Patterns of sleep quality during and after postacute rehabilitation in older adults: a latent class analysis approach

Sleep Quality Should Be Assessed in Inpatient Rehabilitation Settings: A Preliminary Study

OBJECTIVES

In this preliminary, longitudinal study, our objective was to assess changes in sleep quality during an inpatient stay in a rehabilitation setting in the United States and to relate changes to patients' demographic and clinical characteristics (i.e., age, gender, BMI, ethnicity, reason for hospitalization, pre-hospital living setting, prior diagnosis of sleep disorders, and mental health status).

METHODS

A total of 35 patients participated in this preliminary study (age = 61 ± 16 years old, 50% <65; BMI = 30 ± 7 kg/m²; 51% female; 51% Caucasian). The average length of hospitalization was 18 ± 8 days. Reasons for hospitalization included orthopedic-related issues (28%), spinal cord injury (28%), stroke (20%), and other (23%). In this sample, 23% had prior sleep disorders (mostly sleep apnea), and 60% came from an acute care unit. Patients' sleep quality was assessed using the Pittsburgh sleep quality index (PSQI) at admission and before discharge. Demographic and medical data were collected. Patients' mental health status was also assessed at the same intervals. Nighttime sound levels and the average number of sleep disturbances were also collected throughout the study (6 months).

RESULTS

Our data revealed that most patients had poor sleep (PSQI > 5) at admission (86%) and discharge (80%). Using a repeated ANOVA, a significant interaction was obtained between sleep quality and the presence of a diagnosed sleep disorder [F (1, 33) = 12.861, p = 0.001, η²_p = 0.280]. The sleep quality of patients with sleep disorders improved over their stay, while the sleep of patients without such disorders did not. The mean nighttime sound collection level averages and peaks were 62.3 ± 5.1 dB and 86.1 ± 4.9 dB, respectively, and the average number of sleep disturbances was 2.6 ± 1.1.

CONCLUSION

The improved sleep observed in patients with vs. without sleep disorders might be related to the care received for treating such disorders over the stay. Our findings call for the better detection and management of poor sleep in acute inpatient rehabilitation settings. Furthermore, if our findings are replicated in the future, studies on the implementation of quiet times for medical staff, patients, and family should be performed to improve sleep quality in the inpatient rehabilitation setting.

Sleep in Normal Aging, Homeostatic and Circadian Regulation and Vulnerability to Sleep Deprivation

In the context of geriatric research, a growing body of evidence links normal age-related changes in sleep with many adverse health outcomes, especially a decline in cognition in older adults. The most important sleep alterations that continue to worsen after 60 years involve sleep timing, (especially early wake time, phase advance), sleep maintenance (continuity of sleep interrupted by numerous awakenings) and reduced amount of sigma activity (during non-rapid eye movement (NREM) sleep) associated with modifications of sleep spindle characteristics (density, amplitude, frequency) and spindle-Slow Wave coupling. After 60 years, there is a very clear gender-dependent deterioration in sleep. Even if there are degradations of sleep after 60 years, daytime wake level and especially daytime sleepiness is not modified with age. On the other hand, under sleep deprivation condition, older adults show smaller cognitive impairments than younger adults, suggesting an age-related lower vulnerability to extended wakefulness. These sleep and cognitive age-related modifications would be due to a reduced homeostatic drive and consequently a reduced sleep need, an attenuation of circadian drive (reduction of sleep forbidden zone in late afternoon and wake forbidden zone in early morning), a modification of the interaction of the circadian and homeostatic processes and/or an alteration of subcortical structures involved in generation of circadian and homeostatic drive, or connections to the cerebral cortex with age. The modifications and interactions of these two processes with age are still uncertain, and still require further investigation. The understanding of the respective contribution of circadian and homeostatic processes in the regulation of neurobehavioral function with aging present a challenge for improving health, management of cognitive decline and potential early chronobiological or sleep-wake interventions.

