Insomnia severity and its relationship with demographics, pain features, anxiety, and depression in older adults with and without pain: cross-sectional population-based results from the PainS65+ cohort

Risk of Sleep Problems in Middle-Aged and Older Adults Experiencing Bodily Pains: Serial Multiple Mediation Estimates of Emotional Distress and Activity Limitations

OBJECTIVES

Pain is increasingly becoming common among middle-aged and older adults. While research on the association between pain characteristics and sleep problems (SP) is limited in low- and middle-income countries, the underlying mechanisms of the association are poorly understood. This study examines the association of bodily pain intensity and pain interference with SP and investigates the mediating role of activity limitation and emotional distress in this association.

METHODS

We analyzed population-based data, including 1,201 individuals aged ≥50 (mean [SD] age 66.14 [11.85] years) from the 2016-2018 AgeHeaPsyWel-HeaSeeB study in Ghana. Multiple OLS regressions and serial multiple mediation modeling using bootstrapping analyses examined direct and indirect effects from pain to SP through activity limitation and emotional distress.

RESULTS

Regressions demonstrated that pain intensity and interference were significantly associated with higher levels of activity limitation, emotional distress, and SP (range: β = 0.049-0.658). Bootstrapping analysis showed that activity limitation and emotional distress serially mediated the relationship between pain intensity and SP (total effect: β = 0.264, Bootstrap 95% confidence interval [CI] = 0.165-0.362; direct effect: (β = 0.107, Bootstrap 95% CI = 0.005-0.210; total indirect effect: β = 0.156, Bootstrap 95% CI = 0.005-0.210) accounting for ∼59%. Activity limitation and emotional distress mediated pain interference and SP association (total effect: β = 0.404, Bootstrap 95% CI = 0.318-0.490; direct effect: β = 0.292, Bootstrap 95% CI = 0.201-0.384; and total indirect effect: β = 0.112, Bootstrap 95% CI = 0.069-0.156) yielding ∼28%.

CONCLUSION

Our data suggest that activity limitation and emotional distress may convey stress-related risks of pain on SP. Future research should evaluate if activity limitation and emotional distress could be effective targets to reduce the effect of pain on sleep in later-life.

Worldwide prevalence of sleep problems in community-dwelling older adults: A systematic review and meta-analysis

The understanding of the prevalence of sleep problems in older adults can provide a broad and reliable perspective into the occurrence of such issues among older adults. This systematic review and meta-analysis aimed to estimate the worldwide prevalence of sleep problems in community-dwelling older adults. Studies that provide information on the prevalence of sleep problems in community-dwelling older adults (≥60 years) were screened between December 2022 and March 2023. A total of 20,379 studies were identified in database searches, from which 252 were included in this review. These studies covered the last 35 years (from 1988 to 2023) and pooled a sample of 995,544 participants from 36 countries. The most frequent sleep problem worldwide was obstructive sleep apnea (46.0%), followed by poor sleep quality (40.0%), other sleep problems (37.0%), insomnia (29.0%), and excessive daytime sleepiness (19.0%). No significant difference in the prevalence estimates of all sleep problems was observed between the sexes. This systematic review and meta-analysis showed a high prevalence of some sleep problems, mainly obstructive sleep apnea, poor sleep quality, and other sleep problems. Our estimates can be useful for managers and policymakers in planning healthcare strategies for sleep problems aimed at the older population.

Insomnia symptoms and related factors in a community-based population: The Yamagata Cohort study

Objective/background

Insomnia is prevalent and is a risk factor for the development of lifestyle-related diseases and early death. To improve insomnia, it is necessary to identify the factors that affect it. This study investigated the associations between insomnia symptoms and mental, physical, and environmental factors in the general Japanese population.

Patients/methods

The study participants were 7,873 individuals who responded to the Health and Lifestyle Survey questionnaire that included sleep-related items between December 2021 and March 2022. Insomnia symptoms were defined as a score of 6 or higher on the Athens Insomnia Scale (AIS). A multivariate logistic regression analysis was performed to identify factors independently associated with insomnia symptoms.

Results

Of all subjects, 23.4% had insomnia symptoms. Factors associated with insomnia symptoms were older age, female sex, very difficult living conditions on current income, pain/discomfort, anxiety, lack of happiness, frequent nocturia, long duration from bathing time to bedtime, bedroom lighting, and short walking duration. The subgroup analysis showed stronger associations between walking time in men, higher body mass index in women, time from bathing time to bedtime, and daily walking duration in older adults.

Conclusions

Insomnia symptoms were common in community-based populations and were independently associated with three different factor groups including physical, psychological, and environmental factors. Improvements in insomnia symptoms require appropriate practical support tailored to an individual's situation.

Prevalence and Risk of Behavioral Symptoms among Patients with Insomnia and Alzheimer's Disease: A Retrospective Database Analysis

OBJECTIVES

This study evaluated the prevalence and patterns of behavioral symptoms, including agitation/aggression (AA), psychotic symptoms (PS), anxiety/mood disorders (MD), and delirium among patients with Alzheimer's disease (AD) and their association with diagnosed insomnia.

DESIGN

A retrospective cohort analysis was conducted using the MarketScan Multi-State Medicaid Database 2016-2020.

SETTING AND PARTICIPANTS

Patients aged ≥50 with newly diagnosed AD (N = 56,904) were identified during 2017-2019 and categorized into insomnia and non-insomnia groups based on billing codes recorded in medical and pharmacy claims.

METHODS

The index date was defined as the earliest date of diagnosis/medication of insomnia. The new diagnosis of AD had to be established within 12 months before (baseline) or 3 months after the index date. Point prevalence of behavioral symptoms was estimated during baseline and the 12-month follow-up period. Propensity score matching was performed to match patients with and without insomnia. Multivariable conditional logistic regression was used to assess the risk of diagnosis of behavioral symptoms among insomnia and non-insomnia groups.

RESULTS

The study cohort included 7808 patients with newly diagnosed AD (mean age = 79.4, SD = 9.6 years). The point prevalence of behavioral symptoms was as follows: among those with insomnia (n = 3904), in the baseline, AA = 9.0%, PS = 12.5%, and MD = 57.8%, and during the follow-up, AA = 13.9%, PS = 16.3%, and MD = 72.1%; among those without insomnia (n = 3904), in the baseline, AA = 6.2%, PS = 9.2%, and MD = 41.4%; and during the follow-up, AA = 7.4%, PS = 10.4%, and MD = 49.2%. The likelihood of being diagnosed with any behavioral symptoms in the follow-up period was significantly higher among patients with insomnia than those without [adjusted odds ratio (OR), 2.7; 95% confidence interval (CI), 2.4-3.1].

