Insomnia with short sleep duration and mortality: the Penn State cohort

Insomnia and risk of mortality in older adults

Existing evidence linking insomnia to all-cause mortality in older individuals remains inconclusive. We conducted a retrospective study of a large cohort of veterans aged 65-80 years old identified from the Corporate Data Warehouse, a large data repository derived from the Veterans Health Administration integrated medical records. Veterans' enrollees with and without International Classification of Diseases, Ninth and Tenth Revision, codes corresponding to insomnia diagnosis between 1 January 2010 and 30 March 2019 were assessed for eligibility. The primary outcome was all-cause mortality. A total of 36,269 veterans, 9584 with insomnia and 26,685 without insomnia, were included in the analysis. Baseline mean (SD) age was 72.6 (4.2) years. During a mean follow-up of 6.0 (2.9) years of the propensity score matched sample, the mortality rate was 34.8 [95% confidence interval: 33.2-36.6] deaths per 1000 person-years among patients with insomnia compared with 27.8 [95% confidence interval: 26.6-29.1] among patients without insomnia. In a Cox proportional hazards model, insomnia was significantly associated with higher mortality (hazard ratio: 1.39; [95% confidence interval: 1.27-1.52]). Patients with insomnia also had a higher risk of non-fatal cardiovascular events (hazard ratio: 1.21; [95% confidence interval: 1.06-1.37]). Secondary stratified analyses by sex, race, ethnicity and hypertension showed no evidence of effect modification. A higher risk of mortality (hazard ratio: 1.51; [95% confidence interval: 1.33-1.71]) was observed when depression was present compared with absent (hazard ratio: 1.26; [95% confidence interval: 1.12-1.44]; p = 0.02). In this cohort study, insomnia was associated with increased risk-adjusted mortality and non-fatal cardiovascular events in older individuals.

Interaction between sleep duration and trouble sleeping on depressive symptoms among U.S. adults, NHANES 2015-2018

BACKGROUND

This study aims to examine the associations and interaction effects of sleep duration and trouble sleeping on depressive symptoms among U.S. adults.

METHODS

National Health and Nutrition Examination Survey (NHANES) data from 2015 to 2018 were analyzed (N = 10,044). Trouble sleeping and sleep duration were self-reported. Sleep duration was defined as short (≤6 h) or long (≥9 h), compared with normal (>6 and < 9 h). Depressive symptoms were determined by the Patient Health Questionnaire-9 score ≥ 10. Both multiplicative interaction and additive interaction were reported.

RESULTS

There was a significant positive additive interaction between short sleep duration and trouble sleeping on depressive symptoms in the fully adjusted model (Relative excess risk due to interaction, RERIOR = 4.42, 95 % CI: 1.12, 7.73), with 43 % of the association with depressive symptoms attributed to the interaction (attributable proportion of interaction, AP = 0.43, 95 % CI: 0.22, 0.64). Similarly, a significant positive additive interaction between long sleep duration and trouble sleeping on depressive symptoms was found (RERIOR = 4.17, 95 % CI: 0.96, 7.38), with 41 % of the association with depressive symptoms attributed to the interaction (AP = 0.41, 95 % CI: 0.21, 0.60). No multiplicative interaction was detected between short or long sleep duration and trouble sleeping.

LIMITATIONS

The cross-sectional design limits the ability to draw causal inferences.

CONCLUSIONS

Findings suggest that different aspects of sleep health interact synergistically, accounting for a substantial portion of the association with depressive symptoms. This underscores the importance of simultaneously considering multiple dimensions of sleep health in relation to depressive symptoms.

Edward O. Bixler, PhD: from the Apollo project and chimpanzees to sleep epidemiology

What an honor to write about Dr. Edward O. Bixler's contributions to the sleep field. In 1967, Dr. Bixler published a case report on a chimpanzee with implanted brain electrodes while working at an Air Force base in New Mexico. A few years later, in 1971, he published on the sleep effects of flurazepam in individuals with insomnia together with Dr. Anthony Kales, data that he had collected when the Sleep Research & Treatment Center (SRTC) was housed at the University of California Los Angeles. Dr. Bixler, a meticulous scientist, learned from Dr. Kales, a devoted clinician, to study "the whole patient, and all aspects of sleep," a legacy that continued when the SRTC moved to Penn State in Hershey. Indeed, Dr. Bixler's tenure at Penn State from 1971 until 2019 kept the science of the SRTC focused on that premise and helped translate scientific evidence into clinical care. He not only contributed early to the pharmacology of sleep and the effects of hypnotics, but he was also a pioneer in "sleep epidemiology." His "Prevalence of sleep disorders in the Los Angeles metropolitan area" study of 1979 was the first rigorous epidemiological study on sleep disturbances. Starting in 1990, he established the Penn State Adult Cohort to estimate the prevalence and natural history of sleep-disordered breathing and other sleep disorders in adults. Inspired by life-course epidemiology, he established in 2001 the Penn State Child Cohort to estimate the same phenomena in children. This Living Legend paper captures and highlights Dr. Bixler's enduring legacy to sleep science.

Association of resistance training and moderate-to-vigorous physical activity with clinical outcomes in men with airflow limitation: a nationwide population-based study

Aerobic moderate-to-vigorous physical activity (MVPA) is recommended for individuals with chronic diseases. However, the association between resistance training (RT) in addition to moderate to vigorous physical activity (MVPA) and sleep duration, as well as respiratory symptoms, in patients with chronic obstructive pulmonary disease has not been thoroughly investigated. This population-based cross-sectional study used data from the Korea National Health and Nutrition Examination Survey between 2014 and 2019. A total of 61,754 individuals were identified and men with airflow limitation (FEV1/FVC < 0.7) who engaged in aerobic MVPA were selected (n = 794). Weighted percentages and odds ratio (OR) of sleep problems (≤ 5 or ≥ 9 h), chronic cough, and chronic sputum were estimated. A multivariate-adjusted complex sample logistic regression model was used to calculate ORs and 95% confidence intervals (CI). Subgroup analyses were conducted using the forced expiratory volume (FEV1) % of the predicted value (%pred) ≥ 80 vs. < 80. The percentages of sleep problems, chronic cough, and chronic sputum production were lower in men who underwent aerobic MVPA + RT than in those who underwent aerobic MVPA alone. The multivariable-adjusted OR of sleep problems was 0.44 (95% CI 0.25-0.77) in individuals undergoing aerobic MVPA + RT compared to aerobic MVPA alone. The ORs of chronic cough and sputum were 0.35 (95% CI 0.13-0.94) and 0.51 (95% CI 0.30-0.87), respectively. These associations were only significant in individuals with FEV1 < 80% pred. Compared with aerobic MVPA alone, aerobic MVPA + RT was associated with appropriate sleep duration and a decrease in chronic cough and sputum in male with airflow limitation. This was more pronounced in individuals with a FEV1 < 80% pred.

A meta-analysis of the association between insomnia with objective short sleep duration and risk of hypertension

The aim of this meta-analysis was to examine the association between insomnia with objective short sleep duration (ISSD) with prevalent and incident hypertension in cross-sectional and longitudinal studies, respectively. Data were collected from 6 cross-sectional studies with 5914 participants and 2 longitudinal studies with 1963 participants. Odds ratios (ORs) for prevalent and risk ratios (RRs) for incident hypertension were calculated through meta-analyses of adjusted data from individual studies. Compared to normal sleepers with objective normal sleep duration (NNSD), ISSD was significantly associated with higher pooled OR for prevalent hypertension (pooled OR = 2.67, 95%CI = 1.45-4.90) and pooled RR for incident hypertension (pooled RR = 1.95, 95%CI = 1.19-3.20), respectively. Compared to insomnia with objective normal sleep duration, ISSD was associated with significantly higher pooled OR of prevalent hypertension (pooled OR = 1.94, 95%CI = 1.29-2.92) and pooled RR for incident hypertension (pooled RR = 2.07, 95%CI = 1.47-2.90), respectively. Furthermore, normal sleepers with objective short sleep duration were not associated with either prevalent (pooled OR = 1.21, 95%CI = 0.84-1.75) or incident (pooled RR = 0.97, 95%CI = 0.81-1.17) hypertension compared to NNSD. Our findings suggest that ISSD is a more severe phenotype of the disorder associated with a higher risk of hypertension. Objective short sleep duration might be a valid and clinically useful index of insomnia's impact on cardiovascular health.

Associations of sleep disorders with all-cause and cause-specific mortality in cancer survivors: a cross-sectional analysis of the NHANES 2005-2016

BACKGROUND

The circadian clock and endoplasmic reticulum stress signaling play important roles in oncogenesis and development of cancer. Sleep disorders have been linked to an elevated risk of mortality in general populations. Nonetheless, the evidence for the sleep disorders-mortality association among cancer patients is limited. We aimed to prospectively investigate the association of sleep disorders with all-cause, cancer, and cardiovascular disease (CVD) mortality among cancer individuals.

METHODS

We assessed 3187 participants with cancer from the National Health and Nutrition Examination Survey 2005-2016 cohorts with a median follow-up time of 83.0 months. Multivariable Cox proportional hazards models estimated the adjusted hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

Multivariable Cox proportional hazards models showed that sleep disorders were associated with a higher risk of all-cause mortality (HR 1.23, 95%CI: 1.06,1.42), cancer mortality (HR 1.30, 95%CI: 1.02, 1.66), and cardiovascular disease mortality (HR 1.35, 95%CI: 1.02, 1.80). After the total group was stratified by gender, the high HRs were observed in men (P < 0.05), not in women. The correlation between sleep disorders and higher long-term mortality was also significant after individuals who died within 2 years of follow-up were excluded, with HR 1.24 (95%CI: 1.07, 1.45) in model I, HR 1.20 (95%CI: 1.02, 1.42) in model II for long-term all-cause mortality, HR (95%CI: 1.00, 1.74) in model I for long-term cancer mortality, and HR 1.5 (95%CI:1.12, 2.02) in model I, HR 1.45 (95%CI: 1.06, 1.99) in model II for long-term CVD mortality.