Priority-Setting to Address the Geriatric Pharmacoparadox for Pain Management: A Nursing Home Stakeholder Delphi Study

BACKGROUND

Evidence to guide clinical decision making for pain management in nursing home residents is scant.

OBJECTIVE

Our objective was to explore the extent of consensus among expert stakeholders regarding what analgesic issues should be prioritized for comparative-effectiveness studies of beneficial and adverse effects of analgesic regimens in nursing home residents.

METHODS

Two stakeholder panels (nurses only and a mix of clinicians/researchers) were engaged (n = 83). During a three-round online modified Delphi process, participants rated and commented on the need for new evidence on nonopioid analgesic regimens and opioid regimens, short-term adverse effects, long-term adverse effects, comorbid conditions, and other factors in the nursing home setting (9-point scale; 1 = not essential to 9 = very essential to obtain new evidence). The quantitative data were analyzed to determine the existence of consensus using an approach from the RAND/UCLA Appropriateness Method User's Manual. The qualitative data, consisting of participant explanations of their numeric ratings, were thematically analyzed by an experienced qualitative researcher.

RESULTS

For nursing home residents, evidence generation was deemed essential for opioids, gabapentin (alone or with serotonin norepinephrine reuptake inhibitors [SNRIs]), and nonsteroid anti-inflammatory drugs with SNRIs. Experts prioritized the following outcomes as essential: long-term adverse effects, including delirium, cognitive decline, and decline in activities of daily living (ADLs). Kidney disease and depression were deemed essential conditions to consider in studies of pain medications. Coprescribing analgesic regimens with benzodiazepines, sedating medications, serotonergic medications, and non-SNRI antidepressants were considered essential areas of study. Experts noted that additional study was essential in residents with moderate/severe cognitive impairment and limitations in ADLs.

CONCLUSIONS

Stakeholder priorities for more evidence reflect concerns related to treating medically complex residents with complex drug regimens and included long-term adverse effects, coprescribing, and sedating medications. Carefully conducted observational studies are needed to address the vast evidence gap for nursing home residents.

Gender and Age Differences in Sleep Problems in Children: Person-Oriented Approach With Multigroup Analysis

OBJECTIVE/BACKGROUND

This study aimed to identify subtypes of sleep problems in children and to examine whether these patterns differed between gender and age groups.

PARTICIPANTS

There were 3,052 children (951 elementary school boys, 943 elementary school girls, 603 junior high school boys, and 555 junior high school girls) aged 7-16 years from two school-based epidemiological samples.

METHODS

Sleep problems were measured by the Sleep Habit Questionnaire based on parent reports.

RESULTS

Using the latent class modeling, a person-oriented approach, with a multigroup analysis, we identified four classes of sleep problems: moderate to high sleep problems (1.1%-3.1%), sleep-related breathing problems and parasomnias dominant (14.9%-21.1%), insomnias dominant and parasomnias (1.0%-3.1%), and no or low sleep problems (74.7%-81.4%), with varied prevalence rates of sleep problems across gender and age groups.

CONCLUSIONS

This study identified four classes of sleep problems across gender and age groups but with different prevalence rates of sleep problems, suggesting the complex interaction of gender and age in the subtypes of sleep problems. The gender- and age-specific interventions for sleep problems are suggested. Future studies are warranted to replicate these classes and to identify associated factors with each class.

Heterogeneity of sleep quality in relation to circadian preferences and depressive symptomatology among major depressive patients

BACKGROUND

The current study aimed at investigating the latent dimensional structure of sleep quality as indexed by the seven components of the Pittsburgh Sleep Quality Index (PSQI), as well as latent covariance structure between sleep quality, circadian preferences and depressive symptoms.

METHODS

Two hundred twenty-five patients with major depressive disorder (MDD), with an average age of 29.92 ± 10.49 years (aged between 17 and 63), participated in the study. The PSQI, Morningness-Eveningness Questionnaire (MEQ) and Beck Depression Inventory (BDI) were administered to participants. Four sets of latent class analyses were subsequently run to obtain optimal number of latent classes best fit to the data.

