Sleep Disorders and Cognitive Aging Among Cognitively Impaired Versus Unimpaired Older Adults

BACKGROUND AND OBJECTIVES

Sleep disorders often predict or co-occur with cognitive decline. Yet, little is known about how the relationship unfolds among older adults at risk for cognitive decline. To examine the associations of sleep disorders with cognitive decline in older adults with unimpaired cognition or impaired cognition (mild cognitive impairment and dementia).

RESEARCH DESIGN AND METHODS

A total of 5,822 participants (Mage = 70) of the National Alzheimer's Coordinating Center database with unimpaired or impaired cognition were followed for 3 subsequent waves. Four types of clinician-diagnosed sleep disorders were reported: sleep apnea, hyposomnia/insomnia, REM sleep behavior disorder, or "other." Cognition over time was measured by the Montreal Cognitive Assessment (MoCA) or an estimate of general cognitive ability (GCA) derived from scores based on 12 neuropsychological tests. Growth curve models were estimated adjusting for covariates.

RESULTS

In participants with impaired cognition, baseline sleep apnea was related to better baseline MoCA performance (b = 0.65, 95% confidence interval [95% CI] = [0.07, 1.23]) and less decline in GCA over time (b = 0.06, 95% CI = [0.001, 0.12]). Baseline insomnia was related to better baseline MoCA (b = 1.54, 95% CI = [0.88, 2.21]) and less decline in MoCA over time (b = 0.56, 95% CI = [0.20, 0.92]). Furthermore, having more sleep disorders (across the 4 types) at baseline predicted better baseline MoCA and GCA, and less decline in MoCA and GCA over time. These results were only found in those with impaired cognition and generally consistent when using self-reported symptoms of sleep apnea or insomnia.

DISCUSSION AND IMPLICATIONS

Participants with sleep disorder diagnoses may have better access to healthcare, which may help maintain cognition through improved sleep.

Ten-Year Stability of an Insomnia Sleeper Phenotype and Its Association With Chronic Conditions

OBJECTIVE

To identify distinct sleep health phenotypes in adults, examine transitions in sleep health phenotypes over time, and subsequently relate these to the risk of chronic conditions.

METHODS

A national sample of adults from the Midlife in the United States study ( N = 3683) provided longitudinal data with two time points (T1: 2004-2006, T2: 2013-2017). Participants self-reported on sleep health (regularity, satisfaction, alertness, efficiency, duration) and the number and type of chronic conditions. Covariates included age, sex, race, education, education, partnered status, number of children, work status, smoking, alcohol, and physical activity.

RESULTS

Latent transition analysis identified four sleep health phenotypes across both time points: good sleepers, insomnia sleepers, weekend catch-up sleepers, and nappers. Between T1 and T2, the majority (77%) maintained their phenotype, with the nappers and insomnia sleepers being the most stable. In fully adjusted models with good sleepers at both time points as the reference, being an insomnia sleeper at either time point was related to having an increased number of total chronic conditions by 28%-81% at T2, adjusting for T1 conditions. Insomnia sleepers at both time points were at 72%-188% higher risk for cardiovascular disease, diabetes, depression, and frailty. Being a napper at any time point related to increased risks for diabetes, cancer, and frailty. Being a weekend catch-up sleeper was not associated with chronic conditions. Those with lower education and unemployed were more likely to be insomnia sleepers; older adults and retirees were more likely to be nappers.

CONCLUSION

Findings indicate a heightened risk of chronic conditions involved in suboptimal sleep health phenotypes, mainly insomnia sleepers.

Design and methods of the mobile assessment of cognition, environment, and sleep (MACES) feasibility study in newly diagnosed breast cancer patients

Endocrine therapy (ET) for breast cancer treatment is associated with cognitive complaints, but their etiology is poorly understood. To address this, we developed and implemented an ambulatory assessment protocol consisting of wearable activity monitors, brief surveys of affect, context, and perceived impairments, and ultra-brief performance-based measures of cognition. Newly diagnosed, ER/PR+, stage 0-III, female breast cancer patients, were recruited. Ambulatory assessments were conducted on smart phones and wearable activity monitors were used to monitor sleep and physical activity. Participants were asked to complete five 7-day measurement bursts (one before starting ET and one each month for 4 consecutive months while on ET). We observed a consent rate of 36%, 27 women completed the study. Of the women that withdrew, 91% dropped prior to the midpoint of follow up. There were no significant differences in demographics, clinical breast cancer characteristics, sleep or physical activity patterns, or measures of cognition between women who completed versus withdrew. Women who did not complete the study provided fewer valid days of baseline data. In conclusion, while some women may be overwhelmed with their cancer diagnosis, we did not identify any predictive characteristics of women whom did not complete the study. This novel method enables the prospective study of psychological changes associated with cancer treatment, capturing a wide array of information about behavior, experience, and cognition, thus providing a picture of the lived experiences of cancer patients before and during exposure to ET.

Interactive Screen-Based Activities Predict Worse Actigraphic Sleep Health That Night Among Adolescents

PURPOSE

To determine the micro-longitudinal effects of duration and timing of screen-based activities on sleep within and between adolescents.

METHODS

Daily survey and actigraphy data from the age 15 wave of the Future of Families and Child Wellbeing Study were analyzed using multilevel modeling. Four hundred seventy five adolescents provided three or more days of valid daily survey and nighttime sleep data.

RESULTS

Within-person results showed that on days when adolescents played video games more than their daytime average ± SE (1.3 ± 1.2 hours), sleep onset (6 ± 2 minutes, p < .01) and midpoint (4 ± 2 minutes, p < .02) were delayed for each additional hour of gaming. Between-person results showed that for each hour adolescents used screens to communicate with friends across the day, sleep onset was later (11 ± 3 minutes, p < .01), sleep midpoint was later (8 ± 3 minutes, p < .01), and sleep duration was shorter (-5 ± 2 minutes, p < .03). Adolescents who used screens to communicate with friends or play video games in the hour before bed had later sleep onset (30 ± 14 minutes, p < .03) and midpoint (25 ± 13 minutes, p < .05).

DISCUSSION

Among adolescents, passive screen usage such as browsing the Internet or watching videos may not affect sleep timing or duration, but limiting interactive screen-based activities could protect adolescent sleep health and well-being.

Actigraphic sleep dimensions and associations with academic functioning among adolescents

STUDY OBJECTIVES

There is mixed evidence regarding associations of sleep duration with academic functioning in adolescents and a lack of research on other sleep dimensions, particularly using objective sleep measures. We examined associations of multiple actigraphic sleep dimensions with academic functioning among adolescents.

METHODS

Data were from the sleep sub-study of the age 15 wave of the Future of Families and Child Wellbeing Study (n=774-782), a national, diverse sample of teens. Adolescents wore wrist-actigraphs for ~1 week and completed a survey reporting grades and school-related problems. Regression models assessed whether average sleep duration, timing, maintenance efficiency, and SD-variability were associated with self-reported academic functioning in cross-sectional analyses adjusted for demographic characteristics, depressive symptoms, and anxious symptoms.

RESULTS

Later sleep timing (hrs) and greater sleep variability (SD-hrs) were associated with poorer academic outcomes, including sleep onset variability with higher odds of receiving a D or lower (OR=1.29), sleep onset (β=-.07), sleep offset (β=-.08), and sleep duration variability (β=-.08) with fewer A grades, sleep offset with lower GPA (β=-.07), sleep offset (OR=1.11), sleep duration variability (OR=1.31), and sleep onset variability (OR=1.42) with higher odds of being suspended or expelled in the past two years, and sleep duration variability with greater trouble at school (β=.13). Sleep duration, sleep maintenance efficiency, and sleep regularity index were not associated with academic functioning.

CONCLUSION

Later sleep timing and greater sleep variability are risk factors for certain academic problems among adolescents. Promoting sufficient, regular sleep timing across the week may improve adolescent academic functioning.

Multidimensional Sleep Health Problems Across Middle and Older Adulthood Predict Early Mortality

BACKGROUND

Having multiple sleep problems is common in adulthood. Yet, most studies have assessed single sleep variables at one timepoint, potentially misinterpreting health consequences of co-occurring sleep problems that may change over time. We investigated the relationship between multidimensional sleep health across adulthood and mortality.

METHODS

Participants from the Midlife in the United States Study reported sleep characteristics in 2004-2006 (MIDUS-2; M2) and in 2013-2014 (MIDUS-3; M3). We calculated a composite score of sleep health problems across 5 dimensions: Regularity, Satisfaction, Alertness, Efficiency, and Duration (higher = more problems). Two separate models for baseline sleep health (n = 5 140; median follow-up time = 15.3 years) and change in sleep health (n = 2 991; median follow-up time = 6.4 years) to mortality were conducted. Cox regression models controlled for sociodemographics and key health risk factors (body mass index, smoking, depressive symptoms, diabetes, and hypertension).

RESULTS

On average, 88% of the sample reported having one or more sleep health problems at M2. Each additional sleep health problem at M2 was associated with 12% greater risk of all-cause mortality (hazard ratio [HR] = 1.12, 95% confidence interval [CI] = 1.04-1.21), but not heart disease-related mortality (HR = 1.14, 95% CI = 0.99-1.31). An increase in sleep health problems from M2 to M3 was associated with 27% greater risk of all-cause mortality (HR = 1.27, 95% CI = 1.005-1.59), and 153% greater risk of heart disease mortality (HR = 2.53, 95% CI = 1.37-4.68).

