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IntroductionWe aimed to determine whether obesity or metabolic syndrome (MetS) modify associations between sleep-disordered breathing (SDB), self-reported sleep duration (SD), and phenotypes of combined SDB/SD with 7-year neurocognitive decline (ND) in a community based-cohort of U.S. Hispanic/Latinos (N=5500) in different age and sex groups.MethodsThe exposures were baseline SDB (respiratory event index ≥ 15), sleepiness (Epworth Sleepiness Scale ≥ 10), SD (

Nonadherence with positive airway pressure (PAP) therapy impedes the effectiveness of treatment and increases risk of mortality. Disparities in PAP adherence as a function of socioeconomic status (SES) are not well understood. A literature search identified 16 original publications meeting inclusion criteria that described effects of SES factors on objective PAP adherence; 69% of these articles found evidence of lower adherence as a function of SES. This integrative review provides a structured summary of the findings, highlights factors that may contribute to disparities among adult PAP users, and identifies future directions to improve equity in the management of OSA.

Background Insomnia is one of the most common nonmotor features of Parkinson's disease (PD). However, there are few practical guidelines for providers on how to best evaluate and treat this problem. Methods and Findings This review was developed to provide clinicians with a pragmatic approach to assessing and managing insomnia in PD. Recommendations were based on literature review and expert opinion. We addressed the following topics in this review: prevalence of insomnia in PD, sleep–wake mechanisms, theoretical models of insomnia, risk factors, assessment, pharmacologic and nonpharmacologic treatments. Insomnia treatment choices may be guided by PD severity, comorbidities, and patient preference. However, there is limited evidence supporting pharmacotherapy and nonpharmacologic treatments of insomnia in PD. Conclusions We provide a pragmatic algorithm for evaluating and treating insomnia in PD based on the literature and our clinical experience. We propose personalized insomnia treatment approaches based on age and other issues. Gaps in the existing literature and future directions in the treatment of insomnia in PD are also highlighted.

Study Objectives:The Insomnia Severity Index (ISI) has been used to define insomnia symptoms in individuals with obstructive sleep apnea (OSA). However, whether distinct ISI profiles exist in indiv...

Positive airway pressure (PAP) therapy is the “gold standard” of treatment for obstructive sleep apnea; however, rates of non-adherence to PAP therapy remain high despite device improvements and the inclusion of PAP education programs in most comprehensive sleep disorders clinics. We aimed to review recent evidence-based trends for improving PAP adherence. Remote monitoring and telemedicine interventions in conjunction with mobile patient engagement applications have shown promise in facilitating uptake and maintenance of PAP use. New focus on the bedpartner dyad and managing comorbid conditions are also notable, though more recent evidence for specific interventions is limited. Recent trends suggest a shift towards developing more patient-centered programs to support PAP adherence. Advancements in telemedicine and interactive mobile health technologies represent the most promising area of growth for PAP adherence interventions. Continued efforts focused on treatments that address socio-relational factors and comorbid conditions seem warranted.

Background Data on the prevalence and correlates of restless legs syndrome (RLS) in people with HIV are limited. This study sought to determine the prevalence of RLS, associated clinical correlates, and characterize sleep-related differences in men with and without HIV. Methods Sleep-related data were collected in men who have sex with men participating in the Multicenter AIDS Cohort Study (MACS). Demographic, health behaviors, HIV status, comorbidities, and serological data were obtained from the MACS visit coinciding with sleep assessments. Participants completed questionnaires, home polysomnography, and wrist actigraphy. RLS status was determined with the Cambridge-Hopkins RLS questionnaire. RLS prevalence was compared in men with and without HIV. Multinomial logistic regression was used to examine correlates of RLS among all participants and men with HIV alone. Sleep-related differences were examined in men with and without HIV by RLS status. Results The sample consisted of 942 men (56% HIV+; mean age 57 years; 69% white). The prevalence of definite RLS was comparable in men with and without HIV (9.1% vs 8.7%). In multinomial regression, HIV status was not associated with RLS prevalence. However, white race, anemia, depression, and antidepressant use were each independently associated with RLS. HIV disease duration was also associated with RLS. Men with HIV and RLS reported poorer sleep quality, greater sleepiness, and had worse objective sleep efficiency/fragmentation than men without HIV/RLS. Conclusions The prevalence of RLS in men with and without HIV was similar. Screening for RLS may be considered among people with HIV with insomnia and with long-standing disease.

