The effectiveness of diaphragmatic breathing relaxation training for improving sleep quality among nursing staff during the COVID-19 outbreak: a before and after study

ObjectivesRecent studies have demonstrated that first-line nurses involved in the coronavirus disease-2019 (COVID-19) crisis may experience sleep disturbances. As breathing relaxation techniques can improve sleep quality, anxiety, and depression, the current study aimed to evaluate the effectiveness of diaphragmatic breathing relaxation training (DBRT) for improving sleep quality among nurses in Wuhan, China during the COVID-19 outbreak.MethodsThis study used a quasi-experimental (before and after) intervention strategy, with 151 first-line nurses from four wards in Leishenshan hospital. The Pittsburgh Sleep Quality Index (PSQI), Self-Rating Anxiety Scale (SAS), and Self-Rating Depression Scale (SDS) to evaluate the effectiveness of DBRT before and after the intervention. Data were examined using the Shapiro–Wilk test, Levene's test, and paired t-test.ResultsA total of 140 nurses completed the DBRT sessions. First-line nurses achieved significant reductions in global sleep quality (p < 0.01), subjective sleep quality (p < 0.001), sleep latency (p < 0.01), sleep duration (p < 0.001), sleep disturbances (p < 0.001), habitual sleep efficiency (p = 0.015), daytime dysfunction (p = 0.001), and anxiety (p = 0.001). There were no significant reductions in the use of sleeping medication (p = 0.134) and depression (p = 0.359).ConclusionDBRT is a useful non-pharmacological treatment for improving sleep quality and reducing anxiety among first-line nurses involved in the COVID-19 outbreak.The study protocol was clinically registered by the Chinese Clinical Trial Registry. Clinical Trial Registration number: ChiCTR2000032743.     

Comparison of longitudinal diary and actigraphy-assessed sleep in pregnant women

Study objectivesVarious methods are employed to assess sleep in pregnant women, including self-report, sleep diary, and actigraphy. Unfortunately, the data are often contradictory, and interpretations are often inconsistent. The current aims are to compare subjective and objective sleep data in pregnant women collected longitudinally in early pregnancy.MethodsIn this secondary analysis of 104 pregnant women, sleep was collected via diary and actigraphy for 14 days during three separate occasions (10–12 weeks; 14–16 weeks; and 18–20 weeks). Sleep variables included wake after sleep onset (WASO), sleep efficiency (SE), bedtime/lights out, sleep onset latency (SL), and total sleep duration (TST). Repeated measures ANOVAs compared each sleep variable across Time and by Method of data collection, while controlling for parity and daytime naps.ResultsSignificant differences were noted for only the method of data collection for sleep component studied for WASO, F (1, 98) = 147.20, p < 0.001; SE, F (1, 98) = 129.41, p < 0.001); bedtime/lights out, F (1, 103) = 5.33, p < 0.05); and sleep duration, F (1, 104) = 182.75, p < 0.001). Significant variation was not seen in any variable across time-period. Conclusions: There are substantial discrepancies between diary- and actigraphy-assessed sleep measures in pregnant women which is in alignment with previous literature. These data highlight that these methodologies assess different constructs. We contend that these data may be useful as a reference to compare high-risk women or those with sleep disorders. Using a multi-modal approach to identify sleep disturbance in pregnancy is likely a more clinically useful option.     

Aerobic exercise improves self-reported sleep and quality of life in older adults with insomnia

ObjectiveTo assess the efficacy of moderate aerobic physical activity with sleep hygiene education to improve sleep, mood and quality of life in older adults with chronic insomnia.MethodsSeventeen sedentary adults aged ?55 years with insomnia (mean age 61.6 [SD ± 4.3] years; 16 female) participated in a randomized controlled trial comparing 16 weeks of aerobic physical activity plus sleep hygiene to non-physical activity plus sleep hygiene. Eligibility included primary insomnia for at least 3 months, habitual sleep duration <6.5 h and a Pittsburgh Sleep Quality Index (PSQI) score >5. Outcomes included sleep quality, mood and quality of life questionnaires (PSQI, Epworth Sleepiness Scale [ESS], Short-form 36 [SF-36], Center for Epidemiological Studies Depression Scale [CES-D]).ResultsThe physical activity group improved in sleep quality on the global PSQI (p < .0001), sleep latency (p = .049), sleep duration (p = .04), daytime dysfunction (p = .027), and sleep efficiency (p = .036) PSQI sub-scores compared to the control group. The physical activity group also had reductions in depressive symptoms (p = .044), daytime sleepiness (p = .02) and improvements in vitality (p = .017) compared to baseline scores.ConclusionAerobic physical activity with sleep hygiene education is an effective treatment approach to improve sleep quality, mood and quality of life in older adults with chronic insomnia.     