CONCLUSIONS

More sleep health problems may increase the risk of early mortality. Sleep health in middle and older adulthood is a vital sign that can be assessed at medical checkups to identify those at greater risk.

Trends in sleep duration in the U.S. from 2004 to 2018: A decomposition analysis

Average sleep duration in the United States declined in recent years, and the decline may be linked with many biopsychosocial factors. We examine how a set of biopsychosocial factors have differentially contributed to the temporal trends in self-reported sleep duration across racial groups between 2004-2005 and 2017-2018. Using repeated nationally representative cross-sections from the National Health Interview Survey, we decompose the influence of biopsychosocial factors on sleep duration trends into two components. One component corresponds to coefficient changes (i.e., changes in the associations between behaviors or exposures and sleep duration) of key biopsychosocial factors, and the other part accounts for the compositional changes (i.e., changes in the distributions of exposures) in these biopsychosocial factors during the study period. We reveal that changes in the coefficients of some biopsychosocial factors are more important than compositional changes in explaining the decline in sleep duration within each racial/ethnic group. Our findings highlight racial differences manifest across multiple biopsychosocial domains that are shifting in terms of association and composition. Methodologically, we note that the standard regression approach for analyzing temporal trends neglects the role of coefficient changes over time and is thus insufficient for fully capturing how biopsychosocial factors may have influenced the temporal patterns in sleep duration and related health outcomes.

Group-based sleep trajectories in children and adolescents: A systematic review

Sleep is crucial for health and development. Evidence indicates that sleep changes over time and distinct subgroups may experience different longitudinal patterns. This study systematically reviewed the studies that used latent trajectory modeling to investigate sleep trajectories of children and adolescents aged 0-18 years, and summarized the associated determinants and health-related outcomes. We searched PubMed, Embase, CENTRAL, PsycINFO, and Web of Science, identifying 46 articles that met our criteria. To ensure the reliability of the review, only studies rated as good or fair in terms of methodological quality were included, resulting in a total of 36 articles. Group-based trajectories were identified on several sleep dimensions (i.e., sleep duration, general and specific sleep problems, and bed-sharing behavior) and three or four trajectories were reported in most studies. There was a convergence trend across sleep duration trajectories during the first six years of life. Studies on specific sleep problem (i.e., insomnia, night-waking, and sleep-onset difficulties) typically identified two trajectories: consistent, minimal symptoms or chronic yet fluctuating symptoms. Lower socioeconomic status, maternal depression, and night feeding behaviors were the most frequently reported determinants of sleep trajectories. Membership in a group with certain adverse patterns (e.g., persistent short sleep duration) was associated with increased risks of multiple negative health-related conditions, such as obesity, compromised immunity, neurological problems, substance use, or internalizing/externalizing symptoms. Generally, there is potential to improve the quality of studies in this field. Causality is hard to be inferred within the current body of literature. Future studies could emphasize early life sleep, incorporate more assessment timepoints, use objective measures, and employ experimental design to better understand changes of and mechanisms behind the various sleep trajectories and guide targeted interventions for at-risk subpopulations.

Eating during the biological night is associated with nausea

OBJECTIVES

This study assessed whether there was a time-of-day effect on nausea reports in participants during studies employing circadian protocols.

METHODS

Visual-analog-scales of nausea ratings were recorded from 34 participants (18-70years; 18 women) during forced desynchrony studies, where meals were scheduled at different circadian phases. Subjective nausea reports from a further 81 participants (18-35years; 36 women) were recorded during constant routine studies, where they ate identical isocaloric hourly snacks for 36-40 hours.

RESULTS

Feelings of nausea varied by circadian phase in the forced desynchrony studies, peaking during the biological night. Nausea during the constant routine was reported by 27% of participants, commencing 2.9 ± 5.2 hours after the midpoint of usual sleep timing, but was never reported to start in the evening (4-9 PM).

CONCLUSIONS

Nausea occurred more often during the biological night and early morning hours. This timing is relevant to overnight and early morning shift workers and suggests that a strategy to counteract that is to pay careful attention to meal timing.

Poor sleep health predicts the onset of a fear of falling among community-dwelling older adults

INTRODUCTION

A greater fear of falling predicts disability, falls, and mortality among older adults. Although poor sleep has been identified as a relevant risk factor for fear of falling among older adults, evidence is primarily shown in cross-sectional studies using isolated sleep characteristics. Less is known about whether prior fall experiences change the sleep health-fear of falling link among older adults. We investigated the longitudinal relationship between sleep health and the incidence of fear of falling among community-dwelling older adults and how the association differed between those with or without prior fall experiences.

METHODS

Data were from individuals who completed the sleep module in the National Health and Aging Trends Study (2013-2014; n = 686). Fear of falling was assessed with a single item. Multidimensional sleep health was measured with self-reported sleep items based on the SATED model (ie, sleep satisfaction, daytime alertness, timing, efficiency, and duration). Covariates included sociodemographics, assistive device usage, health, risky behavior, and sleep medications. Multiple logistic regression was used to analyze the data.

RESULTS

Poor sleep health was associated with the onset of fear of falling at 1-year follow-up (odds ratios=1.20, 95% confidence interval=1.02-1.41). Moreover, poor sleep health increased the odds of having fear of falling among individuals without prior falls experiences and elevated the already heightened risks of developing fear of falling among those who fell at baseline.

CONCLUSIONS

Given that fear of falling and experiencing a fall each increase the risk of the other occurring in the future, improving sleep health may prevent older adults from stepping into the vicious cycle of fear of falling and falls.

Employee Cardiometabolic Risk Following a Cluster-Randomized Workplace Intervention From the Work, Family and Health Network, 2009-2013

Objectives. To examine whether workplace interventions to increase workplace flexibility and supervisor support and decrease work-family conflict can reduce cardiometabolic risk. Methods. We randomly assigned employees from information technology (n = 555) and long-term care (n = 973) industries in the United States to the Work, Family and Health Network intervention or usual practice (we collected the data 2009-2013). We calculated a validated cardiometabolic risk score (CRS) based on resting blood pressure, HbA1c (glycated hemoglobin), HDL (high-density lipoprotein) and total cholesterol, height and weight (body mass index), and tobacco consumption. We compared changes in baseline CRS to 12-month follow-up. Results. There was no significant main effect on CRS associated with the intervention in either industry. However, significant interaction effects revealed that the intervention improved CRS at the 12-month follow-up among intervention participants in both industries with a higher baseline CRS. Age also moderated intervention effects: older employees had significantly larger reductions in CRS at 12 months than did younger employees. Conclusions. The intervention benefited employee health by reducing CRS equivalent to 5 to 10 years of age-related changes for those with a higher baseline CRS and for older employees. Trial Registration. ClinicalTrials.gov Identifier: NCT02050204. (Am J Public Health. 2023;113(12):1322-1331. https://doi.org/10.2105/AJPH.2023.307413).

Association of Birthplace for Sleep Duration, Sleep Quality, and Sleep Disorder Symptoms, at the US-Mexico Border

OBJECTIVES

The present study investigated the roles birthplace and acculturation play in sleep estimates among Hispanic/Latino population at the US-Mexico border.

MEASURES

Data were collected in 2016, from N = 100 adults of Mexican descent from the city of Nogales, AZ, at the US-Mexico border. Sleep was assessed with the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index categorized as none, mild, moderate, and severe, and Multivariable Apnea Prediction Index (MAP) categorized as never, infrequently, and frequently. Acculturation was measured with the Acculturation Rating Scale for Mexican-Americans II (ARSMA-II).

RESULTS

The sample consisted of majority Mexican-born (66%, vs. born in the USA 38.2%). Being born in the USA was associated with 55 fewer minutes of nighttime sleep (p = .011), and 1.65 greater PSQI score (p = .031). Compared to no symptoms, being born in the USA was associated with greater likelihood of severe difficulty falling asleep (OR = 8.3, p = .030) and severe difficulty staying asleep (OR = 11.2, p = .050), as well as decreased likelihood of breathing pauses during sleep (OR = 0.18, P = .020). These relationships remained significant after Mexican acculturation was entered in these models. However, greater Anglo acculturation appears to mediate one fewer hour of sleep per night, poorer sleep quality, and reporting of severe difficulty falling asleep and staying asleep.

CONCLUSIONS

Among individuals of Mexican descent, being born in the USA (vs Mexico) is associated with about 1 hour less sleep per night, worse sleep quality, more insomnia symptoms, and less mild sleep apnea symptoms. These relationships are influenced by acculturation, primarily the degree of Anglo rather than the degree of Mexican acculturation.

Lay health worker research personnel for home-based data collection in clinical and translational research: Qualitative and quantitative findings from two trials in hard-to-reach populations

Aims

The role of lay health workers in data collection for clinical and translational research studies is not well described. We explored lay health workers as data collectors in clinical and translational research studies. We also present several methods for examining their work, i.e., qualitative interviews, fidelity checklists, and rates of unusable/missing data.

