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The aim is to pilot a low-touch program for reducing benzodiazepine receptor agonist (BZRA; benzodiazepines, z-drugs) prescriptions among older veterans.Pilot randomized controlled trial consists of 2,009 veterans aged ≥ 65 years who received BZRA prescriptions from a Veterans Health Administration pharmacy (Colorado or Montana) during the prior 18 months. Active: Arm 1 was a mailed brochure about BZRA risks that also included information about a free, online cognitive behavioral therapy for the insomnia (CBTI) program. Arm 2 was a mailed brochure (same as arm 1) and telephone reinforcement call. Control: Arm 3 was a mailed brochure without insomnia treatment information. Active BZRA prescriptions at follow-up (6 and 12 months) were measured.In logistic regression analyses, the odds of BZRA prescription at 6- and 12-month follow-ups were not significantly different for arm 1 or 2 (active) versus arm 3 (control), including models adjusted for demographics and prescription characteristics (Although we observed no differences in active BZRA prescriptions, this pilot study provides guidance for conducting a future study, indicating a need for a more potent intervention. A full-scale trial testing an optimized program would provide conclusive results.Mailing information about BZRA risks and CBTI did not affect BZRA prescriptions.

Recent initiatives to discourage overprescription of sleep medications have increased awareness of their potential adverse effects; however, it is unknown whether these efforts translated into a decline in use of these medications in the United States. We assessed recent national trends in the use of medications used for sleep disturbance.We used data from n = 29,400 participants in the 2013-2018 National Health and Nutrition Examination Survey. At each of three waves of in-person assessments, participants presented prescription bottles for all medications used in the prior month. Interviewers recorded each medication and participants self-reported duration and reasons for use. We identified all medications used for sleep disturbance and categorized medications into two categories: Food and Drug Administration-approved sleep medications and those used off-label for sleep disturbance. We examined changes in the prevalence in use of these medications across the study period.The odds of using medications for sleep disturbance decreased 31% between 2013 and 2018 (odds ratio = 0.69, 95% confidence interval = 0.51-0.93,Use of prescription medications for sleep disturbance declined nationally, suggesting a possible effect of efforts to curb overprescription and encourage judicious use of these agents. Future research needs to examine whether these changes have coincided with improved population sleep health.Kaufmann CN, Spira AP, Wickwire EM, et al. Declining trend in use of medications for sleep disturbance in the United States from 2013 to 2018.

Deprescribing of medications such as benzodiazepines and benzodiazepine receptor agonists (z-drugs) can be a complex process that varies across practices, specialties, and health care systems. Care coordination among healthcare providers, patients, families, and other healthcare system components is critical to achieving high levels of deprescribing and person-centered care. We present a framework for promoting care coordination in the context of benzodiazepine/z-drug deprescribing. Future efforts are needed to study the impact of better care coordination on benzodiazepines/z-drug discontinuation and other outcomes that are important to stakeholders.

ObjectiveThis study compared the benefits of cognitive-behavioral therapy for insomnia for sleep, mental health symptoms, and quality of life (QoL) in a sample of women veterans with and without probable post-traumatic stress disorder (PTSD) comorbid with insomnia disorder.MethodsSeventy-three women veterans (30 with probable PTSD) received a manual-based 5-week cognitive-behavioral therapy for insomnia treatment as part of a behavioral sleep intervention study. Measures were completed at baseline, post-treatment, and 3-month follow-up. Sleep measures included the Insomnia Severity Index, Pittsburgh Sleep Quality Index, sleep efficiency measured by actigraphy, and sleep efficiency and total sleep time measured by sleep diary. Mental health measures included the PTSD Checklist-5, nightmares per week, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7 scale. QoL was measured with the Short Form-12. Linear mixed models compared changes over time across groups. Independent t tests examined PTSD symptom changes in women veterans with probable PTSD.ResultsBoth groups demonstrated improvements across sleep (ps&nbsp

Intolerance of positive airway pressure therapy for obstructive sleep apnea is common. Upper airway muscle therapies show promise as alternative treatments. The didgeridoo, which is a musical instrument, can be used for upper airway muscle training. Our goal was to develop a group-based didgeridoo training program for obstructive sleep apnea. We conducted a proof-of-concept single-arm study consisting of a structured didgeridoo training regimen. We surveyed patients at a large medical facility about their interest in the program. We developed and tested a manual of procedures for conducting a 4-session group program that instructed participants on use of the Medical Didgeridoo. We also refined procedures for baseline and 4-month follow-up assessments, which included measures of daytime sleepiness and apnea-hypopnea index. Interviews were conducted at follow-up to obtain feedback about the program. Of the 56 survey respondents, 67% reported difficulty with positive airway pressure, expressed interest in participating in a structured upper airway muscle training program, and indicated that they would be willing to practice exercises for 30 minutes per day. After in-depth screening of 15 patients, we recruited five patients to participate in the structured training program; all five completed the program and were able to learn to play basic sounds on the provided instrument, and four stated they would continue to play the Medical Didgeridoo after completion of the program. Given the significant level of interest and excellent participation in the didgeridoo training program, it may be feasible to conduct a large-scale study to assess treatment response.

STUDY OBJECTIVES: Black individuals are disproportionately affected by diabetes, cardiovascular disease, obesity, and OSA. Adherence to PAP therapy has been reported to be lower among black individuals. This study seeks to examine associations between black race and PAP adherence among veterans with OSA. METHODS: This was a retrospective study. Veterans newly diagnosed with OSA at a single Department of Veterans Affairs sleep center who were prescribed a modem-enabled PAP device between January 2015 and November 2017 were enrolled. PAP adherence was defined as ≥ 4 hours nightly usage for at least 70% of nights measured at 30 days from PAP setup. We examined the relationship between race and adherence, controlling for sex, marital status, age, socioeconomic status, residual apnea-hypopnea index), and mask leak. RESULTS: Of 3013 patients identified with OSA, 2571 (85%) were newly started on PAP therapy (95% male, aged 59 years ± 14 years, 45% married, 8% with neighborhood socioeconomic disadvantage). Twenty-five percent of participants were black, and 57% were white. PAP adherence at 30 days was 50% overall (42% among blacks, 53% among nonblacks). Black race was associated with reduced 30-day PAP adherence in unadjusted (P < .001) and adjusted logistic regression models (odds ratio = 0.64; 95% CI, 0.53 – 0.78; P < .001). CONCLUSIONS: Among veterans with OSA, black race was associated with reduced PAP adherence. These findings suggest health inequality among black individuals in the treatment of OSA. CITATION: Hsu N, Zeidler MR, Ryden AM, Fung CH. Racial disparities in positive airway pressure therapy adherence among veterans with obstructive sleep apnea. J Clin Sleep Med. 2020;16(8):1249–1254.

ObjectivesTo measure the rate of benzodiazepine receptor agonist (BZA) dependence in older veterans with insomnia symptoms chronically using BZAs and to assess for associations between high posttraumatic stress disorder (PTSD) risk and BZA dependence.MethodsA cross-sectional study was conducted among veterans aged 55years and older with insomnia symptoms (current or historical) and chronic use of BZAs (≥3months). Measurements included the Primary Care-PTSD screen (score >2 indicates high PTSD risk) and Benzodiazepine Dependence Questionnaire. Logistic regression was used to test for associations between PTSD risk and BZA dependence.ResultsA high PTSD risk was observed in 40% of the participants (N=33). One-fifth (21.7%, N =18) of participants met the criteria for benzodiazepine dependence (score ≥23 on Benzodiazepine Dependence Questionnaire). Veterans with high PTSD risk were significantly more likely to have BZA dependence (odds ratio 10.09, 95% CI [2.39, 42.54], p =.002).ConclusionsIn older veterans with insomnia symptoms and chronic use of BZAs, high PTSD risk is associated with elevated risk for BZA dependence, which may make discontinuation of these medications difficult.Clinical implicationsClinicians should consider the strong association between PTSD symptoms and benzodiazepine dependence when developing plans to taper a BZA in veterans with these symptoms.

