populations such as caregivers of persons with dementia, as it can offer an accessible, safe, and cost-effective treatment option that can be tailored to meet the needs of a specific population. This case study illustrates the successful implementation of a four-session CBT-I protocol through telehealth with a caregiver of a person with Alzheimer's disease. Given the success of this case and the conditions for psychological care the recent pandemic has created, continued research into the efficacy of sleep-related interventions through telehealth is warranted.
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Affiliation(s)
- Alicia J Roth
- Sleep Disorders Center, Cleveland Clinic, Cleveland, Ohio
| | - Ashley F Curtis
- Department of Psychiatry, University of Missouri, Columbia, Missouri.,Department of Psychological Sciences, University of Missouri, Columbia, Missouri
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24
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Curtis AF, Schmiedeler A, Musich M, Connell M, Miller MB, McCrae CS. COVID-19-Related Anxiety and Cognition in Middle-Aged and Older Adults: Examining Sex as a Moderator. Psychol Rep 2022; 126:1260-1283. [PMID: 35099322 PMCID: PMC8810388 DOI: 10.1177/00332941211064820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Aging populations experience disproportionate risk for cognitive decline, which may be exacerbated by coronavirus (COVID-19) illness, particularly among women. This study tested sex as a moderator of associations between COVID-19 state anxiety and cognition in middle-aged/older adults. Adults aged 50+ (N = 275; 151 men/124 women) completed the Coronavirus Anxiety Scale and Cognitive Failures Questionnaire online from remote locations in July/August 2020. A subset of participants (n = 62) completed an objective cognitive task (Stroop). Multiple regressions determined whether sex moderated associations between COVID-19 anxiety and cognitive outcomes. Sex was a significant moderator, such that for women (not men), greater COVID-19 anxiety was associated with more memory failures and blunders (subjective measures) and worse processing speed (objective measure). COVID-19 state anxiety is linked to everyday cognition and processing speed in women, but not men. Consistency across subjective and objective measures promotes the need for sex-specific understanding of the pandemic’s behavioral and cognitive effects in mid-to-late life.
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Affiliation(s)
- Ashley F. Curtis
- Department of Psychiatry, University of Missouri, Columbia, MO, USA; Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - Anthony Schmiedeler
- Department of Psychiatry, University of Missouri, Columbia, MO, USA; Department of Educational, School, and Counseling Psychology, University of Missouri, Columbia, MO, USA
| | - Madison Musich
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - Maggie Connell
- Department of Psychiatry, University of Missouri, Columbia, MO, USA
| | - Mary Beth Miller
- Department of Psychiatry, University of Missouri, Columbia, MO, USA
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25
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Padron A, McCrae CS, Robinson ME, Waxenberg LB, Antoni MH, Berry RB, Castagno J, Schultz G, Kacel EL, Ulfig C, Garey S, Patidar S, Sannes T, Trinastic L, Wong S, Pereira DB. Impacts of Cognitive Behavioral Therapy for Insomnia and Pain on Sleep in Women with Gynecologic Malignancies: A Randomized Controlled Trial. Behav Sleep Med 2022; 20:460-476. [PMID: 34124972 PMCID: PMC8669057 DOI: 10.1080/15402002.2021.1932500] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Insomnia is an adverse cancer outcome impacting mood, pain, quality of life, and mortality in cancer patients. Cognitive Behavioral Therapy (CBT) is an evidence-based treatment for diverse psychophysiological disorders, including pain and insomnia. Primarily studied in breast cancer, there is limited research on CBT within gynecology oncology. This study examined CBT effects on subjective and behavioral sleep outcomes: Sleep Efficiency (SE), Sleep Quality (SQ), Total Wake Time (TWT), Sleep Onset Latency (SOL), and Wake After Sleep Onset (WASO). Thirty-five women with insomnia status/post-surgery for gynecologic cancer were randomized to CBT for insomnia and pain (CBTi.p., N = 18) or Psychoeducation (N = 17). Sleep was assessed via sleep diaries and wrist-worn actigraphy at baseline (T1), post-intervention (T2), and two-month follow-up (T3). Intent-to-treat analyses utilizing mixed linear modeling examined longitudinal group differences on sleep controlling for age and advanced cancer. All participants demonstrated improved (1) subjective SE (0.5, p < .01), SOL (-1.2, p < .01), TWT (-1.2, p < .01), and (2) behavioral SE (0.1, p = .02), TWT (-1.2, p = .03), WASO (-0.8, p < .01) across time. Group-level time trends were indicative of higher subjective SE (6.8, p = .02), lower TWT (-40.3, p = .01), and lower SOL (-13.0, p = .05) in CBTi.p. compared to Psychoeducation. Supplemental analyses examining clinical significance and acute treatment effects demonstrated clinical improvements in SE (T1), TWT (T2, T3), and SOL (T3). Remaining effects were not significant. Despite lacking power to detect interaction effects, CBTi.p. clinically improved sleep in women with gynecologic cancers and insomnia during the active treatment phase. Future research will focus on developing larger trials within underserved populations.
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Affiliation(s)
- Adaixa Padron
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Christina S. McCrae
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA,Department of Psychiatry, University of Missouri, Columbia, MO, USA
| | - Michael E. Robinson
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Lori B. Waxenberg
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | | | - Richard B. Berry
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL, USA
| | - Jacqueline Castagno
- Department of Obstetrics and Gynecology, University of Florida, Gainesville, FL, USA
| | - Gregory Schultz
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, University of Florida, Gainesville, FL, USA
| | - Elizabeth L. Kacel
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Chantel Ulfig
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Stephanie Garey
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Seema Patidar
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Timothy Sannes
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Laura Trinastic
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Shan Wong
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Deidre B. Pereira
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA,Corresponding author: Deidre B. Pereira, PhD, ABPP. Address: Clinical & Health Psychology, University of Florida, 1225 Center Drive, Room 3151, Gainesville, Florida 32611. Phone: (352) 273-6039.
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26
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McCrae CS, Craggs JG, Curtis AF, Nair N, Kay D, Staud R, Berry RB, Robinson ME. Neural activation changes in response to pain following cognitive behavioral therapy for patients with comorbid fibromyalgia and insomnia: a pilot study. J Clin Sleep Med 2022; 18:203-215. [PMID: 34310276 PMCID: PMC8807905 DOI: 10.5664/jcsm.9540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
STUDY OBJECTIVES To examine whether cognitive behavioral treatments for insomnia (CBT-I) and pain (CBT-P) lead to neural activation changes in response to pain in fibromyalgia. METHODS Thirty-two patients with fibromyalgia (mean age = 55.9, standard deviation = 12.2) underwent an experimental pain protocol during functional magnetic resonance imaging and completed 14-day diaries assessing total wake time, total sleep time, and pain intensity before and after CBT-I, CBT-P, or waitlist control. Random effects analysis of covariance identified regions with significant group (CBT-I, CBT-P, waitlist control) by time (baseline, post-treatment) interactions in blood oxygen level-dependent response to pain. Linear regressions using residualized change scores examined how changes in total wake time, total sleep time, and pain intensity were related to activation (blood oxygen level-dependent) changes. RESULTS Twelve regions exhibited small to moderate effects with significant interactions Ps < .00; right hemisphere: inferior frontal, middle occipital, and superior temporal gyri, insula, lentiform nucleus; left hemisphere: angular, superior temporal, midfrontal, inferior occipital, midtemporal, and inferior frontal gyri. Blood oxygen level-dependent response to pain decreased in 8 regions following CBT-I, and in 3 regions following CBT-P (CBT-I effects > CBT-P). Blood oxygen level-dependent response also increased in 3 regions following CBT-P and in 6 regions following waitlist control. Improved total wake time and/or total sleep time, not pain intensity, predicted decreased blood oxygen level-dependence in 7 regions (Ps < .05), accounting for 18%-47% of the variance. CONCLUSIONS CBT-I prompted greater decreases in neural activation in response to pain across more regions associated with pain and sleep processing than CBT-P. Reported sleep improvements may underlie those decreases. Future research examining the longer-term impact of CBT-I and improved sleep on central pain and sleep mechanisms is warranted. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Title: Sleep and Pain Interventions in Fibromyalgia (SPIN); Identifier: NCT02001077; URL: https://clinicaltrials.gov/ct2/show/NCT02001077. CITATION McCrae CS, Craggs JG, Curtis AF, et al. Neural activation changes in response to pain following cognitive behavioral therapy for patients with comorbid fibromyalgia and insomnia: a pilot study. J Clin Sleep Med. 2022;18(1):203-215.