Methods

We conducted 2 randomized, controlled trials that employed lay health research personnel (LHR) who were employed by community-based organizations. In one study, n = 3 Latina LHRs worked with n = 107 Latino diabetic participants. In another study, n = 6 LHR worked with n = 188 Cambodian American refugees with depression. We investigated proficiency in biological, behavioral, and psychosocial home-based data collection conducted by LHR. We also conducted in-depth interviews with lay LHR to explore their experience in this research role. Finally, we described the training, supervision, and collaboration for LHR to be successful in their research role.

Results

Independent observers reported a very high degree of fidelity to technical data collection protocols (>95%) and low rates of missing/unusable data (1.5%-11%). Qualitative results show that trust, training, communication, and supervision are key and that LHR report feeling empowered by their role. LHR training included various content areas over several weeks with special attention to LHR and participant safety. Training and supervision from both the academic researchers and the staff at the community-based organizations were necessary and had to be well-coordinated.

Conclusions

Carefully selected, trained, and supervised LHRs can collect sophisticated data for community-based clinical and translational research.

Six multidimensional sleep health facets in older adults identified with factor analysis of actigraphy: Results from the Einstein Aging Study

OBJECTIVES

The concept of multi-dimensional sleep health, originally based on self-report, was recently extended to actigraphy in older adults, yielding five components, but without a hypothesized rhythmicity factor. The current study extends prior work using a sample of older adults with a longer period of actigraphy follow-up, which may facilitate observation of the rhythmicity factor.

METHODS

Wrist actigraphy measures of participants (N = 289, Mage = 77.2 years, 67% females; 47% White, 40% Black, 13% Hispanic/Others) over 2 weeks were used in exploratory factor analysis to determine factor structures, followed by confirmatory factor analysis on a different subsample. The utility of this approach was demonstrated by associations with global cognitive performance (Montreal Cognitive Assessment).

RESULTS

Exploratory factor analysis identified six factors: Regularity: standard deviations of four sleep measures: midpoint, sleep onset time, night total sleep time (TST), and 24-hour TST; Alertness/Sleepiness (daytime): amplitude, napping (mins and #/day); Timing: sleep onset, midpoint, wake-time (of nighttime sleep); up-mesor, acrophase, down-mesor; Efficiency: sleep maintenance efficiency, wake after sleep onset; Duration: night rest interval(s), night TST, 24-hour rest interval(s), 24-hour TST; Rhythmicity (pattern across days): mesor, alpha, and minimum. Greater sleep efficiency was associated with better Montreal Cognitive Assessment performance (β [95% confidence interval] = 0.63 [0.19, 1.08]).

CONCLUSIONS

Actigraphic records over 2 weeks revealed that Rhythmicity may be an independent factor in sleep health. Facets of sleep health can facilitate dimension reduction, be considered predictors of health outcomes, and be potential targets for sleep interventions.

Recovery Sleep After Sleep Restriction Is Insufficient to Return Elevated Daytime Heart Rate and Systolic Blood Pressure to Baseline Levels

OBJECTIVE

Sleep restriction alters daytime cardiac activity, including elevating heart rate (HR) and blood pressure (BP). There is minimal research on the cumulative effects of sleep loss and the response after subsequent recovery sleep on HR and BP. This study examined patterns of HR and BP across baseline, sleep restriction, and recovery conditions using multiple daytime cardiac measurements.

METHODS

Participants (15 healthy men, mean [standard deviation] = 22.3 [2.8] years) completed an 11-day inpatient protocol with three nights of 10 hours/night baseline sleep opportunity, five sleep restriction nights (5-hour/night sleep opportunity), and two recovery nights (10-hour/night sleep opportunity). Resting HR and BP were measured every 2 hours during wake. Multilevel models with random effects for individuals examined daytime HR and BP across study conditions and days into the study.

RESULTS

Mean daytime HR was 1.2 (0.5) beats/min lower during sleep restriction compared with baseline ( p < .001). During recovery, HR was 5.5 (1.0) beats/min higher ( p < .001), and systolic BP (SBP) was 2.9 (1.1) mm Hg higher ( p = .009). When accounting for days into the study (irrespective of condition) and measurement timing across the day, HR increased by 7.6 beats/min and SBP increased by 3.4 mm Hg across the study period ( p < .001).

CONCLUSIONS

Our findings suggest that daytime HR and SBP increase after successive nights of sleep restriction, even after accounting for measurement time of day. HR and SBP did not recover to baseline levels after two recovery nights of sleep, suggesting that longer recovery sleep may be necessary to recover from multiple, consecutive nights of moderate sleep restriction.

Performance of an open machine learning model to classify sleep/wake from actigraphy across ∼24-hour intervals without knowledge of rest timing

GOAL AND AIMS

Commonly used actigraphy algorithms are designed to operate within a known in-bed interval. However, in free-living scenarios this interval is often unknown. We trained and evaluated a sleep/wake classifier that operates on actigraphy over ∼24-hour intervals, without knowledge of in-bed timing.

FOCUS TECHNOLOGY

Actigraphy counts from ActiWatch Spectrum devices.

REFERENCE TECHNOLOGY

Sleep staging derived from polysomnography, supplemented by observation of wakefulness outside of the staged interval. Classifications from the Oakley actigraphy algorithm were additionally used as performance reference.

SAMPLE

Adults, sleeping in either a home or laboratory environment.

DESIGN

Machine learning was used to train and evaluate a sleep/wake classifier in a supervised learning paradigm. The classifier is a temporal convolutional network, a form of deep neural network.

CORE ANALYTICS

Performance was evaluated across ∼24 hours, and additionally restricted to only in-bed intervals, both in terms of epoch-by-epoch performance, and the discrepancy of summary statistics within the intervals.

ADDITIONAL ANALYTICS AND EXPLORATORY ANALYSES

Performance of the trained model applied to the Multi-Ethnic Study of Atherosclerosis dataset.

CORE OUTCOMES

Over ∼24 hours, the temporal convolutional network classifier produced the same or better performance as the Oakley classifier on all measures tested. When restricting analysis to the in-bed interval, the temporal convolutional network remained favorable on several metrics.

IMPORTANT SUPPLEMENTAL OUTCOMES

Performance decreased on the Multi-Ethnic Study of Atherosclerosis dataset, especially when restricting analysis to the in-bed interval.

CORE CONCLUSION

A classifier using data labeled over ∼24-hour intervals allows for the continuous classification of sleep/wake without knowledge of in-bed intervals. Further development should focus on improving generalization performance.

Cannabis use and sleep disturbances among White, Black, and Latino adults in the United States: A cross-sectional study of National Comorbidity Survey-Replication (2001-2003) data

OBJECTIVE

Research investigating cannabis use and sleep health is limited, and results are mixed. Few studies were nationally representative with racially-ethnically diverse samples or assessed potential modifiers. Our objective was to investigate cross-sectional associations between reported cannabis use and sleep disturbances by potential modifiers among non-Hispanic White, non-Hispanic Black, and Hispanic/Latino men and women in the United States.

METHODS

We used nationally representative National Comorbidity Survey-Replication data collected from 2001 to 2003 among 3929 adults. Poisson regression with robust variance estimated prevalence ratios (PR) and 95% confidence intervals of patterns of sleep disturbances identified through latent class analysis. Models adjusted for sociodemographic, health behavior, and clinical characteristics were stratified by race-ethnicity and by race-ethnicity along with sex/gender, and age, separately.

RESULTS

Over half of adults reported cannabis use (52%-ever/lifetime vs 48%-never). We identified two latent classes: multiple sleep disturbances with daytime sleepiness and no sleep disturbances with some daytime sleepiness. Prevalence of multiple sleep disturbances with daytime sleepiness was higher among participants reporting lifetime cannabis use (23% vs 20%). Associations did not vary by race-ethnicity or sex/gender. Lifetime vs never cannabis use was marginally associated with a higher prevalence of multiple sleep disturbances with daytime sleepiness only among adults aged 25-29years (PR=1.09 [95% confidence interval: 1.00-1.18]; eg, PRage 40+ years=1.00 [0.97-1.03], pinteraction=0.03).

CONCLUSIONS

Associations between cannabis use and sleep may vary by age. Replication with more recent data and prospective studies that investigate intersectional identities among diverse populations with objective assessments are warranted.

Secondary analysis of a randomized trial testing community health educator interventions for diabetes prevention among refugees with depression: effects on nutrition, physical activity and sleep

BACKGROUND

Refugees have high levels of psychological distress that hamper lifestyle change efforts. We previously reported that community health educator (CHE) diabetes prevention interventions decreased HbA1c and depressive symptoms among Cambodian-American refugees with depression; this paper reports health behavior outcomes of those interventions.

METHODS

Participants were aged 35-75, Khmer speaking, at risk for diabetes, and met study criteria for likely depression by either a) antidepressant medication and/or b) prolonged elevated depressive symptoms. Participants were randomized to one of three CHE interventions: 1) lifestyle intervention called Eat, Walk, Sleep (EWS), 2) EWS plus medication therapy management with a pharmacist/CHE team (EWS + MTM), or, 3) social services (SS; control). Physical activity and sleep were measured with 7 days of actigraphy. Nutrition was measured as carbohydrates as reported in a culturally tailored food frequency questionnaire. Assessments were at baseline, end point (12 months), and follow-up (15 months).