Nocturia and chronic insomnia disorder are common conditions that frequently coexist in older adults. Existing medication treatments for each condition have risks, particularly in older adults. While treatment guidelines recommend starting with behavioural therapy for each condition, no existing program simultaneously addresses nocturia and insomnia. Existing behavioural interventions for nocturia or insomnia contain concordant and discordant components. An expert panel (including geriatricians with sleep or nocturia research expertise, sleep psychologists and a behavioural psychologist) was convened to combine and reconcile elements of behavioural treatment for each condition. Concordant treatment recommendations involve using situational self-management strategies such as urge suppression or techniques to influence homeostatic drive for sleep. Fluid modification such as avoiding alcohol and evening caffeine and regular self-monitoring through a daily diary is also appropriate for both conditions. The expert panel resolved discordant recommendations by eliminating overnight completion of voiding diaries (which can interfere with sleep) and discouraging routine overnight voiding (a stimulus control strategy). The final product is an integrated cognitive behavioural treatment that is delivered by advanced practice providers weekly over 5 weeks. This integrated program addresses the common scenario of coexisting nocturia and chronic insomnia disorder.

Objective/Background: Sleep problems are common in women and caregiving for an adult is a common role among women. However, the effects of caregiving on sleep and related daytime impairment are poorly understood among women veterans. This study compared stress-related sleep disturbances, insomnia symptoms, and sleep-related daytime impairment between women veterans who were caregivers and those who did not have a caregiving role. Participants: Of 12,225 women veterans who received care in one Veterans Administration Healthcare System, 1,457 completed data on a postal survey (mean age=51.7±15.9years). Two hundred forty three (17%) respondents (mean age 53.8±12.7years) were caregivers for an adult, predominantly for a parent, providing transportation. Methods: The survey included items that addressed insomnia symptoms, total sleep time, sleep-related daytime impairments, caregiving characteristics, self-rated health, pain, stress, body mass index, and demographic information. Results: In adjusted analyses, caregiver status did not directly predict sleep complaints alone. However, in multiple regression analyses, being a caregiver (odds ratio 1.7, p =.001) significantly predicted stress-related sleep disturbance, even after adjusting for age, pain, self-rated health, and other characteristics. Furthermore, being a caregiver (β=3.9, p =.031) significantly predicted more symptoms of sleep-related daytime impairment after adjusting for age, pain, self-rated health, and other factors. Conclusions: Compared to noncaregivers, women veterans who were caregivers for an adult were more likely to report stress causing poor sleep, and more daytime impairment due to poor sleep. These findings suggest the need to target stress and other factors when addressing sleep disturbance among women veterans who are caregivers.

Author(s): Fung, Constance H; Martin, Jennifer L; Hays, Ron D; Col, Nananda; Patterson, Emily S; Josephson, Karen; Mitchell, Michael N; Grinberg, Austin; Aysola, Ravi; Song, Yeonsu; Dzierzewski, Joseph M; Liang, Li-Jung; Huang, David; Zeidler, Michelle; Alessi, Cathy

STUDY OBJECTIVES: To estimate the prevalence of insomnia disorder among older veterans and to study relationships among age and self-rated health, with insomnia disorder, self-reported sleep duration and sleep efficiency. METHODS: A cross-sectional postal survey of community-dwelling older veterans (older than 60 years) seen at one VA Healthcare System in the prior 18 months was performed, which was constructed to align with the general diagnostic criteria for insomnia disorder (International Classification of Sleep Disorders, Second Edition [ICSD-2]). The survey also queried self-reported sleep duration, bedtime, and wake time, which were used to calculate sleep efficiency. The survey also asked about race/ethnicity and self-rated health (using the general health item from the Short Form-36). RESULTS: A completed survey was returned by 4,717 individuals (51.9% response rate; mean age 74.1 years). Of those, 2,249 (47.7%) met ICSD-2 diagnostic criteria for insomnia disorder. In logistic regression analyses, insomnia disorder was more likely among younger age categories (odds ratios [OR] 1.4–2.5) and in those with worse self-rated health (OR 2.1–14.4). Both total nocturnal sleep time and time in bed increased with older age (all P < .001), whereas sleep efficiency did not differ. Worse self-rated health was associated with shorter total nocturnal sleep time, more time in bed, and lower (worse) sleep efficiency. CONCLUSIONS: Results of the postal survey suggest that almost half of community-dwelling older veterans have insomnia disorder, which was more common in young-old and among those with worse self-rated health. Additional work is needed to address the high burden of insomnia among older adults, including those with poor health. CITATION: Ryden AM, Martin JL, Matsuwaka S, Fung CH, Dzierzewski JM, Song Y, Mitchell MN, Fiorentino L, Josephson KR, Jouldjian S, Alessi CA. Insomnia disorder among older veterans: results of a postal survey. J Clin Sleep Med. 2019;15(4):543–551.

Background Cognitive behavioral therapy for insomnia (CBTI) targets changing dysfunctional sleep-related beliefs. The impact of these changes on daytime functioning in older adults is unknown. Purpose We examined whether changes in sleep-related beliefs from pre- to post-CBTI predicted changes in sleep and other outcomes in older adults. Method Data included 144 older veterans with insomnia from a randomized controlled trial testing CBTI. Sleep-related beliefs were assessed with the Dysfunctional Beliefs and Attitudes about Sleep-16 (DBAS-16, subscales: Consequences, Worry/Helplessness, Sleep Expectations, Medication). Outcomes included sleep diary variables, actigraphy-measured sleep efficiency, Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), Flinders Fatigue Scale (FFS), Patient Health Questionnaire-9, and health-related quality of life. Analyses compared slope of change in DBAS subscales from baseline to posttreatment between CBTI and control, and assessed the relationship between DBAS change and the slope of change in outcomes from baseline to 6 months. Results Compared to controls, the CBTI group demonstrated stronger associations between improvement in DBAS-Consequences and subsequent improvement in PSQI, ISI, ESS, and FFS. The CBTI group also demonstrated stronger associations between improvement in DBAS-Worry/Helplessness and subsequent improvements in PSQI, ISI, and FFS; improvements in DBAS-Medication and PSQI; and improvements in DBAS-Sleep Expectations and wake after sleep onset (sleep diary) and FFS (all p < .05). Conclusions Significant reduction in dysfunctional sleep-related beliefs following CBTI in older adults predicted improvement in several outcomes of sleep and daytime functioning. This suggests the importance of addressing sleep-related beliefs for sustained improvement with CBTI in older veterans. Trial Registration ClinicalTrials.gov Identifier: NCT00781963.

STUDY OBJECTIVES: Person-centered obstructive sleep apnea (OSA) care is a collaborative approach that is respectful of an individual’s health priorities. Informed decision-making is essential to person-centered care, especially as patients age. In a feasibility study, we evaluated the effects of a new decision aid (Decide2Rest) on OSA treatment decision-making in older adults. METHODS: Patients (aged ≥ 60 years) with newly diagnosed OSA were recruited from two health care systems and randomized either to Decide2Rest or to a control program. Postintervention outcomes included 1) Decisional Conflict Scale (0–100, where 0 = low and 100 = high conflict), which measures perceptions of uncertainty, whether decisions reflect what matters most to patients, and whether patients feel supported in decision-making; 2) Preparation for Decision-Making scale (0–100, where 0 = least and 100 most prepared); and 3) OSA knowledge (0–100, where 0 = poor and 100 = outstanding). Multivariable linear regression models examined relationships between Decide2Rest and outcomes (Decisional Conflict Scale, Preparation for Decision-Making, OSA knowledge). RESULTS: Seventy-three patients were randomized to Decide2Rest (n = 36; mean age, 69 years; 72% male) vs control (n = 37; mean age, 69 years; 70% male). Results from the regressions, controlling for study site, indicate that the Decide2Rest program resulted in less decisional conflict (20.5 vs 32.7 on the Decisional Conflict Scale; P = .014), more preparedness for decision-making (87.8 vs 66.2 on the Preparation for Decision-Making scale; P < .001), and greater OSA knowledge (75.1 vs 65.3 OSA knowledge score; P = .04) scores than in the control group. CONCLUSIONS: The Decide2Rest program promotes person-centered OSA decision-making for older patients with newly diagnosed OSA. Future studies are needed to optimize implementation of the program. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov, Name: Improving Older Adults’ Decision-Making for OSAT (eDecide2Rest); URL: https://clinicaltrials.gov/ct2/show/NCT03138993; Identifier: NCT03138993. CITATION: Fung CH, Martin JL, Liang LJ, et al. Efficacy of a patient decision aid for improving person-centered decision-making by older adults with obstructive sleep apnea. J Clin Sleep Med. 2021;17(2):121–128.

STUDY OBJECTIVES: The goals of this study were to estimate rates of undiagnosed, diagnosed, and treated sleep apnea in women veterans and to identify factors associated with diagnosis and treatment of sleep apnea in this population. METHODS: A large nationwide postal survey was sent to a random sample of 4,000 women veterans who had received health care at a Veterans Health Administration (VA) facility in the previous 6 months. A total of 1,498 surveys were completed. Survey items used for the current analyses included: demographics; sleep apnea risk, diagnostic status, and treatment; symptoms of other sleep disorders (eg, insomnia); mental health symptoms; and comorbidities. RESULTS: Among responders, 13% of women reported a prior sleep apnea diagnosis. Among women who reported a diagnosis of sleep apnea, 65% reported using positive airway pressure therapy. A sleep apnea diagnosis was associated with older age, higher BMI, non-Hispanic African American/Black racial/ethnic identity, being unemployed, other sleep disorder symptoms (eg, insomnia), depression and post-traumatic stress disorder symptoms, and multimorbidity. Among women without a sleep apnea diagnosis, 43% scored as “high risk” on the STOP (snoring, tiredness, observed apneas, blood pressure) questionnaire. High risk scores were associated with older age, higher BMI, African American/Black identity, other sleep disorder symptoms (eg, insomnia), mental health symptoms, and multimorbidity. Only BMI differed between women using vs not using positive airway pressure therapy. CONCLUSIONS: Women veterans with diagnosed sleep apnea were commonly treated with positive airway pressure therapy, which is standard first-line treatment; however, many undiagnosed women were at high risk. Efforts to increase screening, diagnosis, and treatment of sleep apnea in women with comorbid mental and physical health conditions are needed. CITATION: Martin JL, Carlson G, Kelly M, et al. Sleep apnea in women veterans: results of a national survey of VA health care users. J Clin Sleep Med. 2021;17(3):555–565.

Study ObjectivesCognitive behavioral therapy for insomnia (CBTI) for comorbid insomnia and obstructive sleep apnea (OSA) has had mixed results. We integrated CBTI with a positive airway pressure (PAP) adherence program and tested effects on sleep and PAP use.Methods125 veterans (mean age 63.2, 96% men, 39% non-Hispanic white, 26% black/African American, 18% Hispanic/Latino) with comorbid insomnia and newly-diagnosed OSA (apnea-hypopnea index ≥ 15) were randomized to 5-weekly sessions integrating CBTI with a PAP adherence program provided by a “sleep coach” (with behavioral sleep medicine supervision), or 5-weekly sleep education control sessions. Participants and assessment staff were blinded to group assignment. Outcomes (baseline, 3 and 6 months) included Pittsburgh Sleep Quality Index (PSQI), 7-day sleep diary (sleep onset latency [SOL-D], wake after sleep onset [WASO-D], sleep efficiency [SE-D]), 7-day actigraphy (SE-A), and objective PAP use (hours/night and nights ≥ 4 h). Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10) were also collected.ResultsCompared to controls, intervention participants showed greater improvement (baseline to 3 and 6 months, respectively) in PSQI (−3.2 and −1.7), SOL-D (−16.2 and −15.5 minutes), SE-D (10.5% and 8.5%), SE-A (4.4% and 2.6%) and more 90-day PAP use (1.3 and 0.9 more hours/night, 17.4 and 11.3 more nights PAP ≥ 4 h). 90-day PAP use at 3 months was 3.2 and 1.9 h/night in intervention versus controls. Intervention participants also had greater improvements in ISI, ESS, and FOSQ-10 (all p < 0.05).ConclusionsAn intervention integrating CBTI with a PAP adherence program delivered by a supervised sleep coach improved sleep and PAP use in adults with comorbid insomnia and OSA.Trial RegistrationClinicalTrials.govStudy name: Novel Treatment of Comorbid Insomnia and Sleep Apnea in Older VeteransURL: https://clinicaltrials.gov/ct2/results?cond=&term=NCT02027558&cntry=&state=&city=&dist=Registration: NCT02027558

Introduction In our recent national survey study, 13% of women Veterans reported a diagnosis of Sleep Disordered Breathing (SDB), of whom 65% used positive airway pressure (PAP) treatment. We also found many women Veterans at high risk for SDB were undiagnosed (43%). The current study builds upon this survey research to identify rates of evaluation, diagnosis, treatment, and treatment adherence among women Veterans with risk factors for SDB. Methods We analyzed telephone screening data from an ongoing SDB treatment adherence intervention study for women Veterans in Los Angeles county. A total of 173 women Veterans, identified by retrospective chart review as having at least one risk factor for SDB (i.e. high blood pressure, diabetes, obesity, depression, or > 50 years old), completed the screener. Screening questions included 1) previous diagnostic testing for SDB, 2) SDB diagnosis 3) SDB treatment type, and 4) past week SDB treatment use. Descriptive statistics regarding evaluation and treatment of SDB are reported. Results In total, 31% of respondents endorsed having previously completed diagnostic testing, of whom, 54% reported an SDB diagnosis. Of those with diagnosed SDB, 82.8% were prescribed treatment (PAP [72.4%], oral appliance [6.9%], surgery [3.5%]), and 17.2% did not report being prescribed any SDB treatment. Of the 21 (72.4%) women Veterans diagnosed with SDB that were prescribed PAP, only 33% reported using treatment in the past week. Of the 2 women Veterans (6.9%) prescribed an oral appliance, 0% reported past week use. Conclusion Less than 1/3 of women Veterans with at least one risk factor for SDB had previously been evaluated for SDB; however, over 1/2 of women Veterans who were evaluated tested positive for SDB. Additionally, most women Veterans had not used PAP or oral appliance therapy in the past week. Greater clinical attention is needed to identify, evaluate, and diagnose SDB in women Veterans. Moreover, further research is needed to evaluate and inform interventions to address SDB treatment adherence barriers in women Veterans. Support (if any) VA HSR&D IIR 16–244 and RCS 20–191; NIH/NHLBI K24 HL143055, VAGLAHS GRECC and VA Office of Academic Affiliations.