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Affiliation(s)
- Christina S. McCrae
- Department of Psychiatry, University of Missouri, Columbia, Missouri,Address correspondence to: Christina S. McCrae, PhD, Department of Psychiatry, 1 Hospital Drive, Columbia, MO 65212; Tel: (573) 882-0982; Fax: (573) 884-1070;
| | - Jason G. Craggs
- Physical Therapy, University of Missouri, Columbia, Missouri,Department of Psychological Sciences, University of Missouri, Columbia, Missouri
| | - Ashley F. Curtis
- Department of Psychiatry, University of Missouri, Columbia, Missouri,Department of Psychological Sciences, University of Missouri, Columbia, Missouri
| | - Neetu Nair
- Department of Psychiatry, University of Missouri, Columbia, Missouri
| | - Daniel Kay
- Department of Psychology, Brigham Young University, Provo, Utah
| | - Roland Staud
- Rheumatology and Clinical Immunology, University of Florida, Gainesville, Florida
| | - Richard B. Berry
- Division of Pulmonary, Critical Care, and Sleep Medicine, Gainesville, Florida
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27
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Stearns MA, Ievers-Landis CE, McCrae CS, Simon SL. Sleep across childhood during the COVID-19 pandemic: a narrative review of the literature and clinical case examples. Children's Health Care 2021. [DOI: 10.1080/02739615.2021.2016407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | - Carolyn E. Ievers-Landis
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Stacey L. Simon
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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28
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Miller MB, Carpenter RW, Freeman LK, Curtis AF, Yurasek AM, McCrae CS. Cannabis use as a moderator of cognitive behavioral therapy for insomnia. J Clin Sleep Med 2021; 18:1047-1054. [PMID: 34870584 DOI: 10.5664/jcsm.9796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Cannabis use is common among young adults and has been proposed as a potential treatment for insomnia. However, controlled studies examining the impact of cannabis use on insomnia symptoms are rare. This secondary analysis of published trial data tested cannabis use during cognitive behavioral treatment for insomnia (CBT-I) as a moderator of treatment efficacy. METHODS Young adults (ages 18-30 years) who reported past-month binge drinking (4/5+ drinks for women/men) and met DSM-5 and research diagnostic criteria for Insomnia Disorder were randomized to CBT-I (n=28) or sleep hygiene (SH; n=28). Interaction effects were tested using multilevel models. Outcomes included insomnia severity, actigraphy-assessed sleep efficiency, diary-assessed sleep quality, drinking quantity, and alcohol-related consequences. RESULTS Twenty-six participants (46%; 12 SH and 14 CBT-I) reported using cannabis during the treatment phase of the study, on an average of 23% of treatment days (range=3-100%). Relative to those who did not use cannabis, participants who used cannabis during treatment reported heavier drinking and more frequent cigarette use. Approximately 1 in 4 cannabis users (27%) reported using cannabis to help with sleep; however, cannabis and non-cannabis users did not differ in use of alcohol as a sleep aid. Controlling for sex, race, drinking quantity, cigarette use, symptoms of depression, and symptoms of anxiety, use of cannabis during treatment did not moderate CBT-I effects on insomnia severity (b= -.002, p=.99) or other outcomes (all p >.20). CONCLUSIONS CBT-I is effective in reducing insomnia symptoms among young adult drinkers with insomnia, regardless of cannabis use. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Identifier: NCT03627832.
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Affiliation(s)
- Mary Beth Miller
- Department of Psychiatry, University of Missouri School of Medicine, Columbia, MO
| | - Ryan W Carpenter
- Department of Psychological Sciences, University of Missouri-St. Louis, St. Louis, MO
| | - Lindsey K Freeman
- Department of Psychiatry, University of Missouri School of Medicine, Columbia, MO.,Department of Psychological Sciences, University of Missouri, Columbia, MO
| | - Ashley F Curtis
- Department of Psychiatry, University of Missouri School of Medicine, Columbia, MO.,Department of Psychological Sciences, University of Missouri, Columbia, MO
| | - Ali M Yurasek
- Health Education and Behavior Department, College of Health and Human Performance, University of Florida, Gainesville, FL
| | - Christina S McCrae
- Department of Psychiatry, University of Missouri School of Medicine, Columbia, MO
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29
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Davenport MA, Berry JR, Mazurek MO, McCrae CS. Using Telehealth to Deliver Family-Based Cognitive Behavioral Treatment of Insomnia in a School-Aged Child With Autism Spectrum Disorder. J Cogn Psychother 2021; 35:235-254. [PMID: 35236746 DOI: 10.1891/jcpsy-d-20-00062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Chronic insomnia (>3 months) is common in children with autism. Cognitive behavioral treatment for insomnia in children (CBT-CI) holds promise for improving sleep and daytime functioning in school-aged children with autism and their parents, but typical delivery involving multiple in-person office visits limits accessibility. This case study describes telehealth delivery of CBT-CI (teleCBT-CI) with a 7-year 4-month-old biracial boy with autism spectrum disorder (ASD) and insomnia and his parents. He and his mother wore actigraphs and completed electronic sleep diaries for 2 weeks, and his mother completed the Aberrant Behavior Checklist at pre/post/1-month follow-up. He and both of his parents completed eight telehealth treatment sessions. TeleCBT-CI improved the boy's sleep (objective, subjective) and decreased irritability, lethargy, stereotypy, and hyperactivity. This case study shows that teleCBT-CI is feasible and can improve child sleep and functioning.
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Affiliation(s)
| | | | | | - Christina S McCrae
- Department of Psychiatry, University of Missouri, Columbia, Missouri
- Thompson Center for Autism and Neurodevelopmental Disorders, University of Missouri, Columbia, Missouri
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30
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McCrae CS, Mazurek MO, Curtis AF, Beversdorf DQ, Deroche CB, Golzy M, Sohl KA, Ner ZH, Davis BE, Stearns MA, Nair N. Protocol for targeting insomnia in school-aged children with autism spectrum disorder without intellectual disability: a randomised control trial. BMJ Open 2021; 11:e045944. [PMID: 34433593 PMCID: PMC8388273 DOI: 10.1136/bmjopen-2020-045944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 08/07/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Insomnia affects up to 80% of children with autism spectrum disorder (ASD). Negative consequences of insomnia in ASD include decreased quality of life (QOL), impaired learning and cognition, increased stereotypic and challenging behaviours, and increased parental stress. Cognitive behavioural treatment for childhood insomnia (CBT-CI) is a promising treatment for dealing with insomnia and its negative consequences but has not yet been studied in school-aged children with ASD and comorbid insomnia. Access to healthcare is another challenge for children with ASD, particularly in rural and underserved regions. Previous studies indicate that ASD and insomnia share common arousal-based underpinnings, and we hypothesise that CBT-CI will reduce the hyperarousal associated with insomnia and ASD. This trial will be the first to examine CBT-CI adapted for children with ASD and will provide new information about two different modes of delivery across a variety of primary and secondary child and parent sleep and related outcomes. Knowledge obtained from this trial might allow us to develop new or modify current treatments to better target childhood insomnia and ASD. METHODS AND ANALYSIS Children (N=180) 6-12 years of age with ASD and insomnia will be recruited from an established autism database, a paediatric clinic and community outreach in the Columbia, MO and surrounding areas. Participants will be randomised to CBT-CI adapted for children with ASD (in-person or remote using computers with cameras) or Sleep Hygiene and Related Education. Participants will be assessed at baseline, post-treatment, 6-month and 12-month follow-ups. The following assessments will be completed regarding the children: objective and subjective sleep, daytime functioning (adaptive functioning, attention, challenging behaviours, anxiety), QOL and physiological arousal (heart rate variability) and parents: objective and subjective sleep, daytime functioning (anxiety, depression, fatigue), QOL, physiological arousal and parental burden/stress. ETHICS AND DISSEMINATION Ethics approval was obtained in January 2020 from the University of Missouri. Ethics approval was obtained in July 2020 from the US Army Medical Research and Development Command, Office of Research Protections and Human Research Protection Office. All data are expected to be collected by 2024. Full trial results are planned to be published by 2025. Secondary analyses of baseline data will be subsequently published. TRIAL REGISTRATION NUMBER NCT04545606; Pre-results.
