Sleep-disordered breathing and cardiovascular disease in the Bay Area Sleep Cohort

STUDY OBJECTIVES: To examine the relationship between sleep-disordered breathing (SDB) and cardiovascular disease among community-dwelling older adults. Previous studies have suggested relatively stronger associations between SDB and such morbidity in middle-aged, relative to elderly, populations. DESIGN: Cross-sectional analysis of an elderly ambulatory, non-clinic-based cohort (Bay Area Sleep Cohort, BASC) SETTING: Community population studied in a sleep laboratory PARTICIPANTS: One hundred twenty-nine older adults (mean [+/- SD] age = 72.6 [8.3]) (78 women; 51 men). INTERVENTIONS: NA. MEASUREMENTS: Complete clinical history including list of current medications, physical examination, selected blood chemistries, multiple blood pressure measurements, 12-lead electrocardiogram, and 2 consecutive nights of polysomnography. RESULTS: Fifty-one individuals (40%) were taking 1 or more cardiovascular medications and 24 (19%) had an apnea-hypopnea index (AHI) of 10 or more per hour of sleep. Cardiovascular medication use was related to cardiac events or procedures, history of angina, higher systolic or diastolic blood pressure, and abnormal electrocardiogram. Logistic regression showed statistically significant association between cardiovascular medication use and AHI of 10 or greater per hour, independent of age, sex, and body mass index. Supplementary analyses indicated that rapid eye movement AHI of 10 or greater per hour was significantly associated with elevated diastolic blood pressure. CONCLUSIONS: The results suggest that sleep-disordered breathing may contribute to increased cardiovascular morbidity in older adults.     

A nonpharmacological intervention to improve sleep in nursing home patients: results of a controlled clinical trial

OBJECTIVES: To improve nighttime sleep in nursing home patients. DESIGN: Controlled clinical trial. SETTING: Eight community nursing homes enrolled two at a time. PARTICIPANTS: Of 1,077 patients assessed in the eight nursing homes, 638 (59%) were eligible, and consent was obtained for 273 (43% of those eligible). Of the 230 who underwent baseline assessments, 173 completed the immediate-intervention phase of the trial (77 in the intervention group and 96 in the control group). A total of 160 subjects completed the intervention (77 in the immediate-intervention group and 83 in the delayed-intervention phase). INTERVENTION: Trained research staff provided the intervention, which included daytime physical activity and attempts to keep subjects out of bed, evening bright light exposure, a consistent bedtime routine, nighttime care routines designed to minimize sleep disruption, and strategies to reduce nighttime noise. Subjects from one nursing home received the intervention (Group 1), whereas subjects in the second nursing home served as a control group (Group 2); then Group 2 received the intervention. MEASUREMENTS: Primary outcomes included measures of sleep recorded using wrist actigraphy in all subjects and polysomnography in a subgroup of subjects. Secondary measures included assessments of mood and behavior using the Neuropsychiatric Inventory, the Geriatric Depression Scale, and behavioral observations. RESULTS: There were no significant differences in any of the primary actigraphic sleep outcome measures between the intervention and control group after the immediate-intervention phase of the trial. In the 160 subjects who completed the intervention, there were no significant changes in any actigraphic measure of nighttime sleep, nor were there any significant changes in measures of sleep in the 45 subjects who had baseline and intervention polysomnography. CONCLUSION: This multicomponent, nonpharmacological intervention conducted by trained research staff had no effect on nighttime sleep in this sample of nursing home patients. Enhanced nonpharmacological interventions should be developed and tested and combined with environmental interventions to mitigate noise when feasible. Adjunctive drug therapy may be needed to improve sleep in a substantial proportion of this population and should be tested in addition to nonpharmacological interventions in rigorous clinical trials.     