Shorter sleep duration is associated with lower GABA levels in the anterior cingulate cortex

BackgroundAlterations in the levels of gamma-aminobutyric acid (GABA) and glutamate + glutamine (Glx), which are major inhibitory and excitatory neurotransmitters, respectively, are frequently associated with insomnia. Previous reports also suggested the involvement of the anterior cingulate cortex (ACC) and medial prefrontal cortex (mPFC) in insomnia and shorter sleep duration. In the current study, we investigated whether the GABA and Glx levels were altered in the ACC/mPFC in subclinical insomnia while focusing on the sleep duration.MethodsWe examined levels of GABA and Glx in the ACC/mPFC of the brain with magnetic resonance spectroscopy in 166 individuals with subjective sleep complaints but without a diagnosis of insomnia. Participants were divided into two groups according to sleep duration (≥6 h/night: n = 79 vs. < 6 h/night: n = 74), which was measured using a wrist-worn actigraphy. Working memory function and overall subjective sleep quality were assessed with a computerized neuropsychological test and self-report questionnaire, respectively.ResultsGABA levels in the ACC/mPFC were lower in the shorter sleep duration group relative to the longer sleep duration group (t = −2.21, p = 0.03). Glx levels did not differ between the two groups (t = −0.20, p = 0.84). Lower GABA levels were associated with lower spatial working memory performance in the shorter sleep duration group (β = −0.21, p = 0.03), but not the longer sleep duration group (β = 0.04, p = 0.72).ConclusionShorter sleep duration was associated with lower GABA levels in the ACC/mPFC. These findings may provide insight into the underlying mechanisms of impaired working memory function related to insomnia and sleep loss.     

Predictors and patterns of insomnia symptoms in OSA before and after PAP therapy

ObjectiveIdentify factors that predict improvement versus persistence of insomnia symptoms following treatment of obstructive sleep apnea (OSA) with positive airway pressure (PAP) therapy.MethodsArchival data from 68 PAP-treated sleep apnea patients aged 25–83 were analyzed using nonparametric tests and stepwise regression to assess the relationships between insomnia symptoms, multiple OSA variables, and PAP use over time.ResultsPretreatment insomnia symptom severity (ISS; b = −0.72, p < 0.001), PAP average use (b = −0.01, p = 0.01) and respiratory disturbance index (RDI; b = −0.02, p = 0.03) predict change in insomnia following PAP therapy. Forty-five percent (24/53) of the subjects with moderate to severe insomnia at pretreatment reported no/mild symptoms after PAP therapy and were considered improved. Improved subjects had lower pretreatment ISS (p < 0.001), higher RDI (p = 0.01), and higher average PAP use (p < 0.035) than subjects with persistent insomnia. Number of medications and comorbidities were similar between improved and persistent groups. New onset of insomnia symptoms occurred in 13% (2/15) of the patients with no/mild pretreatment insomnia.ConclusionsAlthough ISS declines following PAP treatment, 55% of OSA patients have persistent moderate to severe symptoms despite treatment. More severe OSA is linked to higher likelihood of insomnia improvement and the effect of PAP therapy on insomnia may be mediated by OSA severity. Persistent insomnia is unrelated to medication use or comorbidities and may represent an independent, self-sustaining disorder requiring targeted intervention.     