OBJECTIVE/BACKGROUND: Insomnia is a prevalent and interfering comorbidity of HIV infection. Nearly 70% of people living with HIV/AIDS (PLWHA) experience symptoms of insomnia and associated distress. The current study examined the mechanisms of insomnia in HIV health status and health-related quality of life and explored behavioral pathways to explain relationships. PARTICIPANTS: Participants (N = 103) were active patients in an HIV clinic located within a nonprofit, tertiary care hospital in a large, urban city in the Southeast United States. METHODS: Participants completed a clinical sleep interview and self-report assessments for adherence to antiretroviral medication, depression (PHQ-9), quality of life (ACTG-QOL), and relevant covariates. Viral load and CD4 were obtained via medical chart review. RESULTS: Insomnia affected 67% of the clinic sample. Insomnia symptoms were directly associated with poorer health-related quality of life (p

Preclinical data suggest that hypoxia stimulates fibroblast growth factor 23 (FGF23) transcription and cleavage in osteocytes, resulting in elevated circulating c-terminal (cFGF23) levels but normal intact FGF23 (iFGF23) levels. We conducted a case-control study within the Hispanic Community Health Study/Study of Latinos to investigate whether sleep disordered breathing, as a model of hypoxemia, is independently associated with elevated cFGF23 levels in the general population and with elevated cFGF23 and iFGF23 levels in patients with chronic kidney disease (CKD), in whom FGF23 cleavage may be impaired. Cases (n=602) had severe sleep disordered breathing defined as an apnea/hypopnea index (AHI) of ≥ 30. Controls without severe sleep disordered breathing (n=602) were matched for sex and CKD stage. The median AHI in the cases was 45.8 (IQR 35.5 – 62.5) compared to 2.6 (IQR 0.6 – 8.2) in the controls. Cases had higher cFGF23 levels than controls (66.2 RU/ml, IQR 52.8–98.4 vs. 61.2 RU/ml, IQR 49.5–80.1, p value < 0.001). There were no differences in iFGF23 levels between cases and controls. In adjusted linear regression and multinomial regression analyses, body mass index attenuated the relationship between severe sleep disordered breathing and cFGF23 levels. No significant relationships were seen in analyses of severe sleep disordered breathing and iFGF23 levels or in analyses of iFGF23 and cFGF23 stratified by CKD status. Additional studies using other models of intermittent and chronic hypoxia are needed to confirm whether hypoxia stimulates FGF23 transcription in humans and to determine the impact on iFGF23 levels in CKD.

AIMS: Sleeping oxygen saturation (SaO(2)) and sleep stage duration have been linked with prediabetic alterations but the pathogenic pathways are not well understood. This study of insulin sensitive and resistant adults examined the effect on postprandial metabolic regulation of repeated mixed-meal challenges of different carbohydrate loading. The aim was to examine whether the relationship between lower sleeping oxygen saturation (SaO(2)) and poorer fasting and postprandial metabolic function may be linked with reduced slow wave sleep (SWS) and rapid eye movement (REM) duration, independent of age, sex and total adiposity. METHODS: The 24 men and women, aged 25–54 years, had no diabetes or other diagnosed conditions, were evaluated with polysomnography to derive indices of SaO(2) and sleep architecture. In addition, an OGTT and two 14-hour serial mixed-meal tests were administered over 3 successive in-patient days. The carbohydrate content of the mixed-meals was manipulated to compare a standard-load day with a double-load day (300 vs. 600 kcal/meal). Quantitative modeling was applied to derive β-cell glucose sensitivity (β-GS), early insulin secretion rate sensitivity (ESRS), and total postprandial insulinemia (AUC(INS)). RESULTS: Analyses showed that, for the 14-hour tests, the SaO(2) relationship with metabolic outcomes was associated significantly with percent time spent in REM but not SWS, independent of age, sex and total adiposity. Specifically, indirect pathways indicated that lower SaO(2) was related to shorter REM duration, and shorter REM was respectively associated with higher β-GS, ESRS, and AUC(INS) for the 300- and 600-load days (300 kcal/meal: β=−8.68, p

