CBT for late‐life insomnia and the accuracy of sleep and wake perceptions: Results from a randomized‐controlled trial

Subjective and objective estimates of sleep are often discordant among individuals with insomnia who typically under‐report sleep time and over‐report wake time at night. This study examined the impact and durability of cognitive‐behavioural therapy for insomnia on improving the accuracy of sleep and wake perceptions in older adults, and tested whether changes in sleep quality were related to changes in the accuracy of sleep/wake perceptions. One‐hundred and fifty‐nine older veterans (97% male, mean age 72.2 years) who met diagnostic criteria for insomnia disorder were randomized to: (1) cognitive‐behavioural therapy for insomnia (n = 106); or (2) attention control (n = 53). Assessments were conducted at baseline, post‐treatment, 6‐months and 12‐months follow‐up. Sleep measures included objective (via wrist actigraphy) and subjective (via self‐report diary) total sleep time and total wake time, along with Pittsburgh Sleep Quality Index score. Discrepancy was computed as the difference between objective and subjective estimates of wake and sleep. Minutes of discrepancy were compared between groups across time, as were the relationships between Pittsburgh Sleep Quality Index scores and subsequent changes in discrepancy. Compared with controls, participants randomized to cognitive‐behavioural therapy for insomnia became more accurate (i.e. minutes discrepancy was reduced) in their perceptions of sleep/wake at post‐treatment, 6‐months and 12‐months follow‐up (p < .05). Improved Pittsburgh Sleep Quality Index scores at each study assessment preceded and predicted reduced discrepancy at the next study assessment (p < .05). Cognitive‐behavioural therapy for insomnia reduces sleep/wake discrepancy among older adults with insomnia. The reductions may be driven by improvements in sleep quality. Improving sleep quality appears to be a viable path to improving sleep perception and may contribute to the underlying effectiveness of cognitive‐behavioural therapy for insomnia.     

Subjective–objective sleep discrepancy in patients with insomnia during and after cognitive behavioural therapy: An actigraphy study

Although patients with insomnia often show a discrepancy between self‐reported and objective sleep parameters, the role of and change in this phenomenon during treatment remain unclear. The present study aimed to assess the effect of cognitive behavioural therapy for insomnia on subjective and objective sleep discrepancy of total sleep time, sleep‐onset latency and wake after sleep onset. The total sleep time discrepancy was also assessed across the entire therapy. The second aim was to examine the treatment outcome of two insomnia groups differing in sleep perception. Thirty‐six adults with insomnia (mean age = 46.7 years, SD = 13.9; 22 females) were enrolled in the final analyses. Patients underwent a 6‐week group cognitive behavioural therapy for insomnia programme. Sleep diary and actigraphy measurements were obtained during the therapy. Patients who underestimated total sleep time (n = 16; underestimating group) were compared with patients who accurately perceived or overestimated total sleep time (n = 20; accurate/overestimating group). After cognitive behavioural therapy for insomnia, a significant decrease of total sleep time and sleep‐onset latency discrepancy was observed without a change in wake after sleep onset discrepancy in the total sample. Only the underestimating group reported decreased sleep‐onset latency discrepancy after the treatment, whereas total sleep time discrepancy significantly changed in both groups. The underestimating group showed a significant decrease of total sleep time discrepancy from Week 1 to Week 2 when the sleep restriction was implemented, whereas the accurate/overestimating group showed the first significant change at Week 4. In conclusion, both groups differing in sleep perception responded similarly to cognitive behavioural therapy for insomnia, although different In conclusion, both groups differing in sleep perception responded similarly to cognitive behavioural therapy for insomnia, although different therapeutic components could play important roles in each group. components could play important roles in each group.     

