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Albert SM, Roth T, Toscani M, Vitiello MV, Zee P. Sleep Health and Appropriate Use of OTC Sleep Aids in Older Adults-Recommendations of a Gerontological Society of America Workgroup. THE GERONTOLOGIST 2015; 57:163-170. [PMID: 26511271 DOI: 10.1093/geront/gnv139] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Getting a good night's sleep can be challenging for older adults with chronic medical conditions, which often interfere with sleep. As a result, many older adults turn to over-the-counter (OTC) sleep aids, that is, products with diphenhydramine or doxylamine. However, these products are indicated only for occasional difficulty with sleep, not for chronic use; and their safety and efficacy has not been well established in general and in older adults specifically. To engage national stakeholders in a discussion of OTC sleep aids in older adults, the Gerontological Society of America (GSA) convened a multidisciplinary workgroup. The Workgroup examined differences between younger and older adults in sleep health and use of OTC sleep aids using data from the National Health and Wellness Survey; assessed the pharmacologic properties and medication effects of OTC sleep aids; and worked with stakeholders to promote strategies for safe and effective use. Older adults are more likely to take diphenhydramine or doxylamine products 15 or more days in a month, an indicator of inappropriate use. The Workgroup recommends research to investigate the ways older people use OTC sleep aids. The goal should be reduction in inappropriate use and associated risks, such as daytime sedation, compromised cognitive function, and falls. In addition, the Workgroup recommends a greater role for community pharmacists in counseling older adults on appropriate use of OTC sleep aids.
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Wrede JE, Mengel-From J, Buchwald D, Vitiello MV, Bamshad M, Noonan C, Christiansen L, Christensen K, Watson NF. Mitochondrial DNA Copy Number in Sleep Duration Discordant Monozygotic Twins. Sleep 2015; 38:1655-8. [PMID: 26039967 DOI: 10.5665/sleep.5068] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 04/04/2015] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Mitochondrial DNA (mtDNA) copy number is an important component of mitochondrial function and varies with age, disease, and environmental factors. We aimed to determine whether mtDNA copy number varies with habitual differences in sleep duration within pairs of monozygotic twins. SETTING Academic clinical research center. PARTICIPANTS 15 sleep duration discordant monozygotic twin pairs (30 twins, 80% female; mean age 42.1 years [SD 15.0]). DESIGN Sleep duration was phenotyped with wrist actigraphy. Each twin pair included a "normal" (7-9 h/24) and "short" (< 7 h/24) sleeping twin. Fasting peripheral blood leukocyte DNA was assessed for mtDNA copy number via the n-fold difference between qPCR measured mtDNA and nuclear DNA creating an mtDNA measure without absolute units. We used generalized estimating equation linear regression models accounting for the correlated data structure to assess within-pair effects of sleep duration on mtDNA copy number. MEASUREMENTS AND RESULTS Mean within-pair sleep duration difference per 24 hours was 94.3 minutes (SD 62.6 min). We found reduced sleep duration (β = 0.06; 95% CI 0.004, 0.12; P < 0.05) and sleep efficiency (β = 0.51; 95% CI 0.06, 0.95; P < 0.05) were significantly associated with reduced mtDNA copy number within twin pairs. Thus every 1-minute decrease in actigraphy-defined sleep duration was associated with a decrease in mtDNA copy number of 0.06. Likewise, a 1% decrease in actigraphy-defined sleep efficiency was associated with a decrease in mtDNA copy number of 0.51. CONCLUSIONS Reduced sleep duration and sleep efficiency were associated with reduced mitochondrial DNA copy number in sleep duration discordant monozygotic twins offering a potential mechanism whereby short sleep impairs health and longevity through mitochondrial stress.
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Tang HYJ, Vitiello MV, Perlis M, Riegel B. Open-Loop Neurofeedback Audiovisual Stimulation: A Pilot Study of Its Potential for Sleep Induction in Older Adults. Appl Psychophysiol Biofeedback 2015; 40:183-8. [PMID: 25931250 PMCID: PMC4534306 DOI: 10.1007/s10484-015-9285-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This pilot study tested the efficacy of a 30-min audio-visual stimulation (AVS) program for the treatment of chronic insomnia in older adults. Chronic insomnia has been conceptualized as entailing increased cortical high frequency EEG activity at sleep onset and during NREM sleep. We hypothesized that an AVS program gradually descending from 8 to 1 Hz would potentially reduce the excessive cortical activation that is thought to contribute to difficulties with initiating and maintaining sleep. Accordingly, we conducted an intervention study of AVS using a pre-post design. Eight older adults (88 ± 8.7 years) complaining of chronic insomnia self-administered a 30-min AVS program nightly at bedtime for one month. Sleep was assessed at baseline and throughout the 4-week intervention. After using AVS for 4 weeks, significant improvement was reported in insomnia symptoms (ISI, p = 0.002) and sleep quality (PSQI, p = 0.004); with moderate to large effect sizes (Partial Eta2: 0.20-0.55)(Cohen's d: 0.7-2.3). The training effect (self-reported sleep improvement) was observed at the end of week one and persisted through the 1-month intervention. The results from this pilot study suggest that further exploration of AVS as a treatment for insomnia is warranted.
