Sally Bailes

How is good and poor sleep in older adults and college students related to daytime sleepiness, fatigue, and ability to concentrate?

We compared good sleepers with minimally and highly distressed poor sleepers on three measures of daytime functioning: self-reported fatigue, sleepiness, and cognitive inefficiency. In two samples (194 older adults, 136 college students), we tested the hypotheses that (1) poor sleepers experience more problems with daytime functioning than good sleepers, (2) highly distressed poor sleepers report greater impairment in functioning during the day than either good sleepers or minimally distressed poor sleepers, (3) daytime symptoms are more closely related to psychological adjustment and to psychologically laden sleep variables than to quantitative sleep parameters, and (4) daytime symptoms are more closely related to longer nocturnal wake times than to shorter sleep times. Results in both samples indicated that poor sleepers reported more daytime difficulties than good sleepers. While low- and high-distress poor sleepers did not differ on sleep parameters, highly distressed poor sleepers reported consistently more difficulty in functioning during the day and experienced greater tension and depression than minimally distressed poor sleepers. Severity of all three daytime problems was generally significantly and positively related to poor psychological adjustment, psychologically laden sleep variables, and, with the exception of sleepiness, to quantitative sleep parameters. Results are used to discuss discrepancies between experiential and quantitative measures of daytime functioning.

Doxepin and cognitive behavioural therapy for insomnia in patients with Parkinson's disease – A randomized study

INTRODUCTION Although a variety of pharmacologic and non-pharmacologic treatments are effective for insomnia in the general population, insomnia in Parkinsons disease differs in important ways and may need different treatments. No studies have conclusively demonstrated effective insomnia treatments in Parkinsons disease. METHODS We conducted a three-arm six-week randomized pilot study assessing non-pharmacologic treatment (cognitive behavioural therapy with bright light therapy) or doxepin (10 mg daily), compared to an inactive placebo in Parkinsons patients with insomnia. Sleep outcomes included insomnia scales, clinical global impression, sleep diaries and actigraphy. Secondary outcomes included motor severity, fatigue, depression and quality of life. RESULTS 18 patients were randomized, 6 to each group. Compared to placebo, doxepin improved the Insomnia Severity Index (-9 ± 5.4 vs. -2 ± 3.9, p = 0.03), the SCOPA-night score (-5.2 ± 1.5 vs. -2.3 ± 2.8, p = 0.049), the Pittsburgh Sleep Quality Index-sleep disturbances subscale (-0.5 ± 0.5 vs 0.2 ± 0.4, p = 0.02), and both patient and examiner-rated clinical global impression of change (1.7 ± 0.8 vs. 0.5 ± 0.8, p = 0.03 and 1.4 ± 0.5 vs. 0.3 ± 0.5, p = 0.003). On secondary outcomes doxepin reduced the fatigue severity scale (p = 0.02) and improved scores on the Montreal Cognitive Assessment (p = 0.007). Non-pharmacological treatment reduced the Insomnia Severity Index (-7.8 ± 3.8 vs. -2.0 ± 3.9, p = 0.03), and the examiner-reported clinical global impression of change (p = 0.006), but was associated with decline in Parkinson Disease Questionnaire-39. There were no changes in other primary and secondary outcomes, including actigraphy outcomes. Adverse events were comparable in all groups. CONCLUSION Doxepin and non-pharmacologic treatment substantially improved insomnia in Parkinsons disease. These potential benefits must be replicated in a full confirmatory randomized controlled trial.

Sleep Quality and Psychological Adjustment in Chronic Fatigue Syndrome

Without specific etiology or effective treatment, chronic fatigue syndrome (CFS) remains a contentious diagnosis. Individuals with CFS complain of fatigue and poor sleep—symptoms that are often attributed to psychological disturbance. To assess the nature and prevalence of sleep disturbance in CFS and to investigate the widely presumed presence of psychological maladjustment we examined sleep quality, sleep disorders, physical health, daytime sleepiness, fatigue, and psychological adjustment in three samples: individuals with CFS; a healthy control group; and individuals with a definite medical diagnosis: narcolepsy. Outcome measures included physiological evaluation (polysomnography), medical diagnosis, structured interview, and self-report measures. Results indicate that the CFS sample had a very high incidence (58%) of previously undiagnosed primary sleep disorder such as sleep apnea/hypopnea syndrome and restless legs/periodic limb movement disorder. They also had very high rates of self-reported insomnia and nonrestorative sleep. Narcolepsy and CFS participants were very similar on psychological adjustment: both these groups had more psychological maladjustment than did control group participants. Our data suggest that primary sleep disorders in individuals with CFS are underdiagnosed in primary care settings and that the psychological disturbances seen in CFS may well be the result of living with a chronic illness that is poorly recognized or understood.