ObjectivesTo examine relationships between cognitive expectancies about sleep and hypnotics and use of medications commonly used for insomnia (hypnotics).MethodsWe analyzed baseline data from older veterans who met diagnostic criteria for insomnia and were enrolled in a trial comparing CBTI delivered by a supervised, sleep educator to an attention control condition (N=159; 97% male, mean age 72years). We classified individuals as hypnotic users (N=23) vs. non-users (N=135) based upon medication diaries. Associations between hypnotic status and Dysfunctional Beliefs and Attitudes about Sleep-16 (DBAS) total score (0-10, higher=worse) and two DBAS medication item scores (Item 1: "…better off taking a sleeping pill rather than having a poor night's sleep;" Item 2: "Medication… probably the only solution to sleeplessness"; 0-10, higher=worse) were examined in logistic regression models.ResultsHigher scores on the DBAS medication items (both odds ratios=1.3; p-values < .001) were significantly associated with hypnotic use. DBAS-16 total score was not associated with hypnotic use.ConclusionCognitive expectancy (dysfunctional beliefs) about hypnotics was associated with hypnotic use in older adults with chronic insomnia disorder.Clinical implicationsStrategies that specifically target dysfunctional beliefs about hypnotics are needed and may impact hypnotic use in older adults.

Objectives (1) To examine relationships between frequency of nocturia and self-reported sleep quality and objective sleep measures in older women, and (2) to estimate the amount of variation in sleep measures that is specifically attributable to frequency of nocturia. Design and setting Secondary, cross sectional analysis of the multicenter prospective cohort Study of Osteoporotic Fractures (SOF). Participants Community-dwelling women aged ≥80 years. Measurements Frequency of nocturia in the previous 12 months, Pittsburgh Sleep Quality Index sleep quality subscale, and actigraphy-measured wake after sleep onset (WASO) and total sleep time (TST). Results Of 1,520 participants, 25% (n = 392) reported their nocturia frequency was 3–4 times/night and an additional 60% (n = 917) reported their nocturia frequency was 1–2 times/night. More frequent nocturia was associated with poor sleep quality (3–4/night: 26.8% reported fairly bad or very bad sleep quality; 1–2/night: 14.7%; 0/night: 7.7%; P < .001) and longer WASO (3–4/night: 89.8 minutes; 1–2/night: 70.6; 0/night: 55.5; P < .001). In nested regression models, a nocturia frequency of 3–4/night quadrupled the odds of poor sleep quality (odds ratio: 4.26 [95% CI 1.65, 11.01]; P = .003) and was associated with a 37-minute worsening in WASO (95% CI 26.0, 49.0; P < .001). Frequency of nocturia explained an additional 6% variation in WASO, above and beyond demographic, medical/psychiatric conditions, and medication factors (∆R2 = 0.06). Conclusions Nocturia is common among octogenarian and nonagenarian women and is independently associated with poor sleep quality and longer wake time at night. Interventions that improve nocturia may be useful in improving sleep quality and wake time at night.

Poor sleep among family caregivers of individuals with dementia is associated with higher levels of caregiver stress. Modifiable factors that increase risk of stress among caregivers with poor sleep are targets for intervention. This analysis aimed to identify factors associated with greater caregiver stress among caregivers with poor sleep. Baseline data from an ongoing trial of a dyadic sleep intervention program for individuals with dementia and their caregivers with poor sleep quality (defined by Pittsburgh Sleep Quality Index total score > 5; N=21 dyads; mean age 70.8± 11.1 for caregivers, 80.5± 8.3 for care-recipients) were analyzed. Caregiving factors included Zarit Burden Index (ZBI) and SF-12 Short Form Health Survey (SF-12v2). Care-recipient factors included Mini-Mental State Examination (MMSE) and Revised Memory and Behavior Problems Checklist (RMBPC). Stress was measured with the Perceived Stress Scale (PSS). Analyses included Pearson correlations and t-tests. Caring for multiple care-recipients (n=5: 24.8±2.7) was associated with higher (worse) PSS scores than caring for one care-recipient only (n=16: 19.6±3.7, p=0.011). Caregivers with higher PSS also had a significantly higher ZBI score (r=0.53, p=0.015), higher distress related to care-recipient behaviors on the RMBPC (r=0.57, p=0.009) and worse mental health on the SF-12v2 (r= -0.47, p=0.037). PSS was not associated with care-recipient MMSE. These findings suggest that caregivers with poor sleep who care for multiple care-recipients may be at higher risk of stress. This work also identified potential targets (e.g., caregiver burden, mental health, distress related to care-recipient behavior) for reducing stress in this population.

Introduction Women are at higher risk for cognitive impairment and dementia compared to men. Identifying potentially treatable risk factors such as insomnia is an important clinical goal. In a trial comparing two behavioral treatments for insomnia in women veterans, we hypothesized that 1) worse baseline insomnia severity would be associated with poorer cognitive function, and 2) improvement in insomnia severity with treatment would be associated with improvement in cognitive functioning. Methods 347 women veterans with insomnia disorder [mean age 48.3 (12.9) years] completed baseline testing. Of these, 149 women were randomized to receive cognitive behavioral therapy for insomnia (CBT-I) or acceptance and commitment (ACT) based insomnia treatment (both treatments included sleep restriction, stimulus control, and sleep hygiene). Insomnia Severity Index (ISI) was assessed at baseline, post-treatment, and 3-month follow-up. Cognitive functioning was measured with Symbol Digit Coding (SDC) and Trail Making Test A and B (TMTA and TMTB). Pearson correlations were used to examine associations between insomnia severity and cognitive functioning at baseline and changes in both insomnia severity and cognitive functioning from before to after treatment. Results At baseline (N=347), mean ISI was 14.1 (5.3). Worse baseline ISI was associated with worse baseline cognitive functioning on TMTA (r=-.15, p Conclusion More severe insomnia is associated with worse cognitive functioning in women veterans. The magnitude of improvement in insomnia symptoms may be associated with improvement in cognition. Support NIH/NIA K23AG049955 (PI: Dzierzewski); VA/HSR&D IIR-HX002300 (PI: Martin), NIH/NHLBI K24HL143055 (PI: Martin).

Introduction Sleep apnea (SA) is the most commonly diagnosed sleep disorder among patients in the US Veterans Administration (VA). The dramatic rise in women receiving VA care makes it essential to understand the presentation and treatment of SA in women Veterans. We performed a nationwide survey about sleep among US women Veterans and compared characteristics of respondents with and without a self-reported history of SA diagnosis and treatment. Methods A survey was mailed to a random sample of 4000 women VA healthcare users. The survey included demographics, Insomnia Severity Index (ISI), Patient Health Questionnaire-4 (PHQ-4 depression/anxiety), Primary Care-Post-Traumatic Stress Disorder (PC-PTSD), RLS symptom presence, SA symptoms (snore loudly, observed breathing pauses), diagnosis of SA, and use of PAP therapy (APAP, BPAP, CPAP). We compared women with and without SA, and (among those with SA) women who did and did not use PAP, using Chi-square and t-tests. Results 1,498 completed surveys were returned (mean age 51.6 years, range 18-105 years, 62% non-Hispanic White). 200 respondents (13.4%) reported diagnosed SA. Women with SA were older (p Conclusion One in 7 women who receive VA care report diagnosed SA. Women with SA had more mental health symptoms and comorbid sleep problems. Most reported using PAP therapy, although the amount of use is unknown. Those with SA symptoms were more likely to use PAP. Future work is needed to understand barriers to diagnosis and treatment of SA among women Veterans. Support Funding: VA Quality Enhancement Research Initiative RRP12-189 (Martin); NIH/NHLBI K24 HL143055 (Martin).