Insomnia symptoms increase during pregnancy,but no increase in sleepiness - Associations with symptoms of depression and anxiety

ObjectiveTo evaluate alteration in insomnia and sleepiness symptoms during pregnancy and assess early pregnancy risk factors for these symptoms, especially depressive and anxiety symptoms.MethodsA cohort of 1858 women was enrolled from the FinnBrain Birth Cohort Study. Insomnia and sleepiness symptoms were measured in early, mid- and late pregnancy with the Basic Nordic Sleep Questionnaire. Depressive symptoms were measured using the Edinburgh Postnatal Depression Scale and anxiety symptoms with the Symptom Checklist-90/Anxiety Scale. General linear models for repeated measures were conducted.ResultsGeneral sleep quality decreased (p < 0.001) and all insomnia types (p < 0.001) and sleep latencies (p < 0.001) increased as pregnancy proceeded. Snoring increased, but witnessed apneas remained rare. Nevertheless, morning (p = 0.019) and daytime (p < 0.001) sleepiness decreased from early to both mid-pregnancy and late pregnancy (p = 0.006 and p = 0.039). Women took more naps in early and late pregnancy compared to mid-pregnancy (both p < 0.001). Women with higher baseline anxiety symptoms had greater increase in sleep latency. At each pregnancy point, higher depressive and anxiety symptoms were associated with higher insomnia (p < 0.001) and sleepiness scores (p < 0.001) and higher depressive symptoms with longer sleep latencies (p < 0.001).ConclusionWe found a marked increase in insomnia symptoms throughout pregnancy. However, sleepiness symptoms did not increase correspondingly. Both depressive and anxiety symptoms in early pregnancy were associated with higher insomnia and sleepiness symptoms in later stages of pregnancy which emphasizes the importance of their assessment in early pregnancy.     

Can acupuncture improve objective sleep indices in patients with primary insomnia? A systematic review and meta-analysis

BackgroundThe efficacy of acupuncture for treating primary insomnia (PI) has been explored in several meta-analyses where the outcomes measures were based on subjective self-reported sleep rating scales. Sleep state misperception is common in PI and self-reports underestimate sleep duration and quality. No systematic reviews or meta-analyses have investigated the efficacy of acupuncture in improving objective sleep measures in PI.ObjectiveTo perform a systematic review to determine whether objective sleep parameters are improved by acupuncture in patients with PI.MethodsRandomized controlled trials treating PI via verum-acupuncture versus sham-/placebo-acupuncture or waitlist control were searched for in English [MEDLINE (via PubMed), Sciverse ScienceDirect, Cochrane Central Register of Controlled Trials (CENTRAL), AMED, Springer, EMBASE (Elsevier), Ebsco Medline, and PsycINFO (ProQuest)] and Chinese (SinoMed, CNKI, Wanfang and CQVIP) databases, from the dates of the databases' inception to January 2020. The parameters of polysomnography (PSG), actigraphy, or micromovement sensitive mattress/pillow sleep monitoring systems were considered as the primary outcome measures. Revman 5.3 and Stata 16.0 software were used to conduct the meta-analysis. Heterogeneity was examined by using I² statistics and publication bias was assessed via Egger's test.ResultsEleven studies involving 775 patients met the inclusion criteria. The results of meta-analysis suggested that acupuncture can increase total sleep time [MD = 55.29, 95%CI (29.16, 81.42), p < 0.01], increase sleep efficiency [MD = 8.96, 95%CI (3.97, 13.95), p < 0.01], decrease wake after sleep onset [MD = −49.54, 95%CI (−82.98, −16.09), p < 0.01], and reduce number of awakening times [MD = −6.29, 95%CI (−10.75, −1.82), p < 0.01] compared with either sham-/placebo-acupuncture or waitlist control. Subsequent analysis indicated a superior effect for verum-acupuncture in comparison with sham-/placebo-acupuncture or waitlist-control when the recommended lowest threshold dosage (12 sessions) was met. Despite positive outcomes, most studies reviewed were heterogeneous and at risk of bias due to methodological issues.ConclusionsDespite limited evidence, acupuncture was significantly associated with improvements in several objective sleep parameters (increases in total sleep time and sleep efficiency, and reductions in wake after sleep onset and number of awakening times) as well as subjective sleep quantity and quality in patients with PI. A minimum therapeutic threshold dosage (≥12 sessions) is recommended. Well-designed RCTs using PSG are required to clarify the influence of acupuncture on sleep architecture/structure and to promote better application of acupuncture as a treatment for PI.     

