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Martin JL, DeViva J, McCarthy E, Gehrman P, Josephson K, Mitchell M, de Beer C, Runnals J. In-person and telehealth treatment of veterans with insomnia disorder using cognitive behavioral therapy for insomnia during the COVID-19 pandemic. J Clin Sleep Med 2023; 19:1211-1217. [PMID: 36859803 PMCID: PMC10315602 DOI: 10.5664/jcsm.10540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 03/03/2023]
Abstract
STUDY OBJECTIVES Cognitive behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for insomnia disorder. The goal of this study was to evaluate clinical benefits of CBT-I to veterans with insomnia disorder during the early months of the COVID-19 pandemic using an uncontrolled observational design. METHODS A cohort of 63 Veterans Affairs (VA) mental health providers delivered CBT-I to 180 veterans as part of an evidence-based psychotherapy training program and captured de-identified treatment outcome data through a data portal. The main patient outcomes were change in the Insomnia Severity Index (ISI) total score from the initial clinical assessment session to the last treatment session, response rate (% with ISI change > 7 from assessment to last session), and remission rate (% with ISI < 8 at the last session). We tested the noninferiority of telehealth only compared with at least 1 in-person session. RESULTS Fifty-six percent of veterans seen for an evaluation completed CBT-I treatment during the structured training program phase and completed an initial and final ISI. Among these veterans, ISI scores decreased by an average of 9.9 points from before to after treatment (P < .001), 66% experienced a clinically meaningful treatment response, and 43% experienced insomnia symptom remission. Benefits were similar whether the veteran received some in-person care or received CBT-I entirely via telehealth. CONCLUSIONS Findings suggest, regardless of treatment modality, CBT-I remained highly effective during the early months of the pandemic, which was a challenging time for both clinical providers and veterans in need of insomnia treatment. CITATION Martin JL, DeViva J, McCarthy E, et al. In-person and telehealth treatment of veterans with insomnia disorder using cognitive behavioral therapy for insomnia during the COVID-19 pandemic. J Clin Sleep Med. 2023;19(7):1211-1217.
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Affiliation(s)
- Jennifer L. Martin
- VA Greater Los Angeles Healthcare System, Geriatric Research, Education, and Clinical Center, Los Angeles, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jason DeViva
- VA Connecticut Healthcare System, West Haven, Connecticut
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Elissa McCarthy
- Department of Veterans Affairs National Center for PTSD, White River Junction, Vermont
| | - Philip Gehrman
- Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karen Josephson
- VA Greater Los Angeles Healthcare System, Geriatric Research, Education, and Clinical Center, Los Angeles, California
| | - Michael Mitchell
- VA Greater Los Angeles Healthcare System, Geriatric Research, Education, and Clinical Center, Los Angeles, California
| | - Christopher de Beer
- Department of Veterans Affairs, Durham Healthcare System, Durham, North Carolina
| | - Jennifer Runnals
- Department of Veterans Affairs, Durham Healthcare System, Durham, North Carolina
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
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Moghtaderi I, Kelly M, Carlson G, Fung C, Josephson K, Song Y, Agrawal A, Zhu R, Mitchell M, Badr MS, Washington D, Yano E, Zeidler M, Alessi C, Martin J. 0701 STOP-BANG Score, Age, and Body Mass Index Predict Severity of Sleep Disordered Breathing in Women Veterans. Sleep 2022. [DOI: 10.1093/sleep/zsac079.697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Despite increasing evidence that sleep disordered breathing (SDB) is common in women veterans, little is known of how to screen for SDB in this population. Some evidence suggests there are sex-related differences in SDB presentation, where women may be more likely to present with fatigue or depression, compared to men who may present with daytime sleepiness. The goal of this study was to evaluate whether commonly used measures predict SDB in women veterans.
Methods
Women veterans (N=179) without treated SDB, but with 1 or more SDB risk factors (identified from electronic medical records) completed baseline assessment as part of an ongoing controlled trial of treatment for SDB. Measures included: age, body mass index (BMI), Epworth Sleepiness Scale (ESS), Flinders Fatigue Scale (FSS), Insomnia Severity Index (ISI), Patient-Health Questionnaire 9-item (PHQ-9), STOP-BANG score, and apnea-hypopnea index (AHI via WatchPAT home sleep apnea testing). Descriptive statistics and bivariate correlations testing the relationship between AHI and other measures were performed.
Results
Mean age was 49.8 [±13.8] years and BMI 29.6 [±6.0] kg/m2. Mean ESS was 8.1, FFS 13.9, ISI 14.0, PHQ-9 7.1, and STOP-BANG score 2.7. Mean AHI was 15.4 [±13.2], where higher AHI correlated with higher BMI (r=0.3, p<0.001), higher STOP-BANG score (r=0.4, p<0.001) and older age (r=0.4, p<0.001).
Conclusion
These findings support the use of the STOP-BANG score to predict SDB severity in women veterans with risk factors for SDB. Age and BMI may be particularly important predictors of SDB in this population. Sleepiness, depression, insomnia, and fatigue questionnaires were not related to SDB severity. Further work is needed to understand the role of patient-reported symptoms in those at-risk for SDB and to inform guidelines for the recognition of SDB in this important and understudied population.
Support (If Any)
VA HSR&D IIR 16-244 and RCS 20-191; NIH/NHLBI K24 HL143055, HRS&D COIN; VAGLAHS GRECC.
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Affiliation(s)
- Isabel Moghtaderi
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System and Department of Medicine, David Geffen School of Medicine, University of California , Los Angeles
| | - Monica Kelly
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System and Department of Medicine, David Geffen School of Medicine, University of California , Los Angeles
| | - Gwendolyn Carlson
- Department of Mental Health, VA Greater Los Angeles Healthcare System and VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System and Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California , Los Angeles
| | - Constance Fung
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System and Department of Medicine, David Geffen School of Medicine, University of California , Los Angeles
| | - Karen Josephson
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System , Los Angeles CA
| | - Yeonsu Song
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System and Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles and School of Nursing, University of California , Los Angeles
| | - Alpna Agrawal
- Department of Mental Health, VA Greater Los Angeles Healthcare System and VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System and Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California , Los Angeles
| | - Ruoyan Zhu
- University of Arizona, Phoenix School of Medicine , Phoenix, AZ
| | - Michael Mitchell
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System
| | - M Safwan Badr
- Department of Internal Medicine, Wayne State University School of Medicine and John D. Dingell Veterans Affairs Medical Center
| | - Donna Washington
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles and VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System
| | - Elizabeth Yano
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles and VA Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System and Department of Health Policy & Management, Fielding School of Public Health, University of California , Los Angeles
| | - Michelle Zeidler
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System and Division of Pulmonary, Critical Care and Sleep, VA Greater Los Angeles Healthcare System
| | - Cathy Alessi
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System and Department of Medicine, David Geffen School of Medicine, University of California , Los Angeles
| | - Jennifer Martin
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System and Department of Medicine, David Geffen School of Medicine, University of California , Los Angeles
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Barretto B, Martin J, Fung C, Dzierzewski J, Stepnowsky C, Song Y, Zeidler M, Kelly M, Enamorado D, Schnurrenberger J, Josephson K, Mitchell M, Alessi C. 0758 Behavioral Determinants of PAP Use in Veterans with COMISA: Results of a Randomized Trial. Sleep 2022. [DOI: 10.1093/sleep/zsac079.754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Nonadherence to positive airway pressure (PAP) therapy is common in comorbid insomnia and obstructive sleep apnea (COMISA). We previously reported a novel behavioral treatment for COMISA which improves both PAP adherence and sleep. Our current goal was to assess whether improvements in PAP self-efficacy, knowledge, and decisional balance (targets of treatment) are associated with improvements in PAP use and sleep quality. We also collected participants’ perceptions of benefits and challenges of PAP during intervention.
Methods
125 veterans (96% men, 39% non-Hispanic white, 24% Black, 17% Hispanic/Latino) with COMISA were randomized to a 5-week intervention integrating behavioral insomnia therapy with a PAP adherence program versus general sleep education (control). Objective PAP use data and Pittsburgh Sleep Quality Index (PSQI) were collected over 6 months. Three behavior change subscales (PAP Self-Efficacy [PAP-SE], Decisional Balance Index [DBI], Knowledge [KNOW]) were administered at 6-months. Weekly self-report of participant-perceived benefits and challenges of PAP use were collected among intervention participants. Subscale scores, PAP use and PSQI were compared between intervention and control, and associations were tested. Change in mean number of benefits and challenges of PAP use were also tested (all analyses intent-to-treat).
Results
At 6-months, compared to controls, intervention participants had higher scores on all three subscales: PAP-SE (4.1 intervention versus 3.5 control, respectively), DBI (8.3, 0.9) and KNOW (10.5, 9.6, all p<.05). Intervention participants had more PAP use and lower (better) PSQI scores at 6-months (all p<.05). In the total sample, PAP use and PSQI correlated with PAP-SE (r=.52 PAP use, r=-.27 PSQI, respectively), DBI (r=.49, -.35) and KNOW (r=.43, -.21; all p<.05). Among intervention participants, perceived benefits of PAP increased over time (4.3 at week 2, 5.8 at week 4, respectively), and challenges decreased (3.7, 2.3; all p<.05).
Conclusion
Behavioral treatment for COMISA improves behavioral determinants of PAP use, which is associated with improvements in PAP use and sleep quality. In addition, with treatment, perceived benefits of PAP increase and challenges decrease. These findings suggest improvements in self-efficacy, knowledge and perceived benefits of PAP are important mechanisms through which behavioral interventions improve PAP use in older adults with COMISA.
Support (If Any)
VAHSRD (IIR12–353-Alessi, RCSA20-191-Martin) and NIH (NHLBI K24HL143055-Martin, NIA K23AG049955-Dzierzewski)
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Affiliation(s)
| | - Jennifer Martin
- VA Greater Los Angeles Healthcare System and University of California , Los Angeles
| | - Constance Fung
- VA Greater Los Angeles Healthcare System and University of California , Los Angeles
| | | | - Carl Stepnowsky
- VA San Diego Healthcare System and University of California , San Diego
| | | | - Michelle Zeidler
- VA Greater Los Angeles Healthcare System and University of California , Los Angeles
| | - Monica Kelly
- VA Greater Los Angeles Healthcare System and University of California , Los Angeles
| | | | | | | | | | - Cathy Alessi
- VA Greater Los Angeles Healthcare System and University of California , Los Angeles
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Fung CH, Martin JL, Liang LJ, Hays RD, Col N, Patterson ES, Josephson K, Mitchell MN, Sanchez MC, Aysola R, Song Y, Dzierzewski JM, Huang D, Zeidler M, Alessi C. Efficacy of a patient decision aid for improving person-centered decision-making by older adults with obstructive sleep apnea. J Clin Sleep Med 2021; 17:121-128. [PMID: 32955013 DOI: 10.5664/jcsm.8798] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVES Person-centered obstructive sleep apnea (OSA) care is a collaborative approach that is respectful of an individual's health priorities. Informed decision-making is essential to person-centered care, especially as patients age. In a feasibility study, we evaluated the effects of a new decision aid (Decide2Rest) on OSA treatment decision-making in older adults. METHODS Patients (aged ≥ 60 years) with newly diagnosed OSA were recruited from two health care systems and randomized either to Decide2Rest or to a control program. Postintervention outcomes included 1) Decisional Conflict Scale (0-100, where 0 = low and 100 = high conflict), which measures perceptions of uncertainty, whether decisions reflect what matters most to patients, and whether patients feel supported in decision-making; 2) Preparation for Decision-Making scale (0-100, where 0 = least and 100 most prepared); and 3) OSA knowledge (0-100, where 0 = poor and 100 = outstanding). Multivariable linear regression models examined relationships between Decide2Rest and outcomes (Decisional Conflict Scale, Preparation for Decision-Making, OSA knowledge). RESULTS Seventy-three patients were randomized to Decide2Rest (n = 36; mean age, 69 years; 72% male) vs control (n = 37; mean age, 69 years; 70% male). Results from the regressions, controlling for study site, indicate that the Decide2Rest program resulted in less decisional conflict (20.5 vs 32.7 on the Decisional Conflict Scale; P = .014), more preparedness for decision-making (87.8 vs 66.2 on the Preparation for Decision-Making scale; P < .001), and greater OSA knowledge (75.1 vs 65.3 OSA knowledge score; P = .04) scores than in the control group. CONCLUSIONS The Decide2Rest program promotes person-centered OSA decision-making for older patients with newly diagnosed OSA. Future studies are needed to optimize implementation of the program. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov, Name: Improving Older Adults' Decision-Making for OSAT (eDecide2Rest); URL: https://clinicaltrials.gov/ct2/show/NCT03138993; Identifier: NCT03138993.