Introduction Nocturia is common among patients with both insomnia disorder and obstructive sleep apnea (OSA) and adversely affects quality of life. Within a randomized controlled trial testing an integrated behavioral therapy for positive airway pressure (PAP) adherence and insomnia for patients with coexisting OSA and insomnia disorder, we examined the impact of the integrated therapy on nocturia frequency. Methods Patients aged > 50 years with untreated OSA (apnea hypopnea index > 15) and chronic insomnia disorder were recruited from a VA medical center and randomized to 5 weekly individual integrated behavioral treatment sessions versus control (general sleep education). Nocturia frequency (self-reported average number of nocturia events per night) was assessed at baseline, 3 months, and 6 months. Linear regression models were used to examine relationships between objective PAP adherence (# nights used > 4hrs over the last 30 days) and Insomnia Severity Index (ISI) score (0 [none] - 28 [severe]) and nocturia frequency (0 - 5+/night), and change in nocturia frequency associated with integrated therapy. Results Nocturia data were available for 112 participants (treatment=56, control=56; mean age 63 [SD 7], 95% male). Mean nocturia frequency (episodes/night) was 2.1 (SD 1.3; baseline), 1.6 (SD 1.1; 3 months), and 1.7 (SD 1.2; 6 months). Overall, higher PAP adherence (B=.029, p=.008) and ISI score improvement (B=0.05, p=.004) were associated with decreased nocturia frequency at 3-month follow-up. No differences were observed in nocturia frequency between treatment and control participants at baseline (p=.429). Integrated therapy reduced nocturia frequency at 3 months (B=-0.56, p=.020) but not at 6 months follow-up (B=-0.4, p=.081) compared to control. Conclusion Nocturia frequency improved with integrated behavioral therapy for PAP adherence and insomnia in veterans (primarily male) with co-existing OSA and insomnia. Additional studies are needed to examine the mechanisms underlying the relationship between the behavioral therapy for PAP adherence and insomnia and nocturia. Support VA HSR&D; NIA; VA GRECC

STUDY OBJECTIVES: Home sleep apnea testing (HSAT) is an efficient and cost-effective method of diagnosing obstructive sleep apnea (OSA). However, nondiagnostic HSAT necessitates additional tests that erode these benefits, delaying diagnoses and increasing costs. Our objective was to optimize this diagnostic pathway by using predictive modeling to identify patients who should be referred directly to polysomnography (PSG) due to their high probability of nondiagnostic HSAT. METHODS: HSAT performed as the initial test for suspected OSA within the Veterans Administration Greater Los Angeles Healthcare System was analyzed retrospectively. Data were extracted from pre-HSAT questionnaires and the medical record. Tests were diagnostic if there was a respiratory event index (REI) ≥ 5 events/h. Tests with REI < 5 events/h or technical inadequacy—two outcomes requiring additional testing with PSG—were considered nondiagnostic. Standard logistic regression models were compared with models trained using machine learning techniques. RESULTS: Models were trained using 80% of available data and validated on the remaining 20%. Performance was evaluated using partial area under the precision-recall curve (pAUPRC). Machine learning techniques consistently yielded higher pAUPRC than standard logistic regression, which had pAUPRC of 0.574. The random forest model outperformed all other models (pAUPRC 0.862). Preferred calibration of this model yielded the following: sensitivity 0.46, specificity 0.95, positive predictive value 0.81, negative predictive value 0.80. CONCLUSIONS: Compared with standard logistic regression models, machine learning models improve prediction of patients requiring in-laboratory PSG. These models could be implemented into a clinical decision support tool to help clinicians select the optimal test to diagnose OSA. CITATION: Stretch R, Ryden A, Fung CH, Martires J, Liu S, Balasubramanian V, Saedi B, Hwang D, Martin J, Della Penna N, Zeidler M. Predicting nondiagnostic home sleep apnea tests using machine learning. J Clin Sleep Med. 2019;15(11):1599–1608.

Introduction Sleep disordered breathing (SDB) is underdiagnosed in older women, despite a significant increase in SDB prevalence post-menopause. Few studies have assessed the diagnostic accuracy of SDB screening questionnaires in older women, particularly older Women Veterans (WV). WV have higher rates of SDB compared to non-Veteran women and are particularly vulnerable to sleep disorders in general. We examined the diagnostic accuracy of the STOP questionnaire compared to home sleep apnea testing (HSAT) that includes sleep time estimation (i.e., WatchPAT) in older WV. Methods Cross-sectional baseline data obtained from chart review were combined from two behavioral sleep intervention studies targeting WV with sleep difficulties (i.e., insomnia symptoms) or SDB risk factors (e.g., hypertension, obesity). A total of 136 older WV (50-91y; age=60.0±7.8y) completed the STOP questionnaire (yes/no: snoring, tiredness, observed breathing pauses, and high blood pressure [BP]) and had an apnea-hypopnea index (AHI) available from their baseline HSAT (WatchPAT). Sensitivity, specificity, and positive and negative likelihood ratios (+LR/-LR) were calculated to characterize the diagnostic accuracy of STOP≥2 for AHI≥5 (mild SDB) or AHI≥15 (moderate SDB). Results 70.6% (n=96) of participants endorsed a STOP≥2, 83.8% (n=114) demonstrated an AHI≥5 and 46.3% (n=63) demonstrated an AHI≥15. For AHI≥5, sensitivity was 73.7% (95% CI=64.6,81.5%), specificity was 45.5% (95% CI=24.4,67.8%), +LR was 1.35 (95% CI=0.91, 2.01), and -LR was 0.58 (95% CI=0.33,1.00). For AHI≥15, sensitivity was 76.2% (95% CI=63.8,86%), specificity was 34.2% (95% CI=23.5,46.3%), +LR was 1.16 (95% CI=0.93,1.44), and -LR was 0.70 (95% CI=0.30,1.20). Conclusion The likelihood ratios for STOP≥2 limited the utility of the STOP vs. an HSAT system with sleep scoring in determining AHI. While the STOP correctly identified 3/4 of older WV with SDB on WatchPAT, it correctly identified Support (if any) VA HSR&D IIR-13–058, IIR 16–244 and RCS 20–191; NIH/NHLBI K24 HL143055, VAGLAHS GRECC, VA Office of Academic Affiliations, and AASM Foundation.

Introduction Cognitive behavioral therapy for insomnia (CBT-I) is recommended as first-line treatment for chronic insomnia disorder for all adults. Older adults are often prescribed sedative-hypnotics (e.g., benzodiazepine receptor agonists, BRAs) for insomnia, despite observational studies showing these medications increase risk of falls, fractures, and cognitive decline. In an ongoing randomized controlled trial, we are testing “Sleep EducatioN Information Sent Directly to Patients (SEND),” a novel program combining direct-to-patient mailing with information about access to an online CBT-I resource, compared to a similarly structured control condition. In the current study, we surveyed participants in both groups to examine their self-reported use of intervention or control materials. Methods In the larger trial, 1,672 Veteran participants (aged >=65 years, receiving care from a Colorado VA facility, and prescribed a BRA) were randomized to receive the SEND intervention brochure with information on how to access a free, anonymous online CBT-I resource (n=836) or control condition brochure with information about general sleep education (n=836). Six months after the initial brochure mailing, all participants were mailed a blinded survey querying participants’ recollection and use of the mailed materials. We used chi-squared tests to compare survey responses for SEND versus control groups. Results 354 surveys were returned by study participants (overall response rate: 21%; SEND: 172 [20%], control: 182 [22%]). Respondents were 94% male with mean age 71.7 years (no difference between groups). In the SEND group, 97 (56%) reported receiving the brochure, 18 (10%) visited the website, and 14 (8%) discussed the brochure with their provider. No significant differences between groups were observed in the number of participants who reported receiving the brochure (chi2=2.96, p=.085); visiting the website (chi2=0.0253, p=.874); or discussing the brochure with their provider (chi2=1.91, p=.167). Conclusion At 6-months follow-up, over half of participants recalled receiving a mailing about sedative-hypnotics. A modest number reported visiting the online CBT-I program and a similar number discussed the materials with their healthcare provider. Similar results between groups suggest successful blinding of the intervention and control participants. If successful, the SEND intervention may provide a low-touch, low-cost approach to address BRA over-use in some older adults. Support (if any)