CONCLUSIONS

Sleep disorders were associated with a higher risk of all-cause mortality, cancer mortality, and CVD mortality, as well as long-term mortality in cancer patients. Our finding underlies the importance of screening for sleep disorders for all cancer survivors and the urge to integrate sleep health as an important part of cancer care more effectively. Male individuals may be particularly vulnerable and could benefit from more frequent screening.

Sleep disorders and mortality: A prospective study in the Canadian longitudinal study on aging

BACKGROUND AND OBJECTIVES

Sleep disorders are commonly linked to various health conditions, although it remains unclear to what degree they are linked with overall mortality. We compared mortality in different self-reported sleep disorders in a large population-based prospective study.

METHODS

In this case-control study within the CLSA cohort, participants completed a questionnaire at baseline (2011-2015) measuring overall sleep satisfaction, daily sleep duration, sleep-onset and sleep-maintenance insomnia, daytime somnolence, REM sleep behavior disorder (RBD), restless leg syndrome (RLS), and obstructive sleep apnea (OSA). The vital status of participants was assessed in July 2019. Baseline sleep problems of participants who died (cases) were compared to those who survived (controls). For each case, five age/sex-matched controls were selected. Binary logistic regression was used to estimate the association between sleep symptoms and mortality, adjusting for age, sex, marital status, province, education, alcohol consumption, smoking, caffeine, and body mass index. In a complementary model, anxiety and depression were also added.

RESULTS

Among 30,097 participants at baseline, 974 deaths were reported in 2019 (60.7 % male, age = 72.3 ± 9.4 years). In the initial analysis, mortality cases reported more baseline sleep-maintenance insomnia (12.1 % vs. 8.0 %, Adjusted OR[95%CI] = 1.62[1.15,2.29]), daytime somnolence (2.4 % vs. 1.1 %, AOR = 2.70[1.34,5.44]), and higher possible RLS (16.4 % vs. 12.4 %, AOR = 1.50[1.09,2.05]). They were also more likely to screen positive for possible OSA (33.8 % vs. 24.2 %, AOR = 1.32[1.07,1.64]); however, this effect was not related to core apnea symptoms. Sleep durations exceeding 10 h/day were also associated with increased mortality (3.4 % vs. 1.9 %, AOR = 1.83[1.04,3.24]). Other sleep symptoms/disorders, such as sleep-onset insomnia (7.3 % vs. 4.3 %, AOR = 1.54 [1.00,2.37]), possible RBD (5.3 % vs. 5.1 %, AOR = 1.02[0.62,1.69]), and overall sleep dissatisfaction (26.5 % vs. 22.6 %, AOR = 1.14[0.93,1.41]) were not different among these groups. After adding anxiety and depression to the adjustment model, all differences attenuated to become statistically non-significant, except for daytime somnolence disorder. When stratified by sex, the association between sleep disorders and mortality was only observed in women, with men showing no association.

DISCUSSION

We confirm a relationship between numerous sleep disorders and mortality. This effect is most evident in women, and appears to be strongly related to co-existing anxiety and depression.

Preliminary investigation of the interactive role of physiological arousal and insomnia complaints in gray matter volume alterations in chronic widespread pain

STUDY OBJECTIVES

Brain regions involved in insomnia and chronic pain are overlapping and diffuse. The interactive role of physiological arousal in associations between insomnia symptoms and neural regions is unknown. This preliminary study examined whether arousal interacted with sleep in associations with gray matter volume of frontal (dorsolateral prefrontal cortex, anterior cingulate cortex) and temporal (right/left hippocampus) regions in adults with chronic widespread pain and insomnia complaints.

METHODS

Forty-seven adults with chronic widespread pain and insomnia (mean age = 46.00, standard deviation = 13.88, 89% women) completed 14 daily diaries measuring sleep onset latency (SOL), wake time after sleep onset, and total sleep time (TST), as well as Holter monitor assessments of heart rate variability (measuring physiological arousal), and magnetic resonance imaging. Multiple regressions examined whether average SOL, wake time after sleep onset, or TST were independently or interactively (with arousal/heart rate variability) associated with dorsolateral prefrontal cortex, anterior cingulate cortex, and left/right hippocampus gray matter volumes.

RESULTS

Shorter TST was associated with lower right hippocampus volume. TST also interacted with arousal in its association with right hippocampal volume, Specifically, shorter TST was associated with lower volume at highest and average arousal levels. SOL interacted with arousal in its association with anterior cingulate cortex volume, such that, among individuals with lowest arousal, longer SOL was associated with lower volume.

CONCLUSIONS

Preliminary findings highlight the interactive roles of physiological arousal and insomnia symptoms in associations with neural structure in chronic widespread pain and insomnia. Individuals with the highest physiological arousal may be particularly vulnerable to the impact of shorter TST on hippocampal volume loss. Reducing SOL may only impact anterior cingulate cortex volume in those with lower physiological arousal.

CITATION

Curtis AF, Nair N, Hayse B, et al. Preliminary investigation of the interactive role of physiological arousal and insomnia complaints in gray matter volume alterations in chronic widespread pain. J Clin Sleep Med. 2024;20(2):293-302.

Treating insomnia in people who are incarcerated: a feasibility study of a multicomponent treatment pathway

Around 60% of people who are incarcerated have insomnia; 6-10 times more prevalent than the general population. Yet, there is no standardized, evidence-based approach to insomnia treatment in prison. We assessed the feasibility of a treatment pathway for insomnia in a high-secure prison to inform a future randomized controlled trial (RCT) and initial efficacy data for sleep and mental health outcomes. We used a within-participants pre-post design. The stepped-care pathway included: self-management with peer support, environmental aids, and cognitive behavioral therapy for insomnia (CBTi). Assessment measures for insomnia, well-being, mood, anxiety, suicidality, overall health, sleepiness, fatigue, and cognitive functioning were administered at baseline and pathway exit. Feasibility criteria included eligibility to participate, CBTi uptake, and assessment completion. Forty-two adult males who are incarcerated were approached of which 95.2% were eligible. Of those deemed eligible, most participated (36/40, 90.0%). Most who completed baseline completed post-assessments (28/36, 77.8%) and of these, most showed improvements in their subjective sleep (27/28, 96.4%). Large reductions were found from pre- to posttreatment in insomnia severity (d = -1.81, 95% CI: 8.3 to 12.9) and 57.0% reported no clinically significant insomnia symptoms at post-assessment. There was no overall change in actigraphy-measured sleep. Large treatment benefits were found for depression, anxiety, well-being, and cognitive functioning, with a medium benefit on suicidal ideation. The treatment pathway for insomnia in prison was feasible and may be an effective treatment for insomnia in people who are incarcerated, with additional promising benefits for mental health. A pragmatic RCT across different prison populations is warranted. This paper is part of the Sleep and Circadian Health in the Justice System Collection.

Dose-effect relationship of different acupuncture courses on chronic insomnia disorder: study protocol for a randomized controlled trial

Background

Chronic insomnia disorder (CID) is increasing in prevalence year by year, is long lasting, and potentially risky. Acupuncture has been widely used in the clinical management of this condition. However, there is still a lack of direct evidence on the dose-effect relationship between different acupuncture courses and clinical efficacy. To identify this relationship, we will design a randomized controlled trial to clarify the difference in efficacy of different acupuncture courses for CID.

Methods and design

This is a prospective, parallel, single center randomized controlled trial. Two hundred and one participants with CID will be randomly divided into three groups (Group A, Group B, and Group C). The three groups will be given acupuncture therapy for 4, 6, and 8 weeks, three sessions per week, with at least 1 day between sessions. Follow-up will continue until the third month after the end of treatment. The primary outcome is the Insomnia Severity Index (ISI), and secondary outcomes include percentage of ISI < 8 points, the Pittsburgh Sleep Quality Index (PSQI), Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale (SDS), Fatigue Severity Scale (FSS), medication use, and safety.

Discussion

This study is expected to provide direct evidence for the optimal treatment cycle of acupuncture for CID, as well as to facilitate health economic evaluation.

Clinical trial registration

https://clinicaltrials.gov/, identifier [ChiCTR2300073711].

Insomnia nosology: a systematic review and critical appraisal of historical diagnostic categories and current phenotypes

Insomnia nosology has significantly evolved since the Diagnostic and Statistical Manual (DSM)-III-R first distinguished between 'primary' and 'secondary' insomnia. Prior International Classification of Sleep Disorders (ICSD) nosology 'split' diagnostic phenotypes to address insomnia's heterogeneity and the DSM nosology 'lumped' them into primary insomnia, while both systems assumed causality for insomnia secondary to health conditions. In this systematic review, we discuss the historical phenotypes in prior insomnia nosology, present findings for currently proposed insomnia phenotypes based on more robust approaches, and critically appraise the most relevant ones. Electronic databases PsychINFO, PubMED, Web of Science, and references of eligible articles, were accessed to find diagnostic manuals, literature on insomnia phenotypes, including systematic reviews or meta-analysis, and assessments of the reliability or validity of insomnia diagnoses, identifying 184 articles. The data show that previous insomnia diagnoses lacked reliability and validity, leading current DSM-5-TR and ICSD-3 nosology to 'lump' phenotypes into a single diagnosis comorbid with health conditions. However, at least two new, robust insomnia phenotyping approaches were identified. One approach is multidimensional-multimethod and provides evidence for self-reported insomnia with objective short versus normal sleep duration linked to clinically relevant outcomes, while the other is multidimensional and provides evidence for two to five clusters (phenotypes) based on self-reported trait, state, and/or life-history data. Some approaches still need replication to better support whether their findings identify true phenotypes or simply different patterns of symptomatology. Regardless, these phenotyping efforts aim at improving insomnia nosology both as a classification system and as a mechanism to guide treatment.