CONCLUSIONS AND IMPLICATIONS

In patients with AD, prevalence of behavioral symptoms and likelihood of being diagnosed with behavioral symptoms were significantly higher among patients with diagnosed insomnia. Further investigation is needed to understand the relationship between insomnia and behavioral symptoms in patients with AD.

Insomnia symptoms among older adults during the first year of the COVID-19 pandemic: A longitudinal study

OBJECTIVE

To identify sociodemographic, psychological, and health factors related to trajectories of insomnia symptoms in older adults during the COVID-19 pandemic.

METHODS

From May 2020 to May 2021, 644 older adults (mean age = 78.73, SD = 5.60) completed telephone-administered self-reported measures (ie, Insomnia Severity Index, consensus sleep diaries, UCLA Loneliness Scale, Kessler Psychological Distress Scale, Post-Traumatic Checklist, perceived health threat, and International Physical Activity Questionnaire) and provided sociodemographic data at 4 timepoints. Using the Insomnia Severity Index score at each timepoint, group-based trajectory modeling was conducted to identify groups with distinct insomnia trajectories.

RESULTS

On average, there was no significant change in insomnia symptoms over time. Three groups with distinct sleep trajectories were identified: clinical (11.8%), subthreshold (25.3%), and good sleepers (62.9%). Older adults who were younger, male, had elevated psychological distress and posttraumatic stress disorder symptoms, perceived more SARS-CoV-2 health threat, spent more time in bed, and had shorter sleep duration during the first wave of the pandemic were more likely to belong to the clinical than to the good sleepers group. Those who were younger, female, had elevated psychological distress and PTSD symptoms, greater loneliness, spent more time in bed, and had reduced sleep duration during the first wave were more likely to belong to the subthreshold than to the good sleepers group.

CONCLUSIONS

Over 1 in 3 older adults experienced persistent subthreshold or clinically significant insomnia symptoms. Both sleep-related behaviors as well as general and COVID-19-related psychological factors were associated with insomnia trajectories.

A correlational study on pain and depression in geriatric patients scheduled for orthopaedic surgery

AIM

Pain is prevalent in geriatric patients and is not only a signal of physical diseases but also a symptom of mental health problems. This study aimed to explore the relationship between pain and depression in geriatric patients scheduled for orthopaedic surgery.

METHODS

The study used a correlational and cross-sectional design. The study sample consisted of geriatric patients (n = 200) scheduled for orthopaedic surgery in a research and training hospital in northern Turkey. Data were collected by the researchers using the Geriatric Pain Measure and Geriatric Depression Scale. In the data analysis, descriptive statistics, Pearson's correlation, and hierarchical regression analysis were used.

RESULTS

The patients' mean age was 73.16 ± 8.27 years. It was found that 5.5% (n = 11) of the participants had mild pain, 45.5% (n = 91) had moderate pain, and 49% (n = 98) had severe pain. There was a positive and moderate significant relationship between the mean Geriatric Pain Measure and Geriatric Depression Scale scores (r = 0.479, P < 0.01). Age (β = 0.133; P < 0.05) and education (β = 2.484; P < 0.05) were statistically significantly associated with depression. There was a significant and positive relationship between depression and being dependent in activities of daily living (β = 5.098; P < 0.05).

CONCLUSION

This study demonstrated that geriatric patients who were older, illiterate, dependent in activities of daily living, and with higher levels of pain had higher depression. A multidisciplinary team approach including nurses should be utilised in pain management and it should not be ignored that severe pain may be associated with depression in geriatric patients.

Stigma and Chronic Pain

Stigma is defined by the World Health Organization (WHO) as "a mark of shame, disgrace or disapproval that results in an individual being rejected, discriminated against and excluded from participating in a number of different areas of society". Extensive literature searches have documented stigma in the context of health. Among the physical health conditions that are associated with stigma, chronic pain deserves particular attention. Stigma experienced by individuals with chronic pain affects their entire life. Literature identifies multiple dimensions or types of stigma, including public stigma, structural stigma and internalized stigma. Recent literature supports the biopsychosocial model of pain, according to which biological, psychological and sociocultural variables interact in a dynamic manner to shape an individual's response to chronic pain. Chronic pain affects a higher proportion of women than men around the world. There is an inadequate education of health care professionals regarding pain assessment and their insecurity to manage patients with chronic pain. A first-line intervention strategy could be to promote pain education and to expand knowledge and assessment of chronic pain, as recently highlighted for headache disorders, paradigmatically for resistant or refractory migraine, whose diagnosis, without an adequate education to understand the possible fluctuations of the disease, may have profound psychological implications with the idea of insolvability and contribute to stigmatizing the patient.

Depression, Anxiety, Insomnia, and Quality of Life in a Representative Community Sample of Older Adults Living at Home

Background

The aim of the study was to explore symptoms of anxiety and depression, insomnia, and quality of life in a Norwegian community sample of older adults.

Methods

A representative sample (N = 1069) was drawn from home-dwelling people of 60 years and above, living in a large municipality in Norway (Trondheim).

Results

Based on established cut-off scores, 83.7% of the participants showed no symptoms of anxiety/depression, 12% had mild symptoms, 2.7% moderate symptoms, 1.5% showed severe symptoms of anxiety/depression. A total of 18.4% reported insomnia symptoms. Regarding health-related quality of life, few participants reported problems with self-care, but pain and discomfort were common (59%). Depression/anxiety, insomnia, and health-related quality of life showed moderate to strong associations.

Discussion

The results suggest a close interplay between anxiety/depression, insomnia, and health-related quality of life in older adults.

