Jack D. Edinger

The Consensus Sleep Diary: Standardizing Prospective Sleep Self-Monitoring

STUDY OBJECTIVES To present an expert consensus, standardized, patient-informed sleep diary. METHODS AND RESULTS Sleep diaries from the original expert panel of 25 attendees of the Pittsburgh Assessment Conference(1) were collected and reviewed. A smaller subset of experts formed a committee and reviewed the compiled diaries. Items deemed essential were included in a Core sleep diary, and those deemed optional were retained for an expanded diary. Secondly, optional items would be available in other versions. A draft of the Core and optional versions along with a feedback questionnaire were sent to members of the Pittsburgh Assessment Conference. The feedback from the group was integrated and the diary drafts were subjected to 6 focus groups composed of good sleepers, people with insomnia, and people with sleep apnea. The data were summarized into themes and changes to the drafts were made in response to the focus groups. The resultant draft was evaluated by another focus group and subjected to lexile analyses. The lexile analyses suggested that the Core diary instructions are at a sixth-grade reading level and the Core diary was written at a third-grade reading level. CONCLUSIONS The Consensus Sleep Diary was the result of collaborations with insomnia experts and potential users. The adoption of a standard sleep diary for insomnia will facilitate comparisons across studies and advance the field. The proposed diary is intended as a living document which still needs to be tested, refined, and validated.

Insomnia And The Eye Of The Beholder: Are There Clinical Markers Of Objective Sleep Disturbances Among Adults With And Without Insomnia Complaints?

Previous findings suggest that some who report insomnia sleep well, whereas some noncomplaining individuals sleep rather poorly. This study was conducted to determine if mood, anxiety, and sleep-related beliefs might relate to perceived sleep disturbance. Thirty-two women and 32 men (aged 40-79 years) with primary insomnia and an aged-matched sample of 61 normal sleepers (31 women, 30 men) completed 6 nocturnal sleep recordings, as well as the Beck Depression Inventory (BDI), the Trait portion of the State-Trait Anxiety Inventory (STAI-2), and the Dysfunctional Beliefs and Attitudes About Sleep Questionnaire. Sleep and interview data were used to subdivide the majority of the sample (n = 108) into objective normal sleepers and subjective insomnia sufferers who seemingly slept well and subjective normal sleepers and objective insomnia sufferers who slept poorly. The 2 subjective subgroups showed the most marked differences on most of the psychometric measures. The findings suggest that the psychological factors scrutinized in this study may mediate sleep satisfaction and/or predict objective sleep difficulties.

Daily activities and sleep quality in college students.

There is growing evidence that social rhythms (e.g., daily activities such as getting into or out of bed, eating, and adhering to a work schedule) have important implications for sleep. The present study used a prospective measure of daily activities to assess the relation between sleep and social rhythms. College students (n=243) 18 to 39 yrs of age, completed the Social Rhythm Metric (SRM) each day for 14 d and then completed the Pittsburgh Sleep Quality Index (PSQI). The sample was divided into groups of good or poor sleepers, according to a PSQI cut‐off score of 5 points and was compared on the regularity, frequency, timing, and extent of social engagement during activities. There was a lower frequency and less regularity of social rhythms in poor sleepers relative to good sleepers. Good sleepers engaged more regularly in activities with active social engagement. Earlier rise time, first consumption of a beverage, going outdoors for the first time, and bedtime were associated with better sleep. Greater variability in rise time, consuming a morning beverage, returning home for the last time, and bedtime were associated with more disturbed sleep. The results are consistent with previous findings of reduced regularity in bedtime and rise time schedules in undergraduates, other age groups, and in clinical populations. Results augment the current thought that regulating behavioral zeitgebers may be important in influencing bed and rise times, and suggest that engaging in activities with other people may increase regularity.

Preliminary study of carbamazepine in post-traumatic stress disorder

Ten patients meeting DSM-III criteria for post-traumatic stress disorder (PTSD) participated in a five-week open trial of carbamazepine. Seven patients manifested moderate to very much improvement, as shown on the Clinical Global Impression scale. Among the multiple symptoms associated with PTSD, nightmares, flashbacks, and intrusive recollections were selectively reduced in intensity and frequency. The results suggest that a kindling model or a model of a paroxysmal disorder may be applicable to PTSD.

High-intensity environmental light in dementia: Effect on sleep and activity

OBJECTIVES: To determine whether high‐intensity ambient light in public areas of long‐term care facilities will improve sleeping patterns and circadian rhythms of persons with dementia.

How many nights are enough? The short-term stability of sleep parameters in elderly insomniacs and normal sleepers

Temporal stability is an important fundamental quality when measuring sleep parameters, yet it has been infrequently assessed. Generalizability theory was used to estimate the short-term temporal stability of five variables commonly used to characterize insomnia: sleep onset latency, total sleep time, wake after sleep onset, time in bed, and sleep efficiency. Estimates were calculated for 32 elderly primary insomniacs and 32 elderly normal sleepers, both in the lab and at home, using both sleep logs and polysomnography (PSG). A week of recording using either PSG or sleep logs was typically sufficient to achieve adequate stability (defined as G coefficient of at least 0.80) with some notable exceptions: (a) when using log-derived measures with insomniacs, a 3-week average was necessary for wake after sleep onset and (b) more than a 2-week average was necessary for sleep onset latency. Because of the substantial commitment involved in the physiological recording of sleep, alternative forms of aggregation are considered with the intent of improving temporal stability.