Sleep Deficiency by Caregiving Status: Findings From Nationally Representative Data

OBJECTIVE

Caregiving demands may influence caregivers' sleep duration and quality, which are essential for optimal health. We aimed to examine the association between caregiving status and sleep deficiency (i.e., short sleep duration and/or poor quality) and identify factors associated with sleep deficiency among caregivers.

METHODS

This secondary analysis used data from 3870 adults living in the United States, obtained from the 2019 Health Information National Trends Survey. Multinomial logistic regressions were performed to examine the association between caregiving status (i.e., caregivers vs. non-caregivers) and sleep status (i.e., normal duration-good quality [optimal sleep, reference], short duration-good quality, normal duration-poor quality, and short duration-poor quality), and to identify caregiving-related factors associated with sleep deficiency in the caregiver group.

RESULTS

Compared to non-caregivers, caregivers were more likely to report short sleep duration (<7 hours) with good quality sleep (relative risk ratio [RRR] = 1.566, 95% CI [1.238, 1.980]) or poor quality sleep (RRR = 1.376, 95% CI [1.034, 1.832]) than the optimal sleep status. Caregivers providing care for ≥20 hours per week (vs. <20 hours) and providing care to individuals with dementia (vs. no dementia caregiving) were 2.8 times more likely to report normal sleep duration with poor sleep quality than optimal sleep (RRR = 2.796, 95% CI [1.125, 6.950]; RRR = 2.776, 95% CI [1.154, 6.675], respectively).

CONCLUSION

The findings of a higher risk of sleep deficiency among caregivers suggest that health care providers need to assess both caregivers' sleep duration and quality status. Interventions tailored to the caregiving context are also warranted.

Associations between Combined Psychological and Lifestyle Factors with Pain Intensity and/or Disability in Patients with Chronic Low Back Pain: A Cross-Sectional Study

Chronic low back pain (CLBP) is common in primary care, causing disability and economic burden globally. We aimed to compare socio-demographic, health, lifestyle, and psychological factors in people with and without CLBP and correlate them with clinical outcomes in people with CLBP. A total of 253 volunteers with and 116 without CLBP provided sociodemographic information, daily habits, medical history, subjective sleep complaints (Penn State Sleep Questionnaire), low back pain intensity, and disability (Quebec Back Pain Disability Scale), as well as the Zung Self-Rating Scale for self-assessment of depression and Self-Rating Anxiety Scale. CLBP diagnosis was linked with female gender and older age, as well as a higher level of sleep complaints such as sleepiness, OSA and insomnia symptoms, and a higher prevalence of moderate to severe depressive symptoms. The combination of moderate to severe depressive symptoms with obstructive sleep apnea or insomnia symptoms was the most important predictive factor for functional disability in CBLP patients (OR 13.686, 95% CI 4.581-40.885; p < 0.001). In conclusion, depressive symptoms and subjective sleep complaints appear to relate to greater CLBP intensity and/or CLBP-related disability in people with CLBP. A holistic approach is crucial for treating chronic CLBP patients, including psychological and sleep issue assessment and management, to improve their quality of life.

New insights and potential clinical implications of the odds ratio product

The odds ratio product (ORP) is a continuous metric of sleep depth that ranges from 0 (very deep sleep) to 2. 5 (full wakefulness). Its advantage over the conventional method recommended by AASM is that it discloses different levels of stage wake (sleep propensity) and different sleep depths within the same sleep stage. As such, it can be used to identify differences in sleep depth between subjects, and in the same subjects under different circumstances, when differences are not discernible by conventional staging. It also identifies different sleep depths within stage rapid-eye-movement sleep, with possible implications to disorders during this stage. Epoch-by-epoch ORP can be displayed graphically across the night or as average values in conventional sleep stages. In addition, ORP can be reported as % of recording time in specific ORP ranges (e.g., deciles of the total ORP range) where it produces distinct distribution patterns (ORP-architecture) that have been associated with different clinical disorders and outcomes. These patterns offer unique research opportunities to identify different mechanisms and potential therapy for various sleep complaints and disorders. In this review I will discuss how ORP is measured, its validation, differences from delta power, and the various phenotypes, and their postulated mechanisms, identified by ORP architecture and the opportunities for research to advance management of sleep-disordered breathing, insomnia and idiopathic hypersomnia.

Multi-dimensional sleep and mortality: The Multi-Ethnic Study of Atherosclerosis

STUDY OBJECTIVES

Multiple sleep characteristics are informative of health, sleep characteristics cluster, and sleep health can be described as a composite of positive sleep attributes. We assessed the association between a sleep score reflecting multiple sleep dimensions, and mortality. We tested the hypothesis that more favorable sleep (higher sleep scores) is associated with lower mortality.

METHODS

The Multi-Ethnic Study of Atherosclerosis (MESA) is a racially and ethnically-diverse multi-site, prospective cohort study of US adults. Sleep was measured using unattended polysomnography, 7-day wrist actigraphy, and validated questionnaires (2010-2013). 1726 participants were followed for a median of 6.9 years (Q1-Q3, 6.4-7.4 years) until death (171 deaths) or last contact. Survival models were used to estimate the association between the exposure of sleep scores and the outcome of all-cause mortality, adjusting for socio-demographics, lifestyle, and medical comorbidities; follow-up analyses examined associations between individual metrics and mortality. The exposure, a sleep score, was constructed by an empirically-based Principal Components Analysis on 13 sleep metrics, selected a priori.

RESULTS

After adjusting for multiple confounders, a 1 standard deviation (sd) higher sleep score was associated with 25% lower hazard of mortality (Hazard Ratio [HR]: 0.75; 95% Confidence interval: [0.65, 0.87]). The largest drivers of this association were: night-to-night sleep regularity, total sleep time, and the Apnea-Hypopnea Index.

CONCLUSION

More favorable sleep across multiple characteristics, operationalized by a sleep score, is associated with lower risk of death in a diverse US cohort of adults. Results suggest that interventions that address multiple dimensions may provide novel approaches for improving health.

Insomnia with objective, but not subjective, short sleep duration is associated with increased risk of incident hypertension: the Sleep Heart Health Study

STUDY OBJECTIVES

Insomnia with objective short sleep duration has been associated with higher risk of cardiometabolic morbidity. In this study, we examined the association between insomnia with objective short sleep duration, also based on subjective sleep duration, with incident hypertension in the Sleep Heart Health Study.

METHODS

We analyzed data from 1,413 participants free of hypertension or sleep apnea at baseline from the Sleep Heart Health Study, with a median follow-up duration of 5.1 years. Insomnia symptoms were defined based on difficulty falling asleep, difficulty returning to sleep, early morning awakening, or sleeping pill use more than half the days in a month. Objective short sleep duration was defined as polysomnography-measured total sleep time < 6 hours. Incident hypertension was defined based on blood pressure measures and/or use of antihypertensive medications at follow-up.

RESULTS

Individuals with insomnia who slept objectively < 6 hours had significantly higher odds of incident hypertension compared to normal sleepers who slept ≥ 6 hours (odds ratio = 2.00, 95% confidence interval = 1.09-3.65) or < 6 hours (odds ratio = 2.00, 95% confidence interval = 1.06-3.79) or individuals with insomnia who slept ≥ 6 hours (odds ratio = 2.79, 95% confidence interval = 1.24-6.30). Individuals with insomnia who slept ≥ 6 hours or normal sleepers who slept < 6 hours were not associated with increased risk of incident hypertension compared to normal sleepers who slept ≥ 6 hours. Finally, individuals with insomnia who self-reported sleeping < 6 hours were not associated with significantly increased odds of incident hypertension.

CONCLUSIONS

These data further support that the insomnia with objective short sleep duration phenotype based on objective, but not subjective measures, is associated with increased risk of developing hypertension in adults.

CITATION

Dai Y, Chen B, Chen L, et al. Insomnia with objective, but not subjective, short sleep duration is associated with increased risk of incident hypertension: the Sleep Heart Health Study. J Clin Sleep Med. 2023;19(8):1421-1428.

Acupuncture methods for insomnia disorder in the elderly: protocol for a systematic review and network meta-analysis

BACKGROUND

Insomnia disorder remains one of the most common sleep disorders in the elderly, with high prevalence and substantial consequences for patients' general health. Despite that increasing clinical trials have indicated that acupuncture seems to be effective for insomnia disorder in the elderly, comparative efficacy and safety of different acupuncture methods for elderly individuals with insomnia disorder has been unclear. Therefore, this protocol outlined a plan to evaluate and rank the efficacy and safety of various acupuncture approaches for insomnia disorder in the elderly.

METHODS

A systematic search of 8 bibliographic databases will be conducted from their inception to 18 June 2023, including Cochrane Library, MEDLINE (via PubMed), Embase, Web of Science, Chinese National Knowledge Infrastructure (CNKI), Wanfang Database, VIP Database, and Chinese Biomedical Literature Database (CBM). Randomized controlled trials investigating acupuncture methods for insomnia disorder in the elderly, published in English or Chinese will be included. The primary outcome is sleep quality measured by the Pittsburgh Sleep Quality Index (PSQI). Two reviewers will independently perform study selection, data extraction and risk assessment of bias. The quality of included literatures will be appraised using Cochrane risk-of-bias tool (ROB 2.0). ADDIS (Aggregate Data Drug Information System) V.1.16.8 will be used to conduct Bayesian network meta-analysis. The quality of evidence will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation System (GRADE).

DISCUSSION

In this study, the results will provide credible evidence to assess the efficacy and safety of acupuncture therapies for elderly patients with insomnia disorder, assisting patients, physicians and clinical research investigators to select the most appropriate acupuncture method.

SYSTEMATIC REVIEW REGISTRATION

The protocol has been registered at OSF ( https://osf.io/3kjpq/ ) with a registration number https://doi.org/10.17605/OSF.IO/3KJPQ .