Acupuncture combined with traditional Chinese medicine e-aid cognitive behavioral therapy for insomnia (TCM-eCBT-I) for chronic insomnia: study protocol for a randomized controlled trial

INTRODUCTION

The incidence of insomnia is getting higher and higher. Long-term insomnia seriously affects people's health. Drug use is usually accompanied with adverse events. Both acupuncture and cognitive behavioral therapy for insomnia (CBT-I) have been proven to be safe and effective non-pharmacological treatments for insomnia. As the insomniacs' bad sleep behavior and wrong cognition have not been effectively corrected, acupuncture has a quick effect, high patient compliance but unstable long-term efficacy, while CBT-I is complex, time-consuming, and expensive; additionally, patient compliance is low, and the number of trained therapists is limited, making it difficult to carry out. Therefore, this study aims to use the insomnia TCM system to construct a convenient and feasible traditional Chinese medicine e-aid cognitive behavioral therapy for insomnia (TCM-eCBT-I) for Chinese people, and combine the advantages of acupuncture and TCM-eCBT-I for maintaining long-term efficacy, and three treatments will be evaluated to provide clinicians with a more effective clinical protocol METHODS AND ANALYSIS: This study is a single-center, open-label, randomized controlled trial. Ninety subjects will be recruited and randomly assigned to three groups: the acupuncture group, the TCM-eCBT-I group, and the acupuncture combined with TCM-eCBT-I group, in a ratio of 1:1:1. We will evaluate the Pittsburgh Sleep Quality Index (PSQI) and Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS), Insomnia Severity Index (ISI), sleep diary, Hamilton Anxiety Scale (HAMA), Hamilton Depression Scale (HAMD), and Fatigue Scale-14 Scale (FS-14) scales. All adverse reactions will be assessed through the ADVERSE event table. All outcomes will be evaluated online at 0 weeks, 4 weeks, 8 weeks, 16 weeks, and 28weeks.

ETHICS AND DISSEMINATION

This study has been approved by the Institutional Review Board of the Affiliated Hospital of Nanjing University of Chinese Medicine (2020 NL-018-02). Informed consent will be obtained from all the subjects. The results will be shared with sleep researchers, public, and relevant academic institutions through high-impact peer-reviewed publications.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2000032960. Registered on 17 May 2020.

How Elderly People's Quality of Life Relates to Their Sleep Quality and Sleep-Related Beliefs

OBJECTIVE/BACKGROUND

Quality of life (QoL) is a broad multidimensional construct, which can be influenced by several factors across the lifespan, including sleep quality. The aim of this study was to examine the association between QoL (and its specific domains), objective and self-reported sleep quality, and subjective sleep-related factors (i.e., dysfunctional beliefs and attitudes about sleep, and metacognitive beliefs about sleeping difficulties) in healthy elderly people.

PARTICIPANTS

Fifty healthy older adults (mean age = 70.40 years, SD = 7.43) participated in the study.

METHODS

QoL was assessed using the World Health Organization's Quality of Life Assessment, BREF version (WHOQOL-BREF). Self-reported sleep quality and efficiency were measured with the Pittsburgh Sleep Quality Index (PSQI) and sleep diary. Dysfunctional beliefs and attitudes about sleep (DBAS), and metacognitive beliefs about sleeping difficulties (MCQ-I) (subjective sleep-related factors) were assessed with self-report questionnaires. Objective sleep quality and efficiency were measured using actigraphy over 7 days.

RESULTS

Regression analyses showed that self-reported sleep efficiency and dysfunctional beliefs and attitudes about sleep explained 24% of the variance in global QoL. Dysfunctional beliefs and attitudes about sleep were the only significant predictor of QoL in the environmental domain.

CONCLUSIONS

Taken together, these findings underscore the influence of sleep-related factors, and particularly dysfunctional beliefs and attitudes about sleep, along with sleep efficiency, on the perception of QoL in healthy older adults. These factors need to be considered in efforts to sustain QoL, in late adulthood at least.

Subjective Sleep Disruption and Mood Disorders are Associated with the Risk of Chronic Pain in Patients with Obstructive Sleep Apnea

OBJECTIVE

This study aimed to determine the prevalence of chronic pain and its risk factors in patients with obstructive sleep apnea (OSA).

METHODS

A total of 145 patients diagnosed with OSA were consecutively recruited from the Sleep Medicine Center in West China Hospital. All patients were divided into two groups including OSA with and without chronic pain. They were assessed the subjective sleep (Pittsburgh Sleep Quality Index, Insomnia Severity Index), objective sleep (polysomnography), mood symptoms (Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale), and pain characteristics (Short-Form McGill Pain Questionnaire). Demographic, clinical, subjective and objective sleep parameters were compared between OSA patients with and without chronic pain. Binary logistic regression models and linear regression models were used to examine the risk factors of chronic pain in OSA.

RESULTS

Fifty-five (37.9%) patients with OSA were diagnosed with chronic pain. There were more severe subjective sleep disruption and symptoms of anxiety and depression in patients with chronic pain compared to those without chronic pain. After controlling for potential confounders, poor subjective sleep quality and severe insomnia and mood disorders (all ps < 0.05), but not objective sleep fragmentation or nocturnal hypoxemia (all ps > 0.05) were associated with the increased risk of pain and pain intensity, respectively.

CONCLUSION

More than one-third of patients with OSA had chronic pain. Subjective sleep disruption and mood disorders are the risk factors of chronic pain in OSA. Our findings suggest that subjective sleep quality should be valued highly in the relationship between OSA and pain.

Correlates of sleep disturbance in Veterans with traumatic brain injury and chronic pain: A cross-sectional study

BACKGROUND

Few studies have investigated sleep in Veterans with comorbid traumatic brain injury (TBI) and chronic pain.

OBJECTIVE

To describe mood and cognitive correlates with sleep disturbance in a sample of Veterans with both TBI and chronic pain.

RESEARCH METHOD

Cross-sectional, correlational analyses were completed using baseline data from a randomized controlled trial comparing psychosocial treatments for pain in Veterans with TBI. Enrollment occurred between July 2015 and January 2017. Self-report measures of hours slept, insomnia severity, depression and PTSD symptoms were collected along with a brief neuropsychological assessment.

RESULTS

Participants (n = 221) were an average age of 37.2 years (SD = 8.2) and mostly male (89%). Participants reported sleeping an average of 4.9 h a night (SD = 1.4) with an average Insomnia Severity Index (ISI) score of 17.4 (SD = 5.4) suggesting moderate insomnia symptoms. Fewer hours slept was associated with higher depression scores (r = -0.28, p < 0.001) and slower processing speed (r = 0.23, p < 0.001). Increasing insomnia severity was associated with greater depression (r = 0.57, p < 0.001) and PTSD symptoms (r = 0.44, p < 0.001), and slower processing speed (r = -0.22, p < 0.001).