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Alessi C, Vitiello MV. Insomnia (primary) in older people: non-drug treatments. BMJ CLINICAL EVIDENCE 2015; 2015:2302. [PMID: 25968443 PMCID: PMC4429264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Up to 40% of older adults have insomnia, with difficulty getting to sleep, early waking, or feeling unrefreshed on waking. The prevalence of insomnia increases with age. Other risk factors include psychological factors, stress, daytime napping, and hyperarousal. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical question: What are the effects of non-drug treatments for primary insomnia in older people (aged 60 years and older)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 14 studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review, we present information relating to the effectiveness and safety of the following interventions: cognitive behavioural therapy for insomnia (CBT-I), exercise programmes, and timed exposure to bright light.
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Hirshkowitz M, Whiton K, Albert SM, Alessi C, Bruni O, DonCarlos L, Hazen N, Herman J, Katz ES, Kheirandish-Gozal L, Neubauer DN, O'Donnell AE, Ohayon M, Peever J, Rawding R, Sachdeva RC, Setters B, Vitiello MV, Ware JC, Adams Hillard PJ. National Sleep Foundation’s sleep time duration recommendations: methodology and results summary. Sleep Health 2015; 1:40-43. [PMID: 29073412 DOI: 10.1016/j.sleh.2014.12.010] [Citation(s) in RCA: 2140] [Impact Index Per Article: 237.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 12/24/2014] [Accepted: 12/24/2014] [Indexed: 11/17/2022]
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Parsons EC, Hough CL, Vitiello MV, Zatzick D, Davydow DS. Insomnia is associated with quality of life impairment in medical-surgical intensive care unit survivors. Heart Lung 2015; 44:89-94. [PMID: 25592203 DOI: 10.1016/j.hrtlng.2014.11.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Revised: 11/02/2014] [Accepted: 11/04/2014] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To examine the prevalence of insomnia and its relationship to health-related quality of life (HRQOL) post-intensive care unit (ICU). BACKGROUND The burden of post-ICU insomnia is unknown. METHODS This cross-sectional study examined data from 120 patients with an ICU stay >24 h. Pre-hospital health was assessed in-hospital. Insomnia, HRQOL and post-ICU psychiatric symptoms were assessed at 12 months post-ICU. RESULTS Over one-quarter (28%) of subjects met insomnia criteria at 12 months post-ICU. Post-ICU insomnia was independently associated with worse mental HRQOL (P < 0.01), as well as worse scores on the HRQOL sub-domains of bodily pain (P < 0.001), vitality (P < 0.05) and physical function (P < 0.05). However, these associations were no longer significant after adjusting for post-ICU psychiatric symptoms (P = 0.33). CONCLUSIONS Insomnia is common among ICU survivors. Post-ICU insomnia is significantly associated with mental HRQOL and could identify ICU survivors who may benefit from further psychiatric evaluation.
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Tang HY, Vitiello MV, Perlis M, Mao JJ, Riegel B. A pilot study of audio-visual stimulation as a self-care treatment for insomnia in adults with insomnia and chronic pain. Appl Psychophysiol Biofeedback 2014; 39:219-25. [PMID: 25257144 PMCID: PMC4221414 DOI: 10.1007/s10484-014-9263-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This pilot study tested the efficacy of an audio-visual stimulation (AVS) program for the promotion of sleep in individuals with chronic pain. Insomnia and chronic pain are common comorbid conditions and their relationship has been viewed as bidirectional. Recent studies suggest a relatively dominant role of sleep in this dyad. The premise of this pilot study was that AVS enhances low frequency while reducing high frequency brain activity resulting in decreased hyperarousal and improved sleep with potential consequent reduction in pain. We conducted a pilot intervention study of AVS using a pre-post design. Participants self-administered a 30-min AVS program nightly at bedtime for 1 month. Sleep and pain were assessed at baseline and at the conclusion of the 4-week intervention phase. Nine adults (mean age 33 ± 15.8 years; female, 89 %) completed the study. After using the AVS device for 4 weeks, significant improvement was seen in reported insomnia (ISI, p = 0.003), pain severity (BPI, p = 0.005), and pain interference with functioning (BPI, p = 0.001). Large effect sizes (Partial η(2) 0.20-0.94) (Cohen's d 0.44-1.45) were observed. The results of this pilot study suggest that the AVS program may be efficacious in decreasing both insomnia and pain symptoms. In order to better assess the efficacy of AVS for sleep promotion and possible pain reduction, more definitive randomized controlled trials will be needed. These should include appropriate sample sizes, objective measures of sleep and pain, and longitudinal follow-up.