Contribution of obstructive sleep apnea to disrupted sleep in a large clinical cohort of patients with suspected obstructive sleep apnea

STUDY OBJECTIVES

The response of sleep depth to CPAP in patients with OSA is unpredictable. The odds-ratio-product (ORP) is a continuous index of sleep depth and wake propensity that distinguishes different sleep depths within sleep stages, and different levels of vigilance during stage wake. When expressed as fractions of time spent in different ORP deciles, nine distinctive patterns are found. Only three of these are associated with OSA. We sought to determine whether sleep depth improves on CPAP exclusively in patients with these three ORP patterns.

METHODS

ORP was measured during the diagnostic and therapeutic components of 576 split-night polysomnographic (PSG) studies. ORP architecture in the diagnostic section was classified into one of the nine possible ORP patterns and the changes in sleep architecture were determined on CPAP for each of these patterns. ORP architecture was similarly determined in the first half of 760 full-night diagnostic PSG studies and the changes in the second half were measured to control for differences in sleep architecture between the early and late portions of sleep time in the absence of CPAP.

RESULTS

Frequency of the three ORP patterns increased progressively with the apnea-hypopnea index. Sleep depth improved significantly on CPAP only in the three ORP patterns associated with OSA. Changes in CPAP in the other six patterns, or in full diagnostic PSG studies, were insignificant or paradoxical.

CONCLUSIONS

ORP architecture types can identify patients in whom OSA adversely affects sleep and whose sleep is expected to improve on CPAP therapy.

Nonlinear associations between sleep duration and the risks of all-cause and cardiovascular mortality among the general adult population: a long-term cohort study

Objective

This study aims to investigate the correlation between sleep duration and all-cause and cardiovascular mortality in the general population.

Methods

A total of 26,977 participants aged ≥18 years were included in the analysis from the National Health and Nutrition Examination Survey (NHANES) database covering the period from 2005 to 2014. Data on cardiovascular and all-cause deaths were collected until December 2019. Sleep duration was assessed using a structured questionnaire, and participants were categorized into five groups based on their reported sleep duration (≤5, 6, 7, 8, or ≥9 h). Kaplan-Meier survival curves were employed to examine the mortality rates across different sleep duration groups. Multivariate Cox regression models were utilized to explore the association between sleep duration and mortality. Additionally, a restricted cubic spline regression model was employed to identify the non-linear relationship between sleep duration and all-cause and cardiovascular mortality.

Results

The average age of participants was 46.23 ± 18.48 years, with 49.9% of the subjects being male. Over a median follow-up period of 9.42 years, 3,153 (11.7%) participants died from all-cause mortality, among which 819 (3.0%) were attributed to cardiovascular causes. The groups with sleep durations of ≥9 and ≤5 h exhibited the lowest cumulative survival rates for all-cause mortality and cardiovascular mortality, respectively. When using a sleep duration of 7 h as the reference, the hazard ratios (with 95% confidence intervals) for all-cause mortality were 1.28 (1.14-1.44) for ≤5 h, 1.10 (0.98-1.23) for 6 h, 1.21 (1.10-1.34) for 8 h, and 1.53 (1.35-1.73) for ≥9 h. The hazard ratios (with 95% confidence intervals) for cardiovascular mortality were 1.32 (1.04-1.67) for ≤5 h, 1.22 (0.97-1.53) for 6 h, 1.29 (1.05-1.59) for 8 h, and 1.74 (1.37-2.21) for ≥9 h. A U-shaped non-linear relationship between sleep duration and all-cause and cardiovascular mortality was observed, with inflection point thresholds at 7.32 and 7.04 h, respectively.

Conclusion

The findings suggest that the risk of all-cause and cardiovascular mortality is minimized when sleep duration is approximately 7 h.

The mortality risk of night-time and daytime insomnia symptoms in an older population

The current study examined the association between insomnia symptoms and all-cause mortality in older adults (≥ 65 years). Data was used from 1969 older adults [M = 78 years, SD = 6.7 years] who participated in the Australian Longitudinal Study of Ageing. Insomnia symptoms were defined by nocturnal symptoms (difficulty falling asleep, difficulty maintaining sleep, early morning awakenings) and daytime symptoms (concentration difficulties, effort, inability to get going). Frequency of symptoms were combined to calculate an insomnia symptom score ranging from 0 (no symptoms) to 24 (sever symptoms) and quintiles of the score were constructed to provide a range of symptom severity. Multivariable Cox models were conducted to assess associations between insomnia symptom severity and mortality risk. In the median follow up of 9.2 years, there were 17,403 person-years at risk and the mortality rate was 8-per 100 person-years. Insomnia symptom severity was associated with increased mortality in the most severe quintile (adjusted HR_Q1vsQ5 = 1.26, 95%CI [1.03-1.53], p = .02). Subsequent analyses showed this association was driven by daytime symptoms (adjusted HR_Q1vsQ5 = 1.66, [1.39-2.00], p < .0001), since nocturnal symptoms alone were not associated with increased mortality (adjusted HR _Q1vsQ5 = 0.89, [0.72-1.10], p = .28). Findings suggest daytime symptoms drive increased mortality risk associated with insomnia symptoms. Findings may be therapeutically helpful by reassuring individuals with nocturnal insomnia symptoms alone that their longevity is unlikely to be impacted.

Objective sleep duration and response to combined pharmacotherapy and cognitive behavioral insomnia therapy among patients with comorbid depression and insomnia: a report from the TRIAD study

STUDY OBJECTIVES

Several studies have shown that patients with short sleep duration show a poor response to cognitive behavioral therapy for insomnia (CBT-I), but such studies have not included patients with comorbid conditions. The current study was conducted to determine whether pretreatment sleep duration moderates the response of patients with major depression and insomnia disorders to a combined CBT-I and antidepressant medication treatment.

METHODS

This study comprised a secondary analysis of a larger randomized trial that tested combined CBT-I/antidepressant medication treatment of patients with major depression and insomnia. Participants (n = 99; 70 women; Mage = 47.712.4 years) completed pretreatment polysomnography and then were randomly assigned to a 12-week treatment with antidepressant medication combined with CBT-I or a sham therapy. Short and longer sleepers were defined using total sleep time cutoffs of < 5, < 6, and < 7 hours for short sleep. Insomnia and depression remission ascertained respectively from the Insomnia Severity Index and Hamilton Rating Scale for Depression were used to compare treatment responses of short and longer sleepers defined by the cutoffs mentioned.

RESULTS

Logistic regression analyses showed that statistically significant results were obtained only when the cutoff of < 5 hours of sleep was used to define "short sleep." Both the CBT-I recipients with < 5 hours of sleep (odds ratio = 0.053; 95% confidence interval = 0.006-0.499) and the sham-therapy group with ≥ 5 hours of sleep (odds ratio = 0.149; 95% confidence interval = 0.045-0.493) were significantly less likely to achieve insomnia remission than were CBT-I recipients with ≥ 5 hours of sleep. The shorter sleeping CBT-I group (odds ratio = 0.118; 95% confidence interval = 0.020-0.714) and longer sleeping sham-therapy group (odds ratio = 0.321; 95% confidence interval = 0.105-0.983) were also less likely to achieve insomnia and/or depression remission than was the longer sleeping CBT-I group with ≥ 5 hours of sleep.

CONCLUSIONS

Sleeping < 5 hours may dispose comorbid major depression/insomnia patients to a poor response to combined CBT-I/medication treatments for their insomnia and depression. Future studies to replicate these findings and explore mechanisms of treatment response seem warranted.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Treatment of Insomnia and Depression (TRIAD); URL: https://clinicaltrials.gov/ct2/show/results/NCT00767624; Identifier: NCT00767624.

CITATION

Edinger JD, Smith ED, Buysse DJ, et al. Objective sleep duration and response to combined pharmacotherapy and cognitive behavioral insomnia therapy among patients with comorbid depression and insomnia: a report from the TRIAD study. J Clin Sleep Med. 2023;19(6):1111-1120.

The Effect of Aerobic Exercise on Variation of Oxidative Stress, hs-CRP and Cortisol Induced by Sleep Deficiency

The aim of this study was to investigate the impact of sleep deficiency (SD) on oxidative stress, hs-CRP and cortisol levels and to examine the effects of different intensities of aerobic exercise on these parameters under SD conditions. Thirty-two healthy male university students participated in the study and underwent both normal sleep (NS, 8 h of sleep per night for 3 consecutive days) and SD (4 h of sleep per night for 3 consecutive days). After the SD period, the participants performed treatment for 30 min according to their assigned group [sleep supplement after SD (SSD), low-intensity aerobic exercise after SD (LES), moderate-intensity aerobic exercise after SD (MES), high-intensity aerobic exercise after SD (HES)]. Sleep-related factors were measured at NS and SD, while oxidative stress, hs-CRP and cortisol levels were measured at NS, SD and immediately after treatment by group (AT). The results showed that actual total sleep time (ATST) was significantly reduced during SD compared to NS (p < 0.001), while the visual analogue scale (VAS) and Epworth sleepiness scale (ESS) were significantly increased during SD compared to NS (p < 0.001). The difference in reactive oxygen metabolites (d-ROMs) and cortisol levels showed a significant interaction effect (p < 0.01, p < 0.001, respectively), with LES showing a decrease in d-ROMs and cortisol levels compared to SD (p < 0.05). Similarly, SSD showed a decrease in cortisol levels compared to SD (p < 0.05), while HES led to a significant increase in d-ROMs and cortisol levels compared to SD (p < 0.05). Biological antioxidant potential (BAP) and hs-CRP did not show any significant effect (p > 0.05). These results suggest that LES is the most effective exercise intensity for mitigating the negative effects of SD.

Patients' experience of necrotising otitis externa: a qualitative study

BACKGROUND

Necrotising otitis externa is a serious infective condition. Patients are typically frail, diagnostic delay is common and severe pain is a key feature. This study aimed to qualitatively analyse patient-centred data to identify key themes in the patient's experience.