CONCLUSIONS

The average ISI score was above the clinical cut off for insomnia diagnosis. Results suggest that those with more severe insomnia symptoms report higher depression and PTSD symptoms as well as exhibit slower processing speed. Improving sleep in this population may be important for improving outcome following TBI.

Incremental Healthcare Utilization and Cost Burden of Comorbid Insomnia in Alzheimer's Disease Patients

BACKGROUND

Insomnia is associated with worsened clinical outcomes among Alzheimer's disease dementia (AD) patients, increased caregiver burden, and healthcare utilization.

OBJECTIVE

This study aimed to characterize the incremental healthcare burden of insomnia in AD using real-world data.

METHODS

A retrospective observational study was conducted on AD patients selected from the IBM® MarketScan Commercial and Medicare Supplemental Databases. AD patients with claims-based evidence of insomnia were direct matched to a non-insomnia cohort based on demographic factors. Healthcare utilization and associated costs were assessed for a 12-month follow-up period.

RESULTS

A total of 3,500 insomnia AD patients and 9,884 non-insomnia AD patients were analyzed. The insomnia cohort had a higher comorbidity burden at baseline (mean score on Charlson Comorbidity Index 2.5 versus 2.2, p < 0.001) and higher proportions of patients with baseline diagnoses for other conditions including depression: 40%, insomnia cohort versus 25%, non-insomnia (p < 0.001). AD patients with insomnia were more likely to have a claim for inpatient hospitalizations (39.8%versus 32.3%), emergency room services (56.4%versus 48.0%), and skilled-nursing services (42.6%versus 31.9%) (all p < 0.05). Mean total annual healthcare costs during the 12-month follow-up period were significantly higher among AD patients with insomnia as compared to those without. (Mean costs: $37,356 versus $27,990, p < 0.001).

CONCLUSION

AD patients with comorbid insomnia are more likely to use higher-cost healthcare services such as inpatient hospitalization, and skilled nursing, and have higher total healthcare costs. This real-world analysis provides evidence that AD disease management should consider proper treatment of comorbid insomnia due to the incremental burden and cost implications.

Assessment of sleep problems with the Insomnia Severity Index (ISI) and the sleep item of the Patient Health Questionnaire (PHQ-9) in cancer patients

Objective

The objectives of this study were to examine sleep problems in cancer patients, to test the psychometric properties of the Insomnia Sleep Index (ISI) in comparison with the sleep item of the Patient Health Questionnaire-9 (PHQ-9), and to analyze disrupting factors which might cause the sleep problems.

Methods

A sample of 1026 mixed-site cancer patients in treatment at a German oncological rehabilitation clinic was examined.

Results

The reliability of the ISI was very good (Cronbach’s alpha = 0.92), and the results of the confirmatory factor analysis were acceptable. Females reported worse sleep quality (ISI mean: 13.7 ± 6.6) than males (10.7 ± 6.4). Sleep problems as measured with the PHQ-9 sleep item were markedly higher than those in the general population (effect size d = 1.15).

Patients reported that, of the factors that disrupted their sleep, psychological factors (brooding, worries) were more relevant than symptom factors (pain, nocturnal urination, or restless legs).

Conclusions

The ISI is effective in detecting sleep problems in cancer patients. Normative studies with the ISI would be helpful for assessing ISI mean scores. Sex differences should be taken into account when groups of patients are compared. The sleep item of the PHQ-9 can be used in epidemiological studies.

Cognitive behavioral therapy for insomnia in patients with chronic pain - A systematic review and meta-analysis of randomized controlled trials

Several randomized controlled trials have implemented cognitive behavioral therapy for insomnia (CBT-I) for patients with comorbid insomnia and chronic pain. This systematic review and meta-analysis investigated the effectiveness of CBT-I on patient-reported sleep, pain, and other health outcomes (depressive symptoms, anxiety symptoms, and fatigue) in patients with comorbid insomnia and chronic non-cancer pain. A systematic literature search was conducted using eight electronic databases. Upon duplicate removal, 6374 records were screened against the inclusion criteria. Fourteen randomized controlled trials were selected for the review, with twelve (N = 762 participants) included in the meta-analysis. At post-treatment, significant treatment effects were found on global measures of sleep (standardized mean difference = 0.89), pain (0.20), and depressive symptoms (0.44). At follow-up (up to 12 mo), CBT-I significantly improved sleep (0.56). Using global measures of sleep, we found a probability of 81% and 71% for having better sleep after CBT-I at post-treatment and final follow-up, respectively. The probability of having less pain after CBT-I at post-treatment and final follow-up was 58% and 57%, respectively. There were no statistically significant effects on anxiety symptoms and fatigue at either assessment point. Future trials with sufficient power, longer follow-up periods, and inclusion of CBT for pain components are warranted.

Anxiety of Older Persons Living Alone in the Community

Anxiety is a common mental health problem among older persons, and the prevalence is higher in those who live alone than those who live with others. This study aimed to explore the experiences of anxiety in older persons living alone. A descriptive phenomenological approach was used to collect and analyze the interview data from 15 older persons (5 males, 10 females) living alone in Seoul, South Korea. Four main themes emerged from the data analysis: fear of being alone, concern about having an aged body, apprehension mixed with depression and loneliness, and fear of economic difficulties. These findings indicate that older persons living alone should receive continuous attention to prevent them from being neglected and their anxiety from worsening. Above all, it is vital to ensure comprehensive support for older persons living alone to alleviate their anxiety.