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Affiliation(s)
| | - Micah O Mazurek
- School of Education and Human Development, University of Virginia, Charlottesville, VA, USA
| | - Ashley F Curtis
- Psychiatry, University of Missouri, Columbia, MO, USA
- Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - David Q Beversdorf
- Departments of Radiology, Neurology, Psychological Sciences, and the Thompson Center for Autism and Neurodevelopmental Disorders, University of Missouri, Columbia, MO, USA
| | - Chelsea B Deroche
- Department of Health Management & Informatics, University of Missouri, Columbia, MO, USA
| | - Mojgan Golzy
- Department of Health Management & Informatics, University of Missouri, Columbia, MO, USA
| | - Kristin A Sohl
- Department of Child Health, University of Missouri, Columbia, MO, USA
| | - Zarah H Ner
- Department of Child Health, University of Missouri, Columbia, MO, USA
| | - Beth Ellen Davis
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | | | - Neetu Nair
- Psychiatry, University of Missouri, Columbia, MO, USA
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Miller MB, Freeman LK, Deroche CB, Park CJ, Hall NA, McCrae CS. Sleep and alcohol use among young adult drinkers with Insomnia: A daily process model. Addict Behav 2021; 119:106911. [PMID: 33773200 DOI: 10.1016/j.addbeh.2021.106911] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/13/2021] [Accepted: 03/08/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Previous studies examining associations between sleep and alcohol use have done so primarily at the aggregate (between-person) level and primarily among healthy young adults. This study aimed to examine reciprocal, within-person associations between sleep and alcohol use among young adult drinkers with insomnia. METHODS Young adults who engaged in past-month binge drinking and met diagnostic criteria for insomnia (N = 56) wore wrist actigraphy and completed online daily diaries assessing sleep and drinking for an average of 8.52 days (SD = 2.31), resulting in 477 reports. Multilevel models were used to examine within- and between-person effects of sleep quality and efficiency on alcohol use and vice versa. Bedtime and waketime were included as secondary sleep parameters. RESULTS Participants reported drinking on 231 days (48%). Participants did not report significantly different sleep quality on heavier-drinking days, nor did they demonstrate significant changes in actigraphy-measured sleep efficiency. However, they self-reported better sleep efficiency on heavier-drinking days (driven primarily by improvements in sleep onset latency), and they reported heavier drinking following days of better sleep efficiency (driven by improvements in total sleep time). Drinking was also associated with later bedtimes and waketimes. CONCLUSIONS Young adult drinkers with insomnia report reciprocal associations between subjective sleep efficiency and alcohol use, but these results were not replicated using objective measures. Providers may need to challenge the belief that there is a positive association between alcohol use and sleep among young adults who drink and have insomnia.
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Affiliation(s)
- Mary Beth Miller
- University of Missouri, 1 Hospital Drive DC067.00, Columbia, MO 65212, USA.
| | - Lindsey K Freeman
- University of Missouri, 1 Hospital Drive DC067.00, Columbia, MO 65212, USA
| | - Chelsea B Deroche
- University of Missouri, 1 Hospital Drive DC067.00, Columbia, MO 65212, USA
| | - Chan Jeong Park
- University of Missouri, 1 Hospital Drive DC067.00, Columbia, MO 65212, USA
| | - Nicole A Hall
- University of Missouri, 1 Hospital Drive DC067.00, Columbia, MO 65212, USA
| | - Christina S McCrae
- University of Missouri, 1 Hospital Drive DC067.00, Columbia, MO 65212, USA
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Curtis AF, Rodgers M, Miller MB, McCrae CS. Impact of Sex on COVID-19 Media Exposure, Anxiety, Perceived Risk, and Severity in Middle-Aged and Older Adults. J Aging Health 2021; 34:51-59. [PMID: 34114480 DOI: 10.1177/08982643211025383] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To examine associations between COVID-19 media exposure and anxiety/perceived risk/severity and investigate their dependency on sex in middle-aged/older adults. METHODS Adults aged 50+ years completed online surveys: Coronavirus Anxiety Scale, COVID-19 media exposure, COVID-19 media dependency for health information, and COVID-19 perceived risk and severity. Multiple regressions examined independent and interactive (with sex) associations between COVID-19 media exposure/dependency and COVID-19 anxiety/perceived risk and severity. Analyses controlled for age, education, race, total medical conditions, and COVID-19 status. RESULTS Higher COVID-19 media exposure was associated with higher COVID-19 anxiety among men (not women) and higher perceived risk/severity in both sexes. Higher COVID-19 media dependency was associated with higher COVID-19 anxiety and perceived risk/severity in both sexes. CONCLUSION In middle-aged/older adults, the use/dependency of media for COVID-19 information may be linked to negative psychological health and increased COVID-19 perceived risk and severity. Men may be at increased risk of anxiety related to media exposure.
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Affiliation(s)
- Ashley F Curtis
- Department of Psychiatry, 14716University of Missouri, Columbia, MO, USA.,Department of Psychological Sciences, 14716University of Missouri, Columbia, MO, USA
| | - Mikayla Rodgers
- Department of Psychiatry, 14716University of Missouri, Columbia, MO, USA
| | - Mary Beth Miller
- Department of Psychiatry, 14716University of Missouri, Columbia, MO, USA
| | - Christina S McCrae
- Department of Psychiatry, 14716University of Missouri, Columbia, MO, USA
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Miller MB, Metrik J, McGeary JE, Borsari B, McCrae CS, Maddoux J, Arnedt JT, Merrill JE, Carey KB. Protocol for the Project SAVE randomised controlled trial examining CBT for insomnia among veterans in treatment for alcohol use disorder. BMJ Open 2021; 11:e045667. [PMID: 34103317 PMCID: PMC8190049 DOI: 10.1136/bmjopen-2020-045667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION As many as 74% of veterans with alcohol use disorders (AUDS) report symptoms of insomnia. Insomnia represents a barrier to alcohol treatment because insomnia symptoms (1) may lead to relapse among those who use alcohol to help them sleep and may negatively impact (2) executive functions and (3) emotion regulation skills. Cognitive-behavioural therapy for insomnia (CBT-I) is an efficacious first-line treatment for insomnia; however, no research has examined the impact of CBT-I on individuals' response to alcohol treatment. In the Sleep and Alcohol for Veterans (Project SAVE) randomised controlled trial, we hypothesise that CBT-I will enhance the efficacy of alcohol treatment among Veterans with insomnia by enhancing their abilities to attend to treatment, regulate emotions and initiate sleep without alcohol. METHODS AND ANALYSIS Eighty Veterans enrolled in alcohol treatment at the Veterans Administration (VA) hospital will be randomly assigned to receive either CBT-I or single-session sleep hygiene (SH) education. Individuals will be eligible to participate if they meet Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for moderate to severe AUD and Insomnia Disorder of at least 1-month duration. Participants will complete assessments at baseline, post-treatment and 6-week follow-up. Preliminary process outcomes include retention/recruitment rates and treatment satisfaction (feasibility and acceptability, respectively). Primary outcomes are insomnia severity, percentage of heavy-drinking days and alcohol-related problems. We will assess a variety of secondary clinical and mechanistic outcomes (eg, post-traumatic stress disorder (PTSD) symptoms, attention and working memory). ETHICS AND DISSEMINATION Ethics approval was obtained in October 2018. Data collection began in July 2019 and is planned for completion by July 2021. Trial results will be disseminated at local and national conferences, in peer-reviewed publications and through media outlets, as available. Results will also be shared with interested participants and clinical collaborators at the end of the trial. TRIAL REGISTRATION NUMBER clinicaltrials.gov identifier NCT03806491 (pre-results).