RESULTS

The n = 188 participants were 78% female, average age of 55 years, half had a household income < $20,000, and modal education was 7.0 years. Individuals in the two treatment groups that received the EWS intervention significantly increased their brown rice consumption (p < .001, Cohen's d = 0.76) and their moderate-to-vigorous activity (p = .039, d = 0.32). No intervention changed sleep duration, timing, efficiency or wake after sleep onset. Across groups, individuals who increased brown rice consumption, increased vigorous activity and decreased total sleep time variability showed decreased HbA1c, with small effect sizes.

CONCLUSIONS

CHEs may improve nutrition and physical activity in refugees with depression but more intensive interventions may be required to impact sleep. Improvements in all three behaviors appear to be associated with HbA1c lowering TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02502929.

Actigraphic Sleep Variability is Associated With Lower Positive Mood in Adolescents

PURPOSE

Poor sleep health is associated with lower positive mood in adolescents, and more variable sleep is associated with more negative mood. There is a lack of research on the associations between sleep variability and positive mood in adolescents. We investigated whether several types of sleep variability, measured with actigraphy, were associated with positive mood reported on a daily diary in adolescents.

METHODS

Data were collected from a substudy of the Year 15 wave of the Future of Families and Child Wellbeing Study (n = 580; 53% female, mean age ± standard deviation [SD] = 15.4 ± 0.5 years, range 14.7-17.7). Adolescents wore an actigraphy device (M ± SD = 5.6 ± 1.4 nights per adolescent, range: 3-10) and completed daily diaries (M ± SD = 5.5 ± 1.4 days per adolescent, range: 3-9) for ∼1 week, where they rated their levels of happiness and excitement during that day from 0 (not at all) to 4 (extremely). Happiness and excitement were averaged into "positive mood." Separate linear regression models assessed whether actigraphy-measured variability of sleep duration, onset, and offset (residual individual standard deviation, riSD), sleep regularity index, social jetlag, and free night catch-up sleep were associated with average positive mood per person. Analyses adjusted for age, birth sex, race/ethnicity, household income, and the primary caregiver's education level.

RESULTS

Greater variability in sleep duration (p = .011, β = -0.11) and lower sleep regularity index (p = .034, β = 0.09) were associated with lower ratings of positive mood. There were no other significant associations (p ≥ .10).

DISCUSSION

Variable and irregular sleep are associated with lower levels of positive mood in adolescence, which may increase the risk of poor emotional health in adulthood.

A non-pharmacological multi-modal therapy to improve sleep and cognition and reduce mild cognitive impairment risk: Design and methodology of a randomized clinical trial

Aging populations are at increased risk of sleep deficiencies (e.g., insomnia) that are associated with a variety of chronic health risks, including Alzheimer's disease and related dementias (ADRD). Insomnia medications carry additional risk, including increased drowsiness and falls, as well as polypharmacy risks. The recommended first-line treatment for insomnia is cognitive behavioral therapy for insomnia (CBTi), but access is limited. Telehealth is one way to increase access, particularly for older adults, but to date telehealth has been typically limited to simple videoconferencing portals. While these portals have been shown to be non-inferior to in-person treatment, it is plausible that telehealth could be significantly improved. This work describes a protocol designed to evaluate whether a clinician-patient dashboard inclusive of several user-friendly features (e.g., patterns of sleep data from ambulatory devices, guided relaxation resources, and reminders to complete in-home CBTi practice) could improve CBTi outcomes for middle- to older-aged adults (N = 100). Participants were randomly assigned to one of three telehealth interventions delivered through 6-weekly sessions: (1) CBTi augmented with a clinician-patient dashboard, smartphone application, and integrated smart devices; (2) standard CBTi (i.e., active comparator); or (3) sleep hygiene education (i.e., active control). All participants were assessed at screening, pre-study evaluation, baseline, throughout treatment, and at 1-week post-treatment. The primary outcome is the Insomnia Severity Index. Secondary and exploratory outcomes span sleep diary, actiwatch and Apple watch assessed sleep parameters (e.g., efficiency, duration, timing, variability), psychosocial correlates (e.g., fatigue, depression, stress), cognitive performance, treatment adherence, and neurodegenerative and systemic inflammatory biomarkers.

Why so slangry (sleepy and angry)? Shorter sleep duration and lower sleep efficiency predict worse next-day mood in adolescents

PURPOSE

The goal of this study was to evaluate the relationships of actigraphic nighttime sleep duration and quality with next-day mood among urban adolescents using a micro-longitudinal design.

METHODS

A subsample (N = 525) of participants from the Fragile Families & Child Wellbeing Study (mean age: 15.4 years; 53% female; 42% Black non-Hispanic, 24% Hispanic/Latino, 19% White non-Hispanic) in the United States between 2014 and 2016 concurrently wore a wrist actigraphic sleep monitor and rated their daily mood in electronic diaries for about 1 week. Multilevel models tested the within-person temporal associations of nightly sleep duration and sleep maintenance efficiency with next-day reports of happiness, anger, and loneliness. The models also tested the between-person associations of sleep variables and mood. Models adjusted for sociodemographic and household characteristics, weekend, and school year.

RESULTS

After nights when adolescents obtained longer sleep duration than their usual, they reported lower ratings of anger (B = -.03, p < .01) the next day. After nights when adolescents had higher sleep maintenance efficiency than their usual, they reported higher ratings of happiness (B = .02, p < .01) the next day. Adolescents who had longer average sleep duration reported lower ratings of anger (B = -.08, p < .01) and loneliness (B = -.08, p < .01) compared to others. There was no within-person association of sleep duration or efficiency with loneliness. Sleep duration was not associated with happiness between adolescents, and sleep maintenance efficiency was not associated with any mood measure between adolescents.

CONCLUSIONS

Improvements to nightly sleep may help increase happiness and decrease anger the following day in adolescents. Promoting sleep health is recommended to improve mood.

Community-based diabetes prevention randomized controlled trial in refugees with depression: effects on metabolic outcomes and depression

Depression and antidepressant medications increase risk for type 2 diabetes. Cambodian-Americans have exceedingly high rates of both depression and diabetes. This paper reports outcomes of a diabetes prevention trial for Cambodian-Americans with depression. Primary outcomes were HbA1c, insulin resistance and depressive symptoms. Participants were aged 35-75, Khmer speaking, at risk for diabetes, and met study criteria for likely depression by either (a) antidepressant medication and/or (b) prolonged elevated depressive symptoms. Participants were randomized to one of three community health worker (CHW) interventions: (1) lifestyle intervention called Eat, Walk, Sleep (EWS), (2) EWS plus medication therapy management sessions with a pharmacist/CHW team to resolve drug therapy problems (EWS + MTM), or, (3) social services (SS; control). Assessments were at baseline, post-treatment (12 months), and follow-up (15 months). The n = 188 participants were 78% female, average age of 55 years, half had a household income < $20,000, and modal educational attainment was 7.0 years. Compared to the other arms, EWS + MTM showed a significant decrease in HbA1c and a trend for reduced inflammation and stress hormones. Depressive symptoms improved for EWS and EWS + MTM relative to SS. There was no change in insulin resistance. Cardiometabolic and mental health can be improved in tandem among immigrant and refugee groups.

Goldilocks at work: Just the right amount of job demands may be needed for your sleep health

OBJECTIVES

It has been reported that job demands affect sleep, but how different levels of job demands affect sleep remains unclear. We examined whether curvilinear relationships exist between job demands and multiple sleep health outcomes.

DESIGN

Cross-sectional analyses with linear and quadratic effects, using self-administered survey data.

SETTING

A national sample of US adults.

PARTICIPANTS

Workers from Midlife in the United States Study (MIDUS2; n = 2927).

MEASUREMENTS

The Job Content Questionnaire assessed overall and 5 specific aspects of job demands (intensity, role conflict, work overload, time pressure, and interruptions). Habitual sleep health patterns across 5 dimensions (regularity, satisfaction/quality, daytime alertness, efficiency, and duration) were assessed. Age, sex, race/ethnicity, marital/partnered status, education, job tenure, work hours, body mass index, smoking status, and study sample were covariates.

RESULTS

There were significant linear and quadratic relationships between job demands and sleep outcomes. Specifically, the linear effects indicated that participants with higher job demands had worse sleep health, such as shorter duration, greater irregularity, greater inefficiency, and more sleep dissatisfaction. The quadratic effects, however, indicated that sleep regularity and efficiency outcomes were the best when participants' job demands were moderate rather than too low or too high. These effects were found for overall job demands as well as for specific aspects of job demands. Stratified analyses further revealed that these curvilinear associations were mainly driven by participants with low job control.

CONCLUSIONS

Moderate levels of job demands, especially if combined with adequate job control, are related to optimal sleep health.

Self-reported outcomes of a randomized trial comparing three community health worker interventions for diabetes prevention among Cambodian Americans with depression

OBJECTIVE

Cambodian Americans have complex, interrelated and persistent medical and mental health problems stemming from genocide and the social determinants of health. We examined changes in multiple domains of self-reported health outcomes from a diabetes prevention trial.

METHODS

Cambodian Americans with depression and high risk for diabetes (n = 188) were randomized to one of three community health worker interventions: lifestyle vs lifestyle plus medication therapy management vs social services. Assessments were at baseline, 12- and 15-months.