Minority individuals in the United States (US) have an increased prevalence of obstructive sleep apnea syndrome (OSA) compared to their white/Caucasian counterparts. In general, adherence to positive airway pressure (PAP) therapy is poor and some studies suggest that PAP use among minority individuals is inferior to that of whites. However, there has not been a review of the evidence that addresses racial-ethnic disparities for PAP adherence in the treatment of OSA, and no review has systematically examined the contributing factors to poor adherence among minority individuals compared to whites. We searched the literature for studies published between January 1990 to July 2016 that included objective PAP use comparisons between adult US minority individuals and whites. Twenty-two studies met the inclusion criteria. All studies compared the PAP adherence of blacks to whites. Seven studies compared the PAP adherence of additional minority groups to that of whites. Sixteen of the 22 studies (73%) showed worse PAP adherence in blacks compared to whites. Four studies found equivalent PAP use in US Hispanics compared to whites. Little is known about the PAP adherence of other US minority groups. We present a framework and research agenda for understanding PAP use barriers among US minority individuals.

Background The aim of this study was to evaluate the association between actigraphy-based measures of sleep and prevalent hypertension in a sample of US Latinos. Methods We analyzed data from 2,148 participants of the Sueno Sleep Ancillary Study of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), who underwent 1 week of wrist actigraphy to characterize sleep duration, sleep efficiency, sleep fragmentation index, and daytime naps. Insomnia was defined as an Insomnia Severity Index ≥ 15. Hypertension was defined based on self-reported physician diagnosis. Survey linear regression was used to evaluate the association of sleep measures with hypertension prevalence. Sensitivity analyses excluded participants with an apnea-hypopnea index (AHI) ≥ 15 events/h. Results The mean age was 46.3 ± 11.6 years, and 65% of the sample consisted of women. The mean sleep duration was 6.7 ± 1.1 hours. Thirty-two percent of the sample had hypertension. After adjusting for age, sex, ethnic background, site, and AHI, each 10% reduction in sleep efficiency was associated with a 7.5% (95% CI, –12.9 to –2.2; P = .0061) greater hypertension prevalence, each 10% increase in sleep fragmentation index was associated with a 5.2% (95% CI, 1.4-8.9; P = .0071) greater hypertension prevalence, and frequent napping was associated with a 11.6% greater hypertension prevalence (95% CI, 5.5-17.7; P = .0002). In contrast, actigraphy-defined sleep duration ( P = .20) and insomnia ( P = .17) were not associated with hypertension. These findings persisted after excluding participants with an AHI ≥ 15 events/h. Conclusions Independent of sleep-disordered breathing, we observed associations between reduced sleep continuity and daytime napping, but not short sleep duration, and prevalent hypertension.

Introduction While sleep disturbances and depression often co-occur, these associations are understudied among Hispanics/Latinos. We examined the associations of sleep disturbances and sleep burden with depressive symptoms among Hispanic/Latino adults in the United States. Methods We used cross-sectional data from the Hispanic Community Health Study/Study of Latinos Sueño Ancillary study (2010-2013). The study enrolled 2072 adults (ages 18-64; 51.5% females) who completed one-week wrist-actigraphy and sleep questionnaires. Sleep burden was operationalized as the total count of sleep disturbances across six domains (duration, efficiency, midpoint, variability, insomnia, sleepiness). Depressive symptoms were assessed using the Center for Epidemiological Studies Depression scale (CESD-10). We used weighted survey linear regressions to evaluate the association of sleep disturbances and sleep burden with elevated depressive symptoms (CESD≥10) in individual models adjusted for age, gender, site, heritage, nativity, education, income, and employment. Sensitivity analyses further adjusted for behavioral health risk factors and apnea-hypopnea index. Results An estimated 28.3% had elevated depressive symptoms, 8.0% had short sleep duration (9 hours), 45.2% exhibited a later sleep midpoint (≥4:00AM), 38.4% