Discrepancy between wrist-actigraph and polysomnographic measures of sleep in patients with stable heart failure and a novel approach to evaluating discrepancy

Symptom Cluster Profiles Among Adults with Insomnia and Heart Failure

OBJECTIVE/BACKGROUND

Both heart failure (HF) and insomnia are associated with high symptom burden that may be manifested in clustered symptoms. To date, studies of insomnia have focused only on its association with single symptoms. The purposes of this study were to: (1) describe daytime symptom cluster profiles in adults with insomnia and chronic HF; and (2) determine the associations between demographic and clinical characteristics, insomnia and sleep characteristics and membership in symptom cluster profiles.

PARTICIPANTS

One hundred and ninety-five participants [M age 63.0 (SD12.8); 84 (43.1%) male; 148 (75.9%) New York Heart Association Class I/II] from the HeartSleep study (NCT0266038), a randomized controlled trial of the sustained effects of cognitive behavioral therapy for insomnia (CBT-I).

METHODS

We analyzed baseline data, including daytime symptoms (fatigue, pain, anxiety, depression, dyspnea, sleepiness) and insomnia (Insomnia Severity Index), and sleep characteristics (Pittsburgh Sleep Quality Index, wrist actigraphy). We conducted latent class analysis to identify symptom cluster profiles, bivariate associations, and multinomial regression.

RESULTS

We identified three daytime symptom cluster profiles, physical (N = 73 participants; 37.4%), emotional (N = 12; 5.6%), and all-high symptoms (N = 111; 56.4%). Body mass index, beta blockers, and insomnia severity were independently associated with membership in the all-high symptom profile, compared with the other symptom profile groups.

CONCLUSIONS

Higher symptom burden is associated with more severe insomnia in people with stable HF. There is a need to understand whether treatment of insomnia improves symptom burden as reflected in transition from symptom cluster profiles reflecting higher to lower symptom burden.

Prostate Cancer and Sleep Disorders: A Systematic Review

Simple Summary

Longer survival times for prostate cancer patients due to efficient treatments consisting of local radiotherapy, prostatectomy and androgen-deprivation therapy, as well as androgen-receptor-targeted agents, increases the importance of side effect management. Sleep disturbances are higher in this group than the general population and no clear mechanism(s) explains this. This systematic review finds a reported effect in 14 of 16 included studies on sleep quality changes for these patients. All reported treatments showed some kind of negative effect on sleep quality, including ADT. Limitations are discussed and recommendations made for progressing the understanding and then for mitigation strategies of these side effects.

Abstract

Prostate cancer (PCa) treatment involves multiple strategies depending on the disease’s stage. Androgen deprivation therapy (ADT) remains the gold standard for advanced and metastatic stages. Sleep quality has been suggested as being additionally influenced also by local radiotherapy, prostatectomy and androgen-receptor (AR)-targeted agents. We performed a systematic review exploring the landscape of studies published between 1 January 1990 and 31 July 2021, investigating sleep disturbances in PCa patients receiving active treatments, including the influence of hormonal therapy on sleep quality as a factor affecting their quality of life. Out of 45 articles identified, 16 studies were selected, which recruited patients with PCa, undergoing active treatment in either a prospective longitudinal or cross-sectional study. Development of sleep disorders or changes in sleep quality were reported in 14 out of 16 trials included. Only five trials included objective measurements such as actigraphy, mostly at one time point and without a baseline assessment. Limitations to be addressed are the small number of existing trials, lack of randomized trials and heterogeneity of methodologies used. This systematic review outlines the lack of prospective trials investigating sleep disorders, with a rigorous methodology, in homogeneous cohorts of PCa patients. Future trials are needed to clarify the prevalence and impact of this side effect of PCa treatments.

Sleep Outcomes From AWAKE-HF: A Randomized Clinical Trial of Sacubitril/Valsartan vs Enalapril in Patients With Heart Failure and Reduced Ejection Fraction

BACKGROUND

Heart failure and sleep-disordered breathing have been increasingly recognized as co-occurring conditions. Their bidirectional relationship warrants investigation into whether heart failure therapy improves sleep and sleep-disordered breathing. We sought to explore the effect of treatment with sacubitril/valsartan on sleep-related endpoints from the AWAKE-HF study.