RESULTS

The typical participant was 55 years old, female, earned below $20,000 annually, and had 7 years of education. About one-third were taking antidepressant medication and over half had elevated depressive symptoms. Relative to social services, lifestyle and lifestyle plus medication therapy management were both similarly effective at increasing diabetes knowledge, nutrition habits, sleep quality and decreasing pain; 2) lifestyle alone was superior to social services for self-reported health; and, 3) all three groups showed improved anxiety and insomnia. There were no effects on physical activity or physical functioning.

CONCLUSION

Community health worker interventions have multiple benefits beyond delaying diabetes.

PRACTICE IMPLICATIONS

Health promotion programs that are designed and delivered appropriately can impact even hard to reach and hard to treat groups.

An orderly sequence of autonomic and neural events at transient arousal changes

Resting-state functional magnetic resonance imaging (rsfMRI) allows the study of functional brain connectivity based on spatially structured variations in neuronal activity. Proper evaluation of connectivity requires removal of non-neural contributions to the fMRI signal, in particular hemodynamic changes associated with autonomic variability. Regression analysis based on autonomic indicator signals has been used for this purpose, but may be inadequate if neuronal and autonomic activities covary. To investigate this potential co-variation, we performed rsfMRI experiments while concurrently acquiring electroencephalography (EEG) and autonomic indicator signals, including heart rate, respiratory depth, and peripheral vascular tone. We identified a recurrent and systematic spatiotemporal pattern of fMRI (named as fMRI cascade), which features brief signal reductions in salience and default-mode networks and the thalamus, followed by a biphasic global change with a sensory-motor dominance. This fMRI cascade, which was mostly observed during eyes-closed condition, was accompanied by large EEG and autonomic changes indicative of arousal modulations. Importantly, the removal of the fMRI cascade dynamics from rsfMRI diminished its correlations with various signals. These results suggest that the rsfMRI correlations with various physiological and neural signals are not independent but arise, at least partly, from the fMRI cascades and associated neural and physiological changes at arousal modulations.

The Social Context of Partnered Older Adults' Insomnia Symptoms

The current study included an examination of social factors that mitigate or exacerbate insomnia symptoms among older adults who are married or living with a partner. We first examined the unique effects of spousal support and strain on insomnia symptoms and then evaluated the degree to which extramarital social factors (e.g., friend support) moderated spousal influences. Data came from Waves 2 and 3 of the National Social Life, Health, and Aging Project. Our sample consisted of 495 participants who were either married or cohabitating with a partner (M age in years = 69.84, SD = 8.08). Spousal strain-but not support-predicted higher insomnia symptoms 5 years later. Spousal influences on sleep, however, were moderated by extramarital factors in nuanced ways. Findings highlight the importance of taking into account older adults' wider social context when examining the ways in which sleep is sensitive to positive and negative aspects of marital quality.

Self-reported pain among Cambodian Americans with depression: patient-provider communication as an overlooked social determinant

Objectives

Pain is common among torture survivors and refugees. Clear communication about one’s pain is vital to timely and precise diagnosis and treatment but is rarely recognized as a social determinant of health. We examined whether self-reported difficulty communicating with their health care provider, along with standard social determinants, is associated with self-reported pain in Cambodian American refugees.

Methods

Secondary data analysis was conducted on n = 186 baseline assessments from a diabetes prevention trial of Cambodian Americans with depression. Bilingual, bicultural community health workers (CHWs) conducted surveys including social determinants of health and past week pain occurrence and interference.

Results

The sample was 78% female, modal household income = $25,000, mean age = 55 years, and mean education = 6.9 years. About one-third had private insurance and two-thirds could not speak English conversationally. The average pain score was 2.8 on a scale from 0–8 with 37% reporting no pain at all. In bivariate analyses, predictors of higher pain scores were higher difficulty understanding healthcare provider, depressive symptoms, trauma symptoms, food insecurity, and social isolation; predictors of lower pain scores were higher years of education, income, English language proficiency, social support, working, and having private insurance. In the multivariate backward elimination model only two predictors were retained: difficulty understanding healthcare provider and depressive symptoms.

Discussion

We propose that healthcare communication is a modifiable social determinant of health. Healthcare institutions should receive the resources necessary to secure patients’ rights to clear communication including trained community health workers.

Psychological distress and health behaviours among Cambodian Americans at risk for developing diabetes

This paper reports secondary data analysis of associations between psychological distress and health behaviours among Cambodian Americans. Data are from baseline assessments from a diabetes prevention trial. All participants met stucriteria for depression and were free of diabetes. Participants (n = 191) completed surveys, a food frequency assessment, and wore sleep and physical activity actigraphy devices for 7 days. A factor analysis of symptoms of post-traumatic stress, baksbat (a Cambodian culture-bound syndrome), depression, and anxiety yielded a single factor named 'psychological distress'. Multivariate models controlling for psychotropic medications were run for the following outcomes: sleep actigraphy, self-reported sleep, physical activity actigraphy, self-reported physical activity, nutrition, and substance use. For actigraphy, higher distress was associated with lower moderate/vigorous physical activity and higher mean variability of 24 h total sleep time. Higher distress was also associated with worse self-reported sleep quality as indicated by standard, and culturally-specific, sleep indicators. Higher distress was also associated with lower use of food labels, lower carbohydrate consumption, and higher alcohol consumption as a coping mechanism. Interventions to mitigate diabetes risk in high-distress populations may benefit from strategies to decrease psychological distress. The sequelae of complex trauma may transcend discrete psychiatric diagnoses.

Relationships between daily stress responses in everyday life and nightly sleep

Stress and sleep are related, but the nature and time course of this relation is not well understood. We explored the within-person associations of three components of emotional responses to everyday stressors, indexed by negative affect, reactivity (initial response to a stressor), recovery (persistence of the post-stressor response), and pile-up (accumulation of stress episodes), with sleep indicators. We conducted coordinated analyses of data in several studies employing ecological momentary assessments, which captured naturally occurring, self-reported stress and sleep. We defined proximal reactivity as the emotional response to the stressor moment in question compared to an immediate pre-stressor state, and distal reactivity as the emotional response to the stressor moment in question compared to a typical stressor-free state for that person. Results in two of three studies showed that people reported significantly lower sleep quality following days on which they experienced higher levels of distal reactivity to stressors. Days with greater distal reactivity also predicted significantly more difficulty falling asleep in one of two studies. There was no clear association between proximal reactivity and subsequent sleep. Associations of recovery or pile-up with subsequent sleep emerged only in single studies. Poorer sleep quality was significantly related to higher next day levels of negative affect in all three studies, but there were no consistent relations between sleep and next day stress reactivity, recovery, or pile-up. These exploratory analyses suggest that distal reactivity is associated with a heightened risk of experiencing poor sleep quality the following night, and as such the former may serve as a candidate for potential targets for the remediation of the negative effects of stress on sleep.

Sleep Duration and Kindergarten Adjustment

OBJECTIVES

The current study examined longitudinal linkages between child sleep duration and children's socioemotional, learning engagement, executive functioning, and academic outcomes across the full kindergarten (K) year.

METHODS

A measurement-burst design was employed to examine 3 different measures of child sleep duration in 7-day bursts at pre-K (July-August), early K (late September), mid-K (late November), and late K (mid-to-late April), using wrist actigraphy. These measures included mean amounts of child sleep per 24-hour period across the full week, proportion of 24-hour periods per week that children slept 10 or more hours, and proportion of nighttime sleep periods per week that children slept 10 or more hours. Children's outcomes at early, mid-, and late K were provided by their K teachers blind to children's sleep histories, and by assessments administered by project staff.

RESULTS

Among the 3 sleep measures examined, regularity of nighttime sleep in which children slept 10 or more hours per night, especially at pre-K, consistently predicted more favorable K outcomes in both socioemotional, learning engagement, and academic domains. Results suggested that establishing healthy nighttime sleep habits before K start was especially promotive of better K adjustment across the full K year. These findings were controlled for income-to-poverty threshold ratios, child health status, and number of missed school days.

CONCLUSIONS

Efforts to promote a favorable transition to first-time schooling should pay particular attention to sleep hygiene and regularity of 10-plus hours of nightly child sleep established before the start of K.

Effect of the INSIGHT Firstborn Parenting Intervention on Secondborn Sleep

BACKGROUND AND OBJECTIVES

The Intervention Nurses Start Infants Growing on Healthy Trajectories (INSIGHT) responsive parenting (RP) intervention for first-time mothers improved firstborn infant sleep compared with controls. The goals of this analysis were to test intervention spillover effects on secondborn siblings and examine birth order differences in infant sleep.

METHODS

Secondborns (n = 117) of INSIGHT mothers were enrolled in an observational cohort, SIBSIGHT. The Brief Infant Sleep Questionnaire was collected at 3, 16, and 52 weeks. Generalized linear mixed models assessed differences among secondborns by firstborn randomization, as well as birth order differences at 16 and 52 weeks.

RESULTS

The RP group secondborns slept 42 minutes longer at night (95% confidence interval [95% CI]: 19-64) and 53 minutes longer total (95% CI: 17-90) than control secondborns. RP secondborns were more likely to self-soothe to sleep (odds ratio [OR] = 2.0, 95% CI: 1.1-3.7) and less likely to be fed back to sleep after waking (OR = 0.5, 95% CI: 0.3-0.9) than secondborns of control mothers. RP secondborns were more likely to have a bedtime ≤8 pm at 3 (OR = 2.9, 95% CI: 1.1-7.7) and 16 weeks (OR = 4.7, 95% CI: 2.0-11.0). Few differences in sleep parenting practices were observed when comparing siblings within families. Secondborns slept 37 minutes longer than firstborns at 16 weeks (CI: 7-67, P = .03).