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Affiliation(s)
- Constance H Fung
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California.,David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jennifer L Martin
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California.,David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Li-Jung Liang
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ron D Hays
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | | | - Karen Josephson
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Michael N Mitchell
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Maria C Sanchez
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California.,David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ravi Aysola
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Yeonsu Song
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California.,UCLA School of Nursing, Los Angeles, California
| | | | - David Huang
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Michelle Zeidler
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California.,David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Cathy Alessi
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California.,David Geffen School of Medicine at UCLA, Los Angeles, California
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5
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Song Y, Kelly MR, Fung CH, Dzierzewski JM, Grinberg AM, Mitchell MN, Josephson K, Martin JL, Alessi CA. Change in Dysfunctional Sleep-Related Beliefs is Associated with Changes in Sleep and Other Health Outcomes Among Older Veterans With Insomnia: Findings From a Randomized Controlled Trial. Ann Behav Med 2021; 56:35-49. [PMID: 33944909 DOI: 10.1093/abm/kaab030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Cognitive behavioral therapy for insomnia (CBTI) targets changing dysfunctional sleep-related beliefs. The impact of these changes on daytime functioning in older adults is unknown. PURPOSE We examined whether changes in sleep-related beliefs from pre- to post-CBTI predicted changes in sleep and other outcomes in older adults. METHOD Data included 144 older veterans with insomnia from a randomized controlled trial testing CBTI. Sleep-related beliefs were assessed with the Dysfunctional Beliefs and Attitudes about Sleep-16 (DBAS-16, subscales: Consequences, Worry/Helplessness, Sleep Expectations, Medication). Outcomes included sleep diary variables, actigraphy-measured sleep efficiency, Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), Flinders Fatigue Scale (FFS), Patient Health Questionnaire-9, and health-related quality of life. Analyses compared slope of change in DBAS subscales from baseline to posttreatment between CBTI and control, and assessed the relationship between DBAS change and the slope of change in outcomes from baseline to 6 months. RESULTS Compared to controls, the CBTI group demonstrated stronger associations between improvement in DBAS-Consequences and subsequent improvement in PSQI, ISI, ESS, and FFS. The CBTI group also demonstrated stronger associations between improvement in DBAS-Worry/Helplessness and subsequent improvements in PSQI, ISI, and FFS; improvements in DBAS-Medication and PSQI; and improvements in DBAS-Sleep Expectations and wake after sleep onset (sleep diary) and FFS (all p < .05). CONCLUSIONS Significant reduction in dysfunctional sleep-related beliefs following CBTI in older adults predicted improvement in several outcomes of sleep and daytime functioning. This suggests the importance of addressing sleep-related beliefs for sustained improvement with CBTI in older veterans. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00781963.
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Affiliation(s)
- Yeonsu Song
- School of Nursing, University of California, Los Angeles, CA, USA.,Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, CAUSA.,David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Monica R Kelly
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, CAUSA
| | - Constance H Fung
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, CAUSA.,David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | | | - Austin M Grinberg
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, CAUSA
| | - Michael N Mitchell
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, CAUSA
| | - Karen Josephson
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, CAUSA
| | - Jennifer L Martin
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, CAUSA.,David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Cathy A Alessi
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, CAUSA.,David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Moghtaderi I, Kelly M, Carlson G, Swistun D, Fung C, Zeidler M, Mitchell M, Josephson K, Lee D, Partch L, Badr S, Washington D, Yano E, Alessi C, Martin J. 471 Identifying gaps in evaluation, treatment, and treatment adherence in women Veterans with sleep disordered breathing risk factors. Sleep 2021. [DOI: 10.1093/sleep/zsab072.470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
In our recent national survey study, 13% of women Veterans reported a diagnosis of Sleep Disordered Breathing (SDB), of whom 65% used positive airway pressure (PAP) treatment. We also found many women Veterans at high risk for SDB were undiagnosed (43%). The current study builds upon this survey research to identify rates of evaluation, diagnosis, treatment, and treatment adherence among women Veterans with risk factors for SDB.
Methods
We analyzed telephone screening data from an ongoing SDB treatment adherence intervention study for women Veterans in Los Angeles county. A total of 173 women Veterans, identified by retrospective chart review as having at least one risk factor for SDB (i.e. high blood pressure, diabetes, obesity, depression, or > 50 years old), completed the screener. Screening questions included 1) previous diagnostic testing for SDB, 2) SDB diagnosis 3) SDB treatment type, and 4) past week SDB treatment use. Descriptive statistics regarding evaluation and treatment of SDB are reported.
Results
In total, 31% of respondents endorsed having previously completed diagnostic testing, of whom, 54% reported an SDB diagnosis. Of those with diagnosed SDB, 82.8% were prescribed treatment (PAP [72.4%], oral appliance [6.9%], surgery [3.5%]), and 17.2% did not report being prescribed any SDB treatment. Of the 21 (72.4%) women Veterans diagnosed with SDB that were prescribed PAP, only 33% reported using treatment in the past week. Of the 2 women Veterans (6.9%) prescribed an oral appliance, 0% reported past week use.
Conclusion
Less than 1/3 of women Veterans with at least one risk factor for SDB had previously been evaluated for SDB; however, over 1/2 of women Veterans who were evaluated tested positive for SDB. Additionally, most women Veterans had not used PAP or oral appliance therapy in the past week. Greater clinical attention is needed to identify, evaluate, and diagnose SDB in women Veterans. Moreover, further research is needed to evaluate and inform interventions to address SDB treatment adherence barriers in women Veterans.
Support (if any)
VA HSR&D IIR 16–244 and RCS 20–191; NIH/NHLBI K24 HL143055, VAGLAHS GRECC and VA Office of Academic Affiliations.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Diane Lee
- VA Greater Los Angeles Healthcare System
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Song Y, McGowan SK, Kelly M, Carlson G, Fung C, Josephson K, Zeidler M, Alessi C, Martin J. 351 Informal Caregivers with Insomnia May Benefit From an Insomnia Treatment Using an Acceptance and Commitment Therapy Approach. Sleep 2021. [DOI: 10.1093/sleep/zsab072.350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Insomnia among informal caregivers (providing care to family/friends) is common and associated with worse mental and physical health outcomes. Traditional cognitive behavioral therapy for insomnia may be challenging for caregivers whose beliefs about sleep may relate to beliefs and behaviors that are intertwined with their unique situation of caregiving. We examined whether an insomnia treatment using an acceptance and commitment (ACT) approach (i.e. committing to values-based actions toward goals vs. experiential avoidance of distressing emotions/thoughts) plus sleep restriction, stimulus control and sleep hygiene improves sleep, mental health, and daytime symptoms among caregivers.
Methods
We analyzed data from women veterans with insomnia who were informal caregivers (mean age=44 years [range 25–57]; N=6) and were participating in a clinical trial of an ACT-focused treatment (termed ABC-I). We measured: Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Patient Health Questionnaire (PHQ-9), General Anxiety Disorder (GAD-7), 11 items assessing symptoms of daytime impairment due to poor sleep derived from the International Classification of Sleep Disorders-Third Edition, and the Acceptance and Action Questionnaire (AAQ). Student t-tests were used to compare outcomes between pre- and post-ABC-I.
Results
Caregivers showed significant improvements between pre- and post-ABC-I (all p-values<0.05) in the following outcomes: ISI (14.3±5.4 vs. 3.8±3.2), PHQ-9 (9.8±7.2 vs. 2.8±3.8), GAD-9 (9.0±6.6 vs. 2.0±1.8), and number of symptoms of sleep-related daytime impairment (6.8±4.0 vs. 3.8±3.5). Caregivers also showed improvement trends in PSQI (10.0±4.1 vs. 5.2±1.2, p=0.06) and AAQ score (24.0±12.7 vs. 16.2±8.0, p=0.05).
Conclusion
We found that caregivers with insomnia may benefit from ACT-based treatment in improving perceived sleep quality and insomnia, depression, anxiety, sleep-related daytime impairment and reduced experiential avoidance. This approach may increase motivation by linking the sleep program to core values, and acceptance and tolerance of emotions or thoughts may benefit caregivers with insomnia. Further studies using an ACT-based insomnia program are needed to test its effect in a larger sample of caregivers and evaluate benefits in terms of reduced stress and improved health.
Support (if any)
VA HSR&D (Martin IIR 13-058-2 and RCS-20–191), NIA (K23AG055668, Song), NHLBI (K23HL143055, Martin) of the NIH, VAGLAHS GRECC, and VA Office of Academic Affiliations (Kelly; Carlson).
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Kelly M, Moghtaderi I, McGowan SK, Carlson G, Josephson K, Mitchell M, Swistun D, Fung C, Zeidler M, Badr S, Martin J. 400 Utility of the STOP Questionnaire in Predicting Sleep Disordered Breathing in Older Women Veterans. Sleep 2021. [DOI: 10.1093/sleep/zsab072.399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Sleep disordered breathing (SDB) is underdiagnosed in older women, despite a significant increase in SDB prevalence post-menopause. Few studies have assessed the diagnostic accuracy of SDB screening questionnaires in older women, particularly older Women Veterans (WV). WV have higher rates of SDB compared to non-Veteran women and are particularly vulnerable to sleep disorders in general. We examined the diagnostic accuracy of the STOP questionnaire compared to home sleep apnea testing (HSAT) that includes sleep time estimation (i.e., WatchPAT) in older WV.
Methods
Cross-sectional baseline data obtained from chart review were combined from two behavioral sleep intervention studies targeting WV with sleep difficulties (i.e., insomnia symptoms) or SDB risk factors (e.g., hypertension, obesity). A total of 136 older WV (50-91y; age=60.0±7.8y) completed the STOP questionnaire (yes/no: snoring, tiredness, observed breathing pauses, and high blood pressure [BP]) and had an apnea-hypopnea index (AHI) available from their baseline HSAT (WatchPAT). Sensitivity, specificity, and positive and negative likelihood ratios (+LR/-LR) were calculated to characterize the diagnostic accuracy of STOP≥2 for AHI≥5 (mild SDB) or AHI≥15 (moderate SDB).