Efficient Isolation of Human Immunodeficiency Virus Type 1 RNA from Cervical Swabs

An efficient method for the isolation of human immunodeficiency virus type 1 (HIV-1) nucleic acids from dry cervical swabs was developed. HIV-1 gag and env were detected in 96% (25 of 26) and 81% (21 of 26), respectively, of the samples tested by PCR from HIV-1-seropositive women in a Kenyan cohort study. Eighty-eight percent of the swabs (22 of 25) were positive for gag RNA, and 85% (17 of 20) were positive for env RNA. Fewer than 1,000 copies of HIV-1 gag RNA were detected in four swabs in which a competitive quantitative PCR assay was used. The method described here may be useful for both qualitative and quantitative analyses of HIV RNA in mucosal secretions as well as amplification and cloning of full-length viral genes for functional studies.     

The role of advocacy and empowerment in shaping service development for families raising children with developmental disabilities

IntroductionEmpowerment of families raising children with developmental disabilities (DDs) is essential to achieving rights‐based service development.MethodsIn this qualitative study, we investigated stakeholder perceptions on the role of advocacy and empowerment in developing caregiver interventions for families of children with DDs in a global context. Participants had experience with at least one intervention, namely the Caregiver Skills Training developed by the World Health Organization (WHO). Participants were clinicians, caregivers and researchers representing five continents, and representatives of WHO and Autism Speaks. Two focus group discussions and 25 individual interviews were conducted. Data were analysed thematically.ResultsThree themes were developed: empowerment as independence and as a right; the role and practices of advocacy; and using evidence to drive advocacy. Many professional participants defined empowerment within the realms of their expertise, focusing on caregivers'' individual skills and self‐confidence. Caregivers expressed that this expert‐oriented view fails to acknowledge their intuitive knowledge and the need for community‐level empowerment. Participants discussed the challenges of advocacy in light of competing health priorities. The gap between the rights of caregivers and the availability of services, for example, evidence‐based interventions, was highlighted as problematic. Scientific evidence was identified as a key for advocacy.ConclusionRights‐orientated empowerment of caregivers and advocacy may make vital contributions to service development for children with DDs in contexts worldwide.Patient and Public ContributionResearch questions were revised based on views presented during focus group discussions. Participant feedback on preliminary themes informed the development of the interview guides.     

A multicomponent behavioural and drug intervention for nocturia in elderly men: rationale and pilot results

OBJECTIVES

To evaluate the number of medical and urological conditions associated with nocturia in a cohort of older men who were primary‐care enrolees, and to assess the feasibility and efficacy of using a multicomponent intervention to reduce nocturia and its bother.

SUBJECTS AND METHODS

Men aged ≥50 years and with two or more episodes of nocturia were recruited from the primary‐care clinics at one Veterans Affairs Medical Center to participate in a 4‐week, open‐label, prospective pilot study. A multicomponent intervention composed of behavioural therapy and targeted drug therapy was administered according to a specified protocol based upon identified risk factors for nocturia. Outcome measures included self‐reported nocturia and bother on the American Urological Association (AUA)‐7 Symptom Index, 3‐day bladder diaries and self‐reported sleep‐related measures recorded using 7‐day sleep diaries.

RESULTS

Fifty‐five men completed the protocol (mean age 67 years, sd 8.3); they had a mean of 4.5 of nine defined conditions potentially related to nocturia. Highly prevalent conditions included moderate‐to‐severe benign prostatic hyperplasia (87%), hypertension (86%) and urinary frequency (71%). The mean diary‐recorded nocturia decreased from 2.6 to 1.9 (P < 0.001), and bother score reduced from 3.1 to 1.1, representing a change from a ‘medium’ to a ‘very small’ problem (on a 5‐point scale). Sleep diary‐derived measures also improved significantly (time to initiate sleep, time to return to sleep after awakening, quality of sleep).

CONCLUSIONS

Given that individual older patients often have multiple coexistent risk factors for nocturia, identifying a principal cause of nocturia, a concept emphasized in treatment guidelines, proved to be difficult. Implementing a multicomponent behavioural intervention combined with drug(s) was feasible in older men and reduced nocturia frequency, bother from nocturia, and time to initiate sleep, within 4 weeks. These promising results merit repeating using a randomized, controlled trial.