CONCLUSIONS

The INSIGHT RP intervention for first-time mothers had a spillover effect to secondborns, positively impacting sleep duration and behaviors. Intervening with first-time mothers benefits both firstborns and subsequent children.

Worse sleep health predicts less frequent breakfast consumption among adolescents in a micro-longitudinal analysis

BACKGROUND

Poor self-reported sleep health has been linked to not consuming breakfast in adolescents, but it is unknown whether poor sleep measured objectively predicts next-day breakfast consumption within adolescents. We investigated within- and between-person associations of objectively measured sleep dimensions and subjective sleep quality with adolescent breakfast consumption.

METHODS

Data were collected from a micro-longitudinal substudy of the Year 15 wave of the Fragile Families and Child Wellbeing Study (n = 590). Adolescents wore an actigraphy device and completed daily diaries for ~ 1 week (M ± SD = 5.6 ± 1.4 nights per adolescent, range: 3-9), where they rated their sleep quality and reported whether they had eaten breakfast that day, with no specific definition of breakfast provided (M ± SD = 5.5 ± 1.4 days per adolescent, range: 3-9). Separate mixed models assessed whether actigraphy-measured sleep duration (linear and quadratic, sleep duration x sleep duration), timing, maintenance efficiency, and subjective quality predicted odds of breakfast consumption both within and between adolescents. Variability of sleep duration and timing (standard deviation per person), sleep regularity index (SRI), and social jetlag were tested as additional between-person predictors. Analyses with predictors other than sleep duration were adjusted for sleep duration.

RESULTS

Following nights when adolescents had shorter or longer sleep duration (p = .005; curvilinear association), later sleep onset, or later sleep midpoint (both p = .025) than their own usual, they had lower odds of consuming breakfast the next day (within-person associations). Adolescents who on average had later sleep onset (p = .013) or midpoint (p = .013) or who reported lower sleep quality (p = .011) had lower average odds of consuming breakfast (between-person associations). Adolescents with greater variability of sleep duration (p = .005), midpoint (p = .004), or offset (p < .001) had lower average odds of consuming breakfast (between-person associations). Sleep maintenance efficiency (within or between adolescents), SRI, and social jetlag were not associated with breakfast consumption (all p > .10).

CONCLUSIONS

Multiple dimensions of sleep health are associated with breakfast consumption, both within and between adolescents. Poor sleep and dietary behaviors in adolescence may negatively impact future metabolic health.

0102 Performance Evaluation of a 24-hour Sleep-Wake State Classifier Derived from Research-Grade Actigraphy

Introduction

Wrist-worn research-grade actigraphy devices are commonly used to identify sleep and wakefulness in freely-living people. However, common existing algorithms were developed primarily to classify sleep-wake within a defined in-bed period with PSG, and exhibit relatively high sensitivity (accuracy on sleep epochs) but relatively low specificity (accuracy on wake epochs). This classification imbalance results in the algorithms performing poorly when attempting to classify data that does not have a predefined sleep period, such as over a 24-hour interval. Here, we develop a 24-hour actigraphy classifier to overcome limitations in specificity (accuracy on wake epochs), which typically afflict in-bed focused algorithms.

Methods

Four datasets scored via either PSG or direct observation of daytime wakefulness were combined (n=52 participants of mean age 49.8yrs, age range 19 - 86; 52% male; 221 total days/nights). Actigraphy (counts) and PSG (RPSGT-staged epochs) were temporally aligned. A model was trained to transform a time-series actigraphy counts to a time series of sleep-wake classifications, using the TensorFlow library for Python. 5-fold cross-validation was used to train and evaluate the model. Classification performance was compared to the output of the Spectrum device (Philips-Respironics) using the Oakley algorithm with a wake threshold of ‘medium’.

Results

The developed classifier was compared to the Spectrum classifications across the 24-hour intervals. The developed classifier had higher accuracy (95.4% vs. 76.8%), higher specificity (95.9% vs. 68.9%) and higher balanced-accuracy (95.2% vs. 81.6%) relative to the Spectrum classifications, each assessed via paired-sample t-test. Sensitivity did not statistically differ (94.5% vs. 94.4%).

Conclusion

The model trained and evaluated on 24-hour data outperformed the existing algorithm output in terms of overall accuracy, specificity, and balanced accuracy, while sensitivity did not significantly differ. A model trained on 24-hour data may be more appropriate for analyses of freely living people, or older populations where napping is more common. Developing an accurate 24-hour sleep/wake classifier fosters new opportunities to evaluate sleep patterns in the absence of self-reports or assumptions about time in bed.

Support (If Any)

UL1TR002014, NSF#1622766, R43/44-AG056250

Rigorous performance evaluation (previously, "validation") for informed use of new technologies for sleep health measurement

New sleep technologies have become pervasive in the consumer space, and are becoming highly common in research and clinical sleep settings. The rapid, widespread use of largely unregulated and unstandardized technology has enabled the quantification of many different facets of sleep health, driving scientific discovery. As sleep scientists, it is our responsibility to inform principles and practices for proper evaluation of any new technology used in the clinical and research settings, and by consumers. A current lack of standardized methods for evaluating technology performance challenges the rigor of our scientific methods for accurate representation of the sleep health facets of interest. This special article describes the rationale and priorities of an interdisciplinary effort for rigorous, standardized, and rapid performance evaluation (previously, "validation") of new sleep and sleep disorders related technologies of all kinds (eg, devices or algorithms), including an associated article template for a new initiative for publication in Sleep Health of empirical studies systematically evaluating the performance of new sleep technologies. A structured article type should streamline manuscript development and enable more rapid writing, review, and publication. The goal is to promote rapid and rigorous evaluation and dissemination of new sleep technology, to enhance sleep research integrity, and to standardize terminology used in Rigorous Performance Evaluation papers to prevent misinterpretation while facilitating comparisons across technologies.

Chronic circadian disruption on a high-fat diet impairs glucose tolerance

BACKGROUND

Nearly 14% of Americans experience chronic circadian disruption due to shift work, increasing their risk of obesity, diabetes, and other cardiometabolic disorders. These disorders are also exacerbated by modern eating habits such as frequent snacking and consumption of high-fat foods.

METHODS

We investigated the effects of recurrent circadian disruption (RCD) on glucose metabolism in C57BL/6 mice and in human participants exposed to non-24-h light-dark (LD) schedules vs. those on standard 24-h LD schedules. These LD schedules were designed to induce circadian misalignment between behaviors including rest/activity and fasting/eating with the output of the near-24-h central circadian pacemaker, while minimizing sleep loss, and were maintained for 12 weeks in mice and 3 weeks in humans. We examined interactions of these circadian-disrupted schedules compared to control 24-h schedules with a lower-fat diet (LFD, 13% in mouse and 25-27% in humans) and high-fat diet (HFD, 45% in mouse and 45-50% in humans). We also used young vs. older mice to determine whether they would respond differently to RCD.

RESULTS

When combined with a HFD, we found that RCD caused significant weight gain in mice and increased body fat in humans, and significantly impaired glucose tolerance and insulin sensitivity in both mice and humans, but this did not occur when RCD was combined with a LFD. This effect was similar in both young and older mice.

CONCLUSION

These results in both humans and a model organism indicate that circadian disruption has an adverse effect on metabolism among individuals eating a high-fat Western-style diet, even in the absence of significant sleep loss, and suggest that reducing dietary fat may protect against the metabolic consequences of a lifestyle (such as shift work) that involves chronic circadian disruption.

Impact of chronic sleep restriction on sleep continuity, sleep structure, and neurobehavioral performance

Chronic sleep restriction (CSR) has been associated with adverse effects including cognitive impairment and increased risk of diabetes and cardiovascular disease. Yet, sleep restriction therapy is an essential component of most behavioral treatments for insomnia. Moreover, little is known about the impact of CSR on sleep continuity and structure in healthy people whose need for sleep is satiated. We investigated the impact of CSR on sleep continuity and structure in nine healthy participants. They had 4 nights of sleep extension, 2 nights of post-extension sleep, 21 nights of CSR (5/5.6-hour time-in-bed), and 9 nights of recovery sleep. Compared to postextension sleep, during CSR sleep duration was reduced by 95.4 ± 21.2 min per night, Slow-Wave Activity was significantly increased, and sleep was more consolidated. During recovery, sleep duration was increased by 103.3 ± 23.8 min compared to CSR, and the CSR-induced increase in Slow-Wave Activity persisted, particularly after the 5-hour exposure. Yet, we found that sustained vigilant attention was not fully recovered even after nine nights of recovery sleep. Our results suggest that CSR improves traditional metrics of sleep quality and may have a persistent impact on sleep depth, which is consistent with the reported benefits on sleep continuity and structure of sleep restriction therapy. However, these improvements in traditional metrics of sleep quality were associated with deterioration rather than improvement in neurobehavioral performance, demonstrating that sleep duration should be included in assessments of sleep quality. These results have implications for the long-term use of sleep restriction in the behavioral treatment of insomnia. Clinical Trial Registration: Impact of Chronic Circadian Disruption vs. Chronic Sleep Restriction on Metabolism (https://clinicaltrials.gov/ct2/show/; #NCT02171273).