Results
70.6% (n=96) of participants endorsed a STOP≥2, 83.8% (n=114) demonstrated an AHI≥5 and 46.3% (n=63) demonstrated an AHI≥15. For AHI≥5, sensitivity was 73.7% (95% CI=64.6,81.5%), specificity was 45.5% (95% CI=24.4,67.8%), +LR was 1.35 (95% CI=0.91, 2.01), and -LR was 0.58 (95% CI=0.33,1.00). For AHI≥15, sensitivity was 76.2% (95% CI=63.8,86%), specificity was 34.2% (95% CI=23.5,46.3%), +LR was 1.16 (95% CI=0.93,1.44), and -LR was 0.70 (95% CI=0.30,1.20).
Conclusion
The likelihood ratios for STOP≥2 limited the utility of the STOP vs. an HSAT system with sleep scoring in determining AHI. While the STOP correctly identified 3/4 of older WV with SDB on WatchPAT, it correctly identified <50% of older WV without SDB. Screening measures that better capture predictors of moderate SDB in women at risk for SDB are needed, especially in older women who may not present clinically with the common SDB symptoms (i.e. snoring, tiredness, observed breathing pauses, and high BP). STOP compared to polysomnography studies are also needed.
Support (if any)
VA HSR&D IIR-13–058, IIR 16–244 and RCS 20–191; NIH/NHLBI K24 HL143055, VAGLAHS GRECC, VA Office of Academic Affiliations, and AASM Foundation.
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Mak S, Ulmer C, Kaufman C, Alessi C, Martin J, Smith J, Mitchell M, Josephson K, McCarthy M, Lum H, Fung C. 353 A Direct-to-Patient Mailing about Sedative-Hypnotics and Online CBT-I: Participant Reported Use of Study Materials. Sleep 2021. [DOI: 10.1093/sleep/zsab072.352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Cognitive behavioral therapy for insomnia (CBT-I) is recommended as first-line treatment for chronic insomnia disorder for all adults. Older adults are often prescribed sedative-hypnotics (e.g., benzodiazepine receptor agonists, BRAs) for insomnia, despite observational studies showing these medications increase risk of falls, fractures, and cognitive decline. In an ongoing randomized controlled trial, we are testing “Sleep EducatioN Information Sent Directly to Patients (SEND),” a novel program combining direct-to-patient mailing with information about access to an online CBT-I resource, compared to a similarly structured control condition. In the current study, we surveyed participants in both groups to examine their self-reported use of intervention or control materials.
Methods
In the larger trial, 1,672 Veteran participants (aged >=65 years, receiving care from a Colorado VA facility, and prescribed a BRA) were randomized to receive the SEND intervention brochure with information on how to access a free, anonymous online CBT-I resource (n=836) or control condition brochure with information about general sleep education (n=836). Six months after the initial brochure mailing, all participants were mailed a blinded survey querying participants’ recollection and use of the mailed materials. We used chi-squared tests to compare survey responses for SEND versus control groups.
Results
354 surveys were returned by study participants (overall response rate: 21%; SEND: 172 [20%], control: 182 [22%]). Respondents were 94% male with mean age 71.7 years (no difference between groups). In the SEND group, 97 (56%) reported receiving the brochure, 18 (10%) visited the website, and 14 (8%) discussed the brochure with their provider. No significant differences between groups were observed in the number of participants who reported receiving the brochure (chi2=2.96, p=.085); visiting the website (chi2=0.0253, p=.874); or discussing the brochure with their provider (chi2=1.91, p=.167).
Conclusion
At 6-months follow-up, over half of participants recalled receiving a mailing about sedative-hypnotics. A modest number reported visiting the online CBT-I program and a similar number discussed the materials with their healthcare provider. Similar results between groups suggest successful blinding of the intervention and control participants. If successful, the SEND intervention may provide a low-touch, low-cost approach to address BRA over-use in some older adults.
Support (if any):
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Affiliation(s)
- Selene Mak
- VA Greater Los Angeles Healthcare System
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10
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Alessi CA, Fung CH, Dzierzewski JM, Fiorentino L, Stepnowsky C, Rodriguez Tapia JC, Song Y, Zeidler MR, Josephson K, Mitchell MN, Jouldjian S, Martin JL. Randomized controlled trial of an integrated approach to treating insomnia and improving the use of positive airway pressure therapy in veterans with comorbid insomnia disorder and obstructive sleep apnea. Sleep 2021; 44:zsaa235. [PMID: 33221910 PMCID: PMC8033453 DOI: 10.1093/sleep/zsaa235] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/26/2020] [Indexed: 12/11/2022] Open
Abstract
STUDY OBJECTIVES Cognitive behavioral therapy for insomnia (CBTI) for comorbid insomnia and obstructive sleep apnea (OSA) has had mixed results. We integrated CBTI with a positive airway pressure (PAP) adherence program and tested effects on sleep and PAP use. METHODS 125 veterans (mean age 63.2, 96% men, 39% non-Hispanic white, 26% black/African American, 18% Hispanic/Latino) with comorbid insomnia and newly-diagnosed OSA (apnea-hypopnea index ≥ 15) were randomized to 5-weekly sessions integrating CBTI with a PAP adherence program provided by a "sleep coach" (with behavioral sleep medicine supervision), or 5-weekly sleep education control sessions. Participants and assessment staff were blinded to group assignment. Outcomes (baseline, 3 and 6 months) included Pittsburgh Sleep Quality Index (PSQI), 7-day sleep diary (sleep onset latency [SOL-D], wake after sleep onset [WASO-D], sleep efficiency [SE-D]), 7-day actigraphy (SE-A), and objective PAP use (hours/night and nights ≥ 4 h). Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10) were also collected. RESULTS Compared to controls, intervention participants showed greater improvement (baseline to 3 and 6 months, respectively) in PSQI (-3.2 and -1.7), SOL-D (-16.2 and -15.5 minutes), SE-D (10.5% and 8.5%), SE-A (4.4% and 2.6%) and more 90-day PAP use (1.3 and 0.9 more hours/night, 17.4 and 11.3 more nights PAP ≥ 4 h). 90-day PAP use at 3 months was 3.2 and 1.9 h/night in intervention versus controls. Intervention participants also had greater improvements in ISI, ESS, and FOSQ-10 (all p < 0.05). CONCLUSIONS An intervention integrating CBTI with a PAP adherence program delivered by a supervised sleep coach improved sleep and PAP use in adults with comorbid insomnia and OSA. TRIAL REGISTRATION ClinicalTrials.govStudy name: Novel Treatment of Comorbid Insomnia and Sleep Apnea in Older VeteransURL: https://clinicaltrials.gov/ct2/results?cond=&term=NCT02027558&cntry=&state=&city=&dist=Registration: NCT02027558.
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Affiliation(s)
- Cathy A Alessi
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Constance H Fung
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | | | - Lavinia Fiorentino
- Department of Psychiatry, University of California, San Diego, San Diego, CA
| | - Carl Stepnowsky
- Department of Medicine, University of California, San Diego, San Diego, CA
- VA San Diego Healthcare System, San Diego, CA
| | | | - Yeonsu Song
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
- School of Nursing, University of California Los Angeles, Los Angeles, CA
| | - Michelle R Zeidler
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
- Pulmonary, Critical Care and Sleep Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Karen Josephson
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Michael N Mitchell
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Stella Jouldjian
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Jennifer L Martin
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
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11
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Song Y, Kelly MR, Fung CH, Dzierzewski JM, Grinberg A, Mitchell MN, Josephson K, Fiorentino L, Martin JL, Alessi CA. 0475 Reducing Dysfunctional Sleep-Related Cognitions Improves Nighttime Sleep and Daytime Consequences in Older Adults with Insomnia. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
The long-term impact of addressing sleep-related cognitions, which is an important component of cognitive behavioral therapy for insomnia (CBTI), has not been established, particularly in older adults. We examined whether specific changes in sleep-related cognitions predicted long-term changes in sleep and other outcomes following CBTI in older adults.
Methods
We analyzed data from a randomized controlled trial testing CBTI in older veterans with insomnia (N=159, mean age 72 years). Sleep-related cognitions were assessed with the Dysfunctional Beliefs and Attitudes about Sleep scale (DBAS, subscales: Consequences, Worry/Helplessness, Sleep Expectations, Medication). Outcome measures included the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), sleep diary variables, Flinders Fatigue Scale (FFS), and Short Form-12 health-related quality of life (QOL). Analyses completed slope of change in DBAS subscales (baseline to post-treatment: T1) between CBTI and control with respect to slope of change in sleep and other outcomes from post-treatment to 6-months (T2).
Results
Compared to controls, the CBTI group had significantly stronger associations between improvement (T1) in DBAS-Consequences and subsequent (T2) improvement in PSQI (difference in slopes [DIS]=0.9, 95%CI=[.29, 1.43], p=0.004), ISI (DIS=1.1, 95%CI=[.18, 2.0], p=0.019), ESS (DIS=0.6, 95%CI=[.10, 1.18], p=0.020), and FFS (DIS=1.9, 95%CI=[.76, 3.09], p=0.001). The CBTI group also had significantly stronger associations between improvement in DBAS-Worry/Helplessness and subsequent improvements in PSQI, ISI, and FFS; improvement in DBAS-Medication and PSQI and ISI; and improvement in DBAS-Sleep Expectations and improved FFS. Slopes were not different between groups for sleep diary variables or QOL.
Conclusion
Significant improvements in sleep-related cognitions with CBTI across DBAS subscales in older adults predicted improvement in several outcomes of nighttime sleep and daytime consequences. These findings suggest the importance of addressing dysfunctional sleep-related cognitions for sustained improvement with CBTI in older adults
Support
The study was supported by VA Health Services, Research and Development (Alessi, IIR 08-295), National Institute on Aging (K23AG055668, Song), National Heart, Lung, and Blood Institute (K24HL 143055, Martin) of the National Institutes of Health and VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center.
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Affiliation(s)
- Y Song
- University of California, Los Angeles, Los Angeles, CA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - M R Kelly
- VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - C H Fung
- University of California, Los Angeles, Los Angeles, CA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | | | - A Grinberg
- VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - M N Mitchell
- VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - K Josephson
- VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - L Fiorentino
- University of California, San Diego, San Diego, CA
| | - J L Martin
- University of California, Los Angeles, Los Angeles, CA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - C A Alessi
- University of California, Los Angeles, Los Angeles, CA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA
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12
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Carlson GC, Kelly MR, Josephson K, Mitchell M, Fiorentino L, McGowan S, Culver N, Kay M, Alessi C, Washington DL, Yano E, Martin JL. 0467 Benefits of CBT-I for Women Veterans with and without PTSD. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
A quarter of women Veterans (WVs) receiving VA healthcare meet diagnostic criteria for both insomnia disorder and posttraumatic stress disorder (PTSD). Cognitive Behavioral Therapy for Insomnia (CBT-I) is effective at improving sleep among individuals with comorbid psychiatric conditions; however, no studies have examined the impact of CBT-I in women with insomnia plus PTSD. The current analyses examined changes in sleep symptoms, quality of life (QoL), and mental health symptoms from pre- to post-CBT-I in WVs with and without PTSD.