Autonomic dysregulation and sleep homeostasis in insomnia

Study ObjectivesInsomnia is common in older adults, and is associated with poor health, including cognitive impairment and cardio-metabolic disease. Although the mechanisms linking insomnia with these comorbidities remain unclear, age-related changes in sleep and autonomic nervous system (ANS) regulation might represent a shared mechanistic pathway. In this study, we assessed the relationship between ANS activity with indices of objective and subjective sleep quality in older adults with insomnia.MethodsForty-three adults with chronic insomnia and 16 age-matched healthy sleeper controls were studied. Subjective sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), objective sleep quality by electroencephalogram spectral components derived from polysomnography, and ANS activity by measuring 24-h plasma cortisol and norepinephrine (NE).ResultsSleep cycle analysis displayed lower slow oscillatory (SO: 0.5–1.25 Hz) activity in the first cycle in insomnia compared to controls. In insomnia, 24-h cortisol levels were higher and 24-h NE levels were lower than controls. In controls, but not in insomnia, there was a significant interaction between NE level during wake and SO activity levels across the sleep cycles, such that in controls but not in insomnia, NE level during wake was positively associated with the amount of SO activity in the first cycle. In insomnia, lower 24-h NE level and SO activity in the first sleep cycle were associated with poorer subjective sleep quality.ConclusionDysregulation of autonomic activity may be an underlying mechanism that links objective and subjective measures of sleep quality in older adults with insomnia, and potentially contribute to adverse health outcomes.     

Telehealth‐delivered CBT‐I programme enhanced by acceptance and commitment therapy for insomnia and hypnotic dependence: A pilot randomized controlled trial

Cognitive behavioural therapy for insomnia is the recommended treatment for chronic insomnia. However, up to a quarter of patients dropout from cognitive behavioural therapy for insomnia programmes. Acceptance, mindfulness and values‐based actions may constitute complementary therapeutic tools to cognitive behavioural therapy for insomnia. The current study sought to evaluate the efficacy of a remotely delivered programme combining the main components of cognitive behavioural therapy for insomnia (sleep restriction and stimulus control) with the third‐wave cognitive behavioural therapy acceptance and commitment therapy in adults with chronic insomnia and hypnotic dependence on insomnia symptoms and quality of life. Thirty‐two participants were enrolled in a pilot randomized controlled trial: half of them were assigned to a 3‐month waiting list before receiving the four “acceptance and commitment therapy‐enhanced cognitive behavioural therapy for insomnia” treatment sessions using videoconference. The primary outcome was sleep quality as measured by the Insomnia Severity Index and the Pittsburgh Sleep Quality Index. All participants also filled out questionnaires about quality of life, use of hypnotics, depression and anxiety, acceptance, mindfulness, thought suppression, as well as a sleep diary at baseline, post‐treatment and 6‐month follow‐up. A large effect size was found for Insomnia Severity Index and Pittsburgh Sleep Quality Index, but also daytime improvements, with increased quality of life and acceptance at post‐treatment endpoint in acceptance and commitment therapy‐enhanced cognitive behavioural therapy for insomnia participants. Improvement in Insomnia Severity Index and Pittsburgh Sleep Quality Index was maintained at the 6‐month follow‐up. Wait‐list participants increased their use of hypnotics, whereas acceptance and commitment therapy‐enhanced cognitive behavioural therapy for insomnia participants evidenced reduced use of them. This pilot study suggests that web‐based cognitive behavioural therapy for insomnia incorporating acceptance and commitment therapy processes may be an efficient option to treat chronic insomnia and hypnotic dependence.     

Self-reported cognition in older adults with insomnia: Associations with sleep and domain specific cognition

Poor subjective evaluation of cognition and sleep are associated with cognitive decline in older adults. Relationships among self-reported cognition, sleep, and cognitive domains remain unclear. We evaluated the interactive associations of objective cognition and subjective sleep with self-reported cognition in older adults with insomnia. Fifty-one older adults (M_age = 69.19, SD = 7.95) with insomnia completed 14 days of self-reported cognition ratings (0-very poor, 100-very good), sleep (total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO), sleep efficiency), and daily cognitive tasks: Letter series (reasoning), word list delayed recall (verbal memory), Symbol Digit Modalities Test (SDMT) (attention/processing speed), and number copy (processing speed). Multiple regressions for each cognitive task determined whether average objective cognition or sleep were independently/interactively associated with average self-reported cognition, controlling for age, education, and depression. The interaction between SDMT performance and TST was associated with self-reported cognition. Specifically, the relationship between scores and self-reported cognition was congruent in those with the shortest TST. Similarly, the interactions between SDMT and WASO, as well as sleep efficiency, were associated with self-reported. Specifically, the relationship between scores and self-reported cognition was congruent in those with longest and average WASO, as well as shortest and average sleep efficiency. The findings suggest, in an older adult population with insomnia, a congruent association exists between attention/processing speed and self-reported cognition in those with worse subjective sleep (shorter TST, longer WASO, and lower SE). Insomnia symptoms should be taken into consideration when examining the relationship between objective cognition and self-reported cognition.     

