Recorded and reported sleep in chronic primary insomnia

Cognitive behavioural therapy for insomnia reduces actigraphy and diary measured sleep discrepancy for individuals with comorbid insomnia and major depressive disorder: A report from the TRIAD study

OBJECTIVE/BACKGROUND

Discrepancies between sleep diaries and actigraphy occur among individuals with insomnia. Cognitive behavioural therapy for insomnia (CBT-I) improves insomnia but the impact on discrepancy is unclear. This study examined CBT-I's effects on actigraphy-diary discrepancy and explored sleep-related beliefs and attitudes as a mediator.

PATIENTS/METHODS

Participants were 108 (age M±SD = 47.23 ± 12.42, 67.60 % female) adults with insomnia and major depressive disorder from the Treatment of Insomnia and Depression study. They were randomized to 7 sessions of CBT-I or sham Quasi-Desensitization Therapy for Insomnia (DTI), plus 16 weeks of antidepressants. Two weeks of actigraphy and sleep diary were collected at baseline, mid-treatment, end-treatment. Differences between sleep diary and actigraphy total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO), and sleep efficiency (SE) were calculated. Participants completed Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS) at baseline and mid-treatment.

RESULTS

At baseline, diary (versus actigraphy) TST was shorter (1.1 ± 1.41h), whilst SOL (21.64 ± 41.25min) and WASO (17.45 ± 61.99min) were longer. Mixed effects models using daily data showed that after adjusting for age and sex, participants in the CBT-I group (versus DTI) showed greater reduction in all actigraphy-diary discrepancy domains (all p-values<.01), reductions evident from mid-treatment. Group differences on actigraphy-diary discrepancy reductions in TST, SOL, and SE (not WASO) were mediated by changes in DBAS from baseline to mid-treatment (all p-values<.05). Changes in discrepancy did not mediate insomnia symptom changes (p-values>.39).

CONCLUSIONS

CBT-I reduced actigraphy-diary discrepancy in individuals with comorbid insomnia and depression; this reduction was associated with improved sleep-related attitudes, a therapeutic target of CBT-I.

CLINICAL TRIAL REGISTRATION

TRIAD (Treatment of Insomnia and Depression): Improving Depression Outcome by Adding Insomnia Therapy to Antidepressants. Prospectively registered with Clinical Trials (NCT00767624).

SUPPORT (IF ANY)

MH078924, MH078961, MH079256.

Investigating the subjective and objective efficacy of a cognitive behavioural therapy for insomnia (CBT-I)-based smartphone app on sleep: A randomised controlled trial

Due to insufficient treatment options for insomnia, effective solutions are urgently needed. We evaluated the effects of a CBT-I-based app combining sleep training with subjective and objective sleep monitoring on (i) sleep and (ii) subjective-objective sleep discrepancies (SOSD). Fifty-seven volunteers (20-76 years; MAge  = 45.67 ± 16.38; 39 female) suffering from sleep problems were randomly assigned to an experimental group (EG, n = 28) or a waitlist control group (CG, n = 29). During the 6-week app phase, the EG used the CBT-I-based programme and a heart rate sensor for daily sleep monitoring and -feedback, while the CG used sleep monitoring only. Sleep was measured (i) subjectively via questionnaires (Insomnia Severity Index, ISI; Pittsburgh Sleep Quality Index, PSQI), (ii) objectively via ambulatory polysomnography (PSG), and (iii) continuously via heart-rate sensor and sleep diaries. Data revealed interactions for ISI (p = 0.003, ƞ2 part  = 0.11) and PSQI (p = 0.050, ƞ2 part  = 0.05), indicating training-specific improvements in EG, yet not in CG. While PSG-derived outcomes appear to be less training-specific, a tendential reduction in wake after sleep onset (WASO) was found in EG (p = 0.061, d = 0.55). Regarding changes in SOSD, the results indicate improvements during the app phase (EG) for sleep efficiency, sleep onset latency, and WASO (p ≤ 0.022, d ≥ 0.46); for total sleep time both groups showed a SOSD reduction. The findings indicate beneficial effects of a novel smartphone app on sleep and SOSD. More scientific evaluation of such digital programmes is needed to ultimately help in reducing the gap in non-pharmacological insomnia treatment.

Performance of an open machine learning model to classify sleep/wake from actigraphy across ∼24-hour intervals without knowledge of rest timing

GOAL AND AIMS

Commonly used actigraphy algorithms are designed to operate within a known in-bed interval. However, in free-living scenarios this interval is often unknown. We trained and evaluated a sleep/wake classifier that operates on actigraphy over ∼24-hour intervals, without knowledge of in-bed timing.

FOCUS TECHNOLOGY

Actigraphy counts from ActiWatch Spectrum devices.

REFERENCE TECHNOLOGY

Sleep staging derived from polysomnography, supplemented by observation of wakefulness outside of the staged interval. Classifications from the Oakley actigraphy algorithm were additionally used as performance reference.

SAMPLE

Adults, sleeping in either a home or laboratory environment.

DESIGN

Machine learning was used to train and evaluate a sleep/wake classifier in a supervised learning paradigm. The classifier is a temporal convolutional network, a form of deep neural network.

CORE ANALYTICS

Performance was evaluated across ∼24 hours, and additionally restricted to only in-bed intervals, both in terms of epoch-by-epoch performance, and the discrepancy of summary statistics within the intervals.

ADDITIONAL ANALYTICS AND EXPLORATORY ANALYSES

Performance of the trained model applied to the Multi-Ethnic Study of Atherosclerosis dataset.

CORE OUTCOMES

Over ∼24 hours, the temporal convolutional network classifier produced the same or better performance as the Oakley classifier on all measures tested. When restricting analysis to the in-bed interval, the temporal convolutional network remained favorable on several metrics.

IMPORTANT SUPPLEMENTAL OUTCOMES

Performance decreased on the Multi-Ethnic Study of Atherosclerosis dataset, especially when restricting analysis to the in-bed interval.

CORE CONCLUSION

A classifier using data labeled over ∼24-hour intervals allows for the continuous classification of sleep/wake without knowledge of in-bed intervals. Further development should focus on improving generalization performance.

Does providing feedback and guidance on sleep perceptions using sleep wearables improve insomnia? Findings from "Novel Insomnia Treatment Experiment": a randomized controlled trial

STUDY OBJECTIVES

Insomnia is a disorder diagnosed based on self-reported sleep complaints. Differences between self-reported and sensor-based sleep parameters (sleep-wake state discrepancy) are common but not well-understood in individuals with insomnia. This two-arm, parallel-group, single-blind, superiority randomized-controlled trial examined whether monitoring sleep using wearable devices and providing support for interpretation of sensor-based sleep data improved insomnia symptoms or impacted sleep-wake state discrepancy.

METHODS

A total of 113 (age M = 47.53; SD = 14.37, 64.9% female) individuals with significant insomnia symptoms (Insomnia Severity Index(ISI) ≥10) from the community were randomized 1:1 (permuted block randomization) to receive 5 weeks (1) Intervention (n = 57): feedback about sensor-based sleep (Fitbit and EEG headband) with guidance for data interpretation and ongoing monitoring, and (2) Control (n = 56): sleep education and hygiene. Both groups received one individual session and two check-in calls. The ISI (primary outcome), sleep disturbance (SDis), sleep-related impairment (SRI), depression, and anxiety were assessed at baseline and post-intervention.

RESULTS

In total, 103 (91.2%) participants completed the study. Intention-to-treat multiple regression with multiple imputations showed that after controlling for baseline values, compared to the Control group (n = 51), the Intervention group (n = 52) had lower ISI (p = .011, d = 0.51) and SDis (p = .036, d = 0.42) post-intervention, but differences in SRI, depression, anxiety, and sleep-wake state discrepancy parameters (total sleep time, sleep onset latency, and wake after sleep onset) were not meaningful (P-values >.40).

CONCLUSIONS

Providing feedback and guidance about sensor-based sleep parameters reduced insomnia severity and sleep disturbance but did not alter sleep-wake state discrepancy in individuals with insomnia more than sleep hygiene and education. The role of sleep wearable devices among individuals with insomnia requires further research.

CLINICAL TRIAL REGISTRATION

The Novel Insomnia Treatment Experiment (NITE): the effectiveness of incorporating appropriate guidance for sleep wearables in users with insomnia. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378452, Australia New Zealand Clinical Trials Registry: ACTRN12619001636145.

The Relationship Between Stress and Sleep Sufficiency in the Context of Varied Workplace Social Support

OBJECTIVE

Sufficient sleep is essential for well-being. We examined the relationship between work-related social support, work stress, and sleep sufficiency, predicting that workers with higher social support would report higher sleep sufficiency across varying levels of work stress.

METHODS

The data set analyzed in the present study included 2213 workers from approximately 200 small (<500 employees) businesses in high, medium, and low hazard industries across Colorado.

RESULTS

Perceived social support variables moderated the relationship between work stress and sleep sufficiency such that employees reporting higher levels of social support reported higher sleep sufficiency when work stress was low or moderate but not high.

CONCLUSIONS

Although preventing work stress is optimal, in cases where employers cannot apply primary interventions to prevent stress (eg, eliminating/reducing night shifts), employers should attempt to increase social support or other more relevant resources for employees.

Providing Brief Personalized Therapies for Insomnia Among Workers Using a Sleep Prompt App: Randomized Controlled Trial

Background

Insomnia is the most common sleep disorder and the foremost health concern among workers. We developed a new sleep prompt app (SPA) for smartphones to positively alter the users' consciousness and behavior by sending timely short messages for mild sleep problems at an early stage.

Objective

The aim of this study is to investigate the effectiveness of the SPA in providing brief personalized therapy for insomnia among workers.

Methods

We conducted a 2-arm parallel randomized controlled trial. The intervention group used the SPA, and the control group received no intervention. Participants were recruited between November 2020 and January 2021. The researcher sent emails for recruitment to more than 3000 workers of 2 companies and 1 university in Japan. The SPA provided personalized prompt messages, sleep diaries, sleep hygiene education, stimulus control therapy, and sleep restriction therapy. The prompt messages were sent automatically to the participants to encourage them to improve their sleep habits and sleep status and were optimized to the individual's daily rhythm. The intervention program duration was 4 weeks. The primary outcome was a change in the Insomnia Severity Index (ISI) for the study period. The ISI was obtained weekly using a web questionnaire.

Results

A total of 116 Japanese workers (intervention group n=60, control group n=56) with sleep disorders were recruited. Two participants in the intervention group were excluded from the analyses because of challenges in installing the SPA. The mean ISI scores at baseline were 9.2 for both groups; however, after 4 weeks, the mean ISI scores declined to 6.8 and 8.0 for the intervention and control groups, respectively. Primary analysis using a linear mixed model showed a significant improvement in the temporal trends of the ISI in the SPA group and in the total population (P=.03). Subgroup analyses of ISI-8-insomniacs revealed a significant improvement in the temporal trends of ISI in the SPA group (P=.01), and the CFS score for physical condition significantly improved following the intervention (P=.02).

Conclusions

This study demonstrates the effectiveness of the SPA in providing brief personalized therapy for insomnia among Japanese workers with mild insomnia. The physical fatigue score significantly improved in ISI-8-insomniacs. Thus, SPA could play an important role in reducing the adverse effects of sleep disorders in workers. To promote the wide use of the SPA in the future, further studies are required to examine its effectiveness in other age groups and individuals with health problems.

Trial Registration

University Medical Information Network Clinical Trials Registry (UMIN-CTR) UMIN000042263; https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000046295

Impact of Persistent Poor Sleep Quality on Post-Stroke Anxiety and Depression: A National Prospective Clinical Registry Study

PURPOSE

The impact of poor sleep quality after stroke, especially persistent poor sleep quality, on poststroke anxiety and depression is unclear. We seek to investigate the impact of baseline and persistent poor sleep quality on short-term poststroke anxiety and depression.

PATIENTS AND METHODS

Data were analyzed for 1619 patients with acute ischemic stroke from the Impairment of Cognition and Sleep after Acute Ischemic Stroke or Transient Ischemic Attack in Chinese Patients study (ICONS). The sleep quality was assessed at 2 weeks and 3 months using the Pittsburgh Sleep Quality Index scale (PSQI). Poor sleep quality was defined as a PSQI score of >5, and persistent poor sleep quality was defined as a PSQI score of >5 at each time point. Patients were divided into three groups according to the quality of sleep: good sleep quality, baseline poor sleep quality and persistent poor sleep quality. Patient Health Questionnaire-9 (PHQ-9), General Anxiety Disorder-7 scale (GAD-7), and Modified Rankin Scale (mRS) at 3 months after stroke were taken as the study outcomes.

RESULTS

Persistent poor sleep quality was present in 70.2% of patients after stroke. Compared to those with good sleep quality, patients with baseline poor sleep quality did not show significant differences in disability, anxiety and depression. However, patients with persistent poor sleep were at increased risk of depression (odds ratio, OR 3.04, 95% confidence interval, CI 1.66-5.57, P < 0.01) and anxiety (OR 3.20, 95% CI 1.42-7.19, P < 0.01) at 3 months after stroke. Persistent poor sleep quality was not identified as a risk factor for functional disability at 3 months.

CONCLUSION

Patients with persistent poor sleep quality are at added risks for depression and anxiety after stroke.

Sleep-wake misperception. A comprehensive analysis of a large sleep lab cohort

OBJECTIVES

Sleep-wake misperception has mainly been reported in insomnia patients. Conversely, the present study aimed to assess the prevalence and correlates of sleep-wake misperception in a large cohort of patients with various sleep-wake disorders, all diagnosed along the third version of the International Classification of Sleep Disorders.

METHODS

We retrospectively included 2738 patients examined by polysomnography, who in addition estimated upon awakening their total sleep time, sleep onset latency and Wake after sleep onset (WASO). We computed subjective-objective mismatch by the formula (subjective - objective value)/objective value ×100; negative and positive values indicated under- and overestimation, respectively.

RESULTS

In the entire sample, the magnitude of under- and overestimation of total sleep time was similar, but varied significantly between diagnostic groups, with insomnia and insufficient sleep syndrome showing the most pronounced underestimation and REM parasomnia and circadian rhythm disorders showing the most pronounced overestimation of total sleep time. In all diagnostic categories, a majority tended to overestimate their sleep onset latency and to underestimate the amount of WASO. Younger age was independently correlated with underestimation of total sleep time and WASO, and with overestimation of sleep onset latency. Overestimation of sleep onset latency independently correlated to an increased latency to N3 sleep stage on polysomnography.

CONCLUSIONS

While sleep-wake misperception is highly prevalent in all sleep-wake disorders, significant differences exist in magnitude of under- and overestimation between distinct diagnostic groups.

Social jetlag among Japanese adolescents: Association with irritable mood, daytime sleepiness, fatigue, and poor academic performance

Social jetlag, a form of circadian misalignment, has been suggested to induce several clinical symptoms such as mental/physical health problems. However, evidence on the association of social jetlag with general daytime functioning (e.g., school life) is limited. This cross-sectional study aimed to 1) estimate the distribution of social jetlag exceeding one hour and 2) comprehensively explore the associations between social jetlag and irritable mood, daytime sleepiness, and poor academic performance among Japanese adolescents. The study included 4,782 students aged 12-15 years, from 13 junior high schools, who completed a self-administered questionnaire. Social jetlag was calculated as the difference in the midpoint of sleep between weekdays and weekends and was categorized as follow: negative, <1 h, 1-2 h, or ≥2 h. Outcomes were irritable mood, daytime sleepiness, and academic performance, which were analyzed with generalized linear mixed models to examine the relations with social jetlag, with adjustments for potential confounders like sleep quality. The distribution of social jetlag of ≥1 h was 51.1%, including 1-2 h (35.8%) and ≥2 h (15.3%). Its most frequently observed duration was 0 to <1 h (41.0%), followed by negative social jetlag (7.9%). The full adjusted model revealed that social jetlag of ≥1 h was associated with elevated risk of irritable mood, daytime sleepiness, and poor academic performance, while negative social jetlag was associated only with poor academic performance. Social jetlag was highly prevalent among Japanese adolescents and could be a major risk factor for irritable mood, daytime sleepiness, and poor academic performance.Abbreviations: BMI, Body mass index; DLMO, Dim light melatonin onset; CIs, Confidence intervals; MSF, The midpoints of sleep on free days; MSF_sc, Sleep-corrected MSF; MSW, The midpoints of sleep on weekdays; PDSS, The Pediatric Daytime Sleepiness Scale.

Optimizing computation of overnight decline in delta power: Evidence for slower rate of decline in delta power in insomnia patients

OBJECTIVE

To determine the best of commonly used methods for computing the rate of decline in non-rapid eye movement (NREM) sleep EEG delta power overnight (Delta Decline) in terms of vulnerability to missing data and to evaluate whether this rate is slower in insomnia patients than healthy controls (HC).

METHODS

Fifty-one insomnia patients and 53 HC underwent 6 nights of polysomnography. Four methods for estimating Delta Decline were compared (exponential and linear best-fit functions using NREM (1) episode mean, (2) peak, and (3) total delta power and (4) delta power for all available NREM epochs). The best method was applied to compare groups on linear and exponential rates of Delta Decline.

RESULTS

Best-fit models using all available NREM epochs were significantly less vulnerable to deviation due to missing data than other methods. Insomnia patients displayed significantly slower linear and exponential Delta Decline than HC.

CONCLUSIONS

Computing Delta Decline using all available NREM epochs was the best of the methods studied for minimizing the effects of missing data. Insomnia patients display slower Delta Decline, which is not explained by differences in total sleep time or wake after sleep onset.

SIGNIFICANCE

This study supports using all available NREM epochs in Delta Decline computation and suggests a slower rate in insomnia.

Brain reactivity using fMRI to insomnia stimuli in insomnia patients with discrepancy between subjective and objective sleep

Subjective–objective discrepancy of sleep (SODS) might be related to the distorted perception of sleep deficit and hypersensitivity to insomnia-related stimuli. We investigated differences in brain activation to insomnia-related stimuli among insomnia patients with SODS (SODS group), insomnia patients without SODS (NOSODS group), and healthy controls (HC). Participants were evaluated for subjective and objective sleep using sleep diary and polysomnography. Functional magnetic resonance imaging was conducted during the presentation of insomnia-related (Ins), general anxiety-inducing (Gen), and neutral (Neu) stimuli. Brain reactivity to the contrast of Ins vs. Neu and Gen vs. Neu was compared among the SODS (n = 13), NOSODS (n = 15), and HC (n = 16) groups. In the SODS group compared to other groups, brain areas including the left fusiform, bilateral precuneus, right superior frontal gyrus, genu of corpus callosum, and bilateral anterior corona radiata showed significantly increased blood oxygen level dependent (BOLD) signal in the contrast of Ins vs. Neu. There was no brain region with significantly increased BOLD signal in the Gen vs. Neu contrast in the group comparisons. Increased brain activity to insomnia-related stimuli in several brain regions of the SODS group is likely due to these individuals being more sensitive to sleep-related threat and negative cognitive distortion toward insomnia.

Psychosocial factors affecting sleep misperception in middle-aged community-dwelling adults

Sleep misperception has long been a major issue in the field of insomnia research. Most studies of sleep misperception examine sleep underestimation by comparing the results of polysomnography conducted in a laboratory environment with patients' sleep diary entries. We aimed to investigate psychosocial characteristics of adults who underestimated or overestimated sleep time in a nonclinical, middle-aged community-dwelling population. We collected one week of sleep data with wrist-worn accelerometers. We used egocentric social network analysis to analyze the effects of psychosocial factors. Among 4,060 study participants, 922 completed the accelerometer substudy. Underestimation was defined as an accelerometer-measured sleep time ≥ 6 h and a subjective sleep time < 6 h. Overestimation was defined as an objective sleep time < 6 h and a subjective sleep time ≥ 6 h. Psychosocial characteristics of the sleep misperception group were evaluated using multivariate regression analysis. A total of 47 participants underestimated sleep time, and 420 overestimated sleep time. Regression analysis revealed that women, living with spouse, economic satisfaction, and bridging potential had protective effects against sleep underestimation. Blame from a spouse involved a 3.8-times higher risk of underestimation than the control group (p = 0.002). In men, discussing concerns with a spouse had a protective effect against underestimation (p < 0.001). Economic satisfaction, feeling social network-based intimacy, and support from a spouse were associated with overestimation in women. In men, feeling social network-based intimacy was also associated with overestimation (p < 0.001). We found that social relationship quality was related to sleep overestimation and underestimation. This association was marked in women. Good social relationships may have positive effects on sleep misperception via attenuation of negative emotional reactions and effects on emotional regulation.