Fatigue in COPD: prevalence and effect on outcomes in pulmonary rehabilitation.

Patients with chronic obstructive pulmonary disease (COPD) complain of dyspnea and fatigue. We sought to estimate the prevalence of high fatigue in this population and to determine whether individuals with high fatigue had a different response to pulmonary rehabilitation. This observational study was embedded within a randomized trial. Participants underwent 3 months of pulmonary rehabilitation including education and exercise training. We divided 251 individuals into low and high fatigue groups using population normal scores of the SF-36 vitality domain. Baseline data included spirometry, 6-minute walk distance (6MWD), peak exercise capacity, constant workrate cycling endurance time, and questionnaires including the St. George’s and Chronic Respiratory questionnaires (SGRQ, CRQ). The response to pulmonary rehabilitation was evaluated using changes in these measures at 3 months and 1 year after entry. High fatigue was present in 97/251 (39%) of patients. High fatigue patients were younger, had more depressive symptoms, greater dyspnea and poorer SGRQ scores (p < 0.01). They also had lower 6MWD, endurance times, and peak volume of oxygen consumption (VO2; p < 0.05). Patients in both groups improved similarly in their dyspnea, the 6MWD and endurance time. High-fatigue patients had greater improvements in both the CRQ fatigue (by 0.74 more points) and the SGRQ scores (by 6.0 points; p < 0.01), with clinically significant gains maintained at 1 year. This study suggests that high levels of fatigue is a common feature in patients with COPD. They have a lower exercise capacity and a lower health status. However, they benefit from pulmonary rehabilitation.

Time Estimation in Good and Poor Sleepers

Time estimation was examined in 148 older good and poor sleepers in analogue and naturalistic sleep settings. On analogue tasks, both “empty” time and time listening to an audiobook were overestimated by both good and poor sleepers. There were no differences between groups. “Empty” time was experienced as “dragging.” In the sleep setting, most poor sleepers underestimated nocturnal sleep and overestimated awake times related to their own sleep problem: sleep onset vs. sleep maintenance insomnia. Good sleepers did the opposite. Severity of sleep problem and size of time estimation errors were unrelated. Greater night-to-night wake time variability was experienced by poor than by good sleepers. Psychological adjustment was unrelated to time estimations and to magnification or minimization of sleep problems. The results suggest that for poor sleepers who magnify their sleep problem, self-monitoring can be of benefit by demonstrating that the sleep problem is not as severe as believed.

Sleep Questionnaire Versus Sleep Diary: Which Measure Is Better?

One questionnaire about a typical weeks sleep is more convenient than asking individuals to complete daily sleep diaries. Yet, most clinical evaluations and much sleep and insomnia research rely upon self monitoring via daily sleep diaries. These are often problematic to administer and can be reactive. Therefore, we investigated comparability of two measurement modalities (self monitoring and questionnaire) in a sample of 156 community dwelling older adults, both good and poor sleepers. Results indicate significant and high correlations between corresponding scores on a retrospective sleep questionnaire and on 7 days of self monitoring on a daily sleep diary, thereby suggesting that the two measurement modalities are tapping the same domains. There were, however, significant differences between means on several variables, but there was no systematic pattern to the differences. These findings illustrate the need to tailor measurement modality—retrospective or ongoing—to the setting and the purpose of the evaluation.