A pilot study of a novel smartphone application for the estimation of sleep onset

The aim of the study was to investigate the accuracy of Sleep On Cue: a novel iPhone application that uses behavioural responses to auditory stimuli to estimate sleep onset. Twelve young adults underwent polysomnography recording while simultaneously using Sleep On Cue. Participants completed as many sleep‐onset trials as possible within a 2‐h period following their normal bedtime. On each trial, participants were awoken by the app following behavioural sleep onset. Then, after a short break of wakefulness, commenced the next trial. There was a high degree of correspondence between polysomnography‐determined sleep onset and Sleep On Cue behavioural sleep onset, r = 0.79, P < 0.001. On average, Sleep On Cue overestimated sleep‐onset latency by 3.17 min (SD = 3.04). When polysomnography sleep onset was defined as the beginning of N2 sleep, the discrepancy was reduced considerably (M = 0.81, SD = 1.96). The discrepancy between polysomnography and Sleep On Cue varied between individuals, which was potentially due to variations in auditory stimulus intensity. Further research is required to determine whether modifications to the stimulus intensity and behavioural response could improve the accuracy of the app. Nonetheless, Sleep On Cue is a viable option for estimating sleep onset and may be used to administer Intensive Sleep Retraining or facilitate power naps in the home environment.     

The relationship between a night's sleep and subsequent daytime functioning in older poor and good sleepers

Those suffering insomnia symptoms generally report daytime impairments. However, research has not assessed whether this relationship holds on a nightly basis, despite the strongly held belief that a night of poor sleep impairs mood and functioning the following day. The objective of this study was to test this relationship in a group of older poor sleepers with insomnia symptoms compared with good sleepers. This study utilized a within‐subjects design to investigate day‐to‐day subjective daytime functioning and its relation to the previous night's sleep. Seventeen older individuals (mean age: 67.5 years) were identified with a retrospective questionnaire and 2 weeks of sleep–wake diary to have poor sleep consistent with insomnia. Seventeen good sleepers (mean age: 67.8 years) were selected using the same measures. Participants reported their beliefs about sleep and daytime functioning on the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS‐16). One week later they commenced a 14‐day period of sleep–wake diaries and concurrent responses to a modified Daytime Insomnia Symptom Scale (DISS). Results showed significant night‐to‐day covariation between sleep efficiency and daytime functioning for individuals with poor sleep (r = 0.34), but not for good sleepers (r = 0.08). Those poor sleepers who held this covariation belief most strongly were those who subsequently showed this night‐to‐day relationship the most strongly (r = 0.56). This was not true for good sleepers. For those suffering insomnia, these findings demonstrate their belief that a poor sleep is followed by an impaired daytime, consistent with their experience.     

Subjective insomnia symptoms and sleep duration are not related to hypothalamic–pituitary–adrenal axis activity in older adults