Cardiovascular risks and sociodemographic correlates of multidimensional sleep phenotypes in two samples of US adults

Study Objectives

Sleep is a modifiable risk factor for cardiovascular conditions. Holistic examination of within-person, multidimensional sleep patterns may offer more detailed information about the sleep-cardiovascular condition link, including who is more vulnerable to both. This study aimed to identify common sleep phenotypes in adulthood, establish the validity of the phenotypes in relation to cardiovascular conditions, and explore sociodemographic and background characteristics of the phenotypes.

Methods

Across two independent samples of adults (N ₁ = 4600; N ₂ = 2598) from the Midlife in the United States Study, latent class analysis (LCA) extracted sleep phenotypes using five key self-reported sleep dimensions. Log-binomial regression was used to determine whether sleep phenotypes differentially predicted cardiovascular conditions, adjusting for known risk factors. LCA with covariates was used to compare sociodemographic characteristics of the identified sleep phenotypes.

Results

Four sleep phenotypes were identified consistently across the two samples: good sleepers, nappers, dissatisfied/inefficient sleepers, and irregular sleepers. Compared to good sleepers (reference), dissatisfied/inefficient sleepers exhibited a higher risk of cardiovascular conditions in both samples (RR _Sample1: 29%, RR _Sample2: 53%) and consisted of relatively more racial/ethnic minorities. Nappers exhibited a higher risk of cardiovascular conditions in one sample (RR _Sample1: 38%) and consisted of more women and older adults. Irregular sleepers exhibited no significantly different cardiovascular risk and were relatively younger.

Conclusions

Common sleep phenotypes in adulthood exhibit differential risks for cardiovascular conditions. Cooccurring sleep dissatisfaction and inefficiency, in particular, may relate to increased risk of cardiovascular conditions. Certain sociodemographic groups (racial minorities, women, older adults) disproportionately fit within high-risk sleep phenotypes.

Sleep health composites are associated with the risk of heart disease across sex and race

We examined whether subjectively and objectively measured sleep health composites have a relationship with heart disease. 6,820 adults (M_age = 53.4 years) from the Midlife in the United States study provided self-reported sleep characteristics and heart disease history. A smaller sample (n = 663) provided actigraphy sleep data. We tested two sleep health composites, based on self-report only and both self-report and actigraphy, across multiple sleep dimensions. We used a weighted sum approach, where higher scores indicated more sleep health problems. Modified Poisson regressions adjusted for sociodemographics and known risk factors. Having more sleep health problems was associated with a higher risk of heart disease using the self-report sleep health composite (aRR = 54%, P < .001) and the actigraphy/self-report composite (aRR = 141%, P < .001). Individual sleep dimensions of satisfaction, alertness, and efficiency (from the self-report composite) and regularity, satisfaction, and timing (from the actigraphy/self-report composite) were associated with the risk of heart disease. The effect size of each sleep health composite was larger than the individual sleep dimensions. Race moderated the association between the actigraphy/self-report sleep health composite and heart disease. There was no significant moderation by sex. Findings suggest poorer sleep health across multiple dimensions may contribute to heart disease risk among middle-aged adults.

Daily associations between family interaction quality, stress, and objective sleep in adolescents

OBJECTIVE

To better understand the short-term impact of family interactions on adolescent sleep, this study examined daily associations between family interaction quality and sleep duration, sleep maintenance efficiency, and subjective sleep quality.

METHODS

Participants were 517 diverse youth (M_age = 15.4 years, Range = 15-18) in the Fragile Families and Child Wellbeing Study who completed daily reports of family interaction quality, mood and subjective sleep quality and provided actigraphy-based estimates of sleep duration and sleep maintenance efficiency.

RESULTS

Following days when youth reported that they got along with their parents, they slept 26 minutes (95% CI [2.93, 49.88]) longer. Youth who reported greater quality interactions with other family members on average had longer sleep duration, and youth who reported higher levels of family stress perceived lower sleep quality.

CONCLUSIONS

Findings highlight the importance of considering daily family life, including the quality of brief family interactions, as an entry point for future sleep interventions for adolescents.

Risk factors for drug therapy problems among Cambodian Americans with complex needs: a cross-sectional, observational study

Background

Pharmaceutical drug therapy problems (DTPs) are a major public health problem. We examined patient-level risk factors for DTPs among Cambodian Americans.

Methods

Community health workers (CHWs) verbally administered surveys and completed a detailed medication review form with participants. A doctoral-level pharmacist reviewed the form with the patient and CHW to determine DTP number and type (appropriateness, effectiveness, safety, and adherence).

Results

Participants (n = 63) averaged 55 years old, 6 years of education, 52% were married, 87% spoke Khmer at home, with modal household income <$20,000 (41%). The percentage of participants with DTPs was: 45% appropriateness, 25% effectiveness, 64% safety, and 30% adherence, averaging 3.7 DTPs per patient. In multiple regressions, patient characteristics uniquely predicted each type of DTP. In a multiple regression controlling for number of medications, being married reduced total DTPs (IRR = 0.70) and being depressed increased total DTPs (IRR = 1.26).

Conclusions

Vulnerable patients should be prioritized for pharmacist/CHW teams to identify DTPs.

Trial registration:ClinicalTrials.gov identifier: NCT02502929.

Patterns of Eating Associated with Sleep Characteristics: A Pilot Study among Individuals of Mexican Descent at the US-Mexico Border

Introduction: Previous studies have linked sleep to risk of diabetes and obesity, at least partially via alterations in food intake. Diabetes and obesity are common among Hispanics/Latinos, and studies are needed to better clarify the role of sleep in health among this group. Utilizing the revised TFEQ-R-18, this study will examine whether eating behaviors such as cognitive restraint, emotional eating and uncontrolled eating are related to self-reported sleep experiences. Specifically, we hypothesized that poor eating habits would be associated with (1) more insomnia symptoms, (2) overall worse sleep quality, (3) increased daytime sleepiness, and (4) shorter sleep duration.Methods: Data were collected from N = 100 adults (age 18-60, 47% female) of Mexican descent in the city of Nogales, AZ (34% not born in the US). Surveys were presented in English or Spanish. Eating Patterns were assessed with the Three-Factor Eating Questionnaire (TFEQ), which resulted in a total score and subscales for "cognitive restraint," "uncontrolled eating," and "emotional eating." Insomnia was assessed with the use of the Insomnia Severity Index (ISI), Sleepiness with the use of the Epworth Sleepiness Scale (ESS), Sleep quality with the use of the Pittsburgh Sleep Quality Index (PSQI), and weekday and weekend sleep duration with the use of the Sleep Timing Questionnaire (STQ). Covariates included age, sex, Body Mass Index (BMI), education and immigrant status.Results: Overall TFEQ score (problematic eating) was positively associated with greater insomnia, poorer sleep quality, more sleepiness, and less weekend (but not weekday) sleep. Mean TFEQ score in the sample was 18.7 (range 0-51). In adjusted analyses, every point on the TFEQ was associated with 0.6 ISI points, 0.8 PSQI points, 0.5 ESS points, and 1.1 minutes of less weekend sleep duration. Regarding subscale scores, relationships were generally seenbetween sleep and emotional eating and unrestricted eating, and not cognitive restraint.Conclusions: Greater insomnia, poorer sleep quality, increased daytime sleepiness and decreased weekend sleep duration were associated with eating patterns at the US-Mexico border, particularly in the area of unrestricted eating and emotional eating. This suggests possible mechanisms linking sleep and obesity in Hispanic/Latinos.

Chronic Sleep Restriction While Minimizing Circadian Disruption Does Not Adversely Affect Glucose Tolerance

Insufficient sleep, which has been shown to adversely affect metabolism, is generally associated with prolonged exposure to artificial light at night, a known circadian disruptor. There is growing evidence suggesting that circadian disruption adversely affects metabolism, yet few studies have attempted to evaluate the adverse metabolic effects of insufficient sleep while controlling for circadian disruption. We assessed postprandial glucose and insulin responses to a standard breakfast meal in healthy adults (n = 9) who underwent 3 weeks of chronic sleep restriction (CSR) in a 37-day inpatient study while minimizing circadian disruption by maintaining the same duration of light exposure each study day. We compared these results to findings from an earlier inpatient study which used a forced desynchrony (FD) protocol to assess the influence of 3 weeks of CSR combined with recurrent circadian disruption (RCD) on glycemic control in healthy adults (n = 21). CSR combined with RCD resulted in significantly elevated postprandial plasma glucose levels (p < 0.0001), while CSR with minimized circadian disruption had no adverse glycemic effects after 3 weeks of exposure (EXP). These results suggest that one mechanism by which sleep restriction impacts metabolism may be via concurrent circadian disruption.

Adiposity, Depression Symptoms and Inflammation in Hispanic/Latino Youth: Results From HCHS/SOL Youth

BACKGROUND

Inflammation is implicated as one of many factors related to the development of chronic disease; thus, identifying its modifiable risk factors offers potential intervention targets to reduce risk.

PURPOSE

To investigate whether depression and anxiety symptoms may indirectly affect high-sensitivity C-reactive protein (hs-CRP) and plasminogen activator inhibitor-1 (PAI-1) through sleep duration and adiposity (i.e., percentage body fat and waist circumference).