Pain Catastrophizing in Older Adults with Chronic Pain: The Mediator Effect of Mood Using a Path Analysis Approach

Cognitive models of pain propose that catastrophic thinking is negatively associated with chronic pain. However, pain catastrophizing is a complex phenomenon requiring a multivariate examination. This study estimates the effects of mood variables (anxiety and depression) on pain catastrophizing in older adults with chronic pain. A postal survey addressing pain aspects was sent to 6611 people ≥ 65 years old living in south-eastern Sweden. Pain catastrophizing was measured using the pain catastrophizing scale. Anxiety and depression were assessed using two subscales of the general well-being schedule. Data were analysed using a path analysis approach. A total of 2790 respondents (76.2 ± 7.4 years old) reported chronic pain (≥three months). The mediation model accounted for 16.3% of anxiety, 17.1% of depression, and 30.9% of pain catastrophizing variances. Pain intensity, insomnia, number of comorbidities, and lifestyle factors (smoking, alcohol consumption, and weight) significantly affected both pain catastrophizing and mood. Anxiety (standardized path coefficient (b_std) = 0.324, p < 0.001) in comparison to depression (b_std = 0.125, p < 0.001) had a greater effect on pain catastrophizing. Mood mediated the relationship between pain catastrophizing and pain-related factors accounting for lifestyle and sociodemographic factors.

Economic aspects of insomnia medication treatment among Medicare beneficiaries

STUDY OBJECTIVES

To examine economic aspects of insomnia and insomnia medication treatment among a nationally representative sample of older adult Medicare beneficiaries.

METHODS

Using a random 5% sample of Medicare administrative data (2006-2013), insomnia was defined using International Classification of Disease, Version 9, Clinical Modification diagnostic codes. Treatment was operationalized as one or more prescription fills for an US Food and Drug Administration (FDA)-approved insomnia medication following diagnosis, in previously untreated individuals. To evaluate the economic impact of insomnia treatment on healthcare utilization (HCU) and costs in the year following insomnia diagnosis, a difference-in-differences approach was implemented using generalized linear models.

RESULTS

A total of 23 079 beneficiaries with insomnia (M age = 71.7 years) were included. Of these, 5154 (22%) received one or more fills for an FDA-approved insomnia medication following insomnia diagnosis. For both treated and untreated individuals, HCU and costs increased during the 12 months prior to diagnosis. Insomnia treatment was associated with significantly increased emergency department visits and prescription fills in the year following insomnia diagnosis. After accounting for pre-diagnosis differences between groups, no significant differences in pre- to post-diagnosis costs were observed between treated and untreated individuals.

CONCLUSIONS

These results advance previous research into economics of insomnia disorder by evaluating the impact of medication treatment and highlighting important differences between treated and untreated individuals. Future studies should seek to understand why some individuals diagnosed with insomnia receive treatment but others do not, to identify clinically meaningful clusters of older adults with insomnia, and to explore the economic impact of insomnia and insomnia treatment among subgroups of individuals with insomnia, such as those with cardiovascular diseases, mood disorders, and neurodegenerative disease.

Factors Associated with Life Satisfaction in Older Adults with Chronic Pain (PainS65+)

Background

Chronic pain in later life is a worldwide problem. In younger patients, chronic pain affects life satisfaction negatively; however, it is unknown whether this outcome will extend into old age.

Objective

This study examines which factors determine life satisfaction in older adults who suffer from chronic pain with respect to socio-demographics, lifestyle behaviors, pain, and comorbidities.

Methods

This cross-sectional study recruited a random sample of people ≥65 years old living in south-eastern Sweden (N= 6611). A postal survey addressed pain aspects and health experiences. Three domains from the Life Satisfaction Questionnaire (LiSat-11) were used to capture the individual’s estimations of overall satisfaction (LiSat-life), somatic health (LiSat-somhealth), and psychological health (LiSat-psychhealth).

Results

Respondents with chronic pain (2790, 76.2±7.4 years old) rated lower on life satisfaction than those without chronic pain, with medium effect size (ES) on LiSat-somhealth (r = 0.38, P < 0.001) and small ES on the other two domains (r < 0.3). Among the respondents with chronic pain, severe pain (OR 0.29–0.59) and pain spreading (OR 0.87–0.95) were inversely associated with all three domains of the LiSat-11. Current smoking, alcohol overconsumption, and obesity negatively affected one or more domains of the LiSat-11. Most comorbidities were negatively related to LiSat-somhealth, and some comorbidities affected the other two domains. For example, having tumour or cancer negatively affected both LiSat-life (OR 0.62, 95% CI 0.44–0.88) and LiSat-somhealth (OR 0.42, 95% CI 0.24–0.74). Anxiety or depression disorders had a negative relationship both for LiSat-life (OR 0.54, 95% CI 0.38–0.78) and LiSat-psychhealth (OR 0.10, 95% CI 0.06–0.14).

Conclusion

Older adults with chronic pain reported lower life satisfaction but the difference from their peers without chronic pain was trivial, except for satisfaction with somatic health. Pain management in old age needs to consider comorbidities and severe pain to improve patients’ life satisfaction.

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Chronic Pain and Sleep Disturbances: A Pragmatic Review of Their Relationships, Comorbidities, and Treatments

Objective

The objective of this review is to answer three questions: 1) How are chronic pain severity and pain duration affected in patients with chronic pain and sleep disturbances that occur simultaneously? 2) What are common comorbidities and pain-related symptoms seen in patients with chronic pain and sleep disturbances? and 3) What are potentially effective pharmacological and nonpharmacological treatment options for both conditions?

Methods

Ovid Medline and PubMed were searched. Search terms included sleep wake disorder, chronic pain, fibromyalgia, treatment outcome, psychotherapy, complementary therapies, and therapeutics. Studies that assessed outcomes between individuals with chronic pain and those with concurrent chronic pain and sleep disturbances were included. Randomized controlled clinical trials of treatments for both conditions were included.

Results

Sixteen studies indicated that patients with both chronic pain and sleep disturbances have greater pain severity, longer duration of pain, greater disability, and are less physically active than those without sleep disturbances. Patients with both conditions are more likely to have concurrent depression, catastrophizing, anxiety, and suicidal ideation. Thirty-three randomized controlled trials assessed treatment for both chronic pain and sleep disturbances. Pregabalin was the most frequently studied medication, showing improvement in pain and sleep symptoms. Cognitive behavioral therapy for insomnia showed long-term improvement in sleep for patients with chronic pain.

Conclusions

Individuals with chronic pain and sleep disturbances have greater symptom severity, longer duration of symptoms, more disability, and additional comorbidities. Pharmacological and nonpharmacological treatments may be useful in the treatment of concurrent chronic pain and sleep disturbances, but further study is needed.