Role of Thoughts During Nocturnal Awake Times in the Insomnia Experience of Older Adults

The frequency of difficulty initiating and maintaining sleep increases with age. Yet, not all poor sleepers complain of insomnia. Our cognitive model of insomnia predicts that sleep complaints in poor sleepers are a function of negative thinking during nocturnal wakefulness as well as of poor sleep quality. To test descriptive aspects of the model, we examined the content and valence of thoughts listed or endorsed by two large samples of older adults. We compared positive and negative thoughts reported by good sleepers and by 2 types of poor sleepers: those experiencing either high or low distress about their insomnia. Thought listing and inventory results both support the model: negative thought frequencies were closely related to poor sleep, distress about insomnia, and poor daytime psychological adjustment. The findings provide an empirical basis for the modification of maladaptive cognitions as potentially important in therapeutic intervention for insomnia.

A diagnostic symptom profile for sleep disorder in primary care patients

OBJECTIVE The aim of the present study was (1) to evaluate the extent and nature of sleep disorder-related symptoms in the older primary care patient population and (2) to differentiate a pattern of self-reported symptoms that identify patients who should be referred to the sleep clinic for further evaluation. METHOD One hundred ninety-six older adults recruited from family practice centers were administered a brief symptom survey measure. All were invited to participate in an extensive self-report evaluation, consultation with a sleep medicine specialist, and an overnight polysomnographic study. RESULTS A substantial number of older primary care patients report symptoms related directly or indirectly to physiological sleep disorder. Over 30% of total reported some insomnia, 40% daytime sleepiness, and 10% apnea. Those participants who agreed to pursue further aspects of the study protocol endorsed a higher number and greater severity of primary sleep disorder symptoms than those who declined to continue beyond the first phases. Participants who chose to pursue polysomnography (13% of total) had a very high rate (88.5) of diagnosed sleep disorder. CONCLUSION This study suggests that an older patient, male or female, who both endorses medically unexplained daytime sleepiness, fatigue, or other sleep disorder related symptoms and agrees to further evaluation, including overnight polysomnography, is at substantial risk for physiologically based sleep disorder. In the future, a brief, validated measure, such as the Sleep Symptom Checklist used in this study, would be an important part of the diagnostic process.

Impaired Sleep in Chronic Fatigue Syndrome How Is It Best Measured

The goal was to examine comparative efficacy of polysomnography, actigraphy, and self-report in evaluating the sleep/wake experience of individuals with chronic fatigue syndrome (CFS). Sleep parameters were evaluated by the three measurement modalities for the same night in 49 participants with CFS. Psychological and daytime functioning were measured by self-report. Results indicate that: (a) objectively measured nocturnal sleep time effectively approximated subjective experience although nocturnal wakefulness did not; (b) total sleep time and sleep efficiency differentiated individuals with and without insomnia complaints; (c) daytime sleepiness, fatigue, and non-refreshing sleep were not reflected by the objective sleep-related measures (polysomnography and actigraphy).

Sleep disorder symptoms are common and unspoken in Canadian general practice

OBJECTIVE Primary care patients were surveyed for what sleep disorder symptoms they discussed with their physicians. Their responses were compared with those of new Sleep clinic patients. The goal was to discover what symptom presentation leads to a successful referral to a sleep clinic. METHODS We recruited two samples: 191 older Primary care patients and 138 Sleep clinic patients. Participants completed the Sleep Symptom Checklist (SSC). This consists of 21 symptoms in four domains: insomnia, sleep disorder, daytime symptoms and psychological distress. All respondents indicated which symptoms had been discussed with their physician in the past year. Primary care subjects were designated as Decliners (completed SSC, refused further evaluation), Dropouts [completed some evaluation steps, but not polysomnography (PSG)] and Completers (completed PSG). RESULTS Primary care participants frequently had symptoms but relatively few had discussed them with their doctor. Sleep clinic participants discussed significantly more symptoms with their referring physician than did Primary care Dropouts or Decliners in all categories except psychological distress. Primary care Completers, 88.5% of whom were ultimately diagnosed with sleep apnoea/hypopnoea syndrome and/or periodic limb movement disorder, also discussed their sleep disorder symptoms less frequently than did Sleep clinic patients but tended to give more prominence to symptoms of insomnia and impaired daytime function. CONCLUSIONS The findings suggest that Primary care patients often have symptoms they do not discuss, even when a primary sleep disorder exists. The brief SSC checklist, developed in our laboratory, has potential to improve the referral rates of older primary care patients who have sleep disorder.