Methods
This was a secondary analysis of 75 WVs with insomnia (32 with probable PTSD), who received CBT-I within a behavioral sleep intervention study (NCT02076165). Measures completed at baseline, posttreatment, and 3-month follow-up included: insomnia severity (Insomnia Severity Index, ISI), sleep quality (Pittsburgh Sleep Quality Index, PSQI), PTSD symptoms (PTSD Checklist-5, PCL-5; probable PTSD=total score ≥33), depressive symptoms (Patient Health Qestionnaire-9, PHQ-9), and mental and physical quality of life (Short Form Health Survey, SF-12). One sample T-tests examined changes in ISI, PSQI, PHQ-9, PCL-5, and SF-12 from baseline to posttreatment and baseline to follow-up. Two samples T-tests compared change scores in ISI, PSQI, PHQ-9, and SF-12 between participants with and without PTSD.
Results
There were significant improvements in ISI (p≤.001), PSQI (p≤.001), PHQ-9 (p≤.001), PCL-5 (p=.001), and SF-12 mental (p≤.001) and physical (p=.03) from baseline to posttreatment and 3-month follow-up (p≤.001-.01). There were no significant change score differences between WVs with and without PTSD from baseline to posttreatment (p=.06-.98) or 3-month follow-up (p=.09-.93).
Conclusion
CBT-I appears to be an effective treatment to improve insomnia symptoms among WVs with and without PTSD, and may reduce psychiatric symptoms as well. These findings suggest WVs with comorbid insomnia and PTSD benefit from CBT-I. The appropriate sequencing of CBT-I and PTSD treatments remains potentially important, but unstudied.
Support
VA/HSR&D IIR-HX002300; NIH/NHLBI K24HL14305; VA Office of Academic Affiliations through the Advanced Fellowship Programs in HSR&D and Women’s Health
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Affiliation(s)
- G C Carlson
- HSR&D Center for the Study Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - M R Kelly
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - K Josephson
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - M Mitchell
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - L Fiorentino
- University of California, San Diego, San Diego, CA
| | - S McGowan
- Department of Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Psychiatry, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
| | - N Culver
- Department of Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - M Kay
- Department of Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - C Alessi
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
| | - D L Washington
- HSR&D Center for the Study Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
| | - E Yano
- HSR&D Center for the Study Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA
| | - J L Martin
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
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13
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Song Y, Fung C, Dzierzewski J, Mitchell M, Josephson K, Fiorentino L, Martin J, Alessi C. REDUCING DYSFUNCTIONAL BELIEFS ABOUT SLEEP PROVIDES LONG-TERM BENEFIT IN OLDER ADULTS WITH INSOMNIA. Innov Aging 2019. [PMCID: PMC6845547 DOI: 10.1093/geroni/igz038.1938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Cognitive behavioral therapy for insomnia (CBTI) is recommended as first-line treatment in older adults. Changing dysfunctional beliefs and attitudes about sleep is an important component of CBTI, but the long-term impact of these changes are unknown, particularly in older adults. Methods involved secondary analyses of data from a large randomized controlled trial comparing CBTI (provided in 5 weekly sessions) to sleep education control, among older veterans with insomnia (N=159, mean age 72.2 years, 97% male, 79% non-Hispanic white). The purpose was to examine whether changes in a validated scale of Dysfunctional Beliefs and Attitudes about Sleep (DBAS) with CBTI treatment (baseline to post-treatment) was associated with later changes in self-reported sleep (post-treatment to 6 months follow-up). Sleep measures included Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS) and 7-day sleep diary measures. Analyses compared the slope of change in DBAS (baseline to post-treatment) between CBTI and control with respect to the slope of change in sleep outcomes (post-treatment to 6-months). Compared to controls, the CBTI group had stronger associations between DBAS improvement (baseline to post-treatment) and subsequent PSQI improvement (post-treatment to 6-months) (difference in slopes=1.3, 95% CI=[.52,2.1], p=0.001). This pattern of significant results was also found for ISI (difference in slopes=1.8, 95% CI=[.58,3.0], p=0.004) and ESS (difference in slopes=1.0, 95% CI=[.25,1.7], p=0.009). Slopes were not different for sleep diary measures. These findings suggest that changing dysfunctional beliefs and attitudes may continue to confer sleep benefits well after completion of CBT-I in older adults.
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Affiliation(s)
- Yeonsu Song
- School of Nursing, UCLA, Los Angeles, California, United States
| | - Constance Fung
- VA Greater Los Angeles Healthcare System, Los Angeles, California, United States
| | | | - Michael Mitchell
- VA Greater Los Angeles Healthcare System, North Hills, California, United States
| | - Karen Josephson
- VA Greater Los Angeles Healthcare System, Los Angeles, California, United States
| | - Lavinia Fiorentino
- VA Greater Los Angeles Healthcare System, Los Angeles, California, United States
| | - Jennifer Martin
- VA Greater Los Angeles Healthcare System, North Hills, California, United States
| | - Cathy Alessi
- VA Greater Los Angeles Healthcare System, Los Angeles, California, United States
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14
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Fung CH, Martin JL, Hays RD, Col N, Patterson ES, Josephson K, Mitchell MN, Grinberg A, Aysola R, Song Y, Dzierzewski JM, Liang LJ, Huang D, Zeidler M, Alessi C. Development of a Program Promoting Person-Centered Care of Older Adults with Sleep Apnea. J Am Geriatr Soc 2019; 67:2204-2207. [PMID: 31348531 DOI: 10.1111/jgs.16084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 06/27/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Constance H Fung
- VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, North Hills, California.,David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jennifer L Martin
- VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, North Hills, California.,David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ron D Hays
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | | | - Karen Josephson
- VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, North Hills, California
| | - Michael N Mitchell
- VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, North Hills, California
| | - Austin Grinberg
- VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, North Hills, California.,David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ravi Aysola
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Yeonsu Song
- VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, North Hills, California.,UCLA School of Nursing, Los Angeles, California
| | | | - Li-Jung Liang
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David Huang
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Michelle Zeidler
- VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, North Hills, California.,David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Cathy Alessi
- VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, North Hills, California.,David Geffen School of Medicine at UCLA, Los Angeles, California
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15
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Song Y, McCurry SM, Papazyan A, Lee D, Josephson K, Constance F, Irwin MR, Teng E, Alessi CA, Martin JL. P1-524: DEVELOPMENT OF A DYADIC SLEEP INTERVENTION FOR PERSONS WITH ALZHEIMER'S DISEASE AND THEIR CAREGIVERS. Alzheimers Dement 2019. [DOI: 10.1016/j.jalz.2019.06.1129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Yeonsu Song
- University of California, Los Angeles; Los Angeles CA USA
- VA Greater Los Angeles Healthcare System; North Hills CA USA
| | | | - Anna Papazyan
- University of California, Los Angeles; Los Angeles CA USA
- VA Greater Los Angeles Healthcare System; North Hills CA USA
| | - Diane Lee
- VA Greater Los Angeles Healthcare System; North Hills CA USA
| | - Karen Josephson
- VA Greater Los Angeles Healthcare System; North Hills CA USA
| | - Fung Constance
- University of California, Los Angeles; Los Angeles CA USA
- VA Greater Los Angeles Healthcare System; North Hills CA USA
| | | | | | - Cathy A. Alessi
- University of California, Los Angeles; Los Angeles CA USA
- VA Greater Los Angeles Healthcare System; North Hills CA USA
| | - Jennifer L. Martin
- University of California, Los Angeles; Los Angeles CA USA
- VA Greater Los Angeles Healthcare System; North Hills CA USA
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16
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Dzierzewski JM, Martin JL, Fung CH, Song Y, Fiorentino L, Jouldjian S, Rodriguez JC, Mitchell M, Josephson K, Alessi CA. CBT for late-life insomnia and the accuracy of sleep and wake perceptions: Results from a randomized-controlled trial. J Sleep Res 2019; 28:e12809. [PMID: 30609099 DOI: 10.1111/jsr.12809] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/25/2018] [Accepted: 11/09/2018] [Indexed: 01/26/2023]
Abstract
Subjective and objective estimates of sleep are often discordant among individuals with insomnia who typically under-report sleep time and over-report wake time at night. This study examined the impact and durability of cognitive-behavioural therapy for insomnia on improving the accuracy of sleep and wake perceptions in older adults, and tested whether changes in sleep quality were related to changes in the accuracy of sleep/wake perceptions. One-hundred and fifty-nine older veterans (97% male, mean age 72.2 years) who met diagnostic criteria for insomnia disorder were randomized to: (1) cognitive-behavioural therapy for insomnia (n = 106); or (2) attention control (n = 53). Assessments were conducted at baseline, post-treatment, 6-months and 12-months follow-up. Sleep measures included objective (via wrist actigraphy) and subjective (via self-report diary) total sleep time and total wake time, along with Pittsburgh Sleep Quality Index score. Discrepancy was computed as the difference between objective and subjective estimates of wake and sleep. Minutes of discrepancy were compared between groups across time, as were the relationships between Pittsburgh Sleep Quality Index scores and subsequent changes in discrepancy. Compared with controls, participants randomized to cognitive-behavioural therapy for insomnia became more accurate (i.e. minutes discrepancy was reduced) in their perceptions of sleep/wake at post-treatment, 6-months and 12-months follow-up (p < .05). Improved Pittsburgh Sleep Quality Index scores at each study assessment preceded and predicted reduced discrepancy at the next study assessment (p < .05). Cognitive-behavioural therapy for insomnia reduces sleep/wake discrepancy among older adults with insomnia. The reductions may be driven by improvements in sleep quality. Improving sleep quality appears to be a viable path to improving sleep perception and may contribute to the underlying effectiveness of cognitive-behavioural therapy for insomnia.
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Affiliation(s)
- Joseph M Dzierzewski
- Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jennifer L Martin
- David Geffen School of Medicine, University of California, Los Angeles, California, USA.,VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, Los Angeles, California, USA
| | - Constance H Fung
- David Geffen School of Medicine, University of California, Los Angeles, California, USA.,VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, Los Angeles, California, USA
| | - Yeonsu Song
- VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, Los Angeles, California, USA
| | - Lavinia Fiorentino
- School of Medicine, Psychiatry Department, University of California, San Diego, California, USA
| | - Stella Jouldjian
- VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, Los Angeles, California, USA
| | - Juan Carlos Rodriguez
- David Geffen School of Medicine, University of California, Los Angeles, California, USA.,VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, Los Angeles, California, USA.,Department of Internal Medicine, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Michael Mitchell
- VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, Los Angeles, California, USA
| | - Karen Josephson
- VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, Los Angeles, California, USA
| | - Cathy A Alessi
- David Geffen School of Medicine, University of California, Los Angeles, California, USA.,VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, Los Angeles, California, USA
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17
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Yeung T, Martin JL, Fung CH, Fiorentino L, Dzierzewski JM, Rodriguez Tapia JC, Song Y, Josephson K, Jouldjian S, Mitchell MN, Alessi C. Sleep Outcomes With Cognitive Behavioral Therapy for Insomnia Are Similar Between Older Adults With Low vs. High Self-Reported Physical Activity. Front Aging Neurosci 2018; 10:274. [PMID: 30271340 PMCID: PMC6146107 DOI: 10.3389/fnagi.2018.00274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/27/2018] [Indexed: 11/13/2022] Open
Abstract
We examined whether baseline self-reported physical activity is associated with the efficacy of cognitive behavioral therapy for insomnia (CBT-I) in older veterans. Community-dwelling veterans aged 60 years and older with insomnia received CBT-I in a randomized controlled trial. Participants who received active treatment were divided into low and high physical activity based on self-report. Sleep outcomes were measured by sleep diary, questionnaire and wrist actigraphy; collected at baseline, post-treatment, 6-month and 12-month follow-up. Mixed-effects models compared differences between physical activity groups in change in sleep outcome from baseline to each follow-up, and equivalence tests examined if physical activity groups were clinically equal. There were no significant differences in sleep outcomes between physical activity groups. Equivalence tests suggested possible equality in physical activity groups for five of seven sleep outcomes. Efficacy of CBT-I in older veterans was not associated with self-reported physical activity at baseline. Older adults with insomnia who report low levels of physical activity can benefit from CBT-I.