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Affiliation(s)
- Mary Beth Miller
- Department of Psychiatry, University of Missouri, Columbia, MO, USA
| | - Jane Metrik
- Center for Alcohol and Addiction Studies, Brown University, Providence, Rhode Island, USA
- Mental Health & Behavioral Sciences Service, Providence VA Medical Center, Providence, RI, USA
| | - John E McGeary
- Center for Alcohol and Addiction Studies, Brown University, Providence, Rhode Island, USA
- Mental Health & Behavioral Sciences Service, Providence VA Medical Center, Providence, RI, USA
| | - Brian Borsari
- Mental Health Service, San Francisco VA Health Care System, San Francisco, CA, USA
- Department of Psychiatry and Behavioral Services, University of California San Francisco, San Francisco, CA, USA
| | | | - John Maddoux
- Harry S Truman Memorial Veterans' Hospital, Columbia, Missouri, USA
| | - J Todd Arnedt
- Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer E Merrill
- Center for Alcohol and Addiction Studies, Brown University, Providence, Rhode Island, USA
| | - Kate B Carey
- Center for Alcohol and Addiction Studies, Brown University, Providence, Rhode Island, USA
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Porter JW, Pettit-Mee RJ, Emerson TS, McCrae CS, Lastra G, Vieira-Potter VJ, Parks EJ, Kanaley JA. Modest sleep restriction does not influence steps, physical activity intensity or glucose tolerance in obese adults. J Sleep Res 2021; 30:e13381. [PMID: 33949729 DOI: 10.1111/jsr.13381] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/13/2021] [Accepted: 04/16/2021] [Indexed: 11/30/2022]
Abstract
Sleep restriction (SR) (<6 h) and physical activity (PA) are risk factors for obesity, but little work has examined the inter-related influences of both risk factors. In a free-living environment, 13 overweight/obese adults were sleep restricted for five nights to 6 h time-in-bed each night, with and without regular exercise (45 min/65% VO2 max; counterbalanced design). Two days of recovery sleep followed SR. Subjects were measured during a mixed meal tolerance test (MMT), resting metabolic rate, cognitive testing and fat biopsy (n=8). SR increased peak glucose response (+7.3 mg/dl, p = .04), elevated fasting non-esterified fatty acid (NEFA) concentrations (+0.1 mmol/L, p = .001) and enhanced fat oxidation (p < .001) without modifying step counts or PA intensity. Inclusion of daily exercise increased step count (+4,700 steps/day, p < .001) and decreased the insulin response to a meal (p = .01) but did not prevent the increased peak glucose response or elevated NEFA levels. The weekend recovery period improved fasting glucose (p = .02), insulin (p = .02), NEFA concentrations (p = .001) and HOMA-IR (p < .01) despite reduced steps (p < .01) and increased sedentary time (p < .01). Abdominal adipose tissue (AT) samples, obtained after baseline, SR and exercise, did not differ in lipolytic capacity following SR. Fatty acid synthase protein content tended to increase following SR (p = .07), but not following exercise. In a free-living setting, SR adversely affected circulating NEFAs, fuel oxidation and peak glucose response but did not directly affect glucose tolerance or AT lipolysis. SR-associated metabolic impairments were not mitigated by exercise, yet recovery sleep completely rescued its adverse effects on glucose metabolism.
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Affiliation(s)
- Jay W Porter
- Department of Nutrition and Exercise Physiology, University of Missouri, Columbia, MO, USA
| | - Ryan J Pettit-Mee
- Department of Nutrition and Exercise Physiology, University of Missouri, Columbia, MO, USA
| | - Travis S Emerson
- Department of Nutrition and Exercise Physiology, University of Missouri, Columbia, MO, USA
| | - Christina S McCrae
- Department of Health Psychology, University of Missouri, Columbia, MO, USA
| | - Guido Lastra
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Missouri School of Medicine, Columbia, MO, USA
| | | | - Elizabeth J Parks
- Department of Nutrition and Exercise Physiology, University of Missouri, Columbia, MO, USA
| | - Jill A Kanaley
- Department of Nutrition and Exercise Physiology, University of Missouri, Columbia, MO, USA
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McGovney K, Curtis A, McCrae CS. 648 Associations between objective afternoon and evening physical activity and polysomnographic sleep in fibromyalgia. Sleep 2021. [DOI: 10.1093/sleep/zsab072.646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Patients with fibromyalgia (FM) suffer from pain which limits physical activity and disrupts sleep. Research examining the relationship between pre-bedtime physical activity, pain, and objective sleep is limited. This study examined whether objectively measured activity levels (via actigraphy), pain intensity, or their interaction are associated with polysomnographic sleep outcomes and sleep architecture.
Methods
Adults with FM (n=158, Mage=52, SD=12, 93% female) completed 14 daily pain ratings, 14 days of actigraphy, and a single night of polysomnography. Activity levels (i.e., magnitude of wrist motion captured per 30 second epoch) were recorded, and average afternoon/evening activity for intervals 12:00-15:00, 15:00-18:00, and 18:00-21:00 was computed, removing days in which participants slept during these periods. Sleep architecture was quantified as the percentage of sleep time in rapid eye movement (%rem) and non-rem (i.e. %stage 1, %stage 2, and %stage 3). Multiple regressions examined whether average afternoon/evening activity, average evening pain [0 (no pain)–100 (most intense pain imaginable)], or their interaction predicted polysomnographic sleep onset latency (SOL), wake after sleep onset (WASO), sleep efficiency (SE), %stage 1, %stage 2, %stage 3, and %rem, controlling for age, body mass index, average individual bedtime, time in bed, and sleep or pain medication usage.
Results
Greater afternoon activity from 12:00-15:00 was independently associated with lower SE (B= -.08, p=.01), greater WASO (B=.45, p<.001), and greater %stage 1 (B=.04, p<.01). Pain intensity interacted with physical activity from 12:00-15:00 such that the association between physical activity and higher WASO (p=.05) and greater %stage 1 (p<.01) was stronger for individuals with higher pain. Pain intensity and activity from 15:00-18:00, and 18:00-21:00 were not associated with sleep outcomes.
Conclusion
Our results suggest greater afternoon activity is associated with greater polysomnographic sleep fragmentation and greater %stage 1 sleep in FM, and these relationships are stronger for individuals with higher pain. These relationships are consistent with activity pacing recommendations for chronic pain and suggest pacing in the afternoon may be important for good sleep in FM. However, future research examining causal pathways linking physical activity levels and timing, pain, and sleep is needed.
Support (if any)
Support: NIAMS (R01AR055160/R01AR005160- S1;PI McCrae). Data collected at University of Florida (Clinical Trial-NCT02001077;PI McCrae).
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Stephens R, Curtis A, McCrae CS, McGovney K. 384 Sleep, Pain, and Cognition in Women with Chronic Widespread Pain and Insomnia. Sleep 2021. [DOI: 10.1093/sleep/zsab072.383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Our team has shown pain interacts with sleep in its association with cognition in cardiac patients and older adults, such that better sleep is associated with better cognitive performance in individuals reporting high pain. Whether these associations exist in the context of chronic pain is unknown. This study examines these associations in women with chronic widespread pain and insomnia (CWPI) and extends our prior findings by including objective/subjective pain measures.
Methods
43 adult women (Mage=47.30, SD=13.93) with CWPI completed 14 daily diaries measuring wake time after sleep onset-WASO and total sleep time-TST. Daily diaries and thermal application [thermode on foot plantar] assessed subjective pain [0–100(most intense)]. Tender point testing assessed objective pain threshold [force(kg) on 18 tender points until painful]. Participants completed cognition tasks: Stroop (attention/processing speed) and Sternberg (working memory). Multiple regressions evaluated whether sleep (average WASO/TST) interacted with average subjective (diary/thermal ratings) and objective (force) pain in its association with cognition (Stroop reaction time (RT) on congruent trials/Sternberg #correct), controlling for age/education.
Results
WASO interacted with subjective pain (daily-B=.0003, SE=.0001, p=.009; thermal-B=.0002, SE=.004, p=.01) in its association with attention/processing speed. Higher WASO was associated with longer Stroop RT in high pain (~70/100) participants (B=.005, SE=.003, p=.047) and faster RT in low pain (~30/100) participants (B=-.009, SE=.004, p=.03). Higher WASO was associated with longer Stroop RT in those with high (~74/100; B=.01, SE=.002, p=.01), but not average (~46/100) or low (~19/100) thermal pain ratings (ps>.05). TST interacted with daily pain in its association with attention/processing speed (B=.001, SE=.00, p=.005). In participants with high (B=-.003, SE=.001, p=.02), not average (~50/100) or low pain (~30/100, ps>.05), longer TST was associated with faster Stroop RT. In those with low (~1kg, B=.07, SE=.02, p<.001) and average (~2kg, B=.05, SE=.01, p=.002) pain thresholds, longer TST was associated with better Sternberg performance (trending interaction: B=-.03, SE=.02, p=.09).
Conclusion
In CWPI patients with high pain, better sleep was associated with better cognitive performance. These findings suggest sleep may hold potential to mitigate pain’s impact on cognition. Future studies should examine whether interventions that target sleep also improve cognition in chronic pain patients with high pain.
Support (if any)
NINR(R01NR017168)/ClinicalTrials.gov(NCT02001077), PI McCrae.