METHODS

Open-ended questionnaires were sent to 28 patients. Responses were qualitatively analysed using a grounded theory approach. Iterative cycles were used to develop codes using a constant comparison technique. Emerging categories were refined to identify core themes.

RESULTS

Four main themes emerged: severe pain, mental health, quality of life and diagnostic delays.

CONCLUSION

This is the first study to explore patients' perspectives in necrotising otitis externa. It indicates a need to raise awareness of necrotising otitis externa, and to improve symptom management, pain control and quality of life. This valuable information can be used to identify research priorities, guide service improvements, improve clinical care and feed into the development of a Core Outcome Set for necrotising otitis externa.

Insomnia with objective short sleep duration in community-living older persons: A multifactorial geriatric health condition

BACKGROUND

Insomnia or poor sleep quality with objective short sleep duration (hereafter referred to as ISSD) has been identified as a high-risk phenotype among middle-aged persons. We evaluated the prevalence and clinical correlates of ISSD among community-living older persons.

METHODS

In 3053 men from the Osteoporotic Fractures in Men Sleep Study (MrOS; average age 76.4 ± 5.5 years) and 3044 women from the Study of Osteoporotic Fractures (SOF; average age 83.6 ± 3.8 years), we evaluated the prevalence of ISSD (trouble getting to sleep within 30 minutes, waking up in the middle of the night or early morning, and/or taking a medication to help with sleep ≥3 times per week and actigraphy-estimated sleep duration <6 h). Using separate logistic regression models in men and women, we evaluated the cross-sectional associations between predisposing, precipitating, and perpetuating factors for ISSD, as compared with normal sleep (no insomnia and actigraphy-estimated sleep duration of 6-9 h).

RESULTS

Overall, 20.6% of older men and 12.8% of older women had insomnia with short sleep duration. Multiple predisposing, precipitating, and perpetuating factors were cross-sectionally associated with ISSD in both men and women. In multivariable models that adjusted for predisposing factors (demographics, multimorbidity, obesity), precipitating (depression, anxiety, central nervous system-active medication use, restless legs syndrome) and perpetuating (napping, falls) factors were significantly associated with ISSD in men and women (adjusted odds ratios ranging 1.63-4.57).

CONCLUSIONS

In this cross-sectional study of community-living older men and women, ISSD was common and associated with multiple predisposing, precipitating, and perpetuating factors, akin to a multifactorial geriatric health condition. Future work should examine causal pathways and determine whether the identified correlates represent modifiable risk factors.

The beneficial effects of integrating a personalized telephone-delivered component into digital cognitive behavioral therapy for insomnia in a large, hospital-based population

OBJECTIVES

Although digital cognitive behavior therapy for insomnia (D-CBTI) has been shown to be a viable treatment for insomnia, lacking flexibility of response and direct practitioner-to-patient contact and comfort potentially limited its efficacy. Integrating personalized telephone sessions into D-CBTI may overcome these obstacles, potentially providing additional clinical benefit to chronic insomnia patients. We evaluate the clinical effectiveness of telephone plus D-CBTI (TD-CBTI) versus D-CBTI alone.

METHODS

Insomnia patients were selected consecutively from the Sleep Medicine Center, West China Hospital from March 2020 to February 2021. Insomnia was defined by Diagnostic and Statistical Manual for Mental Disorders criteria with symptoms lasting ≥3 months. Standard D-CBTI was administered through the APP "SUMIAN," which provided fully automated, interactive and standard CBTI over six weekly treatments. TD-CBTI added weekly 10-15 min personalized telephone-based sessions to D-CBTI.

RESULTS

One hundred and seven patients received D-CBTI and 465 patients received TD-CBTI. Pre-to posttreatment differences of ISI and most sleep diary reported sleep indexes were comparable between groups. However, TD-CBTI patients showed significantly increased odds of SE based remission (167%, OR = 2.67, 95% CI 1.34-5.23), and significantly increased odds of reduction of sleep medications (352%, OR = 4.52, 95% CI 1.27-10.05).

CONCLUSIONS

This study demonstrates that integration of personalized telephone sessions into D-CBTI treatment, provides increased clinical benefit to insomnia patients, particularly for successful discontinuation of sleep medications.

Insomnia with objective short sleep duration is associated with hypertension

Insomnia with objective short sleep duration has been proposed as the most biologically severe phenotype of the disorder associated with cardiometabolic morbidity in population-based samples. In this study, we investigated the association between insomnia with objective short sleep duration and hypertension in a large clinical sample. We studied 348 patients diagnosed with chronic insomnia disorder based on International Classification of Sleep Disorders Third Edition criteria and 150 normal sleepers. Objective short sleep duration was defined by the median total sleep time of the sample (< 7 hr) measured with 1-night polysomnography. Hypertension was defined based on blood pressure levels, antihypertensive medication use and/or a physician diagnosis. After adjusting for potential confounders, patients with chronic insomnia disorder who slept < 7 hr were associated with 2.8-fold increased odds of hypertension compared with normal sleepers who slept ≥ 7 hr (odds ratio = 2.81, 95% confidence interval = 1.068-7.411) or < 7 hr (odds ratio = 2.75, 95% confidence interval = 1.005-7.542), whereas patients with chronic insomnia disorder who slept ≥ 7 hr (odds ratio = 1.52, 95% confidence interval = 0.537-4.285) or normal sleepers who slept < 7 hr (odds ratio = 1.07, 95% confidence interval = 0.294-3.904) were not significantly associated with increased odds of hypertension compared with normal sleepers who slept ≥ 7 hr. Linear regression analyses showed that, for every hour decrease in total sleep time, systolic and diastolic blood pressure increased by 1.014 mmHg (p = 0.045) and 0.923 mmHg (p = 0.015), respectively, in patients with chronic insomnia disorder but not in normal sleepers. Our findings further support that insomnia with objective short sleep duration is a risk factor for hypertension, and objective short sleep duration may be a useful marker of the biological severity of chronic insomnia disorder in clinical practice.

Trends in prevalence of short sleep duration and trouble sleeping among US adults, 2005-2018

STUDY OBJECTIVES

To determine trends in prevalence of short sleep duration and trouble sleeping among US adults from 2005 to 2018, and to assess how sleep trends vary by sex and race/ethnicity.

METHODS

Seven cycles of the National Health and Nutrition Examination Survey data between 2005-2006 and 2017-2018 were analyzed. Trouble sleeping and sleep duration were self reported. Short sleep duration was defined as sleep duration ≤6 hr. Age-standardized prevalence of reporting trouble sleeping to a health care provider and short sleep duration were estimated among the overall US adult population, and by sex and race/ethnicity.

RESULTS

From 2005 to 2014, the age-adjusted prevalence of short sleep duration remained similar in the overall population (p for trend >0.05). Non-Hispanic Black people had the highest prevalence of short sleep duration among all race/ethnicity groups in all seven cycles. The prevalence of short sleep duration appears lower in 2015-2018 than in 2005-2014 due to different measurement methods applied. However, from 2005 to 2018, there were increasing trends in age-adjusted prevalence of reporting trouble sleeping to a health care provider in the overall population, among both men and women, and all race/ethnicity groups (p for trend <0.05). Among all the race/ethnicity groups, non-Hispanic White people had the highest prevalence of reporting trouble sleeping to a healthcare provider.

CONCLUSION

Findings depict the persistence of sleep-related issues in the United States and possible risk factors, as well as racial disparities.

Mapping the Insomnia Severity Index Instrument to EQ-5D Health State Utilities: A United Kingdom Perspective

OBJECTIVE

This study aimed to map the Insomnia Severity Index (ISI) to the EQ-5D-3L utility values from a UK perspective.

METHODS

Source data were derived from the 2020 National Health and Wellness Survey (NHWS) for France, Germany, Italy, Spain, the UK and the US. Ordinary least squares regression, generalised linear model (GLM), censored least absolute deviation, and adjusted limited dependent variable mixture model (ALDVMM) were employed to explore the relationship between ISI total summary score and EQ-5D utility while accounting for adjustment covariates derived from the NHWS. Fitting performance was assessed using standard metrics, including mean-squared error (MSE) and coefficient of determination (R²).

RESULTS

A total of 17,955 respondent observations were included, with a mean ISI score of 12.12 ± 5.32 and a mean EQ-5D-3L utility (UK tariff) of 0.71 ± 0.23. GLM gamma-log and ALDVMM were the two best performing models. The ALDVMM had better fitting performance (R² = 0.320, MSE 0.0347) than the GLM gamma-log (R² = 0.303, MSE 0.0353); in train-test split-sample validation, ALDVMM also slightly outperformed the GLM gamma-log model, with an MSE of 0.0351 versus 0.0355. Based on fitting performance, ALDVMM and GLM gamma-log were the preferred models.

CONCLUSIONS

In the absence of preference-based measures, this study provides an updated mapping algorithm for estimating EQ-5D-3L utilities from the ISI summary total score. This new mapping not only draws its strengths from the use of a large international dataset but also the incorporation of adjustment variables (including sociodemographic and general health characteristics) to reduce the effects of confounders.

Emerging applications of objective sleep assessments towards the improved management of insomnia

Self-reported sleep difficulties are the primary concern associated with diagnosis and treatment of chronic insomnia. This said, in-home sleep monitoring technology in combination with self-reported sleep outcomes may usefully assist with the management of insomnia. The rapid acceleration in consumer sleep technology capabilities together with their growing use by consumers means that the implementation of clinically useful techniques to more precisely diagnose and better treat insomnia are now possible. This review describes emerging techniques which may facilitate better identification and management of insomnia through objective sleep monitoring. Diagnostic techniques covered include insomnia phenotyping, better detection of comorbid sleep disorders, and identification of patients potentially at greatest risk of adverse outcomes. Treatment techniques reviewed include the administration of therapies (e.g., Intensive Sleep Retraining, digital treatment programs), methods to assess and improve treatment adherence, and sleep feedback to address concerns about sleep and sleep loss. Gaps in sleep device capabilities are also discussed, such as the practical assessment of circadian rhythms. Proof-of-concept studies remain needed to test these sleep monitoring-supported techniques in insomnia patient populations, with the goal to progress towards more precise diagnoses and efficacious treatments for individuals with insomnia.