Introduction Insomnia among informal caregivers (providing care to family/friends) is common and associated with worse mental and physical health outcomes. Traditional cognitive behavioral therapy for insomnia may be challenging for caregivers whose beliefs about sleep may relate to beliefs and behaviors that are intertwined with their unique situation of caregiving. We examined whether an insomnia treatment using an acceptance and commitment (ACT) approach (i.e. committing to values-based actions toward goals vs. experiential avoidance of distressing emotions/thoughts) plus sleep restriction, stimulus control and sleep hygiene improves sleep, mental health, and daytime symptoms among caregivers. Methods We analyzed data from women veterans with insomnia who were informal caregivers (mean age=44 years [range 25–57]; N=6) and were participating in a clinical trial of an ACT-focused treatment (termed ABC-I). We measured: Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Patient Health Questionnaire (PHQ-9), General Anxiety Disorder (GAD-7), 11 items assessing symptoms of daytime impairment due to poor sleep derived from the International Classification of Sleep Disorders-Third Edition, and the Acceptance and Action Questionnaire (AAQ). Student t-tests were used to compare outcomes between pre- and post-ABC-I. Results Caregivers showed significant improvements between pre- and post-ABC-I (all p-values Conclusion We found that caregivers with insomnia may benefit from ACT-based treatment in improving perceived sleep quality and insomnia, depression, anxiety, sleep-related daytime impairment and reduced experiential avoidance. This approach may increase motivation by linking the sleep program to core values, and acceptance and tolerance of emotions or thoughts may benefit caregivers with insomnia. Further studies using an ACT-based insomnia program are needed to test its effect in a larger sample of caregivers and evaluate benefits in terms of reduced stress and improved health. Support (if any) VA HSR&D (Martin IIR 13-058-2 and RCS-20–191), NIA (K23AG055668, Song), NHLBI (K23HL143055, Martin) of the NIH, VAGLAHS GRECC, and VA Office of Academic Affiliations (Kelly; Carlson).

Introduction We present a case of paradoxically worsened hypoxia during wake phase of polysomnography while undergoing a CPAP titration study. Nighttime hypoxemia is a common feature in obstructive sleep apnea, due to obstructive events that manifest while sleeping. Excluding OSA, there remains an extensive differential for disease processes that cause hypoxemia while asleep; however, none of these processes can explain waking hypoxemia that improves upon sleeping. Report of case(s) A 70 year old male with severe OSA diagnosed by home sleep test (REI 46.5, nadir O2=76%) underwent polysomnography with PAP titration and demonstrated several hours of interrupted sleep without hypoxia and minimal obstructive events on CPAP 9–13 cmH2O. During the study, while awake at CPAP of 14 cmH2O, he developed hypoxia to mid-high 80s and supplemental oxygen bleed in was added starting at 3L and increased to 5L during a prolonged period of wakefulness. On CPAP 15 cmmH2O with 5L bleed-in, the patient fell asleep and oxygen saturation again increased to low 90s. He underwent an extensive workup for other cardiopulmonary causes of hypoxemia, with pulmonary function testing showing moderate obstructive ventilatory defect and mild DLCO impairment. An echocardiogram with saline contrast bubble study was relatively unremarkable, without evidence of right to left shunting. He underwent a chest CTA which was negative for pulmonary embolism, though it did reveal an enlarged pulmonary artery consistent with pulmonary hypertension. His chronic hypoxemia was treated with 2L supplemental oxygen during the day and bleed-in with CPAP at night. Conclusion Though nocturnal hypoxemia is common with OSA, polysomnography with paradoxical hypoxemia during wake phase has not been reported. Notably, the patient was without prolonged hypoxia during his sleep phase while on CPAP treatment with minimal apneic/hypopneic events. Pulmonary hypertension can also present as nocturnal hypoxemia, but it should worsen with sleep, rather than improve. There are case reports of right to left shunting worsened by PAP, though his hypoxemia persisted despite PAP. His paradoxical worsening hypoxemia with wakefulness is still unexplained. Support (if any)

The American Geriatrics Society, with support from the National Institute on Aging and other funders, held its eighth Bedside-to-Bench research conference, entitled “Sleep, Circadian Rhythms, and Aging: New Avenues for Improving Brain Health, Physical Health and Functioning,” October 4 to 6, 2015, in Bethesda, Maryland. Part of a conference series addressing three common geriatric syndromes—delirium, sleep and circadian rhythm (SCR) disturbance, and voiding dysfunction—the series highlighted relationships and pertinent clinical and pathophysiological commonalities between these three geriatric syndromes. The conference provided a forum for discussing current sleep, circadian rhythm, and aging research; identifying gaps in knowledge; and developing a research agenda to inform future investigative efforts. The conference also promoted networking among developing researchers, leaders in the field of SCR and aging, and National Institutes of Health program personnel.

Purpose Female veterans are at high risk for sleep problems, and there is a need to provide effective treatment for this population who experience insomnia. This study’s primary goal was to compare the acceptability of medication versus nonmedication treatments for insomnia among female veterans. In addition, we examined the role of patient age, severity of sleep disturbance, and psychiatric symptoms on acceptability of each treatment approach and on the differences in acceptability between these approaches. Methods A large nationwide postal survey was sent to a random sample of 4000 female veterans who had received health care at a Veterans Administration (VA) facility in the previous 6 months (May 29, 2012–November 28, 2012). A total of 1559 completed surveys were returned. Survey items used for the current analyses included: demographic characteristics, sleep quality, psychiatric symptoms, military service experience, and acceptability of medication and nonmedication treatments for insomnia. For analysis, only ratings of “very acceptable” were used to indicate an interest in the treatment approach (vs ratings of “not at all acceptable,” “a little acceptable,” “somewhat acceptable,” and “no opinion/don׳t know”). Findings In the final sample of 1538 women with complete data, 57.7% rated nonmedication treatment as very acceptable while only 33.5% rated medication treatment as very acceptable. This difference was statistically significant for the group as a whole and when examining subgroups of patients based on age, sleep quality, psychiatric symptoms, and military experience. The percentage of respondents rating medication treatment as very acceptable was higher for women who were younger, had more severe sleep disturbances, had more psychiatric symptoms, who were not combat exposed, and who had experienced military sexual trauma. By contrast, the percentage of respondents rating nonmedication treatment as very acceptable differed only by age (younger women were more likely to find nonmedication treatment acceptable) and difficulty falling asleep. Implications Female veterans are more likely to find nonmedication insomnia treatment acceptable compared with medication treatment. Thus, it is important to match these patients with effective behavioral interventions such as cognitive behavioral therapy for insomnia. Efforts to educate providers about these preferences and about the efficacy of cognitive behavioral therapy for insomnia may serve to connect female veterans who have insomnia to the treatment they prefer. These findings also suggest that older female veterans may be less likely to find either approach as acceptable as their younger counterparts.