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Hayse B, Stearns M, Nair N, Mazurek M, Takahashi N, Muckerman J, McCrae CS. 580 Psychosocial Functioning Mediates Parental Depression and Sleep Behaviors in Children with Autism Spectrum Disorder. Sleep 2021. [DOI: 10.1093/sleep/zsab072.578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Parents who have been diagnosed with depression often report that their children have poor sleep behaviors. This relationship may occur because the children of parents with depression are more likely experience poor psychosocial functioning, which can negatively impact their sleep. Children with Autism Spectrum Disorder (ASD) are particularly at risk for sleep difficulties, and it is important to better understand these relationships as scant to no research has been done which investigates parental depression, child psychosocial functioning, and child sleep among children with ASD. The current study examined whether parental perception of their child’s psychosocial functioning mediated the relationship between parental depression and their child’s sleep behaviors.
Methods
The sample (N=36) consisted of parents (81% female) reporting on their children aged 6–12 (M=8.56, SD = 1.86; 75% male). All children were diagnosed with ASD and had sleep complaints as reported by their parents. Children and their parents were recruited because they expressed interest in a behavioral treatment sleep study and these data come from the baseline data collection associated with that study. Measures included Sleep Behaviors factor from the Child Sleep Health Questionnaire (CSHQ), the Pediatric Symptom Checklist (PSC), and a question asking if the parent had been diagnosed with depression.
Results
Analyses were conducting using AMOS 27.0. Child psychosocial functioning significantly mediated (β = .12) the relation between parental depression and child sleep behavior. Parents who had been diagnosed with depression were more likely to report greater child psychosocial difficulties (β =.39, p = .01) and child psychosocial difficulties were associated with a greater likelihood of the child having worse sleep behavior (β =.32, p = .04). The direct effect between parental depression and child sleep behavior was not significant.
Conclusion
These results indicate that child psychosocial functioning may help to explain the connection between diagnosed parental depression and poor child sleep behavior among children with ASD. This suggests that psychosocial functioning may be an important aspect to target in sleep interventions, particularly for children with ASD.
Support (if any)
University of Missouri Research Board Grant (McCrae, PI); United States Department of Defense USAMRAA Autism Research Program (McCrae, PI; CTA AR190047).
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Stearns M, Hayse B, Nair N, Mazurek M, Curtis A, Beversdorf D, Deroche C, Sohl K, Ner Z, Davis B, Takahashi N, Muckerman J, McCrae CS. 579 Child Sleep Onset Latency Mediates Parental Depression and Non-Compliance in Children with Autism Spectrum Disorder. Sleep 2021. [DOI: 10.1093/sleep/zsab072.577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Parents who have been diagnosed with depression often report that their children are not compliant and have difficulty falling asleep. Parents with depression are less likely to be consistent or enforce bedtimes resulting in the child having less bedtime rules and getting less sleep. Overtime this may mean the child develops poor sleep habits and difficulty falling asleep. Although these relationships have yet to be studied in children with Autism Spectrum Disorder (ASD), it is an important area given the high prevalence of children with ASD who have sleep difficulties. The current study examined whether parent-reported child sleep onset latency mediated the relationship between parental depression and child non-compliance.
Methods
The sample (N=50) consisted of parents (81% female) reporting on their children aged 6–12 (M=8.63, SD = 2.00; 76% male). All children were diagnosed with ASD and had parent reported sleep complaints. Children and their parents were recruited because they expressed interest in a behavioral treatment sleep study and these data come from the baseline data collection associated with that study. Measures included sleep onset latency on the Child Sleep Health Questionnaire (CSHQ), an item on the Pediatric Symptom Checklist (PSC) which asked if a child follows rules, and a question asking if the parent had been diagnosed with depression.
Results
Analyses were conducting using AMOS 27.0. Slightly less than half (45%) of parents reported having been diagnosed with depression. Parent-reported child sleep onset latency significantly mediated (β =.13) the relation between parental depression and non-compliance. Parents who had been diagnosed with depression were associated with greater child sleep onset latency (β =.32, p = .04) and greater child sleep onset latency was associated with greater non-compliance (β =.40, p = .01). The direct effect between parental depression and non-compliance was not significant.
Conclusion
These results suggest that difficulty falling asleep may help to explain why children of parents who have depression are not compliant. Future research should utilize longitudinal and experimental methodology to determine the causality of these relationships.
Support (if any)
University of Missouri Research Board Grant (McCrae, PI); United States Department of Defense USAMRAA Autism Research Program (McCrae, PI; CTA AR190047).
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Curtis A, Schmiedeler A, Jagannathan S, Connell M, Atkinson A, Miller MB, McCrae CS. 037 Subjective sleep and objective cognition in middle-aged and older adults: Does sex matter? Sleep 2021. [DOI: 10.1093/sleep/zsab072.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Worse sleep has been linked to cognitive dysfunction in aging populations. There are known sex differences in the prevalence and presentation of both sleep disturbance and cognitive impairment, but research investigating sex differences in the associations between sleep and objective cognition is limited and inconclusive. We examined sex as a moderator of associations between self-reported sleep and objective cognitive performance in middle-aged/older adults.
Methods
Sixty-four adults aged 50+ (Mage= 63.8, SD=7.7; 33 men/31 women) who were cognitively healthy (no mild cognitive impairment, dementia or neurological disorders) completed an online survey (via Qualtrics) measuring self-reported sleep (Pittsburgh Sleep Quality Index; PSQI). Participants completed online cognitive tasks (via Inquisit) measuring inhibition (Stroop task; interference reaction time scores), attentional orienting (Posner Endogenous Cueing Task; reaction time difference between invalidly cued and validly cued trials), and working memory (Sternberg task; proportion correct). Multiple regressions examined whether PSQI subscores (sleep quality, sleep duration, sleep efficiency) were independently associated with or interacted with sex in their associations with cognition, controlling for age and education.
Results
Sex interacted with sleep quality in the association with endogenous attentional orienting (p=.01, R-squared=.10). Specifically, worse sleep quality was associated with worse attentional orienting in women (B=22.73, SE=9.53, p=.02) but not men (p=.24). Sex interacted with PSQI-sleep duration (p=.03, R-squared=.08) and PSQI-sleep efficiency (p=.03, R-squared=.08) in the association with inhibition performance. Specifically, worse sleep duration (B=235.28, SE=77.51, p=.004) and sleep efficiency (B=211.73, SE=68.70, p=.003) were associated with worse interference scores in men but not women (ps>.05). No variables were associated with working memory.
Conclusion
In middle-aged and older adults, sex moderates associations between self-reported sleep and objective cognition, depending on the sleep parameter and cognitive ability assessed. Findings suggest that women are more vulnerable to the effects of poor sleep quality on spatial attention, whereas men are more vulnerable to the effects of shorter sleep duration and worse overall sleep fragmentation on ability to inhibit task-irrelevant stimuli. Future studies should investigate sex-specific associations between sleep and cognition over time in order to better understand the prospective trajectories of these processes during aging.
Support (if any):
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Curtis A, Nair N, McGovney K, Craggs J, McCrae CS. 065 Sleep and Gray Matter Volume: The Role of Physiological Arousal. Sleep 2021. [DOI: 10.1093/sleep/zsab072.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Insomnia is associated with increased arousal. Brain regions involved in chronic insomnia are diffuse and the potential interactive role of physiological arousal in the association between insomnia symptoms and neural regions is unknown. This study examined whether physiological arousal (heart rate variability, HRV) moderated the association between sleep and gray matter (GM) volume of frontal [dorsolateral prefrontal cortex (DLPFC), anterior cingulate cortex (ACC)] and temporal [right/left (R/L) hippocampus] regions in adults with comorbid chronic widespread pain and insomnia (CWPI).
Methods
Forty-seven adults with CWPI (Mage=46.00, SD=13.88, 89% women) completed two weeks of diaries measuring sleep onset latency (SOL), wake time after sleep onset (WASO) and total sleep time (TST). Resting HRV was assessed via Holter monitoring (5 minutes). Root mean squared standard deviation of successive normal-to-normal heartbeats (RMSDNN) was computed. T1-weighted magnetic resonance images were obtained, segmented and co-registered to MNI space. GM volumes (DLPFC, ACC, R/L hippocampus) were estimated (FSL). Multiple regressions examined whether SOL, WASO or TST were independently associated with or interacted with RMSDNN in their associations with GM volumes, controlling for age.