Key insomnia symptoms and incident pain in older adults: direct and mediated pathways through depression and anxiety

Pain is common among older adults and negatively impacts functioning. Sleep disturbances and mood disorders, specifically depression and anxiety, are closely associated with pain in older individuals, but the directionality of these associations remains unclear. In this study, we deconstruct long-term temporal effects of two key insomnia symptoms on incident pain into direct and indirect pathways, with focus on depression and anxiety symptoms, within a nationally representative sample. We utilized 2011-2013 data from the National Health and Aging Trends Study, a longitudinal survey of 2239 community-dwelling Medicare beneficiaries. Participants completed annual in-person interviews with assessments of sleep initiation and maintenance; depression, and anxiety (using the Patient Health Questionnaire-2 [PHQ-2] and the Generalized Anxiety Disorder Scale-2 [GAD-2] respectively); and bothersome pain. Causal mediation analysis was applied to examine direct effects of the two insomnia symptoms at baseline on incident pain, and their indirect effects through depression and anxiety symptoms. Almost one-third of the study participants were 69 years old or younger. A similar proportion reported bothersome pain in 2013. The two baseline insomnia symptoms predicted the development of pain. Adjusted analyses suggested that compared to older adults without the two baseline insomnia symptoms, participants with sleep initiation or maintenance difficulties had 24% (95% confidence interval [CI] 2%,51%) and 28% (95% CI 4%,55%) higher odds of incident pain, respectively. Anxiety symptoms partially mediated the relationship between the insomnia symptoms and incident pain, accounting for up to 17% of the total effect, but depressive symptoms did not. These results suggest that improved sleep or anxiety could reduce the risk for future pain.

Sleep disorders among educationally active elderly people in Bialystok, Poland: a cross-sectional study

BACKGROUND

Sleep disorders in an ageing society constitute a significant public health problem. It is estimated that approximately 50% of people aged 55 years and older have trouble sleeping, including initiating and maintaining sleep. The aim of this study was to determine the prevalence of sleep disorders in a group of educationally active elderly people living in Bialystok, Poland.

METHODS

The study included a total of 182 people - residents of Bialystok - aged 60 or older; 146 women (80.22%) and 36 men (19.78%). The study used three standardized psychometric scales: The Athens Insomnia Scale (AIS), The Epworth Sleepiness Scale (ESS) and The Insomnia Severity Index (ISI).

RESULTS

More than half of the respondents scored 6 or more points on the AIS, which is considered a value that indicates a high probability of insomnia symptom occurrence. A similar percentage of respondents obtained a point value on the ISI indicating the presence of insomnia. The vast majority of respondents scored below 11 points on the ESS, which means no symptoms of excessive sleepiness. There was a significant correlation between the results of the above scales in the examined group in total and also by sex.

CONCLUSIONS

Sleep disorders, particularly insomnia, constitute a significant social and health problem in the group of educationally active elderly people living in Bialystok. In light of the obtained study results, it is recommended to conduct and improve existing health education programs aimed at the elderly regarding sleep disorders to improve the quality of their sleep, and thus quality of life, and raise the awareness of the elderly about the importance of sleep in everyday life. There is a need for further research in the field of sleep disorders in the elderly to determine the prevalence of these disorders on a national scale.

Insomnia in Patients Seeking Care at an Orofacial Pain Unit

Introduction: Orofacial pain and dysfunction include a broad range of disturbances among which pain and insomnia are some of the most common complaints. Sleep strengthens physiological and psychological resilience and is an absolute requirement for health. Insomnia is a common symptom or sleep disorder, yet data on its prevalence is sparse. Here we extracted data from the insomnia severity index which was part of the web-based interdisciplinary symptom evaluation (WISE) tool given to a large sample of patients seeking care at an orofacial pain unit for analyzing insomnia prevalence in this clinical population.

Material and methods: Anonymized data were available from 952 patients who consulted the Orofacial Pain Unit at the Center of Dental Medicine, University of Zurich, Zurich, Switzerland between January 2017 and December 2018. Prevalence data for insomnia stratified by gender and 10 age groups (decades) were calculated. The distribution of four insomnia severity grades was determined, also stratified by age and gender.

Results: 952 patients (290 men: 30.5%) with a mean age of 44.8 ± 17.4 years completed a WISE. Three hundred and fifty-two (37.0%) patients with a mean age of 45.8 ± 16.7 years positively responded to a screening question for insomnia and/or hypersomnia. Insomnia was severe in women from the 2nd to 8th decade, ranging from 4.3% (3rd decade) to 14.5% (6th decade), and moderately severe from the 2nd to 9th decade, ranging from 18.8% (6th decade) to 27.8% (2nd decade). In men, severe insomnia was present from the 3rd to 7th decade, ranging from 2.3% (7th decade) to 4.4% (4th decade) and moderately severe insomnia from the 3rd to 7th decade, ranging from 4.6% (7th decade) to 12.2% (5th decade).

Conclusions: This is the first study reporting on insomnia in a large sample of patients seeking care at an orofacial pain unit. One in three patients reported some form of sleep disturbances, which for almost half of them was moderate to severe insomnia. The gender ratio was almost equal throughout adulthood, yet younger and older women were more frequently affected and experienced higher insomnia severity than men.

Untreated insomnia increases all-cause health care utilization and costs among Medicare beneficiaries

STUDY OBJECTIVES

To examine the impact of untreated insomnia on health care utilization (HCU) among a nationally representative sample of Medicare beneficiaries.

METHODS

Our data source was a random 5% sample of Medicare administrative data for years 2006-2013. Insomnia was operationalized as the presence of at least one claim containing an insomnia-related diagnosis in any given year based on International Classification of Disease, Version 9, Clinical Modification codes or at least one prescription fill for an insomnia-related medication in Part D prescription drug files in each year. We compared HCU in the year prior to insomnia diagnosis to HCU among to non-sleep disordered controls during the same period.

RESULTS

A total of 151 668 beneficiaries were found to have insomnia. Compared to controls (n = 333 038), beneficiaries with insomnia had higher rates of HCU across all point of service locations. Rates of HCU were highest for inpatient care (rate ratio [RR] 1.61; 95% confidence interval [CI] 1.59, 1.64) and lowest for prescription fills (RR 1.17; 95% CI 1.16, 1.17). Similarly, compared to controls, beneficiaries with insomnia demonstrated $63,607 (95% CI $60,532, $66,685) higher all-cause costs, which were driven primarily by inpatient care ($60,900; 95% CI $56,609, $65,191). Emergency department ($1,492; 95% CI $1,387, $1,596) and prescription costs ($486; 95% CI $454, $518) were also elevated among cases relative to controls.