Objectives To test a new cognitive behavioral therapy for insomnia (CBT-I) program designed for use by nonclinicians. Design Randomized controlled trial. Setting Department of Veterans Affairs healthcare system. Participants Community-dwelling veterans aged 60 and older who met diagnostic criteria for insomnia of 3 months duration or longer (N = 159). Intervention Nonclinician “sleep coaches” delivered a five-session manual-based CBT-I program including stimulus control, sleep restriction, sleep hygiene, and cognitive therapy (individually or in small groups), with weekly telephone behavioral sleep medicine supervision. Controls received five sessions of general sleep education. Measurements Primary outcomes, including self-reported (7-day sleep diary) sleep onset latency (SOL-D), wake after sleep onset (WASO-D), total wake time (TWT-D), and sleep efficiency (SE-D); Pittsburgh Sleep Quality Index (PSQI); and objective sleep efficiency (7-day wrist actigraphy, SE-A) were measured at baseline, at the posttreatment assessment, and at 6- and 12-month follow-up. Additional measures included the Insomnia Severity Index (ISI), depressive symptoms (Patient Health Questionnaire-9 (PHQ-9)), and quality of life (Medical Outcomes Study 12-item Short-form Survey version 2 (SF-12v2)). Results Intervention subjects had greater improvement than controls between the baseline and posttreatment assessments, the baseline and 6-month assessments, and the baseline and 12-month assessments in SOL-D (−23.4, −15.8, and −17.3 minutes, respectively), TWT-D (−68.4, −37.0, and −30.9 minutes, respectively), SE-D (10.5%, 6.7%, and 5.4%, respectively), PSQI (−3.4, −2.4, and −2.1 in total score, respectively), and ISI (−4.5, −3.9, and −2.8 in total score, respectively) (all P < .05). There were no significant differences in SE-A, PHQ-9, or SF-12v2. Conclusion Manual-based CBT-I delivered by nonclinician sleep coaches improves sleep in older adults with chronic insomnia.

Background Nocturnal bladder symptoms and sleep disruption commonly coexist in middle-aged and older women. Although sleep disruption is often attributed to nocturnal bladder symptoms in women with overactive bladder syndrome, nonbladder factors also may influence sleep in this population. Many women with overactive bladder are eager to identify nonpharmacologic strategies for both bladder symptoms and sleep disruption, given the potential adverse effects of sedative and anticholinergic bladder medications in this population. Objectives To provide greater insight into the complex relationship between nighttime overactive bladder symptoms and sleep disruption, and to evaluate the effects of a guided slow-paced respiration intervention on sleep outcomes in women with overactive bladder. Study Design We conducted an ancillary study within a randomized trial of slow-paced respiration in women with overactive bladder symptoms. Ambulatory community-dwelling women who reported ≥3 episodes/day of urgency-associated voiding or incontinence were randomized to use either a portable biofeedback device (RESPeRATE; Intercure, Ltd) to practice guided slow-paced respiration exercises daily for 12 weeks (N=79) or an identical-appearing device programmed to play nonrhythmic music without guiding breathing (N=82). At baseline and after 12 weeks, bladder symptoms were assessed by voiding diary, sleep duration, and disruption were assessed by sleep diary corroborated by wrist actigraphy, and poor sleep quality was determined by a Pittsburgh Sleep Quality Index global score >5. Results Of the 161 women randomized, 31% reported at least twice-nightly nocturia, 26% nocturnal incontinence, and 70% poor sleep quality at baseline. Of the 123 reporting any nighttime awakenings, 89% averaged 1 or more nighttime awakenings, and 83% attributed at least half of awakenings to using the bathroom. Self-reported wake time after sleep onset increased with increasing frequency of nocturnal bladder symptoms (P=.01 for linear trend). However, even among women without nocturia, average sleep quality was poor (Pittsburg Sleep Quality Index global score mean of 7.3; 95% confidence interval, 6.0–8.6). Over 12 weeks, women assigned to slow-paced respiration (N=79) experienced modest improvements in mean nocturnal voiding frequency (0.4 fewer voids/night), sleep quality (1.1 point score decrease), and sleep disruption (1.5% decreased wake time after sleep onset). However, similar improvements were detected in the music control group (N=81), without significant between-group differences. Conclusions Many women with overactive bladder syndrome experience disrupted sleep, but not all nocturnal awakenings are attributable to bladder symptoms, and average sleep quality tends to be poor even in women without nocturia. Findings suggest that clinicians should not assume that poor sleep in women with overactive bladder syndrome is primarily caused by nocturnal bladder symptoms. Guided slow-paced respiration was associated with modest improvements in nocturia frequency and sleep quality in this trial, but the results do not support clinician recommendation to use this technique over other behavioral relaxation techniques for improving sleep.

Introduction Sleep disordered breathing (SDB) is common among individuals with spinal cord injuries or diseases (SCI/D), many of whom are military Veterans, and physical limitations make use of positive airway pressure (PAP) therapy challenging. This study sought to test the effects of an educational and behavioral intervention to improve PAP adherence among Veterans with SCI/D over the first 3 months of use. Methods 63 Veterans (mean age=60.7(10.2) years; 92% male) with SCI/D (33 SCI, 30 SCD; 25 cervical involvement; 38 thoracic and below) and SDB (23 with AHI 5-15; 40 with AHI≥15) who received PAP treatment (CPAP or BPAP) were randomly assigned to receive a comprehensive 3-month intervention (INT) or an equal attention control (EAC). INT and EAC both included 1 face-to-face session (week 1) and 5 additional telephone sessions (weeks 2, 3, 4, 8 and 12). Main outcome measures were PAP use over the first 3 months: nights of use, nights of use ≥4 hours, and mean hours of use per night. Repeated measures ANCOVA models were used to test the differences between INT and EAC over the first 3 months of treatment. Results Number of nights with ≥4 hours of use in months 1-3 was 9, 7, and 6 nights in the INT and 8, 5 and 4 nights in the EAC (p’s≥.37), respectively. There were no significant differences between INT and EAC for number of nights with any use (p’s≥.24), or mean hours of use per night (p’s≥.30). All 3 PAP use variables declined over time in both groups. Conclusion Sustained use of PAP therapy was difficult to achieve among those with SCI/D, and a 6-session behavioral intervention did not lead to significant improvements in use. Even when relatively high levels of initial use are achieved, this is difficult to sustain over time. Future studies should explore whether SCI/D patients experience significant symptom relief with PAP, and if so, whether home-based interventions or more intensive face-to-face PAP adherence programs will be effective. Support VA Rehabilitation Research and Development Service, Merit Review (1RX002116; PI: Badr); NIH/NHLBI K24 HL143055 (Martin).

Introduction The long-term impact of addressing sleep-related cognitions, which is an important component of cognitive behavioral therapy for insomnia (CBTI), has not been established, particularly in older adults. We examined whether specific changes in sleep-related cognitions predicted long-term changes in sleep and other outcomes following CBTI in older adults. Methods We analyzed data from a randomized controlled trial testing CBTI in older veterans with insomnia (N=159, mean age 72 years). Sleep-related cognitions were assessed with the Dysfunctional Beliefs and Attitudes about Sleep scale (DBAS, subscales: Consequences, Worry/Helplessness, Sleep Expectations, Medication). Outcome measures included the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), sleep diary variables, Flinders Fatigue Scale (FFS), and Short Form-12 health-related quality of life (QOL). Analyses completed slope of change in DBAS subscales (baseline to post-treatment: T1) between CBTI and control with respect to slope of change in sleep and other outcomes from post-treatment to 6-months (T2). Results Compared to controls, the CBTI group had significantly stronger associations between improvement (T1) in DBAS-Consequences and subsequent (T2) improvement in PSQI (difference in slopes [DIS]=0.9, 95%CI=[.29, 1.43], p=0.004), ISI (DIS=1.1, 95%CI=[.18, 2.0], p=0.019), ESS (DIS=0.6, 95%CI=[.10, 1.18], p=0.020), and FFS (DIS=1.9, 95%CI=[.76, 3.09], p=0.001). The CBTI group also had significantly stronger associations between improvement in DBAS-Worry/Helplessness and subsequent improvements in PSQI, ISI, and FFS; improvement in DBAS-Medication and PSQI and ISI; and improvement in DBAS-Sleep Expectations and improved FFS. Slopes were not different between groups for sleep diary variables or QOL. Conclusion Significant improvements in sleep-related cognitions with CBTI across DBAS subscales in older adults predicted improvement in several outcomes of nighttime sleep and daytime consequences. These findings suggest the importance of addressing dysfunctional sleep-related cognitions for sustained improvement with CBTI in older adults Support The study was supported by VA Health Services, Research and Development (Alessi, IIR 08-295), National Institute on Aging (K23AG055668, Song), National Heart, Lung, and Blood Institute (K24HL 143055, Martin) of the National Institutes of Health and VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center.