The impact of emotional contagion on workplace safety: Investigating the roles of sleep, health, and production pressure

Using emotional contagion theory and the Job Demands-Resources model as a theoretical foundation, we tested the proposition that higher levels of contagion of anger (i.e., a demand) vs. higher levels of contagion of joy (i.e., a resource) will be associated respectively with more vs. fewer sleep disturbances and health problems, which in turn are related to more workplace accidents and injuries. Moreover, we examined the moderating impact of production pressure (i.e., a contextual demand) on the relationship between emotional contagion and employee poor sleep and health. Data from 1000 employees in Italy showed that the conditional indirect effects of contagion of anger, but not of joy, on accidents and injuries via sleep and health problems were intensified as levels of production pressure increased. Furthermore, contagion of anger was positively associated with both sleep disturbances and health problems whereas contagion of joy was negatively related to only sleep disturbances. These findings suggest that the effect of anger that employees absorb during social interactions at work likely persists when coming at home and represents an emotional demand that impairs the physiological functions that regulate restorative sleep and energies recharging; and, this effect is even stronger among employees who perceived higher levels of organizational production pressure.

The Role of Sleep in Cognitive Function: The Value of a Good Night's Rest

As a universal, evolutionarily conserved phenomenon, sleep serves many roles, with an integral role in memory. This interplay has been examined in a variety of research. The purpose of this article will be to review the literature of sleep, aging, cognition, and the impact of two common clinical conditions (obstructive sleep apnea and insomnia) on cognitive impairment. This article will review data from meta-analyses, population studies, smaller cohort studies, neuropsychological studies, imaging, and bench data. Considerations are given to the current data trends and their limitations. This paper will explore the impact of sleep on cognitive impairment. Finally, we will conclude with integrating the separate mechanisms towards more generalized common pathways: disruption of sleep quality and reduction in sleep quantity lead to excessive neuronal activity without sufficient time for homeostasis. Sleep apnea and chronic insomnia can lead to oxidative stress and neuronal damage. These changes predispose and culminate in the development of cognitive impairment.

Sex- and age-specific all-cause mortality in insomnia with hypnotics: Findings from Japan multi-institutional Collaborative Cohort Study

OBJECTIVE

Findings on the increased mortality risk in individuals with insomnia are inconsistent across studies. Rather than improving insomnia by sleep control, hypnotic use may be one factor in the increased risk of death; however, the effects of hypnotics on mortality remains unclear. This study aimed to examine the association between all-cause mortality and hypnotic use in a large sample, while adjusting for the effects of comorbidities.

METHODS

Overall, 92,527 individuals aged 35-69 years were followed up for mortality in the Japan Multi-Institutional Collaborative Cohort Study. Regular use of hypnotics was assessed using a self-administered questionnaire. Since cancer history carries a substantial risk of death and is associated with the treatment of insomnia with hypnotics, participants with a cancer history were excluded. The hazard ratio (HR) and 95% confidence interval (CI) for all-cause mortality related to hypnotic use were estimated using a Cox proportional hazard model with adjustments for covariates including sleeping hours and comorbidities (body mass index, ischemic heart disease, stroke, and diabetes).

RESULTS

During the follow-up (mean, 8.4 ± 2.5 years), 1,492 mortalities were recorded, and the prevalence of taking hypnotics was 4.2%. Hypnotic use was associated with significantly greater risk of all-cause mortality, even after adjustment for the covariates (HR, 1.32; 95% CI, 1.07-1.63). The association between hypnotic use and all-cause mortality was robust in males (HR, 1.51; 95% CI, 1.15-1.96), and participants aged <60 years (HR, 1.75; 95% CI, 1.21-2.54).

CONCLUSIONS

Our study revealed sex-age specific associations between hypnotic use and all-cause mortality.

Irregular sleep and all-cause mortality: A large prospective cohort study

OBJECTIVES

Previous studies using objective parameters have shown that irregular sleep is associated with the disease incidence, progression, or mortality. This study aimed to determine the association between subjective sleep duration and sleep regularity, with mortality in a large population.

METHODS

Participants were from the Japan Multi-Institutional Collaborative Cohort study. We obtained information from each participant on sleep duration, sleep regularity, and demographics and overall lifestyle using self-administered questionnaires. We defined sleep regularity according to participants' subjective assessment of sleep/wake time regularity. Participants (n = 81,382, mean age: 58.1 ± 9.1years, males: 44.2%) were classified into 6 groups according to sleep duration and sleep regularity. Hazard ratios (HR) for time-to-event of death were calculated using the Cox proportional hazards model.

RESULTS

The mean follow-up period was 9.1 years and the mean sleep duration was 6.6 h/day. Irregular sleep significantly increased the risk of all-cause mortality in all models compared with regular sleep (HR 1.30, 95% confidence interval; CI, 1.18-1.44), regardless of sleep duration. Multivariable analysis of the 6 groups by sleep pattern (sleep regularity and duration) showed irregular sleep and sleep durations of <6 h/day, 6 to <8 h/day, or ≥8 h/day were associated with a 1.2-1.5-fold increases in mortality, compared to regular sleep and sleep duration of 6 to <8 h/day.

CONCLUSIONS

Our study shows an association between sleep irregularity and all-cause mortality in a large Japanese population. Our findings provide further confirmation of the need to consider not only sleep duration, but also the regularity aspect of sleep schedules.

What are the sleep characteristics among early kidney transplant recipients? An objective and subjective measurement from China

OBJECTIVE

To evaluate the sleep quality by self-reported questionnaires and polysomnography (PSG) among early kidney transplant recipients (KTRs) and to further explore their correlation.

DESIGN

This was a prospective and cross-sectional analysis of the sleep characteristics among early kidney transplant recipients through an objective and subjective measurement.

PARTICIPANTS

Patients with end stage renal disease on the transplant waiting list and after kidney transplantation were from a major organ transplantation center in Southern China (n = 83).

PRIMARY AND SECONDARY OUTCOME MEASUREMENTS

Objective outcomes: PSG, noise and light. Subjective outcomes: demographic and clinical questionnaires, self-reported pain and Richards Campbell sleep questionnaire (RCSQ). After agreement with the informed consent, participants first completed demographic and clinical questionnaires, then worn the PSG within 5-10 days after kidney transplantation. Both noise, light and self-reported pain were monitored during sleep. After completion of PSG, the RCSQs were filled out next morning.

RESULTS

A total of 298 patients were recruited and 83 participants were finally analyzed. The total RCSQ mean score was 51.0±18.9mm. The prevalence of poor sleep quality among early KTRs was 45.1%. Most of PSG characteristics were significantly correlated with their corresponding RCSQ items. And the total RCSQ scores were significantly correlated with the number of awakenings, the N2 percentage and the total sleep time (r = 0.79, 0.47 and 0.40, P<0.05) respectively. Noise was a statistically significant factor affecting the subjective sleep quality.

CONCLUSIONS

The sleep quality in early KTRs measured by both PSG and RCSQ exhibits consistency with each other. Sleep disruption always remains a substantial problem and is affected by self-reported noise among early KTRs. The RCSQ is easily applicable and interpretable so that it can be used for future daily clinical practice.

The effect and relative importance of sleep disorders for all-cause mortality in middle-aged and older asthmatics

Background

Previous studies observed that sleep disorders potentially increased the risk of asthma and asthmatic exacerbation. We aimed to examine whether excessive daytime sleepiness (EDS), probable insomnia, objective short sleep duration (OSSD), and obstructive sleep apnea (OSA) affect all-cause mortality (ACM) in individuals with or without asthma.

Methods

We extracted relevant data from the Sleep Heart Health Study established in 1995–1998 with an 11.4-year follow-up. Multivariate Cox regression analysis with a proportional hazards model was used to estimate the associations between ACM and four sleep disorders among asthmatic patients and individuals without asthma. Dose-response analysis and machine learning (random survival forest and CoxBoost) further evaluated the impact of sleep disorders on ACM in asthmatic patients.

Results

A total of 4538 individuals with 990 deaths were included in our study, including 357 asthmatic patients with 64 deaths. Three multivariate Cox regression analyses suggested that OSSD (adjusted HR = 2.67, 95% CI: 1.23–5.77) but not probable insomnia, EDS or OSA significantly increased the risk of ACM in asthmatic patients. Three dose-response analyses also indicated that the extension of objective sleep duration was associated with a reduction in ACM in asthmatic patients compared to very OSSD patients. Severe EDS potentially augmented the risk of ACM compared with asthmatics without EDS (adjusted HR = 3.08, 95% CI: 1.11–8.56). Machine learning demonstrated that OSSD of four sleep disorders had the largest relative importance for ACM in asthmatics, followed by EDS, OSA and probable insomnia.

Conclusions

This study observed that OSSD and severe EDS were positively associated with an increase in ACM in asthmatic patients. Periodic screening and effective intervention of sleep disorders are necessary for the management of asthma.

The association between subjective-objective discrepancies in sleep duration and mortality in older men

A discrepancy in subjective and objective estimations of sleep duration, which often diverge, could have long-term adverse effects on health outcomes in older adults. Using data from 2674 older adult men (≥ 65 years of age) of the Osteoporotic Fractures in Men Sleep Study, we assessed the longitudinal association between misperception index (MI), calculated as MI = (objective sleep duration - subjective sleep duration)/objective sleep duration, and all-cause mortality. During the follow-up with a mean (standard deviation) of 10.8 (4.2) years, 1596 deaths were observed. As a continuous variable, MI showed a linear relationship with all-cause mortality after adjusting for multiple covariates, including polysomnography-measured objective sleep duration [fully adjusted hazard ratio (HR), 0.69; 95% confidence interval [CI], 0.56-0.84]. As a categorical variable, the lowest MI quartile (vs. the interquartile MI range) was associated with increased mortality (fully adjusted HR, 1.28; 95% CI, 1.12-1.46), whereas the highest MI quartile was not associated with mortality (fully adjusted HR, 0.97; 95% CI, 0.85-1.11). The subjective overestimation of sleep duration may be a risk factor for all-cause mortality in older men. Future studies should examine why subjective overestimation of sleep duration is associated with all-cause mortality from a physiological perspective.