The effect of sleep apnea on all-cause mortality in nondialyzed chronic kidney disease patients

BackgroundThe prevalence of sleep-disordered breathing (SDB) in people with chronic kidney disease (CKD) is high. Studies on the effects of sleep apnea (SA) on treatment outcomes have been mostly focused on dialyzed CKD or renal transplant patients. Studies on the effects of SA on all-cause mortality in nondialyzed CKD patients are scarce.MethodsWe enrolled and followed up all adults who were referred for diagnostic testing for sleep apnea between March 2007 and July 2014, had undergone polysomnography, and whose records of serum creatinine levels were available. The outcomes were all-cause mortality and renal outcome.ResultsA total of 1454 participants were included in the study. Of these, 103 patients (7.08%) had CKD and 38 patients (2.61%) died. CKD was associated with central sleep apnea (CSA) (odds ratio [OR] = 5.158 [95% confidence interval {CI} = 1.992–13.355], p = 0.001) and severe SDB (OR = 1.737 [1.119–2.695], p = 0.014). CSA was a risk factor for all-cause mortality in nondialyzed subjects (adjusted hazard ratio [HR]= <4.250 [CI = 1.560–11.573], p = 0.005), whereas CSA was found to be a stronger risk factor for all-cause mortality in subjects with CKD (adjusted HR = 40.728 [CI = 4.765–348.117], p = 0.001). Mixed sleep apnea was related to rapid decline of renal function in nondialyzed subjects (adjusted HR = 1.932 [CI = 1.183–3.155], p = 0.009), whereas, OSA was (adjusted HR = 3.315 [CI = 1.188–9.248], p = 0.022) in CKD subjects.ConclusionIn nondialyzed patients, CKD was each associated with central sleep apnea (CSA) and severe SDB. CSA was an independent risk factor for all-cause mortality, and was a more evident mortality risk in CKD patients than in non-CKD participants. Rapid decline of renal function may play a role in the mortality of CKD patients associated with SA.     

Higher nocturnal systolic blood pressure in patients with restless legs syndrome compared with patients with insomnia

BackgroundThere is evidence linking restless legs syndrome (RLS) with increased blood pressure (BP), but the mechanism of this relation remains unclear. Is the BP increased due to some features of RLS or to deterioration of sleep caused by RLS? This study compared values of nocturnal BP in patients with RLS and patients with insomnia. If increased BP in RLS is a consequence of disordered sleep, then it should be similar to increased BP in insomnia.MethodsPolysomnographic recordings of patients admitted to a sleep center with RLS or insomnia were analyzed. Demographic and clinical data, objective sleep parameters, and nocturnal BP were compared.ResultsRecordings of 35 patients with RLS and 33 patients with insomnia were analyzed. The groups did not significantly differ in terms of demographic traits or prevalence of other comorbidities. Patients with RLS had significantly higher systolic BP during the night (122.4 ± 13.8 vs 116.3 ± 13.4; p = 0.03) and during sleep (121.4 ± 13.3 vs 115.7 ± 13.3; p = 0.04). The only significant difference in sleep architecture was an increased number of periodic limb movements in sleep (PLMS) and PLMS with arousal in the RLS group (25.5 ± 24.6 vs 13.9 ± 22.7; p = 0.02 and 4.7 ± 5.4 vs 2.1 ± 3.4; p = 0.01).ConclusionOur results suggest that patients with RLS have higher nocturnal BP than patients with insomnia, and that increased PLMS is related to the increase in BP.     

Continuous positive airway pressure deepens sleep in patients with Alzheimer’s disease and obstructive sleep apnea

ObjectivePatients with Alzheimer’s disease (AD) and obstructive sleep apnea (OSA) experience disrupted sleep. This study examined the effect of continuous positive airway pressure (CPAP) on sleep parameters in AD patients with OSA.MethodsA randomized placebo-controlled trial of 3 weeks of therapeutic CPAP (tCPAP) vs. 3 weeks placebo CPAP (pCPAP) followed by 3 weeks tCPAP in patients with AD and OSA. Polysomnography data from screening after one night and after 3 weeks of treatment were analyzed. Records were scored for percent of each sleep stage, total sleep time (TST), sleep efficiency (SE), sleep period (SP), time in bed (TIB), sleep onset (SO), wake time after sleep onset (WASO), and arousals. A randomized design comparing one night of pCPAP to tCPAP and a paired analysis combining 3 weeks of tCPAP were performed.ResultsFifty-two participants (mean age = 77.8 years, SD = 7.3) with AD and OSA were included. After one treatment night, the tCPAP group had significantly less % Stage 1 (p = 0.04) and more % Stage 2 sleep (p = 0.02) when compared to the pCPAP group. In the paired analysis, 3 weeks of tCPAP resulted in significant decreases in WASO (p = 0.005), % Stage 1 (p = 0.001), arousals (p = 0.005), and an increase in % Stage 3 (p = 0.006).ConclusionIn mild to moderate AD patients with OSA, the use of tCPAP resulted in deeper sleep after just one night, with improvements maintained for 3 weeks.     