METHODS AND RESULTS

AWAKE-HF was a randomized, double-blind study conducted in 23 centers in the United States. Study participants with heart failure with reduced rejection fraction and New York Heart Association class II or III symptoms were randomly assigned to receive treatment with either sacubitril/valsartan or enalapril. All endpoints were assessed at baseline and after 8 weeks of treatment. Portable sleep-monitoring equipment was used to measure the apnea-hypopnea index, including obstructive and central events. Total sleep time, wake after sleep onset and sleep efficiency were exploratory measures assessed using wrist actigraphy.

THE RESULTS WERE AS FOLLOWS

140 patients received treatment in the double-blind phase (sacubitril/valsartan, n = 70; enalapril, n = 70). At baseline, 39% and 40% of patients randomly assigned to receive sacubitril/valsartan or enalapril, respectively, presented with undiagnosed, untreated, moderate-to-severe sleep-disordered breathing (≥ 15 events/h), and nearly all had obstructive sleep apnea. After 8 weeks of treatment, the mean 4% apnea-hypopnea index changed minimally from 16.3/h to 15.2/h in the sacubitril/valsartan group and from 16.8/h to 17.6/h in the enalapril group. Mean total sleep time was long at baseline and decreased only slightly in both treatment groups at week 8 (-14 and -11 minutes for sacubitril/valsartan and enalapril, respectively), with small changes in wake after sleep onset and sleep efficiency in both groups.

CONCLUSIONS

In a cohort of patients with heart failure with reduced rejection fraction who met prescribing guidelines for sacubitril/valsartan, one-third had undiagnosed moderate-to-severe obstructive sleep apnea. The addition of sacubitril/valsartan therapy did not significantly improve sleep-disordered breathing or sleep duration or efficiency. Patients who meet indications for treatment with sacubitril/valsartan should be evaluated for sleep-disordered breathing.

Perceived Stress, Subjective, and Objective Symptoms of Disturbed Sleep in Men and Women with Stable Heart Failure

Objective/Background: Sleep disturbance is prevalent among patients with heart failure (HF) and is associated with increased morbidity and mortality. Stress also affects health and quality of life among patients with cardiovascular disease and likely plays a prominent role in HF. However, little is known about the associations between stress and sleep among HF patients.Participants: One hundred fifty-three stable New York Heart Association (NYHA) Classification I-IV HF patients with at least low symptoms of insomnia (M_age:63.0 ± 12.8, 42% Women).Methods: We examined baseline stress, sleep disturbance, and sleep-related characteristics from a randomized controlled trial of cognitive behavioral therapy for insomnia, including the Perceived Stress Scale, Insomnia Severity Index, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Sleep Disturbance Questionnaire, Dysfunctional Beliefs about Sleep Scale, PROMIS Cognitive Ability, SF-36 Mental Health, and wrist actigraphy. We used Pearson correlations and general linear models to assess stress-sleep associations, including the potential moderating effects of sex and symptom severity (NYHA).Results: There were moderate-to-large correlations between stress and self-reported sleep disturbance, dysfunctional beliefs about sleep, cognitive ability, and mental health (p's < 0.01). High stress was associated with more objectively-measured (i.e., actigraph-assessed) awakenings and sleep fragmentation among women than men (β = - 0.04, p < 0.01; β = - 0.71, p = 0.04). Relationships between stress and objectively-measured sleep did not vary by symptom severity.Conclusions: Perceived stress is related to sleep disturbance among HF patients, and effects may be sex-dependent. Subsequent research should determine the temporal links between sleep and stress, and optimal opportunities for intervention among HF patients.

Rest-activity rhythms, daytime symptoms, and functional performance among people with heart failure

Sleep disturbance and decreased daytime activity are well-described among people with chronic heart failure (HF) who suffer from disabling daytime symptoms and poor function. Alterations in the circadian rhythmicity of rest-activity may also be associated with these outcomes. However, little is known about the associations between rest-activity rhythms (RARS), symptoms, and functional performance or the extent to which they are explained by sleep characteristics among people with HF. The purpose of this study is to evaluate parametric and non-parametric circadian characteristics of RARs and the associations between these variables, daytime symptoms, and functional performance among patients with stable heart failure (HF). We recruited adults with stable HF from HF disease management programs. Participants wore wrist actigraphs for 3 d, completed one night of unattended polysomnography and the Six Minute Walk Test, and reported daytime symptoms and physical function. We performed cosinor, non-parametric, and spectral analyses to evaluate the rest-activity rhythms and computed bivariate correlations between the rest-activity rhythm, demographics, daytime symptoms, and functional performance. We conducted multiple regression analysis to examine how RARs contribute to daytime symptoms and functional performance after controlling for insomnia and covariates. The sample included 135 participants [Mean age = 60.6 (16.1) y, n = 88 (65.2%) male]. Older age, greater comorbidity, and poorer New York Heart Association (NYHA) Class, and more EEG arousals were associated with greater intra-daily variability of the RAR. More robust rhythmicity represented by the circadian quotient was associated with better NYHA class and less sleep fragmentation. A higher circadian quotient was significantly associated with lower fatigue, depression, and sleepiness, and better functional performance after controlling for insomnia and clinical and demographic characteristics. Circadian parameters of rest-activity are associated with symptoms and functional performance among people with HF independent of insomnia or sleep disordered breathing. Interventions targeted at improving the stability and strength of rest-activity rhythms may improve symptom and functional outcomes for these patients.

Ways of knowing in precision health

Precision health can provide an avenue to bridge and integrate ways of knowing for research and practice. Nurse scientists have a long-standing interest in using multiple sources of information to address research questions of significance to the profession and discipline of nursing, which can lead to much needed contributions to precision health care. In this paper, nursing scientists discuss emerging research methods including omics, electronic sensors, and geospatial data, and mixed methods that further develop nursing science and contribute to precision health initiatives. The authors provide exemplars of the types of knowledge and ways of knowing that, using these and other advanced data and analytic strategies, may advance precision health within the context of nursing science.

Challenging Circadian Rhythm Disorder Cases

The complex interplay of the sleep and circadian systems, which are substantially differentially regulated, provides for plasticity that is expressed in health and disease. The classic circadian rhythm disorders are readily recognizable, but atypical forms can be identified by actigraphy and melatonin profilometry. Although the dim-light melatonin onset test maps the start of the biological night, 24-hour mapping can define the limits of the biological night, whereas other forms of strategic testing can identify conditions such as iatrogenic hypermelatoninemia. Routine testing in clinical practice can expand the range of identifiable circadian rhythm disorders.

Agreement between actigraphic and polysomnographic measures of sleep in adults with and without chronic conditions: A systematic review and meta-analysis

Wrist actigraphy (ACT) may overestimate sleep and underestimate wake, and the agreement may be lower in people with chronic conditions who often have poor sleep and low activity levels. The purpose of this systematic review is to compare the agreement between ACT and polysomnographic (PSG) measures of sleep in adults without chronic conditions and sleep complaints (healthy) and with chronic conditions. We conducted a systematic review and meta-analysis using PRISMA guidelines. We searched PubMed, OVIDEMBASE, OVIDMEDLINE, OVIDPsycINFO, CENTRAL, CINAHL, ClinicalTrials.gov, International Clinical Trials Registry, and Open Grey. We included 96 studies with a total of 4134 participants, of whom 762 (18.4) were healthy adults and 724 (17.5%) were adults with chronic conditions. Among adults with chronic conditions, ACT overestimated TST, compared to PSG [M = 22.42 min (CI 95%: 11.92, 32.91 min)] and SE [M = 5.21% (CI 95%: 1.41%-9.00%)]. ACT underestimated SOL [M = -7.70 min (CI 95%: -15.22, -0.18 min)], and WASO [M = -10.90 min (CI 95%: -26.01, 4.22 min)]. These differences were consistently larger between ACT and PSG sleep measures compared to healthy adults. Research is needed to better understand factors that influence the agreement between ACT and PSG among people with chronic conditions.