Results
SOL interacted with RMSDNN in its association with ACC (B=-4.60, SE=2.06, p=.03, R-squared=.06). Longer SOL was associated with lower ACC volume at highest RMSDNN (lowest arousal; B=-103.54, SE=42.82, p=.02), not average/lowest RMSDNN (highest arousal, ps>.05). TST interacted with RMSDNN in its association with R hippocampus (B=-.22, SE=.10, p=.04, R-squared=.07). Shorter TST was associated with lower R hippocampal volume at lowest RMSDNN (highest arousal; B=7.39, SE=2.29, p=.002) and average RMSDNN (B=4.18, SE=1.50, p=.008), not highest RMSDNN (lowest arousal; p=.64). There was a trending association between WASO and R hippocampus volume (B=-13.67, SE=7.28, p=.07).
Conclusion
In patients with CWPI and highest physiological arousal, achieving longer TST may be important in terms of associations with right hippocampus volume. Improving (reducing) SOL may only impact ACC volume in those with lower physiological arousal. Trends of association between longer WASO and reduced right hippocampus volume warrant follow-up in larger samples. Findings highlight the interactive role of physiological arousal (HRV) in the neural mechanisms associated with sleep in CWPI.
Support (if any)
National Institute of Nursing Research (NR017168; Clinical trial: NCT02001077; PI: McCrae).
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Nair N, Curtis A, Stephens R, Hayse B, Studdard P, Craggs J, McCrae CS. 383 Cortical thickness moderates association between sleep architecture and pain in adults with fibromyalgia. Sleep 2021. [DOI: 10.1093/sleep/zsab072.382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Fibromyalgia is associated with chronic widespread pain and insomnia. While sleep and pain are mutually influential, how the cortical thickness (CT) of pain-related brain regions influences that relationship (i.e., sleep architecture and evening/morning pain) is unknown. This study examined how the CT of two regions involved in pain processing - the anterior cingulate cortex (ACC) and insula - influenced the link between sleep architecture and evening vs next morning pain in women with fibromyalgia.
Methods
Thirty adults with fibromyalgia and insomnia (Mage=57.2, SD=13.1) completed overnight polysomnography and daily diaries (14 days) tracking sleep and pain [0–100 (most intense). Pain discrepancy (PD) is the average difference between nighttime and next morning pain (evening - morning). Participants underwent MRI, and FreeSurfer (v5.1.0) estimated CT. Multiple regressions examined CT’s influence on the sleep stage [%stage1, %stage2, %stage3, %rapid eye movement (REM)] and PD relationship (controlling for age and education). For significant CT moderation, significance of simple slopes at different CT levels were examined: high (1 SD above), average, and low (1 SD below).
Results
Right rostral ACC (rRACC) CT moderated the relationship between %stage2 (B=-1.41, SE=0.6, p=.03, R^2=0.14), %stage3 (B=2.10, SE=0.97, p=.04, R^2 =0.13), %REM (B=2.35, SE=1.12, p=.04, R^2=0.13) and PD. Greater %stage2 was associated with higher morning vs evening pain at high rRACC thickness (B=-0.67, SE=0.22, p=0.005). Greater %stage3 (B=0.97, SE=0.38, p=0.02) and %REM (B=0.92, SE=0.42, p=0.04) were associated with lower morning pain vs evening pain at high, but not average or low rRACC thickness. Left insula CT moderated the association between increased %stage3 and lower morning vs evening pain (B=2.91, SE=1.18, p=.02, R^2=0.34) at the average and high, but not low thickness levels (B=0.36, SE=0.17, p=0.05; B=1.41, SE=0.48, p=0.008 respectively).
Conclusion
High cortical thickness in the rRACC and average to high L-insula cortical thickness moderated the association between restorative sleep (%stage3, REM) and lower morning vs evening pain. Future studies examining the role of CT in pain-related brain regions on the association of restorative sleep with overnight pain processing are warranted.
Support (if any)
National Institute of Nursing Research (NR017168; PI: McCrae). Clinical trial NCT02001077 Sleep and Pain Interventions (SPIN2), University of Missouri (PI: McCrae).
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Miller MB, Curtis A, Hall N, Everson A, Park CJ, Martinez L, Freeman L, McCrae CS. 372 Sleep Hygiene Compliance and Sleep in Young Adult Drinkers with Insomnia: A Daily Analysis. Sleep 2021. [DOI: 10.1093/sleep/zsab072.371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Empirical evidence linking sleep hygiene practices to subsequent sleep parameters – and the extent to which those compare to evidence-based practices such as stimulus control – is limited. This study examined the daily impact of recommendation compliance on sleep in a sample of young adult drinkers with insomnia.
Methods
Young adults (18-30y; N=56, 75% female) who met diagnostic criteria for insomnia and reported past-month binge drinking wore wrist actigraphy and completed online sleep diaries for 7+ days (492 reports). Diaries assessed compliance with nine sleep hygiene recommendations: to limit naps; limit caffeine; avoid caffeine after 12p; avoid tobacco, alcohol, vigorous exercise, and heavy meals within 2 hours of bedtime; avoid bright light within 30 minutes of bedtime; and utilize a bedtime routine. If participants reported wake after sleep onset, diaries also assessed if they had gotten out of bed and returned to bed only when sleepy (partial stimulus control instructions). Multilevel models examined three outcomes: sleep quality, self-reported sleep efficiency, and actigraphy-measured sleep efficiency (α=.05/3≤.017). Covariates included gender; college enrollment; weekday versus weekend; and between-person differences in insomnia severity, hazardous drinking, and average compliance,
Results
Participants self-reported better sleep efficiency on days that they avoided naps (B=3.64, p=.004; 95% CI=1.20, 6.08). They also self-reported better sleep quality (B=0.40, p<.001; 95% CI=0.19, 0.60) and sleep efficiency (B=3.94, p<.001; 95% CI=1.76; 6.12) on days that they followed stimulus control. Surprisingly, they reported worse sleep quality (B=-0.28, p=.017; 95% CI=-0.51, -0.05) and sleep efficiency (B=-3.74, p=.002; 95% CI=-6.08, -1.40) on days that they avoided alcohol use before bedtime. No variables were significantly associated with actigraphy-based sleep efficiency. At the between-person level, participants reporting more at-risk drinking reported worse sleep quality (B=-0.04, p=.017; 95% CI=-0.08, -0.01).
Conclusion
Data provide empirical support for recommendations that young adult drinkers with insomnia avoid naps and get out of bed during nighttime awakenings. Although heavier drinkers reported worse sleep quality than lighter drinkers, they also reported better subjective (but not objective) sleep on nights they drank close to bedtime. We speculate that this is due to later bedtimes on heavy-drinking nights.