Response to placebo acupuncture in insomnia: a secondary analysis of three randomized controlled trials

ObjectiveTo determine the patient characteristics that are associated with a response to noninvasive placebo acupuncture for insomnia.MethodsWe performed a secondary analysis of three randomized, double-blind, placebo-controlled trials of acupuncture for primary insomnia and residual insomnia associated with major depression. A total of 86 participants were randomized to receive placebo acupuncture three times per week for three consecutive weeks. Outcome was assessed at 1-week posttreatment. Response was defined as an Insomnia Severity Index (ISI) score improved by eight points or more from baseline to 1-week posttreatment. Sociodemographic, clinical, and baseline characteristics including sleep diary-derived and actigraph-derived sleep parameters as predictors of placebo response were examined using univariate and multivariate logistic regression.ResultsThe effect size of placebo acupuncture was estimated at 0.18 for total sleep time, 0.08 for sleep efficiency, and 0.92 for ISI score. Eighteen (20.9%) of the 86 participants were responders. Responders had a higher ISI score (p = 0.03), higher sleep diary–derived total sleep time (p = 0.02), less discrepancy between sleep diary–derived and actigraph-derived total sleep time (p = 0.03), and higher expectation toward acupuncture (p = 0.03) at baseline compared to nonresponders. Multivariate regression analysis found that only ISI score remained significant (odds ratio = 1.23, 95% confidence interval = 1.02–1.50, p = 0.03).ConclusionsBaseline sleep parameters and perceived effectiveness were shown to predict the placebo response of acupuncture for insomnia. Although the study was limited by a small sample size, our findings highlighted the potential implication of sleep duration and sleep-state misperception in the treatment of insomnia.     

Effect of Tai Ji Quan training on self-reported sleep quality in elderly Chinese women with knee osteoarthritis: a randomized controlled trail

ObjectiveThe purpose of this study was to explore the effects of a 24-week Tai Ji Quan training program on sleep quality, quality of life, and physical performance among elderly Chinese women with knee osteoarthritis (OA).MethodsA 24-week randomized, controlled trial of 46 elderly women with knee OA. Participants were randomly assigned to either a Tai Ji Quan group (n = 23) or a control group (n = 23). Participants in the Tai Ji Quan group completed training sessions three times per week, while those in the control group had bi-weekly educational classes. The primary outcome was total score of the Pittsburgh Sleep Quality of Index (PSQI). Secondary outcomes were: seven subscales of the PSQI; sleep latency; total sleep time; sleep efficiency; physical component summary (PCS) and mental component summary (MCS) of the 36-item Short Form Health Survey (SF-36); Berg Balance Scale (BBS); and Timed Up and Go (TUG).ResultsCompared with the control group, participants in the Tai Ji Quan group had significantly improved primary outcome (global PSQI score, p = 0.006) and secondary outcomes, including three PSQI sub-scores (sleep latency, p = 0.031; sleep duration, p = 0.043; daytime dysfunction, p = 0.007), total sleep time (p = 0.033), and SF-36 PCS (p = 0.006). The Tai Ji Quan group also had significant improvements compared with baseline in three PSQI sub-scores (sleep latency, p = 0.031; habitual sleep efficiency, p = 0.049; sleep disturbance, p = 0.016), sleep latency (p = 0.003), BBS (p = 0.001), and TUG (p = 0.006).ConclusionTai Ji Quan training is an effective treatment approach to improve sleep quality and quality of life in elderly Chinese women with knee OA.Trial registration: Chinese Clinical Trial Registry (June 16, 2013): ChiCTR-TRC-13003264.     