Examining maladaptive beliefs about sleep across insomnia patient groups.

OBJECTIVES Unhelpful beliefs about sleep have been linked to insomnia, and increasing ones cognitive flexibility about sleep has been linked to posttreatment sleep improvement. This study evaluated whether levels of such beliefs differ across insomnia groups and whether there are particular beliefs that differ for specific insomnia subtypes. METHODS Participants (N=1384) were people with insomnia and good sleepers ranging from 18 to 89 years old (mean=42.6; S.D.=19.4). Data from previous studies at five insomnia clinical sites were pooled to examine responses on the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS) across differing insomnia groups. RESULTS Group analyses revealed that those from community-based insomnia clinics and those who are hypnotic-dependent generally had the highest levels of unhelpful sleep-related beliefs. With the exception of beliefs about sleep needs (wherein only community sleep clinic patients had high scores relative to good sleepers), all insomnia groups had higher scores on the 16-item DBAS (DBAS-16) than good sleepers. A validity analysis suggested that a DBAS-16 index score of >3.8 represented the level of unhelpful beliefs associated with clinically significant insomnia, although a slightly lower cutoff may be useful for identifying an unhelpful degree of sleep-related beliefs in highly screened primary-insomnia-only and medical patient groups. CONCLUSIONS This study offers descriptive data for the use of DBAS-16 across insomnia subgroups, which will help the user understand what degree of maladaptive sleep beliefs is most strongly associated with clinically significant levels of insomnia. Results also may have implications for cognitive targeting during treatment for particular insomnia groups.

Sleep in peri-menopausal and post-menopausal women

Despite the fact that a large number of women report sleep disturbances associated with peri-menopausal and post-menopausal periods, there is a surprising lack of literature related to this issue. In fact, there has not been enough work in this area to even definitively establish whether there is a sleep disorder that is specifically related to these life-stage changes. Herein we review the available literature which suggests that insomnia may be directly linked to the changes that occur during the peri/post-menopausal periods. This insomnia appears to be due to night sweats caused by the hormonal changes which occur and which lead to an increase in arousals. Persistence of insomnia symptoms after adequate hormone replacement therapy may indicate that behavioral conditioning of the insomnia initially triggered by the night sweats may have occurred. Alternatively, such an insomnia in a peri/post-menopausal woman could be due to unresolved grief related to going through menopause or could reflect an independent sleep disorder, such as periodic movements of sleep, sleep apnea, depression, anxiety, etc. Whereas menopausal changes do not directly lead to an increase in sleep apnea they seemingly contribute to an increased risk for this disorder. In view of these considerations, we provide guidelines for the proper diagnosis and treatment of peri/post-menopausal women with sleep complaints.

Slow-wave sleep and waking cognitive performance among older adults with and without insomnia complaints.

Previous research has shown that healthy young adults with relatively fast reaction times on daytime testing have significantly more nocturnal slow-wave sleep than do age-matched subjects with relatively slow reaction times on such testing. The current study was conducted to examine the relationship between slow-wave sleep and cognitive performance among older adults with and without insomnia complaints. A sample of 32 noncomplaining older (age > or = 60 years) normal sleepers and a like-aged sample of 32 insomniacs, recruited to participate in a larger study, served as subjects. All subjects underwent nocturnal sleep monitoring immediately prior to undergoing a battery of daytime tests that measured simple reaction time, vigilance/signal detection, and complex reaction time. Results from the normal sleepers showed no relationship between daytime cognitive performance measures and a variety of computer-derived nocturnal slow-wave sleep measures. In contrast, insomniac subjects with relatively slow reaction times showed relative deficits in a spectral analytically derived measure of slow-wave power in the 2 to 4 Hz bandwidth. These results suggest that relative performance deficits among some older insomniacs may be related to specific slow-wave sleep deficiencies. However, among older normal sleepers, intersubject differences in performance appear unrelated to slow-wave sleep measures. Additional research is needed to further explore the possible restorative role slow-wave sleep may serve for cognitive functions other than those examined herein.

TEST‐RETEST RELIABILITY OF THE PITTSBURGH SLEEP QUALITY INDEX IN NURSING HOME RESIDENTS

12. Silliman RA, Balducci L, Goodwin JS et al. Breat cancer care in old age: What we know, don’t know, and do. J Natl Cancer Inst 1993;85:190-199. Weinberger M, Saunders AF, Bearon LB et al. Physician-related barriers to breast cancer screening in older women. J Gerontol 1992;47 (Special Issue):l l l-I 17. Walsh SJ, Begg CB, Carbone PP. Cancer chemotherapy in the elderly. Semin Oncol 1989;16:66-75. Balducci L, Ades T, Carbone PP et al. Issues in treatment. Cancer