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Fogelberg DJ, Vitiello MV, Hoffman JM, Bamer AM, Amtmann D. Comparison of self-report sleep measures for individuals with multiple sclerosis and spinal cord injury. Arch Phys Med Rehabil 2014; 96:478-83. [PMID: 25450136 DOI: 10.1016/j.apmr.2014.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 09/03/2014] [Accepted: 10/01/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To investigate self-report measures of sleep disturbances and sleep-related impairments in samples of individuals with multiple sclerosis (MS) or spinal cord injury (SCI). DESIGN Cross-sectional survey. SETTING Community based. PARTICIPANTS Adults (age ≥18y) (N=700) with either MS (n=461) or SCI (n=239) who were enrolled in a longitudinal survey of self-reported health outcomes and who completed self-report sleep measures at 1 time point. INTERVENTIONS None. MAIN OUTCOME MEASURES Medical Outcomes Study Sleep Scale (MOS-S), Patient Reported Outcomes Measurement Information System (PROMIS) sleep disturbance short form, and PROMIS sleep-related impairments short form. RESULTS Mean scores on the MOS-S sleep index II were significantly worse for both the MS and SCI samples than those of previously reported samples representative of the U.S. general population (P<.0001 for each group). The PROMIS sleep disturbance short form and PROMIS sleep-related impairments short form scores of the MS sample were also significantly different from those reported for the calibration cohort (P<.0001 on each scale). However, although the scores of the SCI sample were significantly different from those of the comparison cohort for the PROMIS sleep-related impairments short form (P=.045), the differences on the PROMIS sleep disturbance short form were not significant (P=.069). CONCLUSIONS Although the MOS-S scores for the MS and SCI cohorts clearly indicated significantly high levels of sleep-related problems and were consistent with existing literature, the more ambiguous findings from the PROMIS sleep disturbance short form and PROMIS sleep-related impairments short form suggest that not enough is currently known about how these instruments function when applied to those with chronic neurologic dysfunction.
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Fogelberg D, Vitiello MV, Hoffman JM, Amtmann D. Item Level Comparison of Self-Report Sleep Measures for Individuals With Chronic Central Nervous System Dysfunction. Arch Phys Med Rehabil 2014. [DOI: 10.1016/j.apmr.2014.07.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Buchanan DT, Cain K, Heitkemper M, Burr R, Vitiello MV, Zia J, Jarrett M. Sleep measures predict next-day symptoms in women with irritable bowel syndrome. J Clin Sleep Med 2014; 10:1003-9. [PMID: 25142761 DOI: 10.5664/jcsm.4038] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVES Patients with irritable bowel syndrome (IBS) often report sleep disturbances. Previously, we have shown that self-reported sleep difficulties predicted exacerbations of next-day IBS symptoms, mood disturbance, and fatigue. The purpose of this study was to explore whether objectively measured sleep using actigraphy, as well as self-report, predicts next-day symptoms in women with IBS and to explore whether or not symptoms also predict self-report and objective sleep. METHODS Women aged 18-45 years with IBS were community-recruited (n = 24, mean age = 32 ± 8 years). Participants completed sleep and IBS symptom diaries for one menstrual cycle and wore Actiwatch-64 actigraphs for 7 days at home. Statistical analyses used generalized estimating equation (GEE) models. RESULTS Poorer self-reported sleep quality significantly (p < 0.05) predicted higher next-day abdominal pain, anxiety, and fatigue, but was not significant for gastrointestinal (GI) symptoms or depressed mood. Actigraphic sleep efficiency (SEF) significantly predicted worsening next-day anxiety and fatigue, but not abdominal pain, GI symptoms, or depressed mood. On temporally reversed analyses, none of the symptoms significantly predicted subsequent sleep, except that GI symptoms significantly predicted higher actigraphic sleep efficiency. CONCLUSION This small exploratory study supports previous findings that self-reported sleep disturbance predicted exacerbation of next-day symptoms in women with IBS and extends this relationship using an objective sleep measure. The study adds further evidence that sleep quality predicts subsequent IBS symptoms, but not the converse. The findings from this small study support the importance of additional longitudinal research to further understand the relationships between sleep and IBS.
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Gooneratne NS, Vitiello MV. Sleep in older adults: normative changes, sleep disorders, and treatment options. Clin Geriatr Med 2014; 30:591-627. [PMID: 25037297 PMCID: PMC4656195 DOI: 10.1016/j.cger.2014.04.007] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Approximately 5% of older adults meet criteria for clinically significant insomnia disorders and 20% for sleep apnea syndromes. It is important to distinguish age-appropriate changes in sleep from clinically significant insomnia, with the latter having associated daytime impairments. Non-pharmacologic therapies, such as cognitive-behavioral therapy for insomnia, can be highly effective with sustained benefit. Pharmacologic therapies are also available, but may be associated with psychomotor effects. A high index of suspicion is crucial for effective diagnosis of sleep apnea because symptoms commonly noted in younger patients, such as obesity or loud snoring, may not be present in older patients.
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Vitiello MV, McCurry SM, Shortreed SM, Baker LD, Rybarczyk BD, Keefe FJ, Von Korff M. Short-term improvement in insomnia symptoms predicts long-term improvements in sleep, pain, and fatigue in older adults with comorbid osteoarthritis and insomnia. Pain 2014; 155:1547-1554. [PMID: 24793909 DOI: 10.1016/j.pain.2014.04.032] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 02/20/2014] [Accepted: 04/25/2014] [Indexed: 10/25/2022]
Abstract
UNLABELLED In a primary care population of 367 older adults (aged ⩾60 years) with osteoarthritis (OA) pain and insomnia, we examined the relationship between short-term improvement in sleep and long-term sleep, pain, and fatigue outcomes through secondary analyses of randomized controlled trial data. Study participants, regardless of experimental treatment received, were classified either as improvers (⩾30% baseline to 2-month reduction on the Insomnia Severity Index [ISI]) or as nonimprovers. After controlling for treatment arm and potential confounders, improvers showed significant, sustained improvements across 18 months compared with nonimprovers in pain severity (P<0.001, adjusted mean difference=-0.51 [95% CI: -0.80, -0.21), arthritis symptoms (P<0.001, 0.63 [0.26, 1.00]), and fear avoidance (P=0.009, -2.27 [-3.95, -0.58]) but not in catastrophizing or depression. Improvers also showed significant, sustained improvements in ISI (P<0.001, -3.03 [-3.74, -2.32]), Pittsburgh Sleep Quality Index Total (P<0.001, -1.45 [-1.97, -0.93]) and general sleep quality (P<0.001, -0.28 [-0.39, -0.16]) scores, Flinders Fatigue Scale (P<0.001, -1.99 [-3.01, -0.98]), and Dysfunctional Beliefs About Sleep Scale (P=0.037, -2.44 [-4.74, -0.15]), but no improvements on the Functional Outcomes of Sleep Questionnaire or the Epworth Sleepiness Scale. We conclude that short-term (2-month) improvements in sleep predicted long-term (9- and 18-month) improvements for multiple measures of sleep, chronic pain, and fatigue. These improvements were not attributable to nonspecific benefits for psychological well-being, such as reduced depression. These findings are consistent with benefits of improved sleep for chronic pain and fatigue among older persons with osteoarthritis pain and comorbid insomnia if robust improvements in sleep are achieved and sustained. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01142349.
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Vitiello MV, Krieger J. Tales of leaving plateaus and scaling new heights! Sleep Med Rev 2014; 18:1-2. [DOI: 10.1016/j.smrv.2013.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Watson NF, Harden KP, Buchwald D, Vitiello MV, Pack AI, Strachan E, Goldberg J. Sleep duration and depressive symptoms: a gene-environment interaction. Sleep 2014; 37:351-8. [PMID: 24497663 DOI: 10.5665/sleep.3412] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE We used quantitative genetic models to assess whether sleep duration modifies genetic and environmental influences on depressive symptoms. METHOD Participants were 1,788 adult twins from 894 same-sex twin pairs (192 male and 412 female monozygotic [MZ] pairs, and 81 male and 209 female dizygotic [DZ] pairs] from the University of Washington Twin Registry. Participants self-reported habitual sleep duration and depressive symptoms. Data were analyzed using quantitative genetic interaction models, which allowed the magnitude of additive genetic, shared environmental, and non-shared environmental influences on depressive symptoms to vary with sleep duration. RESULTS Within MZ twin pairs, the twin who reported longer sleep duration reported fewer depressive symptoms (ec = -0.17, SE = 0.06, P < 0.05). There was a significant gene × sleep duration interaction effect on depressive symptoms (a'c = 0.23, SE = 0.08, P < 0.05), with the interaction occurring on genetic influences that are common to both sleep duration and depressive symptoms. Among individuals with sleep duration within the normal range (7-8.9 h/night), the total heritability (h2) of depressive symptoms was approximately 27%. However, among individuals with sleep duration within the low (< 7 h/night) or high (≥ 9 h/night) range, increased genetic influence on depressive symptoms was observed, particularly at sleep duration extremes (5 h/night: h2 = 53%; 10 h/night: h2 = 49%). CONCLUSION Genetic contributions to depressive symptoms increase at both short and long sleep durations.