Insomnia symptoms are highly prevalent in depressed older adults. This study investigates the association between hypothalamic–pituitary–adrenal (HPA) axis activity and symptoms of insomnia, respectively, sleep duration among 294 depressed and 123 non‐depressed older adults of the Netherlands Study of Depression in Older people (NESDO) study. Insomnia symptoms were defined as clinically relevant when having a score ≥ 10 points on the Women's Health Initiative Insomnia Rating Scale (WHIIRS). Sleep duration was categorized in short (≤ 6 h per night), normal (7–8 h per night) and long (≥ 9 h per night) duration. Salivary cortisol levels were used to assess the following cortisol parameters for HPA axis activity: area under the curve with respect to the increase (AUCi) and to the ground (AUCg), diurnal slope, evening cortisol level and dexamethasone suppression ratio. Clinically relevant insomnia symptoms were present in 46% of the participants. Thirty‐two per cent of the participants were short sleepers, whereas 16% were long sleepers. However, univariate analyses showed no differences in any of the HPA axis parameters between people with and without insomnia symptoms or between the three groups with different sleep duration. In addition, no significant interaction was found between a diagnosis of depression or the severity of depressive symptoms and any of the cortisol parameters in relation to insomnia symptoms or sleep duration.     

Association between objective sleep measures and cognitive performance: a cross-sectional analysis in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) study

Sleep disturbances often co-exist, which challenges our understanding of their potential impact on cognition. We explored the cross-sectional associations of insomnia and objective measures of sleep with cognitive performance in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) study stratified by middle-aged and older adults. Participants aged ≥55 years underwent cognitive evaluations, polygraphy for 1 night, and actigraphy for 7 days. Insomnia was evaluated using the Clinical Interview Scheduled Revised. Obstructive sleep apnea (OSA) and short sleep duration (SSD) were defined by an apnea–hypopnea index (AHI) of ≥15 events/h and <6 h/ night, respectively. In 703 participants (mean [SD] age 62 [6] years, 44% men), cognition was evaluated using a 10-word list, verbal fluency, and trail-making tests. The frequencies of insomnia, SSD, and OSA were 11%, 24%, and 33%, respectively. In all, 4% had comorbid OSA and insomnia, and 11% had both OSA and SSD. Higher wake after sleep onset (β = −0.004, 95% confidence interval [CI] −0.008, −0.001) and the number of awakenings (β = −0.006, 95% CI −0.012, −0.001) were associated with worse verbal fluency performance. Compared to those without insomnia, older participants with insomnia had worse global performance (β = −0.354, 95% CI −0.671, −0.038). Insomnia was an effect modifier in the associations between AHI and executive function performance (p for the interaction between insomnia and AHI = 0.004) and between oxygen saturation <90% and memory performance (p for the interaction between insomnia and oxygen saturation = 0.02). Although some associations between sleep measures and cognition were significant, they should be considered with caution due to the large sample size and multiple testing performed in this study.     

Validity,potential clinical utility and comparison of a consumer activity tracker and a research‐grade activity tracker in insomnia disorder II: Outside the laboratory

Accurate assessment of sleep can be fundamental for monitoring, managing and evaluating treatment outcomes within diseases. A proliferation of consumer activity trackers gives easy access to objective sleep. We evaluated the performance of a commercial device (Fitbit Alta HR) relative to a research‐grade actigraph (Actiwatch Spectrum Pro) in measuring sleep before and after a cognitive behavioural intervention in insomnia disorder. Twenty‐five individuals with DSM‐5 insomnia disorder (M = 50.6 ± 15.9 years) wore Fitbit and Actiwatch and completed a sleep diary during an in‐laboratory polysomnogram, and for 1 week preceding and following seven weekly sessions of cognitive‐behavioural intervention for insomnia. Device performance was compared for sleep outcomes (total sleep time, sleep latency, sleep efficiency and wake after sleep onset). The analyses assessed (a) agreement between devices across days and pre‐ to post‐treatment, and (b) whether pre‐ to post‐treatment changes in sleep assessed by devices correlated with clinical measures of change. Devices generally did not significantly differ from each other on sleep variable estimates, either night to night, in response to sleep manipulation (pre‐ to post‐treatment) or in response to changes in environment (in the laboratory versus at home). Change in sleep measures across time from each device showed some correlation with common clinical measures of change in insomnia, but not insomnia diagnosis as a categorical variable. Overall, the Fitbit provides similar estimates of sleep outside the laboratory to a research grade actigraph. Despite the similarity between Fitbit and Actiwatch performance, the use of consumer technology is still in its infancy and caution should be taken in its interpretation.     