Electroencephalographic changes associated with subjective under- and overestimation of sleep duration

Feeling awake although sleep recordings indicate clear-cut sleep sometimes occurs in good sleepers and to an extreme degree in patients with so-called paradoxical insomnia. It is unknown what underlies sleep misperception, as standard polysomnographic (PSG) parameters are often normal in these cases. Here we asked whether regional changes in brain activity could account for the mismatch between objective and subjective total sleep times (TST). To set cutoffs and define the norm, we first evaluated sleep perception in a population-based sample, consisting of 2,092 individuals who underwent a full PSG at home and estimated TST the next day. We then compared participants with a low mismatch (normoestimators, n = 1,147, ±0.5 SD of mean) with those who severely underestimated (n = 52, &lt;2.5th percentile) or overestimated TST (n = 53, &gt;97.5th percentile). Compared with normoestimators, underestimators displayed higher electroencephalographic (EEG) activation (beta/delta power ratio) in both rapid eye movement (REM) and non-rapid eye movement (NREM) sleep, while overestimators showed lower EEG activation (significant in REM sleep). To spatially map these changes, we performed a second experiment, in which 24 healthy subjects and 10 insomnia patients underwent high-density sleep EEG recordings. Similarly to underestimators, patients displayed increased EEG activation during NREM sleep, which we localized to central-posterior brain areas. Our results indicate that a relative shift from low- to high-frequency spectral power in central-posterior brain regions, not readily apparent in conventional PSG parameters, is associated with underestimation of sleep duration. This challenges the concept of sleep misperception, and suggests that instead of misperceiving sleep, insomnia patients may correctly perceive subtle shifts toward wake-like brain activity.

Hyperarousal Is Associated with Socioemotional Processing in Individuals with Insomnia Symptoms and Good Sleepers

Despite complaints of difficulties in waking socioemotional functioning by individuals with insomnia, only a few studies have investigated emotion processing performance in this group. Additionally, the role of sleep in socioemotional processing has not been investigated extensively nor using quantitative measures of sleep. Individuals with insomnia symptoms (n = 14) and healthy good sleepers (n = 15) completed two nights of at-home polysomnography, followed by an afternoon of in-lab performance testing on tasks measuring the processing of emotional facial expressions. The insomnia group self-reported less total sleep time, but no other group differences in sleep or task performance were observed. Greater beta EEG power throughout the night was associated with higher intensity ratings of happy, fearful and sad faces for individuals with insomnia, yet blunted sensitivity and lower accuracy for good sleepers. Thus, the presence of hyperarousal differentially impacted socioemotional processing of faces in individuals with insomnia symptoms and good sleepers.

Integrating sleep, neuroimaging, and computational approaches for precision psychiatry

In advancing precision psychiatry, we focus on what imaging technology and computational approaches offer for the future of diagnostic subtyping and personalized tailoring of interventions for sleep impairment in mood and anxiety disorders. Current diagnostic criteria for mood and anxiety tend to lump different forms of sleep disturbance together. Parsing the biological features of sleep impairment and brain circuit dysfunction is one approach to identifying subtypes within these disorders that are mechanistically coherent and offer targets for intervention. We focus on two large-scale neural circuits implicated in sleep impairment and in mood and anxiety disorders: the default mode network and negative affective network. Through a synthesis of existing knowledge about these networks, we pose a testable framework for understanding how hyper- versus hypo-engagement of these networks may underlie distinct features of mood and sleep impairment. Within this framework we consider whether poor sleep quality may have an explanatory role in previously observed associations between network dysfunction and mood symptoms. We expand this framework to future directions including the potential for connecting circuit-defined subtypes to more distal features derived from digital phenotyping and wearable technologies, and how new discovery may be advanced through machine learning approaches.

A Multifactorial Approach to Sleep and Its Association with Health-Related Quality of Life in a Multiethnic Asian Working Population: A Cross-Sectional Analysis

This study aims to explore if objectively and subjectively measured sleep parameters are associated with physical and mental health-related quality of life in a multiethnic working population in Singapore. We performed a cross-sectional analysis with data from 329 full-time employees enrolled in a workplace cohort study in Singapore. The Short-Form 36v2 (SF-36v2) survey was used to assess health-related quality of life, in terms of physical and mental health. Subjective and objective sleep parameters were measured using the Pittsburgh Sleep Quality Index and wrist actigraphy, respectively. Generalized linear modeling was performed to examine the association between sleep parameters and health-related quality of life. After adjusting for confounders, subjectively measured sleep disturbances were associated with a lower physical health-related quality of life, whereas higher, objectively measured sleep efficiency was associated with greater physical health-related quality of life. Subjectively measured daytime dysfunction was associated with impaired mental health-related quality of life. Using both objective and subjective measurements of sleep, the current study suggests that there is an association between sleep and health-related quality of life. Workplace health-promotion planners in Singapore should consider programmes that educate workers on better sleep hygiene practices in an effort to improve sleep and health-related quality of life.

Changes in Subjective-Objective Sleep Discrepancy Following Inpatient Cognitive Behavior Therapy for Insomnia

Discrepancy between objective and subjective sleep parameters is a frequent symptom in persons suffering from insomnia. Since it has an impairing effect on daytime well-being and neglects possible positive objective improvements, it would be useful if it was treated. Apart from hypnotics, cognitive behavior therapy (CBT-I) is the therapy of choice for chronic forms of insomnia. However, there is limited information about whether CBT-I can also improve subjective-objective sleep discrepancy. We investigated a large sample of patients showing chronic forms of insomnia regarding their subjective-objective sleep discrepancy pre and post CBT-I. Objective sleep data were obtained from 3 nights (2 baseline nights and 1 night after therapy) using polysomnography in our sleep laboratory. All 92 patients participated in a 14-day inpatient program with CBT-I including psychoeducation about subjective-objective sleep discrepancy. Repeated measures analyses showed an improvement in subjective-objective sleep discrepancy parameters after CBT-I. Those parameters were also correlated with perceived quality of sleep. We conclude that CBT-I is a useful tool to improve subjective-objective sleep discrepancy in patients showing chronic forms of insomnia.

The Relationship Between PSG and Morning/Evening Emotional Parameters in Patients With Insomnia Disorder and Good Sleepers

Objectives and Introduction: It is as yet unclear how polysomnographically determined sleep parameters determine emotional well-being both generally and particularly in patients with Insomnia Disorder (ID). ID is a frequent and disabling health condition associated with both day- and nighttime hyperarousal, linked to negative sleep-related ruminations as a cognitive component. Information on the immediate influence of objective sleep quality on emotional parameters is important for therapeutic approaches. Methods: The relationship between objective sleep parameters and two emotional questionnaire items obtained both for evening and morning, relaxation and emotional balance, was determined for both sleep lab nights in 161 ID patients and 161 age and gender matched good sleepers (retrospective sample from the Freiburg data base, 98 female, 63 male in each group, age ID: 42.16 ± 11.55, GSC: 41.91 ± 11.30 years). Multivariate mixed effects analysis, corrected for global influences of group, age and first/second night, was employed to determine between- and within-subject influences of sleep and emotional parameters. Results: Main effects: Within-subject, relaxation in the evening was strongly associated with sleep efficiency, REM latency and low arousal index in NREM sleep. No such influence was significant for emotional balance. Also between subjects, evening relaxation was related to increased sleep efficiency. Group interactions: Patients with larger relaxation values in the evening showed a larger reduction of the number of wake periods and the awakening index in NREM sleep than GSC subjects. Discussion: Unexpectedly, no general influence of emotional balance on sleep was found. The subjective feeling of relaxation, however, was associated with sleep efficiency, REM latency and low NREM sleep arousal index. While the first association may be obvious, a direct link to REM latency and NREM arousal index has not previously been shown. We could also directly observe that the number of wake periods in the PSG is more strongly influenced by evening relaxation in ID patients than in good sleepers, asserting the importance of sleep perception and attitude toward sleep in the therapeutic process.