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McCurry SM, Shortreed SM, Von Korff M, Balderson BH, Baker LD, Rybarczyk BD, Vitiello MV. Who benefits from CBT for insomnia in primary care? Important patient selection and trial design lessons from longitudinal results of the Lifestyles trial. Sleep 2014; 37:299-308. [PMID: 24497658 DOI: 10.5665/sleep.3402] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Evaluate long-term effects of group interventions on sleep and pain outcomes in a primary care population of older adults with osteoarthritis pain and sleep disturbance. DESIGN Double-blind, cluster-randomized controlled trial with 18-mo follow-up. SETTING Group Health and University of Washington, Seattle, WA, from 2009 to 2011. PARTICIPANTS Three hundred sixty-seven adults age 60 y and older, with osteoarthritis pain and insomnia symptoms. INTERVENTIONS Six weekly sessions of group cognitive behavioral therapy for insomnia and pain (CBT-PI), pain alone (CBT-P), and education-only control (EOC) delivered in patients' primary care clinics. MEASUREMENTS AND RESULTS There were no significant differences between treatment groups in sleep outcomes at 18 mo. This is a change from published significant 9-mo follow-up results for insomnia severity (Insomnia Severity Index) and sleep efficiency. There were no significant treatment differences in pain at either follow-up. Post hoc analyses of participants with greater insomnia and pain severity at baseline (n = 98) showed significant (P = 0.01) 18-mo reductions in pain comparing CBT-PI versus CBT-P (adjusted mean difference [AMD] = -1.29 [95% confidence interval (CI): -2.24,-0.33]). Moderate, albeit nonsignificant, CBT-PI versus EOC treatment effects for insomnia severity (AMD = -1.43 [95% CI: -4.71, 1.86]) and sleep efficiency (AMD = 2.50 [95% CI: -5.04, 10.05]) were also observed. Possible trial design and methodological considerations that may have affected results are discussed. CONCLUSIONS Results suggest patients with higher levels of comorbid pain and insomnia may be most likely to experience sustained benefit from cognitive behavioral therapy interventions over time, and inclusion of insomnia treatment may yield more clinically meaningful improvements than cognitive behavioral therapy for pain alone. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT01142349.
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Friedman SD, Baker LD, Borson S, Jensen JE, Barsness SM, Craft S, Merriam GR, Otto RK, Novotny EJ, Vitiello MV. Growth hormone-releasing hormone effects on brain γ-aminobutyric acid levels in mild cognitive impairment and healthy aging. JAMA Neurol 2013; 70:883-90. [PMID: 23689947 DOI: 10.1001/jamaneurol.2013.1425] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Growth hormone-releasing hormone (GHRH) has been previously shown to have cognition-enhancing effects. The role of neurotransmitter changes, measured by proton magnetic resonance spectroscopy, may inform the mechanisms for this response. OBJECTIVE To examine the neurochemical effects of GHRH in a subset of participants from the parent trial. DESIGN Randomized, double-blind, placebo-controlled substudy of a larger trial. SETTING Clinical research unit at the University of Washington School of Medicine. PARTICIPANTS Thirty adults (17 with mild cognitive impairment [MCI]), ranging in age from 55 to 87 years, were enrolled and successfully completed the study. INTERVENTIONS Participants self-administered daily subcutaneous injections of tesamorelin (Theratechnologies Inc), a stabilized analogue of human GHRH (1 mg/d), or placebo 30 minutes before bedtime for 20 weeks. At baseline and weeks 10 and 20, participants underwent brain magnetic resonance imaging and spectroscopy protocols and cognitive testing and provided blood samples after fasting. Participants also underwent glucose tolerance tests before and after intervention. MAIN OUTCOMES AND MEASURES Brain levels of glutamate, inhibitory transmitters γ-aminobutyric acid (GABA) and N-acetylaspartylglutamate (NAAG), and myo-inositol (MI), an osmolyte linked to Alzheimer disease in humans, were measured in three 2 × 2 × 2-cm3 left-sided brain regions (dorsolateral frontal, posterior cingulate, and posterior parietal). Glutamate, GABA, and MI levels were expressed as ratios to creatine plus phosphocreatine, and NAAG was expressed as a ratio to N-acetylaspartate. RESULTS After 20 weeks of GHRH administration, GABA levels were increased in all brain regions (P < .04), NAAG levels were increased (P = .03) in the dorsolateral frontal cortex, and MI levels were decreased in the posterior cingulate (P = .002). These effects were similar in adults with MCI and older adults with normal cognitive function. No changes in the brain levels of glutamate were observed. In the posterior cingulate, treatment-related changes in serum insulin-like growth factor 1 were positively correlated with changes in GABA (r = 0.47; P = .001) and tended to be negatively correlated with MI (r = -0.34; P = .06). Consistent with the results of the parent trial, a favorable treatment effect on cognition was observed in substudy participants (P = .03). No significant associations were observed between treatment-related changes in neurochemical and cognitive outcomes. Glucose homeostasis in the periphery was not reliably affected by GHRH administration and did not account for treatment neurochemical effects. CONCLUSIONS Twenty weeks of GHRH administration increased GABA levels in all 3 brain regions, increased NAAG levels in the frontal cortex, and decreased MI levels in the posterior cingulate. To our knowledge, this is the first evidence that 20 weeks of somatotropic supplementation modulates inhibitory neurotransmitter and brain metabolite levels in a clinical trial, and it provides preliminary support for one possible mechanism to explain favorable GHRH effects on cognition in adults with MCI and in healthy older adults. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00257712.