CONCLUSIONS

In this randomly selected and nationally representative sample of older Medicare beneficiaries and compared to non-sleep disordered controls, individuals with untreated insomnia demonstrated increased HCU and costs across all points of service.

Sleep, chronic pain, and opioid risk for apnea

Pain is an unwelcome sleep partner. Pain tends to erode sleep quality and alter the sleep restorative process in vulnerable patients. It can contribute to next-day sleepiness and fatigue, affecting cognitive function. Chronic pain and the use of opioid medications can also complicate the management of sleep disorders such as insomnia (difficulty falling and/or staying asleep) and sleep-disordered breathing (sleep apnea). Sleep problems can be related to various types of pain, including sleep headache (hypnic headache, cluster headache, migraine) and morning headache (transient tension type secondary to sleep apnea or to sleep bruxism or tooth grinding) as well as periodic limb movements (leg and arm dysesthesia with pain). Pain and sleep management strategies should be personalized to reflect the patient's history and ongoing complaints. Understanding the pain-sleep interaction requires assessments of: i) sleep quality, ii) potential contributions to fatigue, mood, and/or wake time functioning; iii) potential concomitant sleep-disordered breathing (SDB); and more importantly; iv) opioid use, as central apnea may occur in at-risk patients. Treatments include sleep hygiene advice, cognitive behavioral therapy, physical therapy, breathing devices (continuous positive airway pressure - CPAP, or oral appliance) and medications (sleep facilitators, e.g., zolpidem; or antidepressants, e.g., trazodone, duloxetine, or neuroleptics, e.g., pregabalin). In the presence of opioid-exacerbated SDB, if the dose cannot be reduced and normal breathing restored, servo-ventilation is a promising avenue that nevertheless requires close medical supervision.

Mild cognitive impairment: associations with sleep disturbance, apolipoprotein e4, and sleep medications

OBJECTIVE

Mild cognitive impairment (MCI) is associated with increased memory problems although the ability to complete daily life activities remains relatively intact. This study examined: (1) if sleep disturbance increased the hazard of MCI; (2) if APOE e4 carriers with sleep disturbance experience an increased risk of MCI; and, (3) if prescription sleep medications provide a protective effect against MCI. We hypothesized that sleep disturbance increases the hazard of MCI, this relationship is stronger among APOE e4 carriers reporting a sleep disturbance. Furthermore, we hypothesized that sleep medications decrease the hazard of MCI.

METHODS

To determine whether sleep medication mediates the risk of developing MCI for individuals with sleep disturbance and/or APOE e4, we analyzed the National Alzheimer's Coordinating Center Uniform Data Set. We selected participants with normal cognition at baseline (n = 6798), and conduced survival analyses.

RESULTS

Our main findings indicated that the hazard of MCI was significantly associated with sleep disturbance. The hazard remained among those who did not use sleep medication. Trazodone and zolpidem users did not have a significant hazard of MCI, but the significant hazard remained for those who did not use these medications. APOE e4 carriers had a significantly higher hazard of MCI. Among e4 carriers who used trazodone or zolpidem, there was not a statistically significant risk of MCI.

CONCLUSION

This study demonstrated the potential utilization of trazodone and zolpidem in the treatment of sleep disturbance while potentially mitigating the risk of MCI. While trazodone and zolpidem have been shown to positively impact sleep disturbance in individuals with normal cognition, further research should explore these findings given that these medications are potentially inappropriate for older adults.

Pain intensity as a moderator of the association between opioid use and insomnia symptoms among adults with chronic pain

OBJECTIVE

Research documenting the impact of opioid use on sleep among individuals with chronic pain has been mixed. This study aimed to determine if pain intensity moderates the association between opioid use and insomnia symptoms among adults with comorbid symptoms of insomnia and chronic widespread pain.

METHODS

Participants (N = 144; 95% female; mean age = 51.6, SD = 11.4) completed assessments of insomnia symptoms, pain and use of sleep/pain medication. Multiple regression was used to determine if pain intensity moderates the association between opioid use (yes/no) sleep onset latency (SOL), wake after sleep onset (WASO), sleep quality, or time in bed. Analyses controlled for gender, symptoms of sleep apnea, symptoms of depression, use of sleep medication (yes/no), and use of non-opioid pain medication (yes/no).

RESULTS

Stronger pain intensity was associated with longer self-reported WASO and worse sleep quality, independent of opioid use. Conversely, opioid use was associated with longer time in bed, independent of pain intensity. Opioid use and pain intensity interacted in the prediction of SOL, such that opioid use (vs. non-use) was associated with longer SOL in the context of mild but not moderate to severe pain intensity.

CONCLUSIONS

Opioid use was associated with more difficulty falling asleep among adults with chronic pain; however, this cross-sectional effect was only significant among those reporting lower pain intensity. Authors speculate that this effect is masked among those with severe pain because the pain-related sleep debt they acquire throughout the night then facilitates sleep onset the next day.

Psychological Interventions for Late-life Insomnia: Current and Emerging Science

Purpose of Review

Late-life insomnia is a serious medical condition associated with many untoward consequences. The high prevalence of late-life insomnia, along with the concomitant risks inherent in the use of hypnotic medications in older adults necessitates non-pharmacological (i.e., psychological) treatment options. We aim to summarize and evaluate the state-of-the-science of psychological treatment options for late-life insomnia.

Recent Findings

Cumulative scientific evidence suggests the efficacy of psychological treatment of late-life insomnia. During the previous decade, trials of psychological treatments for insomnia have begun to test various modifications to treatments that have the potential to improve access for older adults, along with expanding their focus to include individuals with comorbid conditions that are common to older adults. While these modifications represent positive advances in the science of treatment for late-life insomnia, the evidence is still largely explanatory/efficacious in nature.

Summary

Psychological strategies represent the best approaches for the treatment of late-life insomnia. Future investigations would be wise to progressively move towards increasingly pragmatic/effectiveness investigations, adding to the literature base regarding the treatment of late-life insomnia under usual/real-world conditions as opposed to ideal/artificial conditions.