Support (if any)
University of Missouri Research Board (PI Miller)
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Jagannathan S, Rodgers M, McCrae CS, Miller MB, Curtis A. 672 COVID-19 Anxiety and Sleep in Middle-aged and Older Adults: Impact of Age and Sex. Sleep 2021. [PMCID: PMC8135703 DOI: 10.1093/sleep/zsab072.670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction COVID-19 is an infectious respiratory illness that was declared a pandemic in March 2020. During the course of COVID-19, studies have demonstrated worsening sleep quality and anxiety. No studies have examined age-related and sex-specific associations between COVID-19 anxiety and sleep in aging populations. We examined associations between COVID-19 anxiety and sleep, and evaluated age and sex as moderators, in middle-aged/older adults. Methods Two hundred and seventy-seven middle-aged/older adults aged 50+ (Mage=64.68, SD=7.83; 44% women) living in the United States who were cognitively healthy (no cognitive impairment/dementia/neurological disorders) completed an online Qualtrics survey in July/August 2020 measuring sleep (Pittsburgh Sleep Quality Index; PSQI) and COVID-19 anxiety (Coronavirus Anxiety Scale; CAS). Multiple regressions examined whether CAS was independently associated with or interacted with age or sex in its associations with PSQI total score/subscores (sleep quality, sleep duration, sleep efficiency, daytime dysfunction), controlling for age, education, number of medical conditions, sleep/pain medication use, and COVID-19 status. Results CAS interacted with age (B=-.008, SE=.003 p=.02, R-squared=.02), not sex (p=.31), in its association with sleep duration. Higher CAS was associated with shorter sleep duration in oldest-older adults (~73 years old; B=.12, SE=.05, p=.01) and younger-older adults (~65 years old; B=.07, SE=.03, p=.02), not middle-aged adults (~57 years old, p=.47). CAS interacted with age (B=.01, SE=.004, p=.02), not sex (p=.56), in its association with sleep efficiency. Higher CAS was associated with worse sleep efficiency in oldest-older adults (B=.14, SE=.05, p=.009) and younger-older adults (B=.08, SE=.04, p=.03), not middle-aged adults (p=.60). Higher CAS was associated with greater daytime dysfunction (B=.26, SE=.07, p<.001) and higher PSQI total score (B=.82, SE=.33, p=.01), and did not interact with age or sex (ps>.05). Conclusion Increased COVID-19 anxiety is associated with several aspects of worse sleep (shorter sleep duration, sleep efficiency) in older adults but not middle-aged adults. Generally, in middle-aged/older adults, higher COVID-19 anxiety is associated with worse daytime dysfunction and overall sleep quality. Sex does not moderate these associations. Increased COVID-19 morbidity and mortality in aging populations may translate to increased anxiety and subsequent sleep disruptions. Interventions aimed at mitigating negative pandemic-related psychological and sleep outcomes may be particularly relevant for older adults. Support (if any):
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Miller MB, Deroche CB, Freeman LK, Park CJ, Hall NA, Sahota PK, McCrae CS. Cognitive behavioral therapy for insomnia among young adults who are actively drinking: a randomized pilot trial. Sleep 2021; 44:5901605. [PMID: 32886778 DOI: 10.1093/sleep/zsaa171] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/05/2020] [Indexed: 01/18/2023] Open
Abstract
STUDY OBJECTIVES More than half of young adults at risk for alcohol-related harm report symptoms of insomnia. Insomnia symptoms, in turn, have been associated with alcohol-related problems. Yet one of the first-line treatments for insomnia (Cognitive Behavioral Therapy for Insomnia or CBT-I) has not been tested among individuals who are actively drinking. This study tested (1) the feasibility and short-term efficacy of CBT-I among binge-drinking young adults with insomnia and (2) improvement in insomnia as a predictor of improvement in alcohol use outcomes. METHODS Young adults (ages 18-30 years, 75% female, 73% college students) who met criteria for Insomnia Disorder and reported 1+ binge drinking episode (4/5+ drinks for women/men) in the past month were randomly assigned to 5 weekly sessions of CBT-I (n = 28) or single-session sleep hygiene (SH, n = 28). All participants wore wrist actigraphy and completed daily sleep surveys for 7+ days at baseline, posttreatment, and 1-month follow-up. RESULTS Of those randomized, 43 (77%) completed posttreatment (19 CBT-I, 24 SH) and 48 (86%) completed 1-month follow-up (23 CBT-I, 25 SH). CBT-I participants reported greater posttreatment decreases in insomnia severity than those in SH (56% vs. 32% reduction in symptoms). CBT-I did not have a direct effect on alcohol use outcomes; however, mediation models indicated that CBT-I influenced change in alcohol-related consequences indirectly through its influence on posttreatment insomnia severity. CONCLUSIONS CBT-I is a viable intervention among individuals who are actively drinking. Research examining improvement in insomnia as a mechanism for improvement in alcohol-related consequences is warranted. TRIAL REGISTRATION U.S. National Library of Medicine, https://clinicaltrials.gov/ct2/show/NCT03627832, registration #NCT03627832.
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Affiliation(s)
| | | | | | - Chan Jeong Park
- Department of Psychiatry, University of Missouri, Columbia, MO
| | - Nicole A Hall
- Department of Psychiatry, University of Missouri, Columbia, MO
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Miller MB, Curtis AF, Chan WS, Deroche CB, McCrae CS. Daily associations between sleep and opioid use among adults with comorbid symptoms of insomnia and fibromyalgia. J Clin Sleep Med 2021; 17:729-737. [PMID: 33226334 DOI: 10.5664/jcsm.9002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Disturbed sleep and use of opioid pain medication are common among individuals with chronic pain. Anecdotally, opioids are thought to promote sleep by relieving pain. This study aimed to determine whether opioid use is associated with daily sleep parameters (and vice versa) in adults with comorbid symptoms of insomnia and fibromyalgia. METHODS Individuals reporting symptoms of insomnia and opioid use for fibromyalgia (n = 65, 93% women, 79% White) wore wrist actigraphy and completed daily diaries for 14 days (910 observations). Analyses examined daily associations between opioid dose (measured in lowest recommended dosage units) and three sleep parameters (actigraphy/self-reported total wake time and self-reported sleep quality). Multilevel models were used to account for the clustering of daily sleep and opioid assessments (level 1) within individuals (level 2). RESULTS Opioid use did not have a significant daily effect on total wake time or sleep quality, and sleep parameters did not significantly impact opioid use the next day; however, participants reported worse sleep quality and greater doses of opioids on evenings that they experienced greater pain. CONCLUSIONS Among adults reporting symptoms of insomnia and opioid use for fibromyalgia pain, opioid use is not reliably associated with wake time or sleep quality that night, and these sleep parameters are not significantly associated with opioid use the next day; however, evening pain has an adverse daily impact on both sleep quality and opioid use. Studies identifying strategies to prevent and manage fibromyalgia pain are needed, especially for individuals reporting comorbid insomnia and opioid use.
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Affiliation(s)
- Mary Beth Miller
- Department of Psychiatry, University of Missouri School of Medicine, Columbia, Missouri
| | - Ashley F Curtis
- Department of Psychiatry, University of Missouri School of Medicine, Columbia, Missouri.,Department of Psychological Sciences, University of Missouri, Columbia, Missouri
| | - Wai Sze Chan
- Department of Psychology, The University of Hong Kong, Hong Kong
| | - Chelsea B Deroche
- Department of Psychiatry, University of Missouri School of Medicine, Columbia, Missouri
| | - Christina S McCrae
- Department of Psychiatry, University of Missouri School of Medicine, Columbia, Missouri
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Miller MB, Freeman L, Park CJ, Hall NA, Deroche C, Sahota PK, McCrae CS. Insomnia treatment effects among young adult drinkers: Secondary outcomes of a randomized pilot trial. Alcohol Clin Exp Res 2021; 45:1136-1148. [PMID: 33745147 DOI: 10.1111/acer.14603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/05/2021] [Accepted: 03/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cognitive behavioral therapy for insomnia (CBT-I) has moderate-to-large effects on insomnia among young adult drinkers, with preliminary data indicating that improvements in insomnia may have downstream effects on alcohol-related consequences. However, the mechanism(s) by which insomnia treatment may facilitate reductions in alcohol-related problems is unclear. Secondary outcome data from a randomized pilot trial were used to examine CBT-I effects on four proposed mediators of the insomnia/alcohol link: alcohol craving, delay discounting, negative affect, and difficulties with emotion regulation. METHODS Young adults (ages 18 to 30 years) with insomnia who reported 1+ binge drinking episode (4/5+ drinks for women/men) in the past month were randomized to receive CBT-I (n = 28) or to a sleep hygiene control (n = 28). Outcomes were assessed at baseline, after 5 weeks of treatment, and at 1-month posttreatment. RESULTS Relative to those in sleep hygiene, CBT-I participants reported greater decreases in alcohol craving (d = 0.33) at the end of treatment and greater 1-month posttreatment decreases in delay discounting of large rewards (d = 0.42). CBT-I did not have a significant effect on delay discounting of smaller rewards or momentary negative affect. There was also no significant treatment effect on difficulties with emotion regulation, although findings were confounded by a significant group difference at baseline in difficulties with emotion regulation. CONCLUSIONS Treatment of insomnia may lead to improvements in alcohol craving and delay discounting of large rewards among young adult drinkers with insomnia. Additional research examining whether improvement in insomnia is a mechanism for improvement in addiction domains is warranted.