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Geda YE, Schneider LS, Gitlin LN, Miller DS, Smith GS, Bell J, Evans J, Lee M, Porsteinsson A, Lanctôt KL, Rosenberg PB, Sultzer DL, Francis PT, Brodaty H, Padala PP, Onyike CU, Ortiz LA, Ancoli-Israel S, Bliwise DL, Martin JL, Vitiello MV, Yaffe K, Zee PC, Herrmann N, Sweet RA, Ballard C, Khin NA, Alfaro C, Murray PS, Schultz S, Lyketsos CG. Neuropsychiatric symptoms in Alzheimer's disease: past progress and anticipation of the future. Alzheimers Dement 2013; 9:602-8. [PMID: 23562430 PMCID: PMC3766403 DOI: 10.1016/j.jalz.2012.12.001] [Citation(s) in RCA: 245] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Neuropsychiatric symptoms (NPS) in Alzheimer's disease (AD) are widespread and disabling. This has been known since Dr. Alois Alzheimer's first case, Frau Auguste D., presented with emotional distress and delusions of infidelity/excessive jealousy, followed by cognitive symptoms. Being cognizant of this, in 2010 the Alzheimer's Association convened a research roundtable on the topic of NPS in AD. A major outcome of the roundtable was the founding of a Professional Interest Area (PIA) within the International Society to Advance Alzheimer's Research and Treatment (ISTAART). The NPS-PIA has prepared a series of documents that are intended to summarize the literature and provide more detailed specific recommendations for NPS research. This overview paper is the first of these living documents that will be updated periodically as the science advances. The overview is followed by syndrome-specific synthetic reviews and recommendations prepared by NPS-PIA workgroups on depression, apathy, sleep, agitation, and psychosis.
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Faestel PM, Littell CT, Vitiello MV, Forsberg CW, Littman AJ. Perceived insufficient rest or sleep among veterans: Behavioral Risk Factor Surveillance System 2009. J Clin Sleep Med 2013; 9:577-84. [PMID: 23772191 DOI: 10.5664/jcsm.2754] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Sleep problems are of particular concern among the active duty military population as factors such as inconsistent work hours and deployment may compromise adequate sleep and adversely impact performance. However, few prior studies have investigated whether the prevalence of sleep problems differ between Veterans and demographically similar non-Veterans. The purpose of this study is to investigate whether self-reported insufficient rest or sleep varies in relation to Veteran status and to identify high-risk groups of Veterans. METHODS This study used data from the 2009 Behavioral Risk Factor Surveillance System (analyzed in 2011), a state based national telephone survey of non-institutionalized US adults. Insufficient rest was assessed in 411,313 adults aged 21 and older, of whom 55,361 were Veterans. Sleep duration was assessed in 6 states (n = 4,936 Veterans and 30,983 non-Veterans). Model-based direct rate adjustment was used to estimate the prevalence of insufficient rest or sleep while controlling for confounding. Multivariable logistic regression was used to estimate odds ratios of insufficient sleep or rest in subgroups of Veterans. RESULTS After multivariable adjustment, insufficient rest or sleep (22.7% vs. 21.1%, p < 0.001) and short sleep duration (< 7 h/night, 34.9% vs. 31.3%, p = 0.026) were more common among Veterans than non-Veterans. When the Veteran group was further divided among newly transitioned (≤ 12 months) and longer-term Veterans (> 12 months), the overall test for a difference was not statistically significant between groups, mainly because there was little difference in sleep between the two groups of Veterans. High-risk Veteran subgroups included those who were 21-44 years of age (vs. 65-74), women, non-whites, current smokers, obese, unable to work, and those in poor health. CONCLUSIONS This study suggests that Veterans have a high burden of sleep problems and identifies subgroups that should be targeted to receive interventions and enhanced education regarding insufficient sleep.