Cognitive behavioral treatment for insomnia is equally effective in insomnia patients with objective short and normal sleep duration

BACKGROUND

It has been suggested that insomnia patients with short sleep duration and insomnia patients with normal sleep duration may respond differently to cognitive behavioral treatment for insomnia (CBT-I). To evaluate this hypothesis, we retrospectively examined a large sample of patients with chronic insomnia regarding their outcome post-treatment and six months after participating in a two-week standardized inpatient CBT-I program.

OBJECTIVES

Seventy-two women and 20 men with chronic insomnia received standardized inpatient CBT-I and were examined with three nights of polysomnography (two baseline nights and one post-treatment night directly following the two-week treatment). Follow-up measurements of subjective insomnia symptoms were conducted after six months. The CBT-I outcome was compared between insomnia patients with polysomnographically determined short (< 6 h) and normal (≥ 6 h) sleep duration.

RESULTS

Concerning subjective outcomes, CBT-I was equally effective in insomnia patients with objective short and normal sleep duration. Secondary analyses of polysomnographic data collected at post-treatment revealed that insomnia patients with short sleep duration showed a better treatment response in comparison to those with normal sleep duration.

CONCLUSIONS

These results suggest that the distinction in insomnia between objective short and normal sleep duration may be of limited value for treatment decisions regarding CBT-I. However, as the overall picture of the literature on this issue is not conclusive, we conclude that further prospective research is necessary to investigate the clinical validity of phenotyping insomnia patients by objective sleep data.

Subjective-Objective Sleep Discrepancy in Older Adults With MCI and Subsyndromal Depression

BACKGROUND/OBJECTIVES

We investigated the prevalence and correlates of discrepancies between self-reported sleep quality (Pittsburgh Sleep Quality Index) and objective sleep efficiency (actigraphy) in older adults with mild cognitive impairment (MCI) and subsyndromal depression.

METHODS

This was a secondary analysis of a clincial trial with 59 adults aged 60 years and older with MCI and subsyndromal depression. We included baseline data on participants' subjective sleep quality, objective sleep efficiency, depressive symptoms, insomnia diagnosis, and cognitive functioning.

RESULTS

Pittsburgh Sleep Quality Index subjective sleep quality and actigraphy-measured sleep efficiency were not significantly correlated ( r = -.06; P = .64), with 61% of participants having subjective-objective sleep discrepancies. Correlates of subjective-objective sleep discrepancy included the presence of an insomnia diagnosis and impaired memory, particularly delayed memory.

CONCLUSION

These findings are important because subjective underestimation of symptoms in older adults with memory impairments may result in sleep disturbances going unrecognized in clinical practice; on the other hand, an insomnia disorder may be a possible remediable contribution to subjective overestimation of sleep disturbances.

Subjective-Objective Sleep Discrepancy Is Associated With Alterations in Regional Glucose Metabolism in Patients With Insomnia and Good Sleeper Controls

Objectives

Sleep discrepancies are common in primary insomnia (PI) and include reports of longer sleep onset latency (SOL) than measured by polysomnography (PSG) or "negative SOL discrepancy." We hypothesized that negative SOL discrepancy in PI would be associated with higher relative glucose metabolism during nonrapid eye movement (NREM) sleep in brain networks involved in conscious awareness, including the salience, left executive control, and default mode networks.

Methods

PI (n = 32) and good sleeper controls (GS; n = 30) completed [18F]fluorodeoxyglucose positron emission tomography (FDG-PET) scans during NREM sleep, and relative regional cerebral metabolic rate for glucose (rCMRglc) was measured. Sleep discrepancy was calculated by subtracting PSG-measured SOL on the PET night from corresponding self-report values the following morning. We tested for interactions between group (PI vs. GS) and SOL discrepancy for rCMRglc during NREM sleep using both a region of interest mask and exploratory whole-brain analyses.

Results

Significant group by SOL discrepancy interactions for rCMRglc were observed in several brain regions (pcorrected < .05 for all clusters). In the PI group, more negative SOL discrepancy (self-reported > PSG-measured SOL) was associated with significantly higher relative rCMRglc in the right anterior insula and middle/posterior cingulate during NREM sleep. In GS, more positive SOL discrepancy (self-reported < PSG-measured SOL) was associated with significantly higher relative rCMRglc in the right anterior insula, left anterior cingulate cortex, and middle/posterior cingulate cortex.

Conclusions

Although preliminary, these findings suggest regions of the brain previously shown to be involved in conscious awareness, and the perception of PSG-defined states may also be involved in the phenomena of SOL discrepancy.

Optimal Questions for Sleep in Epidemiological Studies: Comparisons of Subjective and Objective Measures in Laboratory and Field Studies

Epidemiological studies on sleep often use questionnaires, and measurement of validity provides necessary guidance in selection of valid single sleep questions. Twenty-five items assessing different aspects of sleep, including overall sleep quality, specific sleep parameters, nocturnal restoration, and exposure-related questions, were tested. This involved coherence with objective polysomnographic (PSG) laboratory measurements of sleep in 47 participants and application of selected items under field conditions in over 3,000 participants. Items on overall sleep quality correlated significantly with PSG data. For specific sleep parameter questions, tiredness in the morning, time to fall asleep, difficulties to sleep and estimated number of awakenings were correlated to PSG data. Questions asking specifically about the effect of potential sleep disturbances correlated poorly with PSG data, but showed highest effects between environmental exposure (noise and vibration) and control nights in the laboratory and highest correlation with the dose of exposure in the field. In conclusion, healthy participants seem to be able to access their sleep reliably; and sleep questions asking about specific sleep parameters can be recommended for the assessment of sleep.

K-band Doppler radar for contact-less overnight sleep marker assessment: a pilot validation study

An estimated 45 million persons in Europe are annually subjected to sleep-wake disorders. State-of-the-art polysomnography provides sophisticated insights into sleep (patho)physiology. A drawback of the method, however, is the obtrusive setting dependent on a clinical-based sleep laboratory with high operational costs. A contact-less prototype was developed to monitor limb movements and vital signs during sleep. A dual channel K-band Doppler radar transceiver captured limb movements and periodic chest wall motion due to respiration and heart activity. A wavelet transform based multi-resolution analysis (MRA) approach isolated limb movements, respiration, and heart rate from the demodulated signal. A test bench setup characterized the prototype simulating near physiological chest wall motions caused by periodic respiration and heartbeats in humans. Single- and multi-tone test bench simulations showed extremely low relative percentage errors of the prototype for respiratory and heart rate within -2 and 1%. The performance of the prototype was validated in overnight comparative studies, involving two healthy volunteers, with polysomnography as the reference. The prototype has successfully classified limb movements, with a sensitivity and specificity of 88.9 and 76.8% respectively, and has achieved accurate respiratory and heart rate measurement performance with overall absolute errors of 1 breath per minute for respiration and 3 beats per minute for heart rate. This pilot study shows that K-band Doppler radar and wavelet transform MRA seem to be valid for overnight sleep marker assessment. The contact-less approach might offer a promising solution for home-based sleep monitoring and assessment.