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Affiliation(s)
- Timothy Yeung
- Washington & Jefferson College, Washington, PA, United States
| | - Jennifer L Martin
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, North Hills, CA, United States.,Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Constance H Fung
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, North Hills, CA, United States.,Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Lavinia Fiorentino
- Department of Psychiatry, University of California, San Diego, San Diego, CA, United States
| | - Joseph M Dzierzewski
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, United States
| | - Juan C Rodriguez Tapia
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States.,Department of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Yeonsu Song
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, North Hills, CA, United States.,Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Karen Josephson
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, North Hills, CA, United States
| | - Stella Jouldjian
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, North Hills, CA, United States
| | - Michael N Mitchell
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, North Hills, CA, United States
| | - Cathy Alessi
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, North Hills, CA, United States.,Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
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Alessi CA, Martin JL, Fung CH, Dzierzewski JM, Fiorentino L, Stepnowsky C, Song Y, Rodriguez JC, Zeidler M, Mitchell M, Jouldjian S, Josephson K. 0407 Randomized Controlled Trial of an Integrated Behavioral Treatment in Veterans with Obstructive Sleep Apnea and Coexisting Insomnia. Sleep 2018. [DOI: 10.1093/sleep/zsy061.406] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- C A Alessi
- VA Greater Los Angeles, Los Angeles, CA
- University of California, Los Angeles, Los Angeles, CA
| | - J L Martin
- VA Greater Los Angeles, Los Angeles, CA
- University of California, Los Angeles, Los Angeles, CA
| | - C H Fung
- VA Greater Los Angeles, Los Angeles, CA
- University of California, Los Angeles, Los Angeles, CA
| | | | - L Fiorentino
- University of California, San Diego, San Diego, CA
| | - C Stepnowsky
- University of California, San Diego, San Diego, CA
- VA San Diego, San Diego, CA
| | - Y Song
- University of California, Los Angeles, Los Angeles, CA
| | - J C Rodriguez
- Pontificia Universidad Catolica de Chile, Santiago, CHILE
| | - M Zeidler
- VA Greater Los Angeles, Los Angeles, CA
- University of California, Los Angeles, Los Angeles, CA
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Fung CH, Alessi C, Mitchell MN, Vaughan EC, Huang AJ, Markland AD, Mc Gowan S, Lee D, Song Y, Jouldjian S, Josephson K, Martin JL. 0913 Nocturia Improves Among Women Treated With Behavioral Therapy For Insomnia. Sleep 2018. [DOI: 10.1093/sleep/zsy061.912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- C H Fung
- VA Greater Los Angeles, North Hills, CA
- UCLA, Los Angeles, CA
| | - C Alessi
- VA Greater Los Angeles, North Hills, CA
- UCLA, Los Angeles, CA
| | | | | | | | - A D Markland
- VA Birmingham, Birmingham, AL
- University of Alabama at Birminghman, Birmingham, AL
| | | | - D Lee
- VA Greater Los Angeles, North Hills, CA
| | - Y Song
- VA Greater Los Angeles, North Hills, CA
| | | | | | - J L Martin
- VA Greater Los Angeles, North Hills, CA
- UCLA, Los Angeles, CA
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Fung CH, Martin JL, Josephson K, Fiorentino L, Dzierzewski JM, Jouldjian S, Song Y, Rodriguez Tapia JC, Mitchell MN, Alessi CA. Cognitive Expectancies for Hypnotic Use among Older Adult Veterans with Chronic Insomnia. Clin Gerontol 2018; 41:130-135. [PMID: 28960164 PMCID: PMC5775935 DOI: 10.1080/07317115.2017.1356895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To examine relationships between cognitive expectancies about sleep and hypnotics and use of medications commonly used for insomnia (hypnotics). METHODS We analyzed baseline data from older veterans who met diagnostic criteria for insomnia and were enrolled in a trial comparing CBTI delivered by a supervised, sleep educator to an attention control condition (N = 159; 97% male, mean age 72 years). We classified individuals as hypnotic users (N = 23) vs. non-users (N = 135) based upon medication diaries. Associations between hypnotic status and Dysfunctional Beliefs and Attitudes about Sleep-16 (DBAS) total score (0-10, higher = worse) and two DBAS medication item scores (Item 1: "…better off taking a sleeping pill rather than having a poor night's sleep;" Item 2: "Medication… probably the only solution to sleeplessness"; 0-10, higher = worse) were examined in logistic regression models. RESULTS Higher scores on the DBAS medication items (both odds ratios = 1.3; p-values < .001) were significantly associated with hypnotic use. DBAS-16 total score was not associated with hypnotic use. CONCLUSION Cognitive expectancy (dysfunctional beliefs) about hypnotics was associated with hypnotic use in older adults with chronic insomnia disorder. CLINICAL IMPLICATIONS Strategies that specifically target dysfunctional beliefs about hypnotics are needed and may impact hypnotic use in older adults.
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Affiliation(s)
- Constance H Fung
- a Geriatric Research, Education and Clinical Center , VA Greater Los Angeles Healthcare System , Los Angeles , California , USA.,b David Geffen School of Medicine at UCLA , Los Angeles , California , USA
| | - Jennifer L Martin
- a Geriatric Research, Education and Clinical Center , VA Greater Los Angeles Healthcare System , Los Angeles , California , USA.,b David Geffen School of Medicine at UCLA , Los Angeles , California , USA
| | - Karen Josephson
- a Geriatric Research, Education and Clinical Center , VA Greater Los Angeles Healthcare System , Los Angeles , California , USA
| | - Lavinia Fiorentino
- c School of Medicine , University of California , San Diego, San Diego , California , USA
| | - Joseph M Dzierzewski
- a Geriatric Research, Education and Clinical Center , VA Greater Los Angeles Healthcare System , Los Angeles , California , USA.,d Department of Psychology , Virginia Commonwealth University , Richmond , Virginia , USA
| | - Stella Jouldjian
- a Geriatric Research, Education and Clinical Center , VA Greater Los Angeles Healthcare System , Los Angeles , California , USA
| | - Yeonsu Song
- b David Geffen School of Medicine at UCLA , Los Angeles , California , USA
| | | | - Michael N Mitchell
- a Geriatric Research, Education and Clinical Center , VA Greater Los Angeles Healthcare System , Los Angeles , California , USA
| | - Cathy A Alessi
- a Geriatric Research, Education and Clinical Center , VA Greater Los Angeles Healthcare System , Los Angeles , California , USA.,b David Geffen School of Medicine at UCLA , Los Angeles , California , USA
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Abstract
Patient-provider communication impacts adherence to therapy. We explored older adults' communication with their providers, preferences for communication, and views on communication attributes and decision aid characteristics, by conducting four focus groups. Several participants reported they had received insufficient information about their sleep apnea diagnosis and treatment options. Most participants felt that it would be helpful to have treatment information tailored to their needs, including information on the negative impact of treatment on comfort and convenience and disclosure about common barriers to adherence. Participants provided desired characteristics for a decision aid, including their preferred delivery method, content, and format. These findings have implications for how to design useful decision aids for older adults with newly diagnosed sleep apnea.
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Affiliation(s)
- Constance H. Fung
- VA Greater Los Angeles Healthcare System, 16111 Plummer Street (11E GRECC), North Hills, CA 91343
- Division of Geriatrics, David Geffen School of Medicine at UCLA, 16111 Plummer Street (11E GRECC), North Hills, CA 91343
| | - Cathy Alessi
- VA Greater Los Angeles Healthcare System, 16111 Plummer Street (11E GRECC), North Hills, CA 91343
- Division of Geriatrics, David Geffen School of Medicine at UCLA, 16111 Plummer Street (11E GRECC), North Hills, CA 91343
| | - Cindy Truong
- VA Greater Los Angeles Healthcare System, 16111 Plummer Street (11E GRECC), North Hills, CA 91343
- Division of Geriatrics, David Geffen School of Medicine at UCLA, 16111 Plummer Street (11E GRECC), North Hills, CA 91343
| | - Karen Josephson
- VA Greater Los Angeles Healthcare System, 16111 Plummer Street (11E GRECC), North Hills, CA 91343
| | - Ron D. Hays
- Division of General Internal Medicine and Health Services Research, UCLA Department of Medicine, 911 Broxton Avenue, Los Angeles, CA 90095
| | - Nananda Col
- University of New England, 11 Hills Beach Road, Biddeford, ME 04005
| | - Emily S. Patterson
- School of Health and Rehabilitation Sciences, Ohio State University, 543 Atwell Hall, 453 W. 10 Avenue, Columbus, OH 43210
| | - Jennifer L. Martin
- VA Greater Los Angeles Healthcare System, 16111 Plummer Street (11E GRECC), North Hills, CA 91343
- Division of Geriatrics, David Geffen School of Medicine at UCLA, 16111 Plummer Street (11E GRECC), North Hills, CA 91343
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Fung CH, Martin JL, Hays RD, Patterson ES, Aysola R, Col N, Mitchell MN, Truong C, Dzierzewski JM, Jouldjian S, Song Y, Rodriguez JC, Josephson K, Alessi C. Patient-Reported Usability of Positive Airway Pressure Equipment Is Associated With Adherence in Older Adults. Sleep 2017; 40:2970288. [PMID: 28364429 DOI: 10.1093/sleep/zsx007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Study objectives To examine the usability of positive airway pressure (PAP) devices and its association with PAP adherence among older adults with sleep-disordered breathing. Methods We mailed questionnaires to patients aged ≥65 years prescribed PAP therapy during the prior 36 months from two large healthcare systems. Survey participants completed the Usability of Sleep Apnea Equipment-Positive Airway Pressure (USE-PAP) questionnaire, which assessed the usability of their PAP device. Other questionnaire items included demographics and self-rated health. We also abstracted adherence data (mean nightly hours of PAP use available from one site) and interface type from the electronic health record. Results Five hundred sixty-four patients completed the survey (response rate = 33%). The mean USE-PAP score (0 = best to 100 = worst) was 20 (SD ± 20). Mean duration of PAP use (available in 189 respondents) was 5.2 hours per night (SD ± 2.0). In a nested regression model predicting nightly hours of PAP use, a 10-point (0.5 SD) increase in USE-PAP score corresponded to a 0.37 hour/night reduction in PAP use. The model including the USE-PAP score explained a significant proportion (R2 = 15%) of the variation in nightly hours of PAP use above and beyond demographics, self-reported health, and interface type (∆R2 = 12%). Conclusions Our results demonstrate that PAP usability varies among older patients and is associated with PAP adherence, above and beyond other predictors of adherence. These results support measuring and improving PAP usability to further improve PAP adherence for older patients.