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Affiliation(s)
| | - Lindsey Freeman
- University of Missouri School of Medicine, Columbia, MO, USA
| | - Chan Jeong Park
- University of Missouri School of Medicine, Columbia, MO, USA
| | - Nicole A Hall
- University of Missouri School of Medicine, Columbia, MO, USA
| | - Chelsea Deroche
- University of Missouri School of Medicine, Columbia, MO, USA
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McCrae CS, Curtis AF, Nair N, Berry J, Davenport M, McGovney K, Berry RB, McCoy K, Marsiske M. Impact of a brief behavioral treatment for insomnia (BBTi) on metacognition in older adults. Sleep Med 2021; 80:286-293. [PMID: 33610076 DOI: 10.1016/j.sleep.2021.01.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/11/2020] [Accepted: 01/26/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Brief (≤4 sessions) behavioral treatment for insomnia (BBTi) improves insomnia symptoms in older adults. Findings for BBTi-related improvements in objective cognition are mixed, with our recent trial reporting no effects. Metacognition (appraisal of one's own performance) has not been examined. This study examined the effects of BBTi on metacognition in older adults with insomnia. METHODS Older adults with insomnia [N = 62, Mage = 69.45 (SD = 7.71)] were randomized to 4-weeks of BBTi (n = 32; psychoeducation, sleep hygiene, stimulus control, sleep restriction, relaxation, review/maintenance) or self-monitoring control (SMC; n = 30; social conversations). Throughout the study (2 week baseline, 4 week treatment, 2 week post-treament, 2 week 3-month followup), participants completed daily paper/pencil cognitive tasks (measuring verbal memory, attention, processing speed and reasoning) and provided daily metacognition ratings of their performance in four areas: quality, satisfaction, compared to same age peers, compared to own ability. Two-week averages of metacognitive ratings were calculated for baseline, treatment-first half, treatment-second half, post-treatment, and 3-month follow-up. Multilevel Modeling examined treatment effects (BBTi/SMC) over time on metacognition, controlling for age and sex. RESULTS A significant group by time interaction (p = 0.05) revealed consistent improvements over time in better metacognitive ratings relative to same age peers for BBTi. Specifically, baseline ratings [mean (M) = 51.21, standard error (SE) = 3.15] improved at first half of treatment (M = 56.65, SE = 3.15, p < 0.001), maintained improvement at second-half of treatment (p = 0.18), showed additional improvement at post-treatment (M = 60.79, SE = 3.15, p = 0.02), and maintained improvement at follow-up (M = 62.30, SE = 3.15; p = 0.02). SMC prompted inconsistent and smaller improvements between baseline (M = 53.24, SE = 3.29) and first-half of treatment (M = 56.62, SE = 3.28; p = 0.004), with additional improvement at second-half of treatment (M = 59.39, SE = 3.28; p = 0.02) that was maintained at post-treatment (p = 0.73) and returned to levels observed at first-half of treatment (M = 57.78, SE = 3.21; p = 0.55). Significant main effects of time (all ps < 0.001) for other metacognition variables (Quality, Satisfaction, Compared to own ability) indicated general improvements over time for both groups. DISCUSSION Metacognition generally improved over time regardless of treatment. BBTi selectively improved ratings of performance relative to same age peers. Repeated objective testing alone may improve metacognition in older adults with insomnia. Better understanding of metacognition and how to improve it has important implications for older adults as metacognitive complaints have been associated with mild cognitive impairment.
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Affiliation(s)
- Christina S McCrae
- Department of Psychiatry, University of Missouri-Columbia, Columbia, MO, USA.
| | - Ashley F Curtis
- Department of Psychiatry, University of Missouri-Columbia, Columbia, MO, USA; Department of Psychological Sciences, University of Missouri-Columbia, Columbia, MO, USA
| | - Neetu Nair
- Department of Psychiatry, University of Missouri-Columbia, Columbia, MO, USA
| | - Jasmine Berry
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, MO, USA
| | - Mattina Davenport
- Department of Psychiatry, University of Missouri-Columbia, Columbia, MO, USA
| | - Kevin McGovney
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, MO, USA
| | - Richard B Berry
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Karin McCoy
- Neuropsychology Service, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Michael Marsiske
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
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Curtis AF, Dzierzewski JM, Buman MP, Giacobbi PR, Roberts BL, Aiken-Morgan AT, Marsiske M, McCrae CS. Preliminary investigation of interactive associations of sleep and pain with cognition in sedentary middle-aged and older adults. J Clin Sleep Med 2021; 17:233-242. [PMID: 33006311 PMCID: PMC7853205 DOI: 10.5664/jcsm.8856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 09/27/2020] [Accepted: 09/28/2020] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The objective of this study was to examine independent and interactive associations between self-reported sleep (sleep efficiency and total sleep time [TST]) and pain with cognition in sedentary middle-aged and older adults. METHODS Seventy-five sedentary adults at least 50 years of age (Mage = 63.24, standard deviation = 8.87) completed 14 daily diaries measuring sleep and pain. Weekly average sleep efficiency, TST, and pain were computed. Participants also completed computerized cognitive tasks: Letter Series (reasoning), N-back (working memory), Symbol Digit Modalities Test (processing speed, attention), and Number Copy (processing speed). Multiple regression analyses were conducted to determine independent and interactive (with pain) associations of sleep efficiency and TST with cognition, controlling for age, education, and sex. RESULTS Sleep efficiency and pain interacted in their associations with Letter Series performance and N-back difference scores (2-back minus 1-back). Specifically, higher sleep efficiency was associated with better reasoning and working memory in those with highest pain but not average or lowest pain. TST and pain also interacted in their associations with Letter Series performance. Specifically, longer TST associated with worse reasoning in those with lowest (not average or highest) pain. CONCLUSIONS Preliminary results show that in sedentary middle-aged and older adults, pain and sleep interact in their associations with executive function tasks. Higher sleep efficiency may be associated with better reasoning and working memory in those with highest pain. Lower TST may be associated with better reasoning in those with lowest pain. Studies evaluating temporal associations between sleep, pain, and cognition are needed.
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Affiliation(s)
- Ashley F. Curtis
- Department of Psychiatry, University of Missouri, Columbia, Missouri
- Department of Psychological Sciences, University of Missouri, Columbia, Missouri
| | | | - Matthew P. Buman
- College of Health Solutions, Arizona State University, Tempe, Arizona
| | - Peter R. Giacobbi
- College of Physical Activity and Sport Sciences, West Virginia University, Morgantown, West Virginia
| | | | - Adrienne T. Aiken-Morgan
- Department of Psychology, North Carolina A&T State University, Greensboro, North Carolina
- Center on Health and Society, Social Science Research Institute, Duke University, Durham, North Carolina
| | - Michael Marsiske
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida
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Chan WS, Dautovich ND, McNamara JP, Stripling A, Dzierzewski JM, McCoy K, McCrae CS. Sleep Discrepancy in a Randomized Controlled Trial of Brief Behavioral Therapy for Chronic Insomnia in Older Adults. Behav Sleep Med 2021; 19:221-231. [PMID: 32039635 PMCID: PMC7981845 DOI: 10.1080/15402002.2020.1726750] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background/Objective: Some older adults with insomnia experience sleep discrepancy, often characterized by greater subjective sleep difficulties and shorter subjective sleep duration than the estimates derived from objective measures. The present study examined whether a brief behavioral therapy for insomnia (BBTi) is efficacious for reducing sleep discrepancy in older adults. Methods: This study is a secondary analysis of a randomized controlled trial of BBTi for community dwelling older adults with chronic insomnia (N = 62). Thirty-two participants received BBTi, delivered in four individual face-to-face sessions. Thirty received the self-monitoring control (SMC). They all completed daily sleep diaries and wore an actigraph from baseline to posttreatment, and for 2 weeks at 3-month follow-up. Sleep discrepancy was calculated by subtracting diary from actigraphy estimates of sleep onset latency (SOL), wake after sleep onset (WASO), and total sleep time (TST). Mixed modeling was used to analyze data. SOL discrepancy decreased significantly in BBTi participants compared to SMC participants. The decreases in SOL discrepancy were explained by changes in diary-assessed SOL and subjective sleep quality but not changes in actigraphy-assessed SOL. Although WASO discrepancy and TST discrepancy decreased from baseline to posttreatment and follow-up, the Time by Group interaction effects were not significant indicating that BBTi participants did not experience greater reductions in WASO discrepancy and TST discrepancy than SMC participants. In conclusion, BBTi is efficacious for reducing SOL discrepancy in older adults with chronic insomnia.
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Affiliation(s)
- Wai Sze Chan
- Department of Psychology, University of Hong Kong, Hong
Kong,Department of Psychiatry, Geisel School of Medicine at
Dartmouth, Lebanon, NH
| | | | | | - Ashley Stripling
- College of Psychology, Nova Southeastern University, Fort
Lauderdale, FL
| | | | - Karin McCoy
- Neuropsychology Service, South Texas Veterans Health Care
System, San Antonio, TX
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50
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McCrae CS, Curtis AF. From bit player to key mechanism: the role of sleep in exercise. J Clin Sleep Med 2020; 16:19-20. [DOI: 10.5664/jcsm.8886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Christina S. McCrae
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri
| | - Ashley F. Curtis
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri
- Department of Psychological Sciences, University of Missouri-Columbia, Columbia, Missouri
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