The association between insomnia-related sleep disruptions and cognitive dysfunction during the inter-episode phase of bipolar disorder

Sleep disturbance and cognitive dysfunction are two domains of impairment during inter-episode bipolar disorder. Despite evidence demonstrating the importance of sleep for cognition in healthy and sleep-disordered samples, this link has been minimally examined in bipolar disorder. The present study tested the association between insomnia-related sleep disruptions and cognitive dysfunction during inter-episode bipolar disorder. Forty-seven participants with bipolar disorder and a comorbid insomnia diagnosis (BD-Insomnia) and 19 participants with bipolar disorder without sleep disturbance in the last six months (BD-Control) participated in the study. Two domains of cognition were assessed: working memory and verbal learning. Insomnia-related sleep disruptions were assessed both categorically (i.e., insomnia diagnosis) and dimensionally (i.e., total wake time, total sleep time, total wake time variability, and total sleep time variability). Hierarchical linear regressions, adjusting for participant age, demonstrated that insomnia diagnosis did not have an independent or interactive effect on cognition. However, regardless of insomnia diagnosis, greater total sleep time variability predicted poorer working memory and verbal learning performance. Further, following sleep treatment, a reduction in total wake time predicted improved working memory performance and a reduction in total sleep time variability predicted improved verbal learning performance. These findings raise the possibility that sleep disturbance may contribute to cognitive dysfunction in bipolar disorder and highlight the importance of treating sleep disturbance in bipolar disorder.

Predictors of Nightly Subjective-Objective Sleep Discrepancy in Poor Sleepers over a Seven-Day Period

This study sought to examine predictors of subjective/objective sleep discrepancy in poor sleepers. Forty-two individuals with insomnia symptoms (mean age = 36.2 years, 81% female) were recruited to take part in a prospective study which combined seven days of actigraphy with daily assessment of sleep perceptions, self-reported arousal, sleep effort, and mood upon awakening. A high level of intra-individual variability in measures of sleep discrepancy was observed. Multilevel modelling revealed that higher levels of pre-sleep cognitive activity and lower mood upon awakening were significantly and independently predictive of the underestimation of total sleep time. Greater levels of sleep effort predicted overestimation of sleep onset latency. These results indicate that psychophysiological variables are related to subjective/objective sleep discrepancy and may be important therapeutic targets in the management of insomnia.

The association between sleep dysfunction and psychosis-like experiences among college students

Sleep problems are prominent and pervasive clinical issues experienced by many people with psychotic disorders, often causing distress and functional impairment. Sleep problems are also related to psychosis-like experiences (PLE; non-diagnosable phenomenon such as transient perceptual disturbances, unusual thoughts, periodic suspiciousness) in epidemiological studies. Prior studies in this field have used brief measures that precluded the ability to test (1) whether risk for psychosis-like experiences are related to specific sub-types of sleep disturbance, and (2) whether sleep disturbance is specifically related to clinically significant (i.e., distressing) psychosis-like experiences. The current project examined the relation between specific sleep issues, and PLEs and distress associated with PLEs, in a college sample. Participants (N=420) completed the Prodromal Questionnaire-Brief (PQ-B), which assesses PLEs and associated distress, and the Iowa Sleep Disturbances Inventory - extended version (ISDI-E), which assesses thirteen separate disturbed sleep domains. Symptoms of fragmented sleep, sleep hallucinations, and night anxiety significantly correlated with PLEs, and several sleep domains were significantly associated with PLE-related distress.

Sleep architecture parameters as a putative biomarker of suicidal ideation in treatment-resistant depression

BACKGROUND

Disturbed sleep may confer risk for suicidal behaviors. Polysomnographic (PSG) sleep parameters have not been systematically evaluated in association with suicidal ideation (SI) among individuals with treatment-resistant depression (TRD).

METHODS

This secondary data analysis included 54 TRD individuals (N=30 with major depressive disorder (MDD) and N=24 with bipolar depression (BD)). PSG sleep parameters included Sleep Efficiency (SE), Total Sleep Time (TST), Wakefulness After Sleep Onset (WASO), REM percent/latency, and non-REM (NREM) Sleep Stages 1-4. The Hamilton Depression Rating Scale (HAM-D) was used to group participants according to presence or absence of SI. Sleep abnormalities were hypothesized among those with current SI. ANOVA analyses were conducted before (Model 1) and after adjusting for depression (Model 2) and diagnostic variables (Model 3).

RESULTS

Significant differences in PSG parameters were observed in Model 1; those with SI had less NREM Stage 4 sleep (p<.05). After adjusting for central covariates, Models 2 and 3 revealed significantly less NREM Stage 4 sleep, lower SE (P<.05), and higher WASO (P<.05) among those with SI. BD participants with SI also had less NREM Stage 4 and more NREM Stage 1 sleep.

LIMITATIONS

1) a predominantly white sample; 2) exclusion of imminent suicide risk; 3) concomitant mood stabilizer use among BD patients; and 4) single-item SI assessment.

CONCLUSIONS

Independent of depression severity, SI was associated with less NREM Stage 4 sleep, and higher nocturnal wakefulness across diagnostic groups. Sleep may warrant further investigation in the pathogenesis of suicide risk, particularly in TRD, where risk may be heightened.

Bright Light Treatment Has Limited Effect in Subjects over 55 Years with Mild Early Morning Awakening

31 subjects, age 55 yr. or older, suffering from mild early morning awakening were randomized to either a bright light (10,000 lux) or to a red dim light placebo condition (200 lux). Light exposure took place in the evening in the patients' homes, 60 to 30 min. before bedtime and lasted for 3 wk. The subjects kept a sleep diary for 2 wk. and wore an actigraph for 1 wk. both before treatment and at post-treatment. Of the eight sleep diary outcome variables, significant effects that could be attributed to the light treatment were only detected for time spent in bed after final morning awakening. None of the six actigraph outcome variables yielded any significant effect of the light therapy. Explanations for the limited therapeutic effects of bright light treatment obtained in the present study are discussed, such as the criteria defining early morning awakening, the selection procedure, problems with compliance, age of the sample, and the dose of light. The lack of an objective circadian marker in this study could represent a problem concerning the timing of the light exposure. Despite the limited success of bright light therapy in this study, bright light therapy should still be considered as a treatment option for early morning awakening.