Effects of insomnia symptoms and objective short sleep duration on memory performance in youths

Sleep quantity and quality are both important for optimal development and functioning during youth. Yet few studies have examined the effects of insomnia symptoms and objective short sleep duration on memory performance among adolescents and young adults. One‐hundred and ninety participants (female: 61.6%) aged from 12 to 24 years completed this study. All participants underwent a clinical interview, a 7‐day actigraphic assessment, a battery of self‐report questionnaires and cognitive tests to assess working memory and episodic memory. Insomnia symptoms were defined as a score ≥ 9 on the Insomnia Severity Index, and objective short sleep duration was defined as average total sleep time less than 7 hr for those aged 12–17 years, and 6 hr for those aged 18 years and above as assessed by actigraphy. Insomnia symptoms were significantly associated with worse self‐perceived memory (p < .05) and poorer performance on the digit span task (p < .01), but not the dual N‐back task and verbal learning task. There was no significant difference in any of the memory measures between participants with objective short sleep duration and their counterparts. No interaction effect was found between insomnia and short sleep duration on any of the objective memory outcomes. Insomnia symptoms, but not objective short sleep duration, were associated with poorer subjective memory and objective working memory performance in youths. Further studies are needed to investigate the underlying mechanisms linking insomnia and memory impairments, and to delineate the long‐term impacts of insomnia on other aspects of neurocognitive functioning in youth.     

Sleep patterns and insomnia among adolescents: a population‐based study

The aim of the current study was to examine sleep patterns and rates of insomnia in a population‐based study of adolescents aged 16–19 years. Gender differences in sleep patterns and insomnia, as well as a comparison of insomnia rates according to DSM‐IV, DSM‐V and quantitative criteria for insomnia (Behav. Res. Ther., 41 , 2003, 427), were explored. We used a large population‐based study in Hordaland county in Norway, conducted in 2012. The sample included 10 220 adolescents aged 16–18 years (54% girls). Self‐reported sleep measurements included bedtime, rise time, time in bed, sleep duration, sleep efficiency, sleep onset latency, wake after sleep onset, rate and frequency and duration of difficulties initiating and maintaining sleep and rate and frequency of tiredness and sleepiness. The adolescents reported short sleep duration on weekdays (mean 6:25 hours), resulting in a sleep deficiency of about 2 h. A majority of the adolescents (65%) reported sleep onset latency exceeding 30 min. Girls reported longer sleep onset latency and a higher rate of insomnia than boys, while boys reported later bedtimes and a larger weekday–weekend discrepancy on several sleep parameters. Insomnia prevalence rates ranged from a total prevalence of 23.8 (DSM‐IV criteria), 18.5 (DSM‐V criteria) and 13.6% (quantitative criteria for insomnia). We conclude that short sleep duration, long sleep onset latency and insomnia were prevalent in adolescents. This warrants attention as a public health concern in this age group.     

Insomnia as a mediating therapeutic target for depressive symptoms: A sub‐analysis of participant data from two large randomized controlled trials of a digital sleep intervention

Insomnia predicts the onset of depression, commonly co‐presents with depression and often persists following depression remission. However, these conditions can be challenging to treat concurrently using depression‐specific therapies. Cognitive behavioural therapy for insomnia may be an appropriate treatment to improve both insomnia and depressive symptoms. We examined the effects of a fully‐automated digital cognitive behavioural therapy intervention for insomnia (Sleepio) on insomnia and depressive symptoms, and the mediating role of sleep improvement on depressive symptoms in participants from two randomized controlled trials of digital cognitive behavioural therapy for insomnia. We also explored potential moderators of intervention effects. All participants met criteria for probable insomnia disorder and had clinically significant depressive symptomatology (PHQ‐9 ≥ 10; n = 3,352). Individuals allocated to treatment in both trials were provided access to digital cognitive behavioural therapy. Digital cognitive behavioural therapy significantly improved insomnia (p < .001; g = 0.76) and depressive symptoms (p < .001; g = 0.48) at post‐intervention (weeks 8–10), and increased the odds (OR = 2.9; 95% CI = 2.34, 3.65) of clinically significant improvement in depressive symptoms (PHQ‐9 < 10). Improvements in insomnia symptoms at mid‐intervention mediated 87% of the effects on depressive symptoms at post‐intervention. No variables moderated effectiveness outcomes, suggesting generalizability of these findings. Our results suggest that effects of digital cognitive behavioural therapy for insomnia extend to depressive symptoms in those with clinically significant depressive symptomatology. Insomnia may, therefore, be an important therapeutic target to assist management of depressive symptoms.     