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Affiliation(s)
- Constance H Fung
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jennifer L Martin
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ron D Hays
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Emily S Patterson
- School of Health and Rehabilitation Sciences, Ohio State University, Columbus, Ohio
| | - Ravi Aysola
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Michael N Mitchell
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Cindy Truong
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Joseph M Dzierzewski
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Psychology, Virginia Commonwealth University, Richmond, Virginia
| | - Stella Jouldjian
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Yeonsu Song
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Juan Carlos Rodriguez
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California.,Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Karen Josephson
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Cathy Alessi
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
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Song Y, Dzierzewski J, Fung C, Rodriguez J, Jouldjian S, Josephson K, Alessi C, Martin J. SLEEP AND CAREGIVING AMONG ADULT DAY HEALTH CARE PROGRAM CAREGIVERS: A PILOT STUDY. Innov Aging 2017. [DOI: 10.1093/geroni/igx004.2927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Y. Song
- VA Greater Los Angeles Healthcare System, North Hills, California,
- University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California,
| | - J.M. Dzierzewski
- Virginia Commonwealth University, Department of Psychology, Richmond, Virginia,
| | - C. Fung
- VA Greater Los Angeles Healthcare System, North Hills, California,
- University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California,
| | - J.C. Rodriguez
- VA Greater Los Angeles Healthcare System, North Hills, California,
- Pontificia Universidad Catolica, Santiago, Chile
| | - S. Jouldjian
- VA Greater Los Angeles Healthcare System, North Hills, California,
| | - K. Josephson
- VA Greater Los Angeles Healthcare System, North Hills, California,
| | - C.A. Alessi
- VA Greater Los Angeles Healthcare System, North Hills, California,
- University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California,
| | - J.L. Martin
- VA Greater Los Angeles Healthcare System, North Hills, California,
- University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California,
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Petro A, Dzierzewski JM, Martin JL, Alessi C, Jouldjian S, Josephson K, Suarez A, Fung C. 0573 A SURVEY TO ASSESS PATIENTS’ INTEREST IN THE DIDGERIDOO AS AN ALTERNATIVE THERAPY FOR OBSTRUCTIVE SLEEP APNEA. Sleep 2017. [DOI: 10.1093/sleepj/zsx050.572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Alessi CA, Martin JL, Fung CH, Dzierzewski JM, Rodriguez Tapia JC, Song Y, Fiorentino L, Stepnowsky C, Zeidler M, Jouldjian S, Mitchell M, Josephson K. 0329 INSOMNIA PREVALENCE AMONG VETERANS REFERRED FOR DIAGNOSTIC TESTING FOR SLEEP DISORDERED BREATHING. Sleep 2017. [DOI: 10.1093/sleepj/zsx050.328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Fung CH, Jackson N, Martin JL, Col N, Hays RD, Patterson ES, Jouldjian S, Josephson K, Alessi C. 1190 OLDER ADULTS’ PREFERENCES FOR OBSTRUCTIVE SLEEP APNEA TREATMENT ELICITED FROM A PILOT DISCRETE CHOICE EXPERIMENT. Sleep 2017. [DOI: 10.1093/sleepj/zsx050.1189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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27
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Carballo NJ, Alessi CA, Martin JL, Mitchell MN, Hays RD, Col N, Patterson ES, Jouldjian S, Josephson K, Fung CH. Perceived Effectiveness, Self-efficacy, and Social Support for Oral Appliance Therapy Among Older Veterans With Obstructive Sleep Apnea. Clin Ther 2016; 38:2407-2415. [PMID: 27751674 DOI: 10.1016/j.clinthera.2016.09.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/15/2016] [Accepted: 09/22/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE Obstructive sleep apnea is a prevalent sleep disorder among older adults. Oral appliances are increasingly prescribed as therapy for obstructive sleep apnea. Adherence to oral appliance therapy is highly variable. Based on value-expectancy theory and other social-psychological theories, adherence to oral appliance therapy may be influenced by patients' perceived effectiveness of the therapy, self-efficacy, and availability of social support. We examined these perceptions among older adults with obstructive sleep apnea who were prescribed oral appliance therapy. METHODS We mailed surveys to all patients aged ≥65 years who had been prescribed oral appliance therapy for obstructive sleep apnea over the prior 36 months at a Veterans Affairs medical center. We examined frequencies of responses to items that assessed perceived effectiveness, self-efficacy, and social support for nightly use of oral appliances from friends, family, or health care staff. FINDINGS Thirty-nine individuals responded (response rate, 30%; mean [SD] age 71.4 [SD 6.3] years; 97% male). Thirty-six percent of the respondents perceived regular use of oral appliance therapy to be effective in managing obstructive sleep apnea; 39% agreed that they felt confident about using oral appliances regularly; 41% felt supported by people in their life in using oral appliance therapy; and 38% agreed that health care staff would help them to use their oral appliance regularly. These rates represented less than half of respondents despite the finding that 65% of patients believed that they would use their oral appliance regularly. IMPLICATIONS Although oral appliance therapy is increasingly prescribed for obstructive sleep apnea, only about one third of older adults prescribed it perceived it to be an effective treatment, were confident about oral appliance use, and/or believed that they would receive needed support. Future research is needed to better understand older adults' perceptions so that interventions can be designed to improve the effectiveness of oral appliances, their self-efficacy for using oral appliances, and their social support for this therapy, which may, in turn, improve oral appliance therapy adherence.
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Affiliation(s)
- Nancy J Carballo
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; David Geffen School of Medicine, University of California, Los Angeles.
| | - Cathy A Alessi
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; Department of Medicine, University of California, Los Angeles, California; David Geffen School of Medicine, University of California, Los Angeles
| | - Jennifer L Martin
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; David Geffen School of Medicine, University of California, Los Angeles
| | - Michael N Mitchell
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Ron D Hays
- Department of Medicine, University of California, Los Angeles, California
| | - Nananda Col
- Center of Excellence in the Neurosciences, University of New England, Biddeford, Maine
| | - Emily S Patterson
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio
| | - Stella Jouldjian
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Karen Josephson
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Constance H Fung
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; Department of Medicine, University of California, Los Angeles, California; David Geffen School of Medicine, University of California, Los Angeles
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Alessi C, Martin JL, Fiorentino L, Fung CH, Dzierzewski JM, Rodriguez Tapia JC, Song Y, Josephson K, Jouldjian S, Mitchell MN. Cognitive Behavioral Therapy for Insomnia in Older Veterans Using Nonclinician Sleep Coaches: Randomized Controlled Trial. J Am Geriatr Soc 2016; 64:1830-8. [PMID: 27550552 DOI: 10.1111/jgs.14304] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To test a new cognitive behavioral therapy for insomnia (CBT-I) program designed for use by nonclinicians. DESIGN Randomized controlled trial. SETTING Department of Veterans Affairs healthcare system. PARTICIPANTS Community-dwelling veterans aged 60 and older who met diagnostic criteria for insomnia of 3 months duration or longer (N = 159). INTERVENTION Nonclinician "sleep coaches" delivered a five-session manual-based CBT-I program including stimulus control, sleep restriction, sleep hygiene, and cognitive therapy (individually or in small groups), with weekly telephone behavioral sleep medicine supervision. Controls received five sessions of general sleep education. MEASUREMENTS Primary outcomes, including self-reported (7-day sleep diary) sleep onset latency (SOL-D), wake after sleep onset (WASO-D), total wake time (TWT-D), and sleep efficiency (SE-D); Pittsburgh Sleep Quality Index (PSQI); and objective sleep efficiency (7-day wrist actigraphy, SE-A) were measured at baseline, at the posttreatment assessment, and at 6- and 12-month follow-up. Additional measures included the Insomnia Severity Index (ISI), depressive symptoms (Patient Health Questionnaire-9 (PHQ-9)), and quality of life (Medical Outcomes Study 12-item Short-form Survey version 2 (SF-12v2)). RESULTS Intervention subjects had greater improvement than controls between the baseline and posttreatment assessments, the baseline and 6-month assessments, and the baseline and 12-month assessments in SOL-D (-23.4, -15.8, and -17.3 minutes, respectively), TWT-D (-68.4, -37.0, and -30.9 minutes, respectively), SE-D (10.5%, 6.7%, and 5.4%, respectively), PSQI (-3.4, -2.4, and -2.1 in total score, respectively), and ISI (-4.5, -3.9, and -2.8 in total score, respectively) (all P < .05). There were no significant differences in SE-A, PHQ-9, or SF-12v2. CONCLUSION Manual-based CBT-I delivered by nonclinician sleep coaches improves sleep in older adults with chronic insomnia.
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Affiliation(s)
- Cathy Alessi
- Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California. .,Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California.
| | - Jennifer L Martin
- Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Lavinia Fiorentino
- Department of Psychiatry, University of California at San Diego, San Diego, California
| | - Constance H Fung
- Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Joseph M Dzierzewski
- Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Juan C Rodriguez Tapia
- Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California.,Department of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Yeonsu Song
- Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Karen Josephson
- Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Stella Jouldjian
- Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Michael N Mitchell
- Geriatric Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
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Fung CH, Martin JL, Hays RD, Rodriguez JC, Igodan U, Jouldjian S, Dzierzewski JM, Kramer BJ, Josephson K, Alessi C. Development of the Usability of Sleep Apnea Equipment-Positive Airway Pressure (USE-PAP) questionnaire. Sleep Med 2015; 16:645-51. [PMID: 25890783 DOI: 10.1016/j.sleep.2015.01.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 01/28/2015] [Accepted: 01/30/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND A growing number of positive airway pressure (PAP) device users will develop physical/sensory impairments such as arthritis. For these individuals, the usability of their PAP devices (e.g., efficiency and satisfaction) may impact the frequency and safety of device usage. Questionnaires to assess PAP usability are unavailable; therefore, we developed the Usability of Sleep Apnea Equipment-Positive Airway Pressure (USE-PAP) questionnaire. METHODS Questionnaire development included in-depth interviews to identify relevant content areas, a technical advisory panel to review/edit items, cognitive interviews to refine items, and a cross-sectional survey of Veterans Affairs sleep clinic patients assessing PAP device usability overall (one multi-item scale), usability of PAP components (multi-item scales for machine controls, mask/headgear, tubing, and humidifier), frequency of usability-related issues (one multi-item scale), PAP device characteristics, and demographics. RESULTS After conducting 19 in-depth interviews, a panel meeting, and 10 cognitive interviews, we administered the survey to 100 PAP device users (67% ≥60 years; 90% male). The items assessing machine control usability received the least favorable ratings. Twenty percent of respondents reported difficulty getting equipment ready for use, and 33 percent had difficulty cleaning equipment. The six multi-item scales had excellent internal consistency reliability (alpha ≥0.84) and item-rest correlations (≥0.39). CONCLUSIONS This study provides initial support for the USE-PAP for measuring PAP device usability. Studies that include large samples are needed to further evaluate the psychometric properties of the USE-PAP. In addition, comparisons of USE-PAP responses with direct observations of PAP-related tasks and objectively measured PAP adherence are needed to fully evaluate the questionnaire.