METHODS

Multiple regression analyses were performed on Hispanic Community Health Study/Study of Latinos Youth (ages 8-16 years) cross-sectional baseline data, which were weighted to adjust for sampling design. Data were collected at a clinical assessment, including fasting blood samples, self-report surveys, and objectively measured anthropometrics.

RESULTS

Adjusting for sociodemographic covariates, depression symptoms were associated with log hs-CRP (β = .011, p = .047) but not PAI-1 (p = .285). Percentage body fat and waist circumference were positively related to depression symptoms (p = .026 and p = .028, respectively) and log hs-CRP (p < .001 for both). When including adiposity in the hs-CRP model, the associations of depression symptoms with hs-CRP were attenuated and became nonsignificant. Monte Carlo confidence intervals (CIs) showed that the indirect effects from depression symptoms to CRP through percentage body fat (95% CI: .0006, .0119) and waist circumference (95% CI: .0004, .0109) were statistically significant.

CONCLUSIONS

Results indicate that the association between psychological distress and inflammation may occur indirectly through adiposity in Hispanic/Latino children. If findings are replicated in causal designs, reducing depression symptoms and adiposity among Hispanic/Latino children may be avenues for primary prevention of inflammation in later years.

A Systematic Review of Workplace-Based Employee Health Interventions and Their Impact on Sleep Duration Among Shift Workers

BACKGROUND

Shift work is associated with long-term health risks. Workplace-based health interventions hold promise for improving or maintaining the health of shift workers; yet, the impact of workplace-based interventions on shift worker sleep duration has not been assessed. We conducted a systematic review of workplace interventions on shift worker sleep.

METHODS

We conducted searches in PubMed, Web of Knowledge, EMBASE, Scopus, and PsycINFO (n = 6,868 records) of all studies published through May 15, 2019. Eligibility criteria included the following: (a) individuals aged ≥18 years; (b) a workplace-based employee intervention; (c) an employee population comprised predominantly of shift workers (>50%); and (d) sleep duration as a study outcome.

FINDINGS

Twenty workplace interventions met eligibility criteria. Mean intervention duration was 125 (SD = 187) days and mean sample size was 116 employees (SD = 256) with a mean age of 36.4 years (SD = 6.5). Interventions most commonly focused on light exposure (25%) or shift timing (25%), followed by sleep hygiene (20%). Most interventions were conducted in the health care and social assistance sector (60%). Study quality on average was 64% (SD = 7%). A majority of the studies found that a workplace-based health intervention was associated with a desirable increase in 24-hour total sleep duration (55%). The overall average increase in daily employee sleep duration achieved by interventions ranged for RCT studies from 0.34 to 0.99 hours and for non-RCT studies from 0.02 to 1.15 hours.

CONCLUSIONS/APPLICATIONS TO PRACTICE

More than half of the employee health interventions, especially yoga or mindfulness interventions, resulted in a desirable increase in sleep duration. Workplaces hold promise as an avenue? for delivering programs and policies that aim to improve sleep duration among shift workers.

A randomized trial to decrease risk for diabetes among Cambodian Americans with depression: Intervention development, baseline characteristics and process outcomes

Background:

Depression and antidepressant medications are associated with increased risk for type 2 diabetes. It is not known if diabetes can be prevented in the setting of depression. Cambodian Americans have high rates of both depression and diabetes. This paper reports intervention development, experimental design, baseline characteristics, and process outcomes of diabetes prevention interventions for Cambodian Americans with depression, “Diabetes Risk Reduction through Eat, Walk, Sleep and Medication Therapy Management” (DREAM).

Methods:

Participants were aged 35–75, Khmer speaking, at high risk for developing diabetes, and met criteria for likely depression by either a) antidepressant medication and/or b) elevated depressive symptoms at two time-points during a study eligibility period. Treatment arms were: 1) community health educator (CHE) delivered lifestyle intervention called Eat, Walk, Sleep (EWS), 2) EWS plus pharmacist/CHE-delivered medication therapy management (EWS + MTM), and, 3) social services (SS; control).

Results:

188 participants were randomized. Treatment fidelity was high (98% checklist adherence) and on a scale from 0 to 3, participants reported high EWS treatment satisfaction (M = 2.9, SD = 0.2), group cohesion (M = 2.9, SD = 0.3), and therapeutic alliance to CHEs (M = 2.9, SD = 0.2) and to pharmacists (2.9, SD = 0.3). Attendance was challenging but highly successful; in EWS, 99% attended ≥ one session and 86% completed ≥ 24 sessions, M = 27.3 (SD = 3.7) sessions. Of those randomized to EWS + MTM, 98% attended at least one MTM session and 77%) completed ≥ 4 sessions. Retention was high, 95% at 12-month and 96% at 15-month assessments.

Conclusions:

The interventions were successfully implemented. Lessons learned and suggestions for future trials are offered.

ClinicalTrials.gov identifier: NCT02502929

Social disconnection and metabolic syndrome score among Cambodian Americans with depression

AIMS

Migrants experience social disconnection and also have high risk for metabolic syndrome (MetS). This study explored associations of social alienation, social isolation, and social support with MetS among Cambodian Americans.

METHODS

We conducted secondary data analysis on baseline assessments from a diabetes prevention trial for Cambodian Americans with depression and high risk for diabetes. Participants were aged 35-75, Cambodian or Cambodian-American, Khmer speaking, lived in Cambodia during the Pol Pot regime, lived in the northeastern U.S. at the time of study, endorsed elevated risk factors for diabetes and met criteria for depression by medication for depression and/or elevated depressive symptoms. They completed surveys and provided anthropometric and blood pressure measurements and fasting blood samples.

RESULTS

In multiple linear regressions, greater social alienation was associated with increased risk for MetS. The social alienation-MetS association was stronger in men than women. Associations were not better accounted for by crude indicators of social isolation such as marital status, living alone, and number of people in the household. Social support was not associated with MetS and did not buffer the deleterious association between social alienation and MetS.

CONCLUSIONS

Decreasing social alienation may mitigate risk for MetS among migrant populations.

Detecting sleep using heart rate and motion data from multisensor consumer-grade wearables, relative to wrist actigraphy and polysomnography

STUDY OBJECTIVES

Multisensor wearable consumer devices allowing the collection of multiple data sources, such as heart rate and motion, for the evaluation of sleep in the home environment, are increasingly ubiquitous. However, the validity of such devices for sleep assessment has not been directly compared to alternatives such as wrist actigraphy or polysomnography (PSG).

METHODS

Eight participants each completed four nights in a sleep laboratory, equipped with PSG and several wearable devices. Registered polysomnographic technologist-scored PSG served as ground truth for sleep-wake state. Wearable devices providing sleep-wake classification data were compared to PSG at both an epoch-by-epoch and night level. Data from multisensor wearables (Apple Watch and Oura Ring) were compared to data available from electrocardiography and a triaxial wrist actigraph to evaluate the quality and utility of heart rate and motion data. Machine learning methods were used to train and test sleep-wake classifiers, using data from consumer wearables. The quality of classifications derived from devices was compared.

RESULTS

For epoch-by-epoch sleep-wake performance, research devices ranged in d' between 1.771 and 1.874, with sensitivity between 0.912 and 0.982, and specificity between 0.366 and 0.647. Data from multisensor wearables were strongly correlated at an epoch-by-epoch level with reference data sources. Classifiers developed from the multisensor wearable data ranged in d' between 1.827 and 2.347, with sensitivity between 0.883 and 0.977, and specificity between 0.407 and 0.821.

CONCLUSIONS

Data from multisensor consumer wearables are strongly correlated with reference devices at the epoch level and can be used to develop epoch-by-epoch models of sleep-wake rivaling existing research devices.

Emotional Vulnerability to Short Sleep Predicts Increases in Chronic Health Conditions Across 8 Years

BACKGROUND

Sleep is a robust determinant of next-day emotions, but people vary in the extent that their emotions fluctuate on days following short sleep duration. These individual differences in day-to-day sleep and emotion dynamics may have long-term health implications.

PURPOSE

To evaluate emotional vulnerability to short sleep (within-person associations between sleep duration and next-day emotions) as a risk factor for future chronic conditions.

METHODS

Adults aged 33-84 (N = 1,426; 57% female) in the Midlife in the United States Study reported sleep duration and emotions by telephone for eight consecutive days. Chronic conditions were assessed via checklist at baseline and at a median follow-up of eight years (range: 5-10 years). Short sleep was examined in three ways: person-centered continuous variable, ≤6 hr, and <7 hr; long sleep was defined as ≥9 hr.

RESULTS

Multilevel structural equation models revealed that people with greater negative emotions following nights of sleep ≤6 hr (vs. their negative emotions after longer sleep) had increased chronic conditions at follow-up, compared to people who were less emotionally vulnerable to short sleep (Est. = 1.04, SE = .51, p < .028). Smaller declines in positive emotions following ≤6 hr of sleep were marginally predictive of lower risk for chronic conditions (Est. = -.77, SE = .44, p = .054). Emotional vulnerability to <7, ≥9, and continuous sleep hours were not associated with subsequent chronic conditions.

CONCLUSIONS

Emotional vulnerability to short sleep is a unique risk factor for the development of chronic conditions, independent of mean-level sleep duration and emotions.