I sleep with my Mind's eye open: Cognitive arousal and overgeneralization underpin the misperception of sleep

BACKGROUND AND OBJECTIVES

Misperception of sleep (e.g., underestimation of sleep time relative to objective measures) is a common feature of insomnia and other psychopathologies. To elucidate the mechanisms underlying this tendency, we examined the role of pre-sleep cognitive arousal and overgeneralization.

METHODS

We monitored the sleep of 54 community dwellers (the majority being university students), using actigraphy and a sleep diary for 7 days. Immediately after this period, the participants provided an additional global evaluation of their sleep for the past week. In this global evaluation, participants were asked to estimate their average number of hours of sleep and the duration of time taken to fall asleep (sleep onset latency) across the past seven nights.

RESULTS

Single-night misperceptions (difference between actigraphy and sleep diary estimations) of sleep time and sleep onset latency were significantly associated with pre-sleep cognitive arousal, but not with overgeneralization. In contrast, global misperception of sleep (difference between sleep diary and global estimations) were associated with overgeneralization, but not with cognitive arousal.

LIMITATIONS

Our sample mainly consisted of female university students, which limits the generalizability of the results.

CONCLUSIONS

Misperception of sleep occurs in two cases: (1) in the case of a single night due to excessive arousal, and (2) in the case of multiple nights due to overgeneralization.

Sleep Habits in the Elderly

Little information is available on the normal aspects of sleep in the elderly, and almost none from a cross-cultural perspective. The subjects of this study consisted of 562 elderly from Mexico, Spain, Venezuela, and the United States, who completed a 55-item Sleep Questionnaire, yielding scores on nine scales. Statistically significant differences between cultural groups on five scales and significant sex differences on three scales were obtained. These differences may reflect sample differences or cultural differences related to such themes as concern with death and attitudes toward sleep.

Lifestyle Practices and Nocturnal Sleep in Midlife Women with and without Insomnia

Relationships between common lifestyle practices important to sleep hygiene (e.g., smoking cigarettes, drinking alcohol, ingesting caffeine, exercising, bedtimes, getting-up times) and nocturnal sleep have not been documented for women with insomnia in their home environments. This community-based sample of 121 women, ages 40 to 55 years, included 92 women who had experienced insomnia for at least 3 months and 29womenwith good-quality sleep. Women recorded lifestyle practices and sleep perceptions (time to fall asleep, awakenings during sleep, feeling rested after sleeping, and overall sleep quality) in diaries while undergoing 6 nights of somnographic sleep monitoring at home. Compared to women with good-quality sleep, women with insomnia reported greater nightto-night variation in perceived sleep variables, poorer overall sleep quality (M = 2.8,SD = 0.7 vs.M = 1.9,SD = 0.5,P < 0.05), and longer times to fall asleep (M = 25 min,SD = 14.2 vs.M = 12.9 min,SD = 5.8,P < 0.05). Correlations between mean individual lifestyle practice scores and mean perceived or somnographic sleep variables were low, ranging from 0 to 0.20. An aggregated sleep hygiene practice score was not associated with either perceived or somnographic sleep variables. Regression analysis using dummy variables showed that combinations of alcohol, caffeine, exercise, smoking, and history of physical disease explained 9% to 19% of variance in perceived or somnographic sleep variables. Lifestyle practices, and combinations thereof, do warrant consideration when assessing or treating insomnia, but these data fail to support a dominant relationship between lifestyle practices and either perceived or somnographic sleep variables.

Sleep Spindles Characteristics in Insomnia Sufferers and Their Relationship with Sleep Misperception

Cortical hyperarousal is higher in insomnia sufferers (INS) than in good sleepers (GS) and could be related to an alteration in sleep protection mechanisms, like reduced density or altered characteristics in sleep spindles. The deficient sleep protection mechanisms might in turn enhance underestimation of sleep. This study's objective was to document sleep spindles characteristics in INS compared with GS and to investigate their potential role in sleep consolidation and misperception. Seventeen individuals with paradoxical insomnia (PARA-I), 24 individuals with psychophysiological insomnia (PSY-I), and 29 GS completed four consecutive polysomnographic nights in laboratory. Sleep spindles were detected automatically during stage 2 and SWS (3-4) on night 3. Number, density, duration, frequency, and amplitude of sleep spindles were calculated. A misperception index was used to determine the degree of discrepancy between subjective and objective total sleep times. Kruskal-Wallis H tests and post hoc tests revealed that PARA-I had significantly shorter sleep spindles than GS but that PSY-I and GS did not differ on spindles length. A standard multiple regression model revealed that neither sleep spindles characteristics nor objective sleep measures were predictive of sleep misperception. A longer duration of spindles could reflect a higher gating process but this hypothesis still needs to be confirmed in replication studies.

Bedtime Routines: Do They Influence the Sleep of Elderly Women?

A total of 45 institutionalized and 42 noninstitutionalized women over 65 years of age participated in a study to identify and describe their bedtime routines and nocturnal sleep patterns. Differences and relationships between these routines and patterns according to whether or not the subject was institutionalized were also investigated. Findings suggest that all of the subjects perceived disturbances in their sleep patterns. The majority of subjects also followed a bedtime routine. Women in nursing homes reported the most disturbed sleep patterns regardless of whether or not they followed a bedtime routine. Women who resided in their own homes reported the least disturbed sleep patterns and the most consistent bedtime routines. Findings also suggest that bedtime routines need not be elaborate to provide comfort and promote sleep.

The relation between polysomnography and subjective sleep and its dependence on age - poor sleep may become good sleep

Women complain more about sleep than men, but polysomnography (PSG) seems to suggest worse sleep in men. This raises the question of how women (or men) perceive objective (PSG) sleep. The present study sought to investigate the relation between morning subjective sleep quality and PSG variables in older and younger women. A representative sample of 251 women was analysed in age groups above and below 51.5 years (median). PSG was recorded at home during one night. Perceived poor sleep was related to short total sleep time (TST), long wake within total sleep time (WTSP), low sleep efficiency and a high number of awakenings. The older women showed lower TST and sleep efficiency and higher WTSP for a rating of good sleep than did the younger women. For these PSG variables the values for good sleep in the older group were similar to the values for poor sleep in the young group. It was concluded that women perceive different levels of sleep duration, sleep efficiency and wake after sleep onset relatively well, but that older women adjust their objective criteria for good sleep downwards. It was also concluded that age is an important factor in the relation between subjective and objective sleep.

Clinical Characteristics of Primary Insomniacs with Sleep-State Misperception

BACKGROUND AND PURPOSE

The aims of this study were to determine the prevalence of sleep-state misperception and to identify any differences in the clinical characteristics of primary insomniacs with and without misperception.

METHODS

In total, 250 adult primary insomniacs were enrolled whose objective total sleep time (TST) was more than 120 min, as assessed by full-night polysomnography. Sleep state misperception was defined objectively as a TST of at least 6.5 h and an objective sleep efficiency (SE) of at least 85%.