Objective/backgroundTo identify caregiving-related sleep problems and their relationship to mental health and daytime function in female Veterans.ParticipantsFemale Veterans (N = 1,477) from cross-sectional, nationwide, postal survey data.MethodsThe survey respondent characteristics included demographics, comorbidity, physical activity, health, use of sleep medications, and history of sleep apnea. They self-identified caregiving- related sleep problems (i.e., those who had trouble sleeping because of caring for a sick adult, an infant/child, or other respondents). Patient Health Questionnaire (PHQ-4) was used to assess mental health, and daytime function was measured using 11 items of International Classification of Sleep Disorders-2 (ICSD-2).ResultsFemale Veterans with self-identified sleep problems due to caring for a sick adult (n = 59) experienced significantly more symptoms of depression and anxiety (p < 0.001) and impairment in daytime function (e.g., fatigue, daytime sleepiness, loss of concentration, p < 0.001) than those with self-identified sleep problems due to caring for an infant or child (n = 95) or all other respondents (n = 1,323) after controlling for the respondent characteristics.ConclusionsHealthcare providers should pay attention to assessing sleep characteristics of female Veterans with caregiving responsibilities, particularly those caregiving for a sick adult.

OBJECTIVES:This study compared subjective (questionnaire) and objective (actigraphy) sleep assessments, and examined agreement between these methods, in vulnerable older adults participating in a Veterans Administration Adult Day Health Care (ADHC) program. METHODS:59 ADHC participants (95% male, mean age=78years) completed sleep questionnaires and 72 continuous hours of wrist actigraphy. Linear regression was used to examine agreement between methods and explore discrepancies in subjective/objective measures. RESULTS:Disturbed sleep was common, yet there was no agreement between subjective and objective sleep assessment methods. Compared with objective measures, one-half of participants reported worse sleep efficiency (SE) on questionnaires while one-quarter over-estimated SE. Participants reporting worse pain had a greater discrepancy between subjective and objective SE. CONCLUSIONS:Vulnerable older adults demonstrated unique patterns of reporting sleep quality when comparing subjective and objective methods. Additional research is needed to better understand how vulnerable older adults evaluate sleep problems. CLINICAL IMPLICATIONS:Objective and subjective sleep measures may represent unique and equally important constructs in this population. Clinicians should consider utilizing both objective and subjective sleep measures to identify individuals who may benefit from behavioral sleep treatments, and future research is needed to develop and validate appropriate sleep assessments for vulnerable older adults.

Background Evidence suggests that medical equipment often fails to accommodate the needs of individuals with disabling conditions. Few studies have focused on the accessibility of home medical devices such as positive airway pressure (PAP), which is a type of home medical equipment prescribed for long-term therapy. Objective The purpose of this study was to explore in detail the types of difficulties experienced by patients with physical/sensory impairments who use PAP devices, as an initial step in designing a questionnaire to survey users about this topic. Methods In this descriptive study, in-depth interviews were conducted with 19 participants (9 patients with physical/sensory impairment and 10 health care providers). Interviews were coded and analyzed for major topics. Results Participants detailed the numerous ways in which current PAP devices fail to meet the needs of individuals with physical/sensory impairments (e.g., tremor, poor depth perception, paresis), by requiring patients to perform manually difficult tasks, such as inserting PAP parts through small apertures, attaching parts using a twisting motion, and lifting arms overhead to apply PAP headgear. These demands contributed to patients' frustration with and reduced usage of the home medical device. Conclusions Our findings suggest that home medical devices such as PAP may not be currently designed to meet the needs of some users with physical/sensory impairments. Additional studies are needed to measure the prevalence and impact of impairment-related barriers on PAP adherence for this common medical equipment.

ObjectivesThis pilot study explored caregivers' attitudes toward core elements of a behavioral sleep intervention for managing sleep problems of older veteran care recipients and the caregivers, as an initial step for developing a dyadic sleep intervention program.MethodsFive caregivers (all women; age range, 66-75years) participated in a focus group discussion. Data were collected at one Veterans Affairs, adult day health care program.ResultsCaregivers' poor sleep was not necessarily explained by their caregiving responsibility. Caregivers felt that behavioral recommendations regarding sleep compression scheduling, increased indoor physical activity, and outdoor light exposure would be acceptable sleep interventions for themselves and the care recipients. Some challenges to the sleep recommendation were identified and they included limiting naptime of care recipients and change of their current sleep schedule.ConclusionsCaregivers are receptive to some key components of behavioral approaches to improving sleep. Tailored sleep recommendation strategy is needed to address potential challenges.Clinical implicationsIf available within clinical care settings or delivered at the patient's home, caregivers of older veterans are likely to engage in behavioral sleep intervention programs.

The American Geriatrics Society, with support from the National Institute on Aging and other funders, held its eighth Bedside-to-Bench research conference, entitled “Sleep, Circadian Rhythms, and Aging: New Avenues for Improving Brain Health, Physical Health and Functioning,” October 4 to 6, 2015, in Bethesda, Maryland. Part of a conference series addressing three common geriatric syndromes—delirium, sleep and circadian rhythm (SCR) disturbance, and voiding dysfunction—the series highlighted relationships and pertinent clinical and pathophysiological commonalities between these three geriatric syndromes. The conference provided a forum for discussing current sleep, circadian rhythm, and aging research; identifying gaps in knowledge; and developing a research agenda to inform future investigative efforts. The conference also promoted networking among developing researchers, leaders in the field of SCR and aging, and National Institutes of Health program personnel.

Study Objective To test the effectiveness of a 4-week behavioral Sleep Intervention Program (SIP: sleep compression, modified stimulus control, and sleep hygiene) compared to a 4-week information-only control (IC) among older adults attending a VA Adult Day Health Care (ADHC) program in a double-blind, randomized, clinical trial. Methods Forty-two individuals (mean age: 77 years, 93% male) enrolled in a VA ADHC program were randomized to receive SIP or IC. All completed in-person sleep and health assessments at baseline, post-treatment and 4-months follow-up that included 3 days/nights of wrist actigraphy, the Pittsburgh Sleep Quality Index (PSQI), and the Insomnia Severity Index (ISI). Mixed repeated measures analysis was used to compare sleep outcomes at post-treatment and 4-months follow-up, with baseline values as covariates. Results SIP participants (n = 21) showed significant improvement on actigraphy sleep efficiency (p = .007), number of nighttime awakenings (p = .016), and minutes awake at night (p = .001) at post-treatment, compared to IC participants (n = 21). Benefits were slightly attenuated but remained significant at 4-month follow-up (all p's < .05). There were no differences in total sleep time between groups. There was significant improvement on PSQI factor 3 (daily disturbances) at 4-month follow-up (p = .016), but no differences were observed between SIP and IC on other PSQI components or ISI scores at post-treatment or 4-month follow-up. Conclusions A short behavioral sleep intervention may have important benefits in improving objectively measured sleep in older adults participating in ADHC. Future studies are needed to study implementation of this intervention into routine clinical care within ADHC.