Associations among Alcohol Drinking, Smoking, and Nonrestorative Sleep: A Population-Based Study in Japan

Nonrestorative sleep (NRS) is a common sleep disorder. It is associated with several unhealthy lifestyle factors, such as skipping breakfast and lack of exercise. However, the associations between alcohol drinking, smoking, and NRS are unclear. This study examined the prevalence of NRS within the Japanese general population and the relationships among alcohol drinking, smoking, and NRS. We analyzed an anonymized dataset from a 2013 nationwide population survey (35,717 men and 39,911 women). NRS was assessed through a single-item question, and socio-demographic and lifestyle factors were assessed through self-reports. Multivariable logistic regression analyses were used to examine the associations between alcohol drinking, smoking, and NRS. The total prevalence of NRS was 22.2% (95% CI 21.8-22.7) in men and 23.4% (95% CI 23.0-23.8) in women. Further, we found that sleep duration and prevalence of NRS shared an inverse J-shaped relationship. Heavy alcohol drinking was significantly associated with NRS in both sexes. Short sleep duration and certain socioeconomic factors modified the effect of smoking on NRS in men. These results could be useful in the development of more effective sleep health policies to establish better sleep hygiene.

Heart failure and cancer: From active exposure to passive adaption

The human body seems like a "balance integrator." On the one hand, the body constantly actively receives various outside stimuli and signals to induce changes. On the other hand, several internal regulations would be initiated to adapt to these changes. In most cases, the body could keep the balance in vitro and in vivo to reach a healthy body. However, in some cases, the body can only get to a pathological balance. Actively exposed to unhealthy lifestyles and passively adapting to individual primary diseases lead to a similarly inner environment for both heart failure and cancer. To cope with these stimuli, the body must activate the system regulation mechanism and face the mutual interference. This review summarized the association between heart failure and cancer from active exposure to passive adaption. Moreover, we hope to inspire researchers to contemplate these two diseases from the angle of overall body consideration.

Association of healthy beverage index with circadian rhythm and quality of sleep among overweight and obese women: a cross-sectional study

PURPOSE

Circadian rhythm is a behavioral, physiological, and molecular change with a cycle length of approximately 24 h. Changes to the circadian rhythm can result in sleep difficulty. The healthy beverage index (HBI) is a holistic concept for evaluating the quality of overall beverage intake and its association with health-related outcomes in nutritional epidemiological studies. This study aimed to assess the relationship of HBI with circadian rhythm and sleep quality among overweight/obese women.

METHODS

The current study was conducted among 208 overweight and obese women between 18-48 years in Tehran, Iran. We evaluated potential HBI with a valid food frequency questionnaire. Following standard procedures, trained personnel assessed anthropometric measures, blood samples, and other baseline characteristics. The Pittsburgh Sleep Quality Index and the morning-eveningness questionnaire were applied to evaluate sleep quality and circadian rhythm respectively.

RESULTS

The mean (SD) BMI for this study was 30.8 (4.2) kg/m². We observed that subjects in the least tertile had significantly high levels of triglyceride (p = 0.04) and low-density lipoprotein (p = 0.009). High-density lipoprotein was significantly different across the tertiles (p = 0.003). After adjusting for potential covariates, subjects in the second tertile of HBI had 5.07 odds of having the worst quality of sleep as compared to those in the third tertile, p < 0.05. We also observed a significant inverse association between the HBI and the "moderately evening type" participants (OR 0.86; 95% CI 0.68-0.99; p: 0.02) after adjusting for potential confounders.

CONCLUSION

Healthy beverage consumption may have the potential of improving sleep quality among overweight and obese subjects.

LEVEL OF EVIDENCE

Level IV, evidence obtained from a descriptive study.

Insomnia

Insomnia is highly prevalent in clinical practice, occurring in up to 50% of primary care patients. Insomnia can present independently or alongside other medical conditions or mental health disorders and is a risk factor for the development and exacerbation of these other disorders if not treated. In 2016, the American College of Physicians recommended that insomnia be specifically targeted for treatment. The recommended first-line treatment for insomnia, whether the underlying cause has been identified or not, is cognitive behavioural therapy for insomnia (CBT-I). Currently, there is no global consensus regarding which pharmacological treatment has the best efficacy or risk-benefit ratio. Both CBT-I and pharmacological intervention are thought to have similar acute effects, but only CBT-I has shown durable long-term effects after treatment discontinuation. Administering a combined treatment of CBT-I and medication could decrease the latency to treatment response, but might diminish the durability of the positive treatment effects of CBT-I.

Infra-low frequency neurofeedback and insomnia as a model of CNS dysregulation

This paper will review what is conventionally known of sleep homeostasis and focus on insomnia as a primary manifestation of brain dysregulation, whether as a solitary symptom or as part of a larger syndrome such as post-traumatic stress disorder, PTSD. It will discuss in brief behavioral/mindfulness treatments that have been used to treat neurologic diseases, as this is germane to the phenomenology of neurofeedback (NF). It will explore how neurofeedback may work at the subconscious level and cover the current clinical experience of the effectiveness of this technique in the treatment of insomnia. It will conclude with a case presentation.

Sleep optimization to improve glycemic control in adults with type 1 diabetes: study protocol for a randomized controlled parallel intervention trial

BACKGROUND

Despite improvements in treatment regimens and technology, less than 20% of adults with type 1 diabetes (T1D) achieve glycemic targets. Sleep is increasingly recognized as a potentially modifiable target for improving glycemic control. Diabetes distress, poor self-management behaviors, and reduced quality of life have also been linked to sleep variability and insufficient sleep duration. A significant gap of knowledge exists regarding interventions to improve sleep and the effects of sleep optimization on glycemic control in T1D. The purpose of this study is to determine the efficacy of a T1D-specific sleep optimization intervention (Sleep-Opt) on the primary outcomes of sleep variability, sleep duration, and glycemic control (A1C); other glycemic parameters (glycemic variability, time-in-range [TIR]); diabetes distress; self-management behaviors; quality of life; and other patient-reported outcomes in adults with T1D and habitual increased sleep variability or short sleep duration.

METHODS

A randomized controlled parallel-arm study will be employed in 120 adults (aged 18 to 65 years) with T1D. Participants will be screened for habitual sleep variability (> 1 h/week) or insufficient sleep duration (< 6.5 h per night). Eligible subjects will be randomized to the Sleep-Opt intervention group or healthy living attention control group for 12 weeks. A 1-week run-in period is planned, with baseline measures of sleep by actigraphy (sleep variability and duration), glycemia (A1C and related glycemic measures: glycemic variability and TIR using continuous glucose monitoring), and other secondary outcomes: diabetes distress, self-management behaviors, quality of life, and additional patient-reported outcomes. Sleep-Opt is a technology-assisted behavioral sleep intervention that we recently developed that leverages the rapidly increasing public interest in sleep tracking. Our behavioral intervention employs four elements: a wearable sleep tracker, didactic content, an interactive smartphone application, and brief telephone counseling. The attention control group will participate in a healthy living information program. Baseline measures will be repeated at midpoint, program completion, and post-program (weeks 6, 12, and 24, respectively) to determine differences between the two groups and sustainability of the intervention.

DISCUSSION

A better understanding of strategies to improve sleep in persons with T1D has the potential to be an important component of diabetes.

TRIAL REGISTRATION

Clinical Trial Registration: NCT04506151 .

Comparative effects of pharmacological interventions for the acute and long-term management of insomnia disorder in adults: a systematic review and network meta-analysis

BACKGROUND

Behavioural, cognitive, and pharmacological interventions can all be effective for insomnia. However, because of inadequate resources, medications are more frequently used worldwide. We aimed to estimate the comparative effectiveness of pharmacological treatments for the acute and long-term treatment of adults with insomnia disorder.

METHODS

In this systematic review and network meta-analysis, we searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Embase, PsycINFO, WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and websites of regulatory agencies from database inception to Nov 25, 2021, to identify published and unpublished randomised controlled trials. We included studies comparing pharmacological treatments or placebo as monotherapy for the treatment of adults (≥18 year) with insomnia disorder. We assessed the certainty of evidence using the confidence in network meta-analysis (CINeMA) framework. Primary outcomes were efficacy (ie, quality of sleep measured by any self-rated scale), treatment discontinuation for any reason and due to side-effects specifically, and safety (ie, number of patients with at least one adverse event) both for acute and long-term treatment. We estimated summary standardised mean differences (SMDs) and odds ratios (ORs) using pairwise and network meta-analysis with random effects. This study is registered with Open Science Framework, https://doi.org/10.17605/OSF.IO/PU4QJ.