RESULTS

The prevalence of sleep-state misperception in primary insomniacs was 26.4%. The (low) quality of sleep and psychiatric parameters were similar in the two groups, although the objective sleep architecture was relatively normal for the misperception group. Multivariate analysis revealed that both SE and sleep quality were significant factors associated with subjective TST in the misperception group, while only SE was significant in those without misperception. Subjective TST was a significant effect factor with respect to sleep quality in the misperception group, while the Beck Depression Inventory-2 score and age were significant factors in those without misperception.

CONCLUSIONS

The clinical characteristics of patients with sleep-state misperception differed from those without this condition. This suggests that these two groups should be separated and the treatment goals tailored specifically to each.

Measuring sleep quality in older adults: a comparison using subjective and objective methods

Sleep quality decreases with aging and thus sleep complaints are prevalent in older adults, particularly for those with cognitive impairment and dementia. For older adults, emerging evidence suggests poor sleep quality increases risk of developing cognitive impairment and dementia. Given the aging population-and the impending economic burden associated with increasing numbers of dementia patients-there is pressing need to improve sleep quality among older adults. As such, research efforts have increased focus on investigating the association between age-related sleep changes and cognitive decline in older adults. Sleep quality is a complex construct to evaluate empirically, and yet the Pittsburg Sleep Quality Index (PSQI) is commonly used in studies as their only measure of sleep quality. Furthermore, the PSQI may not be the best sleep quality measure for older adults, due to its reliance on the cognitive capacity to reflect on the past month. Further study is needed to determine the PSQI's validity among older adults. Thus, the current study examined sleep quality for 78 community dwelling adults 55+ to determine the PSQI's predictive validity for objective sleep quality (as measured by actigraphy). We compared two subjective measures of sleep quality-the PSQI and Consensus Sleep Diary (CSD)-with actigraphy (MotionWatch 8©; camntech). Our results suggest perceived sleep quality is quite different from objective reality, at least for adults 55+. Importantly, we show this difference is unrelated to age, gender, education, or cognitive status (assessed using standard screens). Previous studies have shown the PSQI to be a valuable tool for assessing subjective sleep quality; however, our findings indicate for older adults the PSQI should not be used as a substitute for actigraphy, or vice versa. Hence, we conclude best practice is to include both subjective and objective measures when examining sleep quality in older adults (i.e., the PSQI, CSD, and actigraphy).

Subjective-objective sleep discrepancy among older adults: associations with insomnia diagnosis and insomnia treatment

Discrepancy between subjective and objective measures of sleep is associated with insomnia and increasing age. Cognitive behavioural therapy for insomnia improves sleep quality and decreases subjective-objective sleep discrepancy. This study describes differences between older adults with insomnia and controls in sleep discrepancy, and tests the hypothesis that reduced sleep discrepancy following cognitive behavioural therapy for insomnia correlates with the magnitude of symptom improvement reported by older adults with insomnia. Participants were 63 adults >60 years of age with insomnia, and 51 controls. At baseline, participants completed sleep diaries for 7 days while wearing wrist actigraphs. After receiving cognitive behavioural therapy for insomnia, insomnia patients repeated this sleep assessment. Sleep discrepancy variables were calculated by subtracting actigraphic sleep onset latency and wake after sleep onset from respective self-reported estimates, pre- and post-treatment. Mean level and night-to-night variability in sleep discrepancy were investigated. Baseline sleep discrepancies were compared between groups. Pre-post-treatment changes in Insomnia Severity Index score and sleep discrepancy variables were investigated within older adults with insomnia. Sleep discrepancy was significantly greater and more variable across nights in older adults with insomnia than controls, P ≤ 0.001 for all. Treatment with cognitive behavioural therapy for insomnia was associated with significant reduction in the Insomnia Severity Index score that correlated with changes in mean level and night-to-night variability in wake after sleep onset discrepancy, P < 0.001 for all. Study of sleep discrepancy patterns may guide more targeted treatments for late-life insomnia.

Subjective reports versus objective measurement of sleep latency and sleep duration in pregnancy

This study compared self-reported sleep latency (SL) and total sleep time (TST) to objective measures on polysomnography (PSG) during pregnancy. Thirty-three women in the third trimester (T3) of pregnancy, 16 women in the first trimester (T1) of pregnancy, and 15 non-pregnant women underwent overnight PSG, and shortly after awakening reported their perceived SL and TST. Results showed that, on average, the T3 group slightly overestimated their TSTs, whereas the T1 and non-pregnant groups underestimated TSTs when compared with objective measurement. All groups overestimated SL, and perceived SL was closest to the first epoch of 10 min of uninterrupted sleep or the first epoch of slow-wave sleep, rather than the first epoch of sleep (the current definition used for diagnostic sleep studies). The wide variation in discrepancies between estimation and PSG measurement for both TST and SL shows that self-reports made by both pregnant and non-pregnant women tend to be unreliable, which has important implications both clinically and for the many studies based on self-reported sleep patterns in pregnancy.

Relationship between hostility and subjective sleep quality

While hostility and sleep disturbance are the potential risk factors for health problems and disease, few studies have examined the relationship between the two factors. The present study was performed to investigate the relationship between hostility and sleep problems assessed both subjectively and objectively in a nonclinical sample. Sixty-one healthy subjects were enrolled in this study. Hostility was measured according to the Cook-Medley hostility scale. Subjective sleep quality was evaluated according to the global score of the Pittsburgh Sleep Quality Index. Objective sleep was evaluated using actigraphy. A multiple regression analysis revealed that a higher level of hostility was significantly associated with the global score of the Pittsburgh Sleep Quality Index and that a higher level of depression was not associated with the global score of the Pittsburgh Sleep Quality Index. Objective sleep measures were not found to be associated with hostility. Confirming the robust relationship between poor sleep and hostility would have several important treatment implications for preventing health problems.

The subjective-objective mismatch in sleep perception among those with insomnia and sleep apnea

The diagnosis and management of insomnia relies primarily on clinical history. However, patient self-report of sleep-wake times may not agree with objective measurements. We hypothesized that those with shallow or fragmented sleep would under-report sleep quantity, and that this might account for some of the mismatch. We compared objective and subjective sleep-wake times for 277 patients who underwent diagnostic polysomnography. The group included those with insomnia symptoms (n = 92), obstructive sleep apnea (n = 66) or both (n = 119). Mismatch of wake duration was context dependent: all three groups overestimated sleep latency but underestimated wakefulness after sleep onset. The insomnia group underestimated total sleep time by a median of 81 min. However, contrary to our hypothesis, measures of fragmentation (N1, arousal index, sleep efficiency, etc.) did not correlate with the subjective sleep duration estimates. To unmask a potential relationship between sleep architecture and subjective duration, we tested three hypotheses: N1 is perceived as wake; sleep bouts under 10 min are perceived as wake; or N1 and N2 are perceived in a weighted fashion. None of these hypotheses exposed a match between subjective and objective sleep duration. We show only modest performance of a Naïve Bayes Classifier algorithm for predicting mismatch using clinical and polysomnographic variables. Subjective-objective mismatch is common in patients reporting insomnia symptoms. We conclude that mismatch was not attributable to commonly measured polysomnographic measures of fragmentation. Further insight is needed into the complex relationships between subjective perception of sleep and conventional, objective measurements.