Discrepancies in sleep diary and actigraphy assessments in adults with fibromyalgia: Associations with opioid dose and age

Sleep diary and actigraphy assessments of insomnia symptoms in patients with fibromyalgia (FM) are often discrepant. We examined whether opioid dose and age interact in predicting magnitude or direction of discrepancies. Participants (N = 199, M = 51.5 years, SD = 11.7) with FM and insomnia completed 14 days of diaries and actigraphy. Multiple regressions determined whether average opioid dose and its interaction with age predicted magnitude or direction of diary/actigraphy discrepancies in sleep onset latency (SOL), wake after sleep onset (WASO) and sleep efficiency (SE), controlling for sex, use of sleep medication, evening pain and total sleep time. Higher opioid dose predicted greater magnitude of discrepancy in SOL and SE. Opioid dose interacted with age to predict direction but not magnitude of discrepancy in SOL and SE. Specifically, higher opioid use was associated with better subjective (shorter SOL, higher SE) than objective reports of sleep among younger adults, and longer subjective than objectively measured SOL among older adults. Opioid dose did not predict magnitude or direction of WASO discrepancies. In FM, a higher opioid dose increases diary/actigraphy SOL and SE discrepancies, and direction of discrepancies may depend on age. We speculate that increased opioid use combined with age‐related factors, such as slow wave sleep disruption, increased awakenings and/or cognitive decline, may impact perceived sleep.     

Alpha‐wave frequency characteristics in health and insomnia during sleep

Appearances of alpha waves in the sleep electrencephalogram indicate physiological, brief states of awakening that lie in between wakefulness and sleep. These microstates may also cause the loss in sleep quality experienced by individuals suffering from insomnia. To distinguish such pathological awakenings from physiological ones, differences in alpha‐wave characteristics between transient awakening and wakefulness observed before the onset of sleep were studied. In polysomnographic datasets of sleep‐healthy participants (n = 18) and patients with insomnia (n = 10), alpha waves were extracted from the relaxed, wake state before sleep onset, wake after sleep‐onset periods and arousals of sleep. In these, alpha frequency and variability were determined as the median and standard deviation of inverse peak‐to‐peak intervals. Before sleep onset, patients with insomnia showed a decreased alpha variability compared with healthy participants (P < 0.05). After sleep onset, both groups showed patterns of decreased alpha frequency that was lower for wake after sleep‐onset periods of shorter duration. For patients with insomnia, alpha variability increased for short wake after sleep‐onset periods. Major differences between the two groups were encountered during arousal. In particular, the alpha frequency in patients with insomnia rebounded to wake levels, while the frequency in healthy participants remained at the reduced level of short wake after sleep‐onset periods. Reductions in alpha frequency during wake after sleep‐onset periods may be related to the microstate between sleep and wakefulness that was described for such brief awakenings. Reduced alpha variability before sleep may indicate a dysfunction of the alpha generation mechanism in insomnia. Alpha characteristics may also prove valuable in the study of other sleep and attention disorders.     