FINDINGS

We included 170 trials (36 interventions and 47 950 participants) in the systematic review and 154 double-blind, randomised controlled trials (30 interventions and 44 089 participants) were eligible for the network meta-analysis. In terms of acute treatment, benzodiazepines, doxylamine, eszopiclone, lemborexant, seltorexant, zolpidem, and zopiclone were more efficacious than placebo (SMD range: 0·36-0·83 [CINeMA estimates of certainty: high to moderate]). Benzodiazepines, eszopiclone, zolpidem, and zopiclone were more efficacious than melatonin, ramelteon, and zaleplon (SMD 0·27-0·71 [moderate to very low]). Intermediate-acting benzodiazepines, long-acting benzodiazepines, and eszopiclone had fewer discontinuations due to any cause than ramelteon (OR 0·72 [95% CI 0·52-0·99; moderate], 0·70 [0·51-0·95; moderate] and 0·71 [0·52-0·98; moderate], respectively). Zopiclone and zolpidem caused more dropouts due to adverse events than did placebo (zopiclone: OR 2·00 [95% CI 1·28-3·13; very low]; zolpidem: 1·79 [1·25-2·50; moderate]); and zopiclone caused more dropouts than did eszopiclone (OR 1·82 [95% CI 1·01-3·33; low]), daridorexant (3·45 [1·41-8·33; low), and suvorexant (3·13 [1·47-6·67; low]). For the number of individuals with side-effects at study endpoint, benzodiazepines, eszopiclone, zolpidem, and zopiclone were worse than placebo, doxepin, seltorexant, and zaleplon (OR range 1·27-2·78 [high to very low]). For long-term treatment, eszopiclone and lemborexant were more effective than placebo (eszopiclone: SMD 0·63 [95% CI 0·36-0·90; very low]; lemborexant: 0·41 [0·04-0·78; very low]) and eszopiclone was more effective than ramelteon (0.63 [0·16-1·10; very low]) and zolpidem (0·60 [0·00-1·20; very low]). Compared with ramelteon, eszopiclone and zolpidem had a lower rate of all-cause discontinuations (eszopiclone: OR 0·43 [95% CI 0·20-0·93; very low]; zolpidem: 0·43 [0·19-0·95; very low]); however, zolpidem was associated with a higher number of dropouts due to side-effects than placebo (OR 2·00 [95% CI 1·11-3·70; very low]).

INTERPRETATION

Overall, eszopiclone and lemborexant had a favorable profile, but eszopiclone might cause substantial adverse events and safety data on lemborexant were inconclusive. Doxepin, seltorexant, and zaleplon were well tolerated, but data on efficacy and other important outcomes were scarce and do not allow firm conclusions. Many licensed drugs (including benzodiazepines, daridorexant, suvorexant, and trazodone) can be effective in the acute treatment of insomnia but are associated with poor tolerability, or information about long-term effects is not available. Melatonin, ramelteon, and non-licensed drugs did not show overall material benefits. These results should serve evidence-based clinical practice.

FUNDING

UK National Institute for Health Research Oxford Health Biomedical Research Centre.

Poor Sleep in Inflammatory Bowel Disease Is Reflective of Distinct Sleep Disorders

BACKGROUND

Poor sleep is common in inflammatory bowel disease (IBD), predicting increased risk of flares, surgery, and/or hospitalization and reducing quality of life.

AIMS

To profile specific sleep disorder symptoms in IBD, informing intervention efforts.

METHODS

312 adults with Crohn's disease or ulcerative colitis were recruited from an academic medical center in New Hampshire, USA. Participants completed online surveys about sleep including well-validated measures of sleep quality, insomnia, restless leg syndrome, sleep apnea, and circadian rhythms. Participants also answered questions about IBD-related problems that could interfere with sleep.

RESULTS

69.4% of participants reported experiencing poor sleep and 50% reported clinically significant insomnia. Participants with active IBD symptoms were more likely to have poor sleep and insomnia. Of those with poor sleep, 67.8% met the clinical threshold for insomnia disorder and 31.3% met criteria for two or more sleep disorders. IBD-related sleep disruptions (e.g., nighttime awakenings due to bowel movements) were not significantly related to poor sleep quality, but significantly related to insomnia severity for participants with active Crohn's disease.

CONCLUSIONS

While poor sleep in IBD is reflective of a number of different sleep problems, it is most frequently related to insomnia. IBD symptom severity contributes to insomnia, but insomnia is also distinct from IBD-related sleep disruptions. Future research on the treatment of insomnia disorder in particular in individuals with IBD is warranted.

Sleep architecture based on sleep depth and propensity: patterns in different demographics and sleep disorders and association with health outcomes

Study Objectives

Conventional metrics of sleep quantity/depth have serious shortcomings. Odds-Ratio-Product (ORP) is a continuous metric of sleep depth ranging from 0 (very deep sleep) to 2.5 (full-wakefulness). We describe an ORP-based approach that provides information on sleep disorders not apparent from traditional metrics.

Methods

We analyzed records from the Sleep-Heart-Health-Study and a study of performance deficit following sleep deprivation. ORP of all 30-second epochs in each PSG and percent of epochs in each decile of ORPs range were calculated. Percentage of epochs in deep sleep (ORP < 0.50) and in full-wakefulness (ORP > 2.25) were each assigned a rank, 1–3, representing first and second digits, respectively, of nine distinct types (“1,1”, “1,2” … ”3,3”). Prevalence of each type in clinical groups and their associations with demographics, sleepiness (Epworth-Sleepiness-Scale, ESS) and quality of life (QOL; Short-Form-Health-Survey-36) were determined.

Results

Three types (“1,1”, “1,2”, “1,3”) were prevalent in OSA and were associated with reduced QOL. Two (“1,3” and “2,3”) were prevalent in insomnia with short-sleep-duration (insomnia-SSD), but only “1,3” was associated with poor sleep depth and reduced QOL, suggesting two phenotypes in insomnia-SSD. ESS was high in types “1,1” and “1,2”, and low in “1,3” and “2,3”. Prevalence of some types increased with age while in others it decreased. Other types were either rare (“1,1” and “3,3”) or high (“2,2”) at all ages.

Conclusions

The proposed ORP histogram offers specific and unique information on the underlying neurophysiological characteristics of sleep disorders not captured by routine metrics, with potential of advancing diagnosis and management of these disorders.

Effectiveness of Digital Cognitive Behavioral Therapy for Insomnia in Young People: Preliminary Findings from Systematic Review and Meta-Analysis

Various forms of cognitive behavioral therapy for insomnia (CBT-i) have been developed to improve its scalability and accessibility for insomnia management in young people, but the efficacy of digitally-delivered cognitive behavioral therapy for insomnia (dCBT-i) remains uncertain. This study systematically reviewed and evaluated the effectiveness of dCBT-i among young individuals with insomnia. We conducted comprehensive searches using four electronic databases (PubMed, Cochrane Library, PsycINFO, and Embase; until October 2021) and examined eligible records. The search strategy comprised the following three main concepts: (1) participants were adolescents or active college students; (2) dCBT-I was employed; (3) standardized tools were used for outcome measurement. Four randomized controlled trials qualified for meta-analysis. A significant improvement in self-reported sleep quality with a medium-to-large effect size after treatment (Hedges’s g = −0.58~−0.80) was noted. However, a limited effect was detected regarding objective sleep quality improvement (total sleep time and sleep efficiency measured using actigraphy). These preliminary findings from the meta-analysis suggest that dCBT-i is a moderately effective treatment in managing insomnia in younger age groups, and CBT-i delivered through the web or a mobile application is an acceptable approach for promoting sleep health in young people.

Sleep Disorders in Acute Stroke

Background

Stroke patients have sleep-wake disorders, mostly in form of insomnia, excessive daytime sleepiness/fatigue, or hypersomnia (increased sleep needs).

Objective

The aim of this study was to analyze types of sleep disorder (SD) and their frequency in patients with sleep apnea and acute stroke in relation to the type of stroke and side of lesion.

Methods

The study analyzed 110 patients with sleep apnea and acute stroke hospitalized in the Clinic of Neurology, University Clinical Centre Tuzla. Acute stroke has been verified either by computerized tomography or magnetic resonance imaging of the brain. SD was verified according to the Berlin Questionnaire Test, The Epworth Sleepiness Scale, The Stanford Sleepiness Scale and the General sleep questionnaire. Strokes were divided by: a) type, into hemorrhagic and ischemic, and b) the localization of the stroke, to right and left cerebral hemispheres.

Results

Of the total number of respondents, all had some sleep disorder. 20% of respondents had severe level of SD, 35.4% moderate, 37.3% moderate- severe and 7.3% mild problems. There were no statistically significant differences in the frequency of SD among patients with ischemic and hemorrhagic stroke (p = 0.58). In relation to the side of lesion, there was more patient with SD and stroke in the both sides, but there were no statistically significant differences (X²=1.98, p=0.161). According Epworth Sleepiness Scale, Stanford Sleepiness Scale and Berlin Questionnaire test snoring was present in 81% and daytime sleepiness in all patients.

Conclusion

SD as a neuropsychological disorder has a significant incidence in the acute phase of stroke in patients with sleep apnea. Sleep disorder is more common in ischemic stroke and stroke in the both hemisphere, but it is not statistically significant difference. Daytime sleepiness, fatigue and snoring are the most common sleep problems in patients with acute stroke and apnea, but it is not statistically significant.

Chronic Sleep Deprivation Blocks Voluntary Morphine Consumption but Not Conditioned Place Preference in Mice

The opioid epidemic remains a significant healthcare problem and is attributable to over 100,000 deaths per year. Poor sleep increases sensitivity to pain, impulsivity, inattention, and negative affect, all of which might perpetuate drug use. Opioid users have disrupted sleep during drug use and withdrawal and report poor sleep as a reason for relapse. However, preclinical studies investigating the relationship between sleep loss and substance use and the associated underlying neurobiological mechanisms of potential interactions are lacking. One of the most common forms of sleep loss in modern society is chronic short sleep (CSS) (<7 h/nightly for adults). Here, we used an established model of CSS to investigate the influence of disrupted sleep on opioid reward in male mice. The CSS paradigm did not increase corticosterone levels or depressive-like behavior after a single sleep deprivation session but did increase expression of Iba1, which typically reflects microglial activation, in the hypothalamus after 4 weeks of CSS. Rested control mice developed a morphine preference in a 2-bottle choice test, while mice exposed to CSS did not develop a morphine preference. Both groups demonstrated morphine conditioned place preference (mCPP), but there were no differences in conditioned preference between rested and CSS mice. Taken together, our results show that recovery sleep after chronic sleep disruption lessens voluntary opioid intake, without impacting conditioned reward associated with morphine.