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Affiliation(s)
- Constance H Fung
- Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - Jennifer L Martin
- Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ron D Hays
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Juan Carlos Rodriguez
- Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Medicine Department, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Uyi Igodan
- Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Stella Jouldjian
- Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Joseph M Dzierzewski
- Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - B Josea Kramer
- Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Karen Josephson
- Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Cathy Alessi
- Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Fung CH, Igodan U, Alessi C, Martin JL, Dzierzewski JM, Josephson K, Kramer BJ. Human factors/usability barriers to home medical devices among individuals with disabling conditions: in-depth interviews with positive airway pressure device users. Disabil Health J 2014; 8:86-92. [PMID: 25126995 DOI: 10.1016/j.dhjo.2014.06.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 05/19/2014] [Accepted: 06/17/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Evidence suggests that medical equipment often fails to accommodate the needs of individuals with disabling conditions. Few studies have focused on the accessibility of home medical devices such as positive airway pressure (PAP), which is a type of home medical equipment prescribed for long-term therapy. OBJECTIVE The purpose of this study was to explore in detail the types of difficulties experienced by patients with physical/sensory impairments who use PAP devices, as an initial step in designing a questionnaire to survey users about this topic. METHODS In this descriptive study, in-depth interviews were conducted with 19 participants (9 patients with physical/sensory impairment and 10 health care providers). Interviews were coded and analyzed for major topics. RESULTS Participants detailed the numerous ways in which current PAP devices fail to meet the needs of individuals with physical/sensory impairments (e.g., tremor, poor depth perception, paresis), by requiring patients to perform manually difficult tasks, such as inserting PAP parts through small apertures, attaching parts using a twisting motion, and lifting arms overhead to apply PAP headgear. These demands contributed to patients' frustration with and reduced usage of the home medical device. CONCLUSIONS Our findings suggest that home medical devices such as PAP may not be currently designed to meet the needs of some users with physical/sensory impairments. Additional studies are needed to measure the prevalence and impact of impairment-related barriers on PAP adherence for this common medical equipment.
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Affiliation(s)
- Constance H Fung
- David Geffen School of Medicine at University of California, Los Angeles, 16111 Plummer Street (11E), North Hills, CA 91343, USA; Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, 16111 Plummer Street (11E), North Hills, CA 91343, USA.
| | - Uyi Igodan
- Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, 16111 Plummer Street (11E), North Hills, CA 91343, USA
| | - Cathy Alessi
- David Geffen School of Medicine at University of California, Los Angeles, 16111 Plummer Street (11E), North Hills, CA 91343, USA; Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, 16111 Plummer Street (11E), North Hills, CA 91343, USA
| | - Jennifer L Martin
- David Geffen School of Medicine at University of California, Los Angeles, 16111 Plummer Street (11E), North Hills, CA 91343, USA; Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, 16111 Plummer Street (11E), North Hills, CA 91343, USA
| | - Joseph M Dzierzewski
- David Geffen School of Medicine at University of California, Los Angeles, 16111 Plummer Street (11E), North Hills, CA 91343, USA; Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, 16111 Plummer Street (11E), North Hills, CA 91343, USA
| | - Karen Josephson
- Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, 16111 Plummer Street (11E), North Hills, CA 91343, USA
| | - B Josea Kramer
- David Geffen School of Medicine at University of California, Los Angeles, 16111 Plummer Street (11E), North Hills, CA 91343, USA; Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, 16111 Plummer Street (11E), North Hills, CA 91343, USA
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Fung CH, Martin JL, Dzierzewski JM, Jouldjian S, Josephson K, Park M, Alessi C. Prevalence and symptoms of occult sleep disordered breathing among older veterans with insomnia. J Clin Sleep Med 2013; 9:1173-8. [PMID: 24235899 DOI: 10.5664/jcsm.3162] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
STUDY OBJECTIVES To determine the prevalence of occult sleep disordered breathing (SDB) and describe the relationship between classic SDB symptoms (e.g., loud snoring) and occult SDB in older veterans with insomnia. METHODS We analyzed baseline survey and in-home sleep study data for 435 veterans (mean age = 72.0 years [SD 8.0]) who had no known history of SDB, met International Classification of Sleep Disorders 2(nd) Edition criteria for insomnia, and were enrolled in a behavioral intervention trial for insomnia. Variables of interest included apnea-hypopnea index (AHI) ≥ 15, age, race/ethnicity, marital status, body mass index (BMI), insomnia subtype (i.e., onset, maintenance, or terminal), self-reported excessive daytime sleepiness, snoring, and witnessed breathing pause items from the Berlin Questionnaire. We computed the frequency of AHI ≥ 15 and assessed whether each classic SDB symptom was associated with an AHI ≥ 15 in 4 separate multivariate logistic regression models. RESULTS Prevalence of AHI ≥ 15 was 46.7%. Excessive daytime sleepiness (adjusted odds ratio 1.63, 95% CI 1.02, 2.60, p = 0.04), but not snoring loudness, snoring frequency, or witnessed breathing pauses was associated with occult SDB (AHI ≥ 15). Insomnia subtypes were not significantly associated with occult SDB (p > 0.38). CONCLUSIONS In our sample of older veterans with insomnia, nearly half had occult SDB, which was characterized by reported excessive daytime sleepiness, but not loud or frequent snoring or witnessed breathing pauses. Insomnia subtype was unrelated to the presence of occult SDB.
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Affiliation(s)
- Constance H Fung
- Geriatric Research, Education and Clinical Center (GRECC): Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, CA ; David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
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Razani J, Bayan S, Funes C, Mahmoud N, Torrence N, Wong J, Alessi C, Josephson K. Patterns of deficits in daily functioning and cognitive performance of patients with Alzheimer disease. J Geriatr Psychiatry Neurol 2011; 24:23-32. [PMID: 21164171 PMCID: PMC5646669 DOI: 10.1177/0891988710390812] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Previous research has identified patterns of cognitive deficits in patients with Alzheimer disease (AD), but little is known about their pattern of daily functional impairment. A total of 49 patients with AD and 52 healthy elderly controls were administered neuropsychological tests as well as the Direct Assessment of Functional Status (DAFS) test, an observation-based test of activities of daily living (ADLs). In this project, we assessed 14 separate tasks assessed by the DAFS. To analyze the data, 4 cognitive domains were created using neuropsychological composite z scores (means and standard deviation obtained from control data) for patients with AD. Results revealed that patients with AD performed worse on the memory, language, and visual-spatial relative to the executive domain. Additionally, patients with AD performed poorer than the controls on nearly all 14 DAFS tasks, with their worse performance being on the shopping-related tasks which, in part, requires memory skills. Logistic regression revealed better specificity than sensitivity classifications based on the DAFS tasks, and stepwise regression analyses indicated that cognitive domains predicted specific aspects of functional abilities. These findings suggest that patients with AD display a distinct pattern of ADLs performance, that traditional neuropsychological tests are useful in predicting daily functioning, and the DAFS has some strengths and weaknesses in classifying AD and controls.
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Affiliation(s)
- Jill Razani
- Department of Psychology, California State University, Northridge, CA 91330, USA.
| | - Stacey Bayan
- Department of Psychology, California State University, Northridge, CA, USA
| | - Cynthia Funes
- Department of Psychology, California State University, Northridge, CA, USA
| | - Nouran Mahmoud
- Department of Psychology, California State University, Northridge, CA, USA
| | - Nicole Torrence
- Department of Psychology, California State University, Northridge, CA, USA
| | | | - Cathy Alessi
- VA Greater Los Angeles Healthcare System Geriatric Research, Education and Clinical Center and Department of Medicine, University of California, Los Angeles, CA, USA
| | - Karen Josephson
- VA Greater Los Angeles Healthcare System Geriatric Research, Education and Clinical Center and Department of Medicine, University of California, Los Angeles, CA, USA
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Razani J, Wong JT, Dafaeeboini N, Edwards-Lee T, Lu P, Alessi C, Josephson K. Predicting everyday functional abilities of dementia patients with the Mini-Mental State Examination. J Geriatr Psychiatry Neurol 2009; 22:62-70. [PMID: 19196632 PMCID: PMC2679691 DOI: 10.1177/0891988708328217] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The Mini-Mental State Examination is a widely used cognitive screening measure. The purpose of the present study was to assess how 5 specific clusters of Mini-Mental State Examination items (ie, subscores) correlate with and predict specific areas of daily functioning in dementia patients, 61 patients with varied forms of dementia were administered the Mini-Mental State Examination and an observation-based daily functional test (the Direct Assessment of Functional Status). The results revealed that the orientation and attention subscores of the Mini-Mental State Examination correlated most significantly with most functional domains. The Mini-Mental State Examination language items correlated with all but the shopping and time orientation tasks, while the Mini-Mental State Examination recall items correlated with the Direct Assessment of Functional Status time orientation and shopping tasks. Stepwise regression analyses found that among the Mini-Mental State Examination subscores, orientation was the single, best independent predictor of daily functioning.
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Affiliation(s)
- Jill Razani
- Department of Psychology, California State University, Northridge, California 91330, USA.
| | | | | | - Terri Edwards-Lee
- Harbor-UCLA Medical Center Department of Neurology, David Geffen School of Medicine at UCLA Department of Neurology, Los Angeles Biomedical Research Institute at Harbor UCLA Medical Center
| | - Po Lu
- University of California, Los Angeles
| | - Cathy Alessi
- VA Greater Los Angeles Healthcare System and Department of Medicine, University of California, Los Angeles
| | - Karen Josephson
- VA Greater Los Angeles Healthcare System and Department of Medicine, University of California, Los Angeles
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Razani J, Kakos B, Orieta-Barbalace C, Wong JT, Casas R, Lu P, Alessi C, Josephson K. Predicting caregiver burden from daily functional abilities of patients with mild dementia. J Am Geriatr Soc 2007; 55:1415-20. [PMID: 17767684 PMCID: PMC2288619 DOI: 10.1111/j.1532-5415.2007.01307.x] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To assess the relationship between performance- and informant-based measures of activities of daily living (ADLs) in patients with early dementia and burden or psychological distress experienced by the patients' caregivers. DESIGN Descriptive study. SETTING Ambulatory center. PARTICIPANTS Thirty-four patient-caregiver dyads in which the patient had mild dementia (Mini-Mental State Examination score >17). MEASUREMENTS A performance-based ADL measure (the Direct Assessment of Functional Status (DAFS)) was administered to patients with mild dementia. Caregivers completed an informant-based measure of patient functional status (instrumental activities of daily living). Caregivers also completed the Caregiver Burden Inventory (CBI) and the Brief Symptom Inventory (BSI). RESULTS Significant correlations were found between the informant-based ADL measure and caregiver burden (CBI) and psychological distress (BSI) (correlation coefficient (r)=-0.34 to -0.71, all P<.05). Alternatively, fewer and weaker relationships were observed between the DAFS (performance-based) ADL measure and caregiver burden or distress ratings (r=-0.32 to -0.43, all P<.05). Of the seven tasks assessed using the DAFS, impairments in orientation, communication, financial, and transportation skills in patients were associated with greater time and developmental burden and greater hostility in caregivers. Impairment in financial skills in patients was the strongest predictor of time-dependence burden and hostility in caregivers, whereas impairment in patient transportation skills was the best predictor of developmental burden. CONCLUSIONS The ADL abilities of cognitively impaired patients can predict caregiver burden and psychological distress, with informant-based measures having the greatest association with patient impairment.
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Affiliation(s)
- Jill Razani
- Department of Psychology, California State University, Northridge, Northridge, California 91330, USA.