RESULTS

Mixture models revealed that sleep quality is multifaceted in MDD. The data best fit to four-latent-class model: Poor Habitual Sleep Quality (PHSQ), Poor Subjective Sleep Quality (PSSQ), Intermediate Sleep Quality (ISQ), and Good Sleep Quality (GSQ). MDD patients classified into GSQ latent class (23.6%) reported the lowest depressive symptoms and were more prone to morningness diurnal preferences compared to other three homogenous sub-groups. Finally, the significant association between eveningness diurnal preferences and depressive symptomatology was significantly mediated by poor sleep quality.

LIMITATION

The cross-sectional nature of the study and the lack of an objective measurement of sleep such as polysomnography recordings was the most striking limitation of the study.

CONCLUSIONS

We concluded sleep quality in relation to circadian preferences and depressive symptoms has a heterogeneous nature in MDD.

Transitions in sleep problems from late adolescence to young adulthood: A longitudinal analysis of the effects of peer victimization

Adolescence is a developmental period with high vulnerability to sleep problems. However, research identifying distinct patterns and underlying determinants of sleep problems is scarce. This study investigated discrete subgroups of, changes in, and stability of sleep problems. We also examined whether peer victimization influenced sleep problem subgroups and transitions in patterns of sleep problems from late adolescence to young adulthood. Sex differences in the effects of peer victimization were also explored. In total, 1,455 male and 1,399 female adolescents from northern Taiwan participated in this longitudinal study. Latent transition analysis was used to examine changes in patterns of sleep problems and the effects of peer victimization on these changes. We identified three subgroups of sleep problems in males and two in females, and found that there was a certain level of instability in patterns of sleep problems during the study period. For both sexes, those with greater increases in peer victimization over time were more likely to change from being a good sleeper to a poor sleeper. The effects of peer victimization on baseline status of sleep problems, however, was only significant for males, with those exposed to higher levels of peer victimization more likely to be poor sleepers at baseline. Our findings reveal an important role of peer victimization in predicting transitions in patterns of sleep problems. Intervention programs aimed at decreasing peer victimization may help reduce the development and escalation of sleep problems among adolescents, especially in males.

Patterns and predictors of sleep quality before, during, and after hospitalization in older adults

STUDY OBJECTIVES

The impact of hospitalization on sleep in late-life is underexplored. The current study examined patterns of sleep quality before, during, and following hospitalization, investigated predictors of sleep quality patterns, and examined predictors of classification discordance between two suggested clinical cutoffs used to demarcate poor/good sleep.

METHODS

This study included older adults (n = 163; mean age 79.7 ± 6.9 years, 31% female) undergoing inpatient post-acute rehabilitation. Upon admission to inpatient post-acute rehabilitation, patients completed the Pittsburgh Sleep Quality Index (PSQI) retrospectively regarding their sleep prior to hospitalization. They subsequently completed the PSQI at discharge, and 3 months, 6 months, 9 months, and 1 year post discharge. Patient demographic and clinical characteristics (pain, depression, cognition, comorbidity) were collected upon admission.

RESULTS

Using latent class analysis methods, older adults could be classified into (1) Consistently Good Sleepers and (2) Chronically Poor Sleepers based on patterns of self-reported sleep quality pre-illness, during, and up to 1 year following inpatient rehabilitation. This pattern was maintained regardless of the clinical cutoff employed (> 5 or > 8). Logistic regression analyses indicated that higher pain and depressive symptoms were consistently associated with an increased likelihood of being classified as a chronic poor sleeper. While there was substantial classification discordance based on clinical cutoff employed, no significant predictors of this discordance emerged.

CONCLUSIONS

Clinicians should exercise caution in assessing sleep quality in inpatient settings. Alterations in the cutoffs employed may result in discordant clinical classifications of older adults. Pain and depression warrant detailed considerations when working with older adults on inpatient units when poor sleep is a concern.