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Baker LD, Vitiello MV. Growth hormone-releasing hormone improves cognitive function in older adults: sleep on it--reply. JAMA Neurol 2013; 70:529-30. [PMID: 23568654 DOI: 10.1001/jamaneurol.2013.2064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Vitiello MV, McCurry SM, Shortreed SM, Balderson BH, Baker LD, Keefe FJ, Rybarczyk BD, Von Korff M. Cognitive-behavioral treatment for comorbid insomnia and osteoarthritis pain in primary care: the lifestyles randomized controlled trial. J Am Geriatr Soc 2013; 61:947-956. [PMID: 23711168 DOI: 10.1111/jgs.12275] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To assess whether older persons with osteoarthritis (OA) pain and insomnia receiving cognitive-behavioral therapy for pain and insomnia (CBT-PI), a cognitive-behavioral pain coping skills intervention (CBT-P), and an education-only control (EOC) differed in sleep and pain outcomes. DESIGN Double-blind, cluster-randomized controlled trial with 9-month follow-up. SETTING Group Health and University of Washington, 2009 to 2011. PARTICIPANTS Three hundred sixty-seven older adults with OA pain and insomnia. INTERVENTIONS Six weekly group sessions of CBT-PI, CBT-P, or EOC delivered in participants' primary care clinics. MEASUREMENTS Primary outcomes were insomnia severity and pain severity. Secondary outcomes were actigraphically measured sleep efficiency and arthritis symptoms. RESULTS CBT-PI reduced insomnia severity (score range 0-28) more than EOC (adjusted mean difference = -1.89, 95% confidence interval = -2.83 to -0.96; P < .001) and CBT-P (adjusted mean difference = -2.03, 95% CI = -3.01 to -1.04; P < .001) and improved sleep efficiency (score range 0-100) more than EOC (adjusted mean difference = 2.64, 95% CI = 0.44-4.84; P = .02). CBT-P did not improve insomnia severity more than EOC, but improved sleep efficiency (adjusted mean difference = 2.91, 95% CI = 0.85-4.97; P = .006). Pain severity and arthritis symptoms did not differ between the three arms. A planned analysis in participants with severe baseline pain revealed similar results. CONCLUSION Over 9 months, CBT of insomnia was effective for older adults with OA pain and insomnia. The addition of CBT for insomnia to CBT for pain alone improved outcomes.
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Taibi DM, Landis CA, Vitiello MV. Concordance of polysomnographic and actigraphic measurement of sleep and wake in older women with insomnia. J Clin Sleep Med 2013; 9:217-25. [PMID: 23493815 PMCID: PMC3578686 DOI: 10.5664/jcsm.2482] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The objective of this secondary analysis was to evaluate concurrent validity of actigraphy and polysomnography (PSG) in older women with insomnia. METHODS Concurrent validity of actigraphy and PSG was examined through (1) comparison of sleep outcomes from each recording method; (2) calculation of sensitivity, specificity, accuracy, and predictive values from epoch-by-epoch data; and (3) statistical and graphical exploration of the relationship between sleep disturbance severity and concordance of actigraphy and PSG. Subjects were 16 community-dwelling older women (mean age 69.4 ± 8.1) with insomnia who underwent 8 nights of concurrent actigraphy and PSG. RESULTS Sleep efficiency reflected much greater sleep disturbance on PSG (66.9%) than actigraphy (84.4%). Based on generalized linear models, the parameter estimates for agreement between actigraphy and PSG were statistically significant (p < 0.05) for total sleep time and sleep latency, verged on significance for WASO (p = 0.052), but was not significant for sleep efficiency (p = 0.20). Epoch-by-epoch analysis showed high sensitivity (96.1%), low specificity (36.4%), and modest values on agreement (75.4%) and predictive values of sleep (74.7%) and wake (80.2%). Generalized linear models showed that overall accuracy of actigraphy declined as sleep efficiency declined (unstandardized Beta = 0.741, p < 0.001). Based on this model, sleep efficiency of 73% was the point at which accuracy declined below an acceptable accuracy value of 80%. CONCLUSIONS Actigraphy offers a relatively inexpensive and unobtrusive method for measuring sleep, but it appears to underestimate sleep disturbance, particularly at sleep efficiency levels below 73%, in older women with insomnia.