Resiliency among older adults: dispositional hope as a protective factor in the insomnia-depressive symptoms relation

OBJECTIVES

Depression is a significant mental health issue among older Australian adults. Research has indicated that insomnia is a key risk factor for the development of depressive symptoms in older adults, and that dispositional hope may be protective against the development of depressive symptoms in this population. This study examined whether dispositional hope and its dimensions, agency and pathways, moderated the relationship between insomnia symptoms and depressive symptoms among older Australian adults.

METHOD

A community sample of 88 men (M_age = 71.11, SD_age = 5.54) and 111 women (M_age = 70.25, SD_age = 4.64), aged 65-94 years, completed the Insomnia Severity Index, Adult Dispositional Hope Scale, and Centre of Epidemiologic Studies Depression Scale.

RESULTS

After controlling for gender, age, relationship status, education level, method of participation, and perceived physical health, results supported the moderation models. The insomnia-depressive symptoms relation was significant for older adults with low and average (but not high) levels of dispositional hope, agency, and pathways. The Johnson-Neyman analyses indicated that the insomnia-depressive symptoms relation was significant for older adults who scored below 27.10 on dispositional hope, below 13.73 on agency, and below 13.49 and above 15.64 on pathways.

CONCLUSION

The results of this study imply that interventions aimed at increasing dispositional hope, agency, and pathways among older adults who experience symptoms of insomnia may reduce their depressive symptoms. A cautionary note, however, is that very high scores on pathways among older adults who experience insomnia symptoms may be detrimental to their mental health.

Insomnia in Community-Living Persons with Advanced Age

OBJECTIVE

To evaluate the epidemiology of insomnia, including demographic and clinical correlates, in older adults.

DESIGN

Cross-sectional.

SETTING

Community.

PARTICIPANTS

Yale Precipitating Events Project participants (N=379; mean age 84.3; 67.8% female; 11.9% African American).

MEASUREMENTS

Insomnia Severity Index (ISI), with scores of 8 and higher indicating insomnia, which was further stratified according to ISI score as mild (8-14), moderate (15-21), or severe (22-28). Baseline characteristics included age, sex, race, education, smoking, obesity, medical conditions, depressive symptoms (Center for Epidemiologic Studies Depression score ≥16), cognitive impairment (Mini-Mental State Examination score <24), restless legs syndrome (RLS), self-reported sleep-disordered breathing (SDB), medications, and daytime sleepiness (Epworth Sleepiness Scale (ESS), range 0-24).

RESULTS

Insomnia was established in 163 (43.0%) participants (average ISI score 12.3 (mild)). For the entire sample, average baseline characteristics were as follows: 30.1% did not complete high school, 5% were current smokers, 19.2% were obese, 28.2% had cardiovascular disease, 19.3% had chronic lung disease, 27.2% had depressive symptoms, 16.1% had cognitive impairment, 36.8% had RLS, and 3.4% had self-reported SDB; mean number of medications was 9.2, and mean ESS was 6.4. In multivariable regression models, only depressive symptoms (adjusted odds ratio (aOR)=8.34, 95% confidence interval (CI)=4.49, 15.47) and RLS (aOR=2.49, 95% CI=1.48, 4.21) were significantly associated with insomnia.

CONCLUSION

In a sample of older adults with high medical burden and polypharmacy, insomnia was highly prevalent but unexpectedly mild and associated only with depressive symptoms and RLS. The discordance of high prevalence but mild severity of insomnia in the oldest adults highlights the need for diagnostic confirmation with objective measures of sleep disturbances, whereas the strong associations with depressive symptoms and RLS inform priorities in managing insomnia.

Age-related physical and psychological vulnerability as pathways to problem gambling in older adults

Background To inform clinical treatment and preventative efforts, there is an important need to understand the pathways to late-life gambling disorder. Aims This study assesses the association between age-related physical health, social networks, and problem gambling in adults aged over 65 years and assesses the mediating role of affective disorders in this association. Methods The sample comprised 595 older adults (mean age: 74.4 years, range: 65-94 years; 77.1% female) who were interviewed using a structured questionnaire to assess physical frailty, geriatric pain, loneliness, geriatric depression, geriatric anxiety, and problem gambling. Results Pathway analysis demonstrated associations between these variables and gambling problems, providing a good fit for the data, but that critically these relationships were mediated by both anxiety and depression symptoms. Conclusions This study indicates that late-life problem gambling may develop as vulnerable individuals gamble to escape anxiety and depression consequent to deteriorating physical well-being and social support. When individuals develop late-life problem gambling, it is recommended that the treatment primarily focuses upon targeting and replacing avoidant coping approaches.

Association of insomnia severity with well-being, quality of life and health care costs: A cross-sectional study in older adults with chronic pain (PainS65+)

BACKGROUND

Insomnia is one of the most common complaints in chronic pain. This study aimed to evaluate the association of insomnia with well-being, quality of life and health care costs.

METHODS

The sample included 2790 older individuals (median age = 76; interquartile range [IQR] = 70-82) with chronic pain. The participants completed a postal survey assessing basic demographic data, pain intensity and frequency, height, weight, comorbidities, general well-being, quality of life and the insomnia severity index (ISI). Data on health care costs were calculated as costs per year (€ prices) and measured in terms of outpatient and inpatient care, pain drugs, total drugs and total health care costs.

RESULTS

The overall fraction of clinical insomnia was 24.6% (moderate clinical insomnia: 21.9% [95% CI: 18.8-23.3]; severe clinical insomnia: 2.7% [95% CI: 1.6-3.2]). Persons who reported clinical insomnia were more likely to experience pain more frequently with higher pain intensity compared to those reported no clinically significant insomnia. Mean total health care costs were € 8469 (95% CI: €4029-€14,271) for persons with severe insomnia compared with € 4345 (95% CI: €4033-€4694) for persons with no clinically significant insomnia. An association between severe insomnia, well-being, quality of life, outpatient care, total drugs costs and total health care costs remained after controlling for age, sex, pain intensity, frequency, body mass index and comorbidities using linear regression models.

CONCLUSIONS

Our results determine an independent association of insomnia with low health-related quality of life and increased health care costs in older adults with chronic pain.

SIGNIFICANCE

The concurrence and the severity of insomnia among older adults with chronic pain were associated with decreased well-being and quality of life, and increased health care costs to society.