Sleep characteristics as predictor variables of stress systems markers in insomnia disorder

This study investigates the extent to which sleep characteristics serve as predictor variables for inflammatory, hypothalamic–pituitary–adrenal and autonomic systems markers. Twenty‐nine participants with a diagnosis of insomnia disorder based on the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (age 25.3 ± 1.6 years, insomnia duration 6.6 ± 0.8 years) and 19 healthy control sleepers (age 25.4 ± 1.4 years) underwent a 2‐week at‐home evaluation keeping a sleep diary and wearing an actigraph, followed by a visit to the Research Center to measure blood pressure, and collect blood and urine samples. The actigraphy‐ and diary‐based variables of sleep duration, sleep‐onset latency, wake after sleep onset and sleep fragmentation/number of night‐time awakenings were averaged and entered as dependent variables in regression analyses. Composite scores were calculated for the autonomic (blood pressure, norepinephrine), inflammatory (monocyte counts, interleukin‐6, C‐reactive protein) and hypothalamic–pituitary–adrenal systems (cortisol), and used as predictor variables in regression models. Compared with controls, individuals with insomnia had a shorter sleep duration (P < 0.05), and a higher hypothalamic–pituitary–adrenal and inflammatory composite score (P < 0.05). The higher inflammatory score was mainly due to higher circulating monocytes (P < 0.05), rather than differences in interleukin‐6 or C‐reactive protein. In persistent insomnia disorder, cortisol is upregulated and associated with actigraphy‐ and diary‐based wake after sleep onset, suggesting that wake after sleep onset may serve as a marker to identify individuals at increased risks for disorders associated with a hyperactive hypothalamic–pituitary–adrenal system. The absence of autonomic and pro‐inflammatory changes (interleukin‐6, C‐reactive protein), despite a substantial decrease in actigraphic sleep duration, may relate to a higher resilience to the adverse biological consequences of insomnia in this young age group.     

Sleep patterns and insomnia in a large population‐based study of middle‐aged and older adults: The Tromsø study 2015–2016

Epidemiological studies assessing adult sleep duration have yielded inconsistent findings and there are still large variations in estimation of insomnia prevalence according to the most recent diagnostic criteria. Our objective was to describe sleep patterns in a large population of middle‐aged and older adults, by employing accurate measures of both sleep duration and insomnia. Data stem from the Tromsø Study (2015–2016), an ongoing population‐based study in northern Norway comprising citizens aged 40 years and older (n = 21,083, attendance = 64.7%). Sleep parameters were reported separately for weekdays and weekends and included bedtime, rise time, sleep latency and total sleep time. Insomnia was defined according to recent diagnostic criteria (International Classification of Sleep Disorders; ICSD‐3). The results show that 20% (95% confidence interval,19.4–20.6) fulfilled the inclusion criteria for insomnia. The prevalence was especially high among women (25%), for whom the prevalence also increased with age. For men, the prevalence was around 15% across all age groups. In all, 42% of the women reported sleeping <7 hr (mean sleep duration of 7:07 hr), whereas the corresponding proportion among males was 52% (mean sleep duration of 6:55 hr). We conclude that the proportion of middle‐aged and older adults not getting the recommended amount of sleep is worryingly high, as is also the observed prevalence of insomnia. This warrants attention as a public health problem in this population.     

Case-control study of subjective and objective differences in sleep patterns in older adults with insomnia symptoms

Older adults have high prevalence rates of insomnia symptoms, yet it is unclear if these insomnia symptoms are associated with objective impairments in sleep. We hypothesized that insomnia complaints in older adults would be associated with objective differences in sleep compared with those without insomnia complaints. To test this hypothesis, we conducted a cross‐sectional study in which older adults with insomnia complaints (cases, n = 100) were compared with older adults without insomnia complaints (controls, n = 100) using dual‐night in‐lab nocturnal polysomnography, study questionnaires and 7 days of at‐home actigraphy and sleep diaries. Cases were noted to have reduced objective total sleep time compared with controls (25.8 ± 8.56 min, P = 0.003). This was largely due to increased wakefulness after sleep onset, and not increased sleep latency. When participants with sleep‐related breathing disorder or periodic limb movement disorder were excluded, the polysomnography total sleep time difference became even larger. Cases also had reduced slow‐wave sleep (5.10 ± 1.38 min versus 10.57 ± 2.29 min, effect size −0.29, P = 0.04). When comparing self‐reported sleep latency and sleep efficiency with objective polysomnographic findings, cases demonstrated low, but statistically significant correlations, while no such correlations were observed in controls. Cases tended to underestimate their sleep efficiency by 1.6% (±18.4%), while controls overestimated their sleep efficiency by 12.4% (±14.5%). In conclusion, we noted that older adults with insomnia complaints have significant differences in several objective sleep findings relative to controls, suggesting that insomnia complaints in older adults are associated with objective impairments in sleep.     