Treatment of elderly primary insomnia patients with EVT 201 improves sleep initiation,sleep maintenance,and daytime sleepiness

ObjectiveTwo doses of EVT 201, a partial positive allosteric modulator of the GABA_A system, were evaluated in elderly primary insomnia patients with daytime sleepiness.Patients and methodsParticipants were 149 elderly patients with DSM-IV primary insomnia including evidence of daytime sleepiness (53 males, 96 females; mean age 71.3 yrs, range 65–86 yrs). A randomized, multicentre, double-blind, placebo-controlled, parallel-group design was used to assess the hypnotic efficacy of EVT 201 1.5 and 2.5 mg during seven consecutive nights. Polysomnography (PSG) was performed on nights 1, 6 and 7 of treatment. Daytime assessments on Day 8 included the multiple sleep latency test (MSLT), Rey Auditory Verbal Learning Test (RAVLT), Psychomotor Vigilance Task (PVT) and the Karolinska Sleepiness Scale (KSS). The primary endpoint was total sleep time (TST) and the key secondary endpoint was mean MSLT latency.ResultsCompared to placebo, EVT 201 1.5 and 2.5 mg increased TST (30.9, 56.4 min, respectively; p = 0.0001, p < 0.0001); reduced wake after sleep onset (WASO; ?15.2, ?36.1 min, respectively; p = 0.014, p < 0.0001); reduced latency to persistent sleep (LPS; ?15.9, ?19.9 min, respectively; p = 0.009, p = 0.001). The 2.5 mg dose also reduced WASO in hours 5–8 (?16.3 min, p = 0.001). Both doses also improved subjective sleep quality and usual subjective efficacy measures. A significantly longer mean MSLT latency was observed on Day 8 with both doses, compared to placebo (2 min increase; p = 0.03, both doses). The PVT, RAVLT, and POMS did not differ among treatment groups. No serious or unexpected treatment emergent adverse events were noted.ConclusionEVT 201 improved PSG measures of sleep onset and sleep maintenance and significantly reduced daytime physiological sleep tendency. These findings suggest that treatment of primary insomnia in older patients has the potential to improve daytime sleepiness as well as sleep.     

Is digital cognitive behavioural therapy for insomnia effective in treating sub-threshold insomnia: a pilot RCT

Objective/BackgroundMany patients find cognitive behavioral therapy for insomnia (CBT-I) useful. However, it is currently unknown if those with sub-threshold insomnia also benefit. Here we assessed whether CBT-I is both feasible and acceptable in participants with sub-threshold insomnia. The primary aims were to evaluate participation rates and treatment acceptability, and to establish an effect size for symptom improvement.Patients/MethodsA total of 199 female participants (M_age 20 ± 5 years) took part. Following baseline assessments, participants were randomly allocated to either a six-week digital CBT-I intervention or a six-week control group receiving puzzles. Additional assessments were performed three-weeks, six-weeks, and six-months later.ResultsParticipation rates at each survey assessment wave did not differ between the groups (ps > 0.140), though adherence to completing each weekly task was lower in the CBT-I group, p = 0.02. Treatment acceptability was high (M (SD) = 33.61 (4.82), theoretical range 6–42). The CBT-I group showed greater improvement in insomnia symptoms at the end of the intervention compared to the control group (p = 0.013, d = 0.42), with significant variation in outcome (M = 4.69, SD = 5.41). Sub-threshold participants showed a similar pattern of results, whilst those meeting insomnia criteria showed a smaller between-group difference. CBT-I led to improvements in anxiety, paranoia and perceived stress between baseline and end of intervention. Changes in insomnia symptoms were mediated by cognitions about sleep and somatic pre-sleep arousal.ConclusionsCBT-I provides a benefit even in sub-threshold insomnia. CBT-I may be useful to tackle insomnia symptoms even when they are sub-threshold.     

Psychometric properties and clinical relevance of the Adolescent Sleep Hygiene Scale in Dutch adolescents

ObjectiveThis study investigated reliability, validity, and clinical relevance of the Adolescent Sleep Hygiene Scale (ASHS) in Dutch adolescents.MethodsThe Dutch translation of the ASHS was administered to 186 normal-sleeping adolescents and 112 adolescents with insomnia. Their sleep variables were measured using sleep logs and questionnaires. From the insomnia group, scores were also obtained after six weeks of cognitive behavioral therapy for insomnia (n = 58) or waiting list (n = 22).ResultsThe full scale of the ASHS had acceptable internal consistency. The results showed moderate to strong correlations of the ASHS (domains) with sleep quality, sleep duration and chronic sleep reduction. Furthermore, the Dutch ASHS was able to discriminate between normal sleepers and adolescents with insomnia, and scores of adolescents with insomnia improved after treatment.ConclusionsThese findings confirm the importance of sleep hygiene in adolescent sleep, and contribute to the validity of the ASHS and its applicability in research and clinical practice.     