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Razani J, Casas R, Wong JT, Lu P, Alessi C, Josephson K. Relationship between executive functioning and activities of daily living in patients with relatively mild dementia. Appl Neuropsychol 2007; 14:208-14. [PMID: 17848131 PMCID: PMC2384078 DOI: 10.1080/09084280701509125] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
There is very little research regarding the relationship between tests of executive functioning and actual functional ability in patients with dementia. Thirty-three patients diagnosed with dementia and 35 age- and education-matched healthy controls were administered tests of executing functioning and an observation- and informant-based activities of daily living (ADL). As expected, the results revealed that the controls outperformed the dementia patients on the executive and ADL tests. Additionally, executive functioning correlated significantly with aspects of functional ability in patients with dementia. This relationship was strongest for tests of verbal fluency and a complex test of cognitive flexibility and reasoning ability (i.e., Wisconsin Card Sorting Test). These findings suggest that some executive function tests are more sensitive than others for predicting specific functional abilities and that they may be most useful to healthcare professionals for treatment planning.
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Affiliation(s)
- Jill Razani
- Department of Psychology, California State University, Northridge, California 91330-8255, USA.
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v. Euler H, Josephson K. Zur Bezeichnung der enzymatischen Aktivität von enzym-haltigen Präparaten, Enzym-Lösungen und lebenden Zellen. ACTA ACUST UNITED AC 2006. [DOI: 10.1002/cber.19260590432] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Wang G, Gentry TJ, Grass G, Josephson K, Rensing C, Pepper IL. Real-time PCR quantification of a green fluorescent protein-labeled, genetically engineered Pseudomonas putida strain during 2-chlorobenzoate degradation in soil. FEMS Microbiol Lett 2004; 233:307-14. [PMID: 15063501 DOI: 10.1016/j.femsle.2004.02.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2003] [Revised: 02/23/2004] [Accepted: 02/28/2004] [Indexed: 09/30/2022] Open
Abstract
The potential for real-time PCR (RTm-PCR) detection of the genetically engineered strain Pseudomonas putida GN2 was studied during 2-chlorobenzoate (2-CB) degradation in three different soils. The strain contained the constructed plasmid pGN2 which encoded genes for 2-CB oxidation (cbdA) and the green fluorescent protein (gfp). P. putida GN2 numbers were assessed by plating onto 2-CB minimal media and also by RTm-PCR detection of cbdA and gfp. Addition of P. putida GN2 decreased the time required to degrade 2-CB in all tested soils by more than 7 days. The RTm-PCR estimations of P. putida GN2 numbers strongly correlated with those obtained from plate count methods during active 2-CB degradation. However, after 2-CB degradation in the soils had ceased, RTm-PCR estimations of cbdA and gfp genes were generally one order of magnitude lower than those from plate counts. These results indicate the potential for RTm-PCR to rapidly determine degrader numbers in soil following bioaugmentation but also the need to exercise caution when attempting to determine cell numbers of degraders from the RTm-PCR quantification of plasmid encoded genes after substrate is depleted.
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Affiliation(s)
- Gejiao Wang
- Department of Soil, Water and Environmental Science, University of Arizona, Tucson, AZ 85721, USA
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Wang G, Gentry TJ, Grass G, Josephson K, Rensing C, Pepper IL. Real-time PCR quantification of a green fluorescent protein-labeled, genetically engineeredPseudomonas putidastrain during 2-chlorobenzoate degradation in soil. FEMS Microbiol Lett 2004. [DOI: 10.1111/j.1574-6968.2004.tb09497.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Josephson K, McPherson DT, Walter MR. Purification, crystallization and preliminary X-ray diffraction of a complex between IL-10 and soluble IL-10R1. Acta Crystallogr D Biol Crystallogr 2001; 57:1908-11. [PMID: 11717514 DOI: 10.1107/s0907444901016249] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2001] [Accepted: 09/25/2001] [Indexed: 11/10/2022]
Abstract
A complex between interleukin-10 and the extracellular domain of its high-affinity receptor (sIL-10R1) has been crystallized from polyethylene glycol solutions. Crystals suitable for diffraction analysis required the modification of the NXS/T glycosylation sites on sIL-10R1 by site-directed mutagenesis and inclusion of the detergent cyclohexyl-methyl-beta-D-maltopyranoside in the crystallization experiments. The crystals belong to space group P3(2)12 or its enantimorph P3(1)12, with unit-cell parameters a = b = 46.23, c = 307.78 A, alpha = beta = 90, gamma = 120 degrees, and diffract X-rays to approximately 2.9 A. The IL-10 dimer is positioned on a crystallographic twofold, resulting in one IL-10 chain and one sIL-10R1 chain in the asymmetric unit, which corresponds to a solvent content of approximately 44%.
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Affiliation(s)
- K Josephson
- Center for Biophysical Sciences and Engineering, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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Abstract
Interleukin 10 (IL-10) is a dimeric cytokine that plays a central role in suppressing inflammatory responses. These activities are dependent on the interaction of IL-10 with its high-affinity receptor (IL-10R1). This intermediate complex must subsequently recruit the low-affinity IL-10R2 chain before cell signaling can occur. Here we report the 2.9 A crystal structure of IL-10 bound to a soluble form of IL-10R1 (sIL-10R1). The complex consists of two IL-10s and four sIL-10R1 molecules. Several residues in the IL-10/sIL-10R1 interface are conserved in all IL-10 homologs and their receptors. The data suggests that formation of the active IL-10 signaling complex occurs by a novel molecular recognition paradigm where IL-10R1 and IL-10R2 both recognize the same binding site on IL-10.
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Affiliation(s)
- K Josephson
- Center for Macromolecular Crystallography, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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Abstract
CONTEXT Pressure ulcers are an understudied problem in home care. OBJECTIVE To determine the prevalence of pressure ulcers among patients admitted to home care services, describe the demographic and health characteristics associated with pressure ulcers in this setting, and identify the percentage of these patients at risk for developing pressure ulcers. DESIGN Cross-sectional survey of patients on admission to home care agencies. SETTING Forty-one home care agencies in 14 states. PATIENTS A consecutive sample of 3,048 patients admitted March 1 through April 30, 1996 (86% of all admissions). Subjects had a mean age of 75 years; 63% were female and 85% white. MAIN OUTCOME MEASURES Demographic, social, and clinical characteristics, functional status (Katz activities of daily living scale and Lawton instrumental activities of daily living scale), mental status (Katzman Short Memory-Orientation-Concentration test), pressure ulcer risk (Braden Scale), pressure ulcer status (Bates-Jensen Pressure Ulcer Status Tool), and a checklist of pressure-reducing devices and wound care products being used. RESULTS In the total sample of 3,048 patients, 9.12% had pressure injuries: 37.4% had more than one ulcer and 14.0% had three or more ulcers. Considering the worst ulcer for each subject, 40.3% had Stage II and 27% had Stage III or IV injuries. Characteristics associated with pressure ulcers included recent institutional discharge, functional impairment, incontinence, and having had a previous ulcer. About 30% of subjects were at risk for new pressure ulcers. Pressure-relieving devices and other wound care strategies appeared to be underutilized and often indiscriminately applied. CONCLUSIONS There is substantial need for pressure ulcer prevention and treatment in home care settings.
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Affiliation(s)
- B A Ferrell
- Division of Geriatrics, UCLA School of Medicine, Los Angeles, California 90095-1687, USA
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Josephson K, DiGiacomo R, Indelicato SR, Iyo AH, Nagabhushan TL, Parker MH, Walter MR, Ayo AH. Design and analysis of an engineered human interleukin-10 monomer. J Biol Chem 2000; 275:13552-7. [PMID: 10788470 DOI: 10.1074/jbc.275.18.13552] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A monomeric form of human interleukin 10 (IL-10M1) has been engineered for detailed structure-function studies on IL-10 and its receptor complexes. Wild type IL-10 (wtIL-10) is a domain swapped dimer whose structural integrity depends on the intertwining of two peptide chains. wtIL-10 was converted to a monomeric isomer by inserting 6 amino acids into the loop connecting the swapped secondary structural elements. Characterization of IL-10M1 by mass spectroscopy, size exclusion chromatography, cross-linking, and circular dichroism shows that IL-10M1 is a stable alpha-helical monomer at physiological pH whose three-dimensional structure closely resembles one domain of wtIL-10. As previously reported, incubation of wtIL-10 with a soluble form of the IL-10Ralpha (sIL-10Ralpha) generates a complex that consists of 2 wtIL-10 molecules and 4 sIL-10Ralphas. In contrast, IL-10M1 forms a 1:1 complex with the sIL-10Ralpha. Characterization of the interaction using isothermal titration calorimetry confirmed the 1:1 stoichiometry and yielded a dissociation constant of 30 nm with an apparent binding enthalpy of -12.2 kcal/mol. Despite forming a 1:1 complex, IL-10M1 is biologically active in cellular proliferation assays. These results indicate that the 1:1 interaction between IL-10M1 and IL-10Ralpha is sufficient for recruiting the signal transducing receptor chain (IL-10Rbeta) into the signaling complex and eliciting IL-10 cellular responses.
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Affiliation(s)
- K Josephson
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA
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Abstract
PURPOSE An experimental treatment for benign essential blepharospasm and hemifacial spasm involves the direct injection of doxorubicin into the eyelids to permanently kill muscle. This study examined the extent of local and systemic spread of doxorubicin after localized injections of low doses into the eyelid and determined the length of time doxorubicin was retained in the eyelid after injection. METHODS Two mg doxorubicin was injected subcutaneously into the lower eyelids of rabbits. After various time periods, the eyelids were removed and dissected into three separate specimens consisting of skin, subcutaneous connective tissue including orbicularis oculi muscle, or palpebral conjunctiva. Nearby tissues were also collected, including facial muscles and extraocular muscles. Urine, blood, kidney, spleen, heart and liver samples were collected. All tissues were prepared for HPLC determination of doxorubicin concentration. RESULTS Doxorubicin was detected in all three eyelid specimens for the first 4 days after injection, although by the fourth day the level of doxorubicin was greatly reduced. On and after the seventh day, there was no detectable doxorubicin in the treated eyelid tissues. There were no detectable levels of doxorubicin in the urine or any other body tissue at any of the post-injection intervals examined. There was no long term retention in any of the eyelid tissues examined. CONCLUSIONS The well described array of serious systemic side effects caused by the use of high systemic doses of doxorubicin as a chemotherapeutic agent made it critical to ascertain how long doxorubicin remained within the injected eyelids, and to determine to what extent and with what time course local injections of chemically intact doxorubicin might spread systemically. The short retention of the active or unmetabolized drug at the injection site is important, since more than one set of injections has been required for satisfactory amelioration of muscle spasms in blepharospasm and hemifacial spasm patients. The lack of detectable systemic spread of the drug distant from the local site of injection as well as the lack of long term retention of the locally injected doxorubicin lends support for the safety of doxorubicin administered in this manner to blepharospasm and hemifacial spasm patients.
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Affiliation(s)
- L K McLoon
- University of Minnesota, Department of Ophthalmology, Minneapolis 55455, USA
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Affiliation(s)
- D T Costakos
- Franciscan Skemp Health Care, Mayo Health System, La Crosse, Wis 54601, USA.
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Clark F, Azen SP, Zemke R, Jackson J, Carlson M, Mandel D, Hay J, Josephson K, Cherry B, Hessel C, Palmer J, Lipson L. Occupational Therapy for Independent-Living Older Adults. JAMA 1997. [PMID: 9343462 DOI: 10.1001/jama.1997.03550160041036] [Citation(s) in RCA: 312] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- F Clark
- Department of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles 90033, USA
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