Associations of domain‐specific physical activities with insomnia symptoms among 0.5 million Chinese adults

Previous studies have demonstrated the association between physical activity and sleep quality. However, there is little evidence regarding different domains of physical activity. This study aimed to examine the associations between domain‐specific physical activities and insomnia symptoms among Chinese men and women. Data of 452 024 Chinese adults aged 30–79 years from the China Kadoorie Biobank Study were analysed. Insomnia symptoms were assessed with self‐reported difficulties in initiating or maintaining sleep, early morning awakening, daytime dysfunction and any insomnia symptoms. Physical activity assessed by questionnaire consisted of four domains, including occupational, commuting‐related, household and leisure‐time activities. Gender‐specific multiple logistic regression models were employed to estimate independent associations of overall and domain‐specific physical activities with insomnia symptoms. Overall, 12.9% of men and 17.8% of women participants reported having insomnia symptoms. After adjustment for potential confounders, a moderate to high level of overall activity was associated with reduced risks of difficulties in initiating or maintaining sleep and daytime dysfunction in both sexes (odds ratios range: 0.87–0.94, P < 0.05). As to each domain of physical activity, similar associations were identified for occupational, household and leisure‐time activities in women but not men (odds ratios range: 0.84–0.94, P < 0.05). Commuting‐related activity, however, was associated with increased risks of difficulties in initiating or maintaining sleep and any insomnia symptoms in both sexes (odds ratios range: 1.07–1.17, P < 0.05). In conclusion, a moderate to high level of physical activity was associated with lower risks of insomnia symptoms among Chinese adults. However, such associations varied hugely in different domains of physical activity and with gender differences, which could help with better policy‐making and clinical practice.     

Am I (hyper)aroused or anxious? Clinical significance of pre‐sleep somatic arousal in young adults

Self‐reported somatic arousal remains a challenging clinical construct, particularly because only a subset of patients report symptoms such as racing heart, palpitations or increased body temperature interfering with their sleep. It is unclear whether self‐reported somatic arousal is a marker of hyperarousal or co‐morbid clinical anxiety in individuals with insomnia. Participants included 196 young adults aged 20.2 ± 1.0 years old who were predominantly females (75%). About 39% of the sample reported subthreshold insomnia, and about 8% reported clinically significant insomnia, based on their Insomnia Severity Index. Participants completed the Pre‐Sleep Arousal Scale, Beck Anxiety Inventory, Beck Depression Inventory, Arousal Predisposition Scale, and Ford Insomnia Response to Stress Test. Multivariable stepwise regression assessed which factors were independently associated with pre‐sleep cognitive (Pre‐Sleep Arousal Scale‐Cognitive) and somatic (Pre‐Sleep Arousal Scale‐Somatic) arousal. Receiver‐operating characteristic analysis assessed the predictive value to identify clinically significant anxiety (Beck Anxiety Inventory ≥ 20), insomnia (Insomnia Severity Index ≥ 15) and arousability (Arousal Predisposition Scale ≥ 32). Beck Anxiety Inventory (β = 0.42) was the best single correlate of Pre‐Sleep Arousal Scale‐Somatic, while Insomnia Severity Index (β = 0.33) was of Pre‐Sleep Arousal Scale‐Cognitive. A Pre‐Sleep Arousal Scale‐Somatic score of 12 or more identified those with clinically significant anxiety with 65% specificity and 65% sensitivity, while a cut‐off score of 14 increased its sensitivity (86%). Self‐reported pre‐sleep somatic arousal may be an index of co‐morbid clinical anxiety in individuals with insomnia. These findings aid clinicians with assessment and treatment, particularly in the absence of clinical guidelines indicating when somatically focused relaxation techniques should be included as part of multicomponent cognitive behavioural treatment of insomnia.