Impact of a brief behavioral treatment for insomnia (BBTi) on metacognition in older adults

IntroductionBrief (≤4 sessions) behavioral treatment for insomnia (BBTi) improves insomnia symptoms in older adults. Findings for BBTi-related improvements in objective cognition are mixed, with our recent trial reporting no effects. Metacognition (appraisal of one's own performance) has not been examined. This study examined the effects of BBTi on metacognition in older adults with insomnia.MethodsOlder adults with insomnia [N = 62, Mage = 69.45 (SD = 7.71)] were randomized to 4-weeks of BBTi (n = 32; psychoeducation, sleep hygiene, stimulus control, sleep restriction, relaxation, review/maintenance) or self-monitoring control (SMC; n = 30; social conversations). Throughout the study (2 week baseline, 4 week treatment, 2 week post-treament, 2 week 3-month followup), participants completed daily paper/pencil cognitive tasks (measuring verbal memory, attention, processing speed and reasoning) and provided daily metacognition ratings of their performance in four areas: quality, satisfaction, compared to same age peers, compared to own ability. Two-week averages of metacognitive ratings were calculated for baseline, treatment-first half, treatment-second half, post-treatment, and 3-month follow-up. Multilevel Modeling examined treatment effects (BBTi/SMC) over time on metacognition, controlling for age and sex.ResultsA significant group by time interaction (p = 0.05) revealed consistent improvements over time in better metacognitive ratings relative to same age peers for BBTi. Specifically, baseline ratings [mean (M) = 51.21, standard error (SE) = 3.15] improved at first half of treatment (M = 56.65, SE = 3.15, p < 0.001), maintained improvement at second-half of treatment (p = 0.18), showed additional improvement at post-treatment (M = 60.79, SE = 3.15, p = 0.02), and maintained improvement at follow-up (M = 62.30, SE = 3.15; p = 0.02). SMC prompted inconsistent and smaller improvements between baseline (M = 53.24, SE = 3.29) and first-half of treatment (M = 56.62, SE = 3.28; p = 0.004), with additional improvement at second-half of treatment (M = 59.39, SE = 3.28; p = 0.02) that was maintained at post-treatment (p = 0.73) and returned to levels observed at first-half of treatment (M = 57.78, SE = 3.21; p = 0.55). Significant main effects of time (all ps < 0.001) for other metacognition variables (Quality, Satisfaction, Compared to own ability) indicated general improvements over time for both groups.DiscussionMetacognition generally improved over time regardless of treatment. BBTi selectively improved ratings of performance relative to same age peers. Repeated objective testing alone may improve metacognition in older adults with insomnia. Better understanding of metacognition and how to improve it has important implications for older adults as metacognitive complaints have been associated with mild cognitive impairment.     

Prevalence and associations of co-morbid insomnia and sleep apnoea in an Australian population-based sample

IntroductionInsomnia and obstructive sleep apnoea (OSA) are the two most prevalent sleep disorders, and frequently co-occur (COMISA) in sleep clinic samples. However, few studies have investigated the prevalence or associations of COMISA in the general population.MethodsWe used population-based online survey data from 2044 Australian adults. The prevalence and associations of insomnia, OSA and COMISA were investigated according to symptom-level, and disorder-level definitions. Insomnia was defined according to chronic difficulties initiating and/or maintaining sleep (DIMS; symptom-level), and ICSD-3 chronic insomnia disorder (disorder-level). OSA was defined according to self-reported frequent obstructive events, snoring or doctor-diagnosed OSA (symptom-level), and doctor-diagnosed OSA (disorder-level). COMISA was defined if both conditions were met (for symptom-level, and disorder-level threshold). Associations with other conditions, and general health were investigated with Poisson regression analyses.ResultsChronic insomnia occurred more frequently among participants with doctor-diagnosed OSA (22.3%), compared to those without (14.3%, p = 0.010). Doctor-diagnosed OSA was more common among participants with chronic insomnia (10.2%) compared to those without (6.2%; p = 0.010). DIMS also occurred more frequently among participants with OSA symptoms (66.6%), compared to those without (47.2%; p < 0.001). Participants with symptom-level COMISA reported increased co-morbid conditions, and worse general health compared to participants with symptoms of insomnia-alone, OSA-alone, or neither insomnia/OSA.ConclusionsCOMISA at symptom and disorder level were common and associated with increased medical and psychiatric co-morbidity, as well as poor general health. More investigation is required to understand bi-directional associations underpinning the high co-morbidity, and improve diagnostic and treatment approaches for COMISA to reduce associated morbidity.     

Lack of hippocampal volume differences in primary insomnia and good sleeper controls: An MRI volumetric study at 3 Tesla

BackgroundA recent pilot study reported that hippocampal volume (HV) was reduced in patients with primary insomnia (PI) relative to normal sleepers. Loss of HV in PI might be due to chronic hyperarousal and/or chronic sleep debt. The aim of this study was to replicate the earlier pilot report while employing a larger sample, more rigorous screening criteria, and objective sleep data.MethodsThis cross-sectional design included community recruits meeting DSM-IV criteria for PI (n = 20, 10 males, mean age 39.3 ± 8.7) or good sleeper controls (n = 15, 9 males, mean age 38.8 ± 5.3). All subjects were unmedicated and rigorously screened to exclude comorbid psychiatric and medical illness. PI subjects underwent overnight polysomnography to screen for sleep-related breathing and movement disorders. HV and total brain volumes were derived by MRI employing a Siemens/Trio scanner operating at 3 Tesla. Data also included 2 weeks of sleep diaries and wrist actigraphy.ResultsMean HV was 4322.0 ± 299.7 mm³ for the good sleeper controls and 4601.55 ± 537.4 mm³ for the PI group. The dependent variable, HV, was analyzed by ANCOVA. Main effects were diagnosis and gender; whole brain volume served as the covariate. Although the overall model was significant (F = 6.3, p = 0.001), the main effects of diagnosis (F = 2.14) and gender (F = 0.04) were not significant. The covariate of whole brain volume was significant (F = 5.74, p = 0.023) as was the interaction of diagnosis with gender (F = 10.22, p = 0.003), with male insomniacs having larger HVs than male controls.ConclusionsThis study did not replicate a previously published report of HV loss in primary insomnia. Differences between our finding and the previous report might be due to sample composition and method of MRI assessment. Furthermore, we demonstrated no objective differences between the controls and PIs in actigraphic measures of sleep maintenance. Within the PIs, however, actigraphic measures of poor sleep maintenance were associated with smaller HV.     

The efficacy of cognitive-behavioral therapy for insomnia in patients with chronic pain

Study objectivesTo assess the efficacy of cognitive-behavioral therapy for insomnia (CBT-I) in patients with non-malignant chronic pain.MethodsTwenty-eight subjects with chronic neck and back pain were stratified according to gender, age, and ethnicity, then assigned to one of the two treatment groups: CBT-I or a contact control condition.InterventionEight weeks of CBT-I including sleep restriction, stimulus control, sleep hygiene, and one session of cognitive therapy devoted to catastrophic thoughts about the consequences of insomnia.Measurements and resultsOutcomes included sleep diary assessments of sleep continuity, pre–post measures of insomnia severity (ISI), pain (Multidimensional Pain Inventory), and mood (BDI and POMS). Subjects receiving CBT-I (n = 19), as compared to control subjects (n = 9), exhibited significant decreases in sleep latency, wake after sleep onset, number of awakenings, and significant increase in sleep efficiency. The diary findings were paralleled by significant changes in the ISI (p = 0.05). Significant improvement (p = 0.03) was found on the Interference Scale of the Multidimensional Pain Inventory. The groups did not significantly differ on mood measures or measures of pain severity.ConclusionsCBT-I was successfully applied to patients experiencing chronic pain. Significant improvements were found in sleep as well as in the extent to which pain interfered with daily functioning. The observed effect sizes for the sleep outcomes appear comparable to or better than meta-analytic norms for subjects with Primary Insomnia.