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Baker LD, Barsness SM, Borson S, Merriam GR, Friedman SD, Craft S, Vitiello MV. Effects of growth hormone–releasing hormone on cognitive function in adults with mild cognitive impairment and healthy older adults: results of a controlled trial. ACTA ACUST UNITED AC 2013; 69:1420-9. [PMID: 22869065 DOI: 10.1001/archneurol.2012.1970] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Growth hormone–releasing hormone(GHRH), growth hormone, and insulin like growth factor 1 have potent effects on brain function, their levels decrease with advancing age, and they likely play a role in the pathogenesis of Alzheimer disease. Previously, we reported favorable cognitive effects of short-term GHRH administration in healthy older adults and provided preliminary evidence to suggest a similar benefit in adults with mild cognitive impairment (MCI). OBJECTIVE To examine the effects of GHRH on cognitive function in healthy older adults and in adults with MCI. DESIGN Randomized,double-blind,placebo-controlled trial. SETTING Clinical Research Center, University of Washington School of Medicine in Seattle. PARTICIPANTS A total of 152 adults (66 with MCI) ranging in age from 55 to 87 years (mean age, 68 years); 137 adults (76 healthy participants and 61 participants with MCI) successfully completed the study. INTERVENTION Participants self-administered daily subcutaneous injections of tesamorelin (Theratechnologies Inc),a stabilized analog of human GHRH (1 mg/d), or placebo 30 minutes before bedtime for 20 weeks. At baseline, at weeks 10 and 20 of treatment, and after a 10-week washout(week 30), blood samples were collected, and parallel versions of a cognitive battery were administered. Before and after the 20-week intervention, participants completed an oral glucose tolerance test and a dual-energy x-ray absorptiometry scan to measure body composition. MAIN OUTCOME MEASURES Primary cognitive outcomes were analyzed using analysis of variance and included 3 composites reflecting executive function, verbal memory, and visual memory. Executive function was assessed with Stroop Color-Word Interference,Task Switching, the Self-Ordered Pointing Test, and Word Fluency, verbal memory was assessed with Story Recall and the Hopkins Verbal Learning Test,and visual memory was assessed with the Visual-Spatial Learning Test and Delayed Match-to-Sample. RESULTS The intent-to-treat analysis indicated a favorable effect of GHRH on cognition (P=.03), which was comparable in adults with MCI and healthy older adults.The completer analysis showed a similar pattern, with a more robust GHRH effect (P=.002). Subsequent analyses indicated a positive GHRH effect on executive function (P=.005) and a trend showing a similar treatment-related benefit in verbal memory(P=.08). Treatment with GHRH increased insulin like growth factor 1 levels by 117 %(P.001), which remained within the physiological range, and reduced percent body fat by 7.4%(P.001). Treatment with GHRH increased fasting insulin levels within the normal range by 35%in adults with MCI (P.001) but not in healthy adults. Adverse events were mild and were reported by 68%of GHRH treated adults and 36% of those who received placebo. CONCLUSIONS Twenty weeks of GHRH administration had favorable effects on cognition in both adults with MCI and healthy older adults. Longer-duration treatment trials are needed to further examine the therapeutic potential of GHRH administration on brain health during normal aging and “pathological aging.” TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00257712
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Vitiello MV. [Promoting recognition of sleep disorders in the elderly in China]. ZHONGHUA YI XUE ZA ZHI 2013; 93:401-402. [PMID: 23660253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Vitiello MV, McCurry SM, Rybarczyk BD. The Future of Cognitive Behavioral Therapy for Insomnia: What Important Research Remains to Be Done? J Clin Psychol 2013; 69:1013-21. [DOI: 10.1002/jclp.21948] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Vitiello MV, Schwartz RS, Moe KE, Mazzoni G, Merriam GR. Treating age-related changes in somatotrophic hormones, sleep, and cognition. DIALOGUES IN CLINICAL NEUROSCIENCE 2012. [PMID: 22034239 PMCID: PMC3181657 DOI: 10.31887/dcns.2001.3.3/mvvitiello] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Many of the body's systems that function to maintain optimal health and well-being decline with advancing age. Aerobic capacity, muscle mass, and strength all progressively decline. Significant sleep disturbances are associated with increases in morbidity and mortality. Cognition declines, impacting an older individual's ability to function independently. Interventions that could at least stabilize or possibly improve functional capacity, sleep quality, and cognitive function have the theoretical potential to prolong an older individual's ability to live independently, and interest in their possible utility is growing rapidly. One such intervention may be stimulation of the “somatotrophic” axis via growth hormone-releasing hormone (GHRH). Here we review the evidence for such somatotrophic interventions. We also report preliminary findings on the effects of chronic GHRH treatment on the somatotrophic hormones, body composition, functional status, sleep, and cognitive function of healthy older men and women from two major GHRH intervention studies, one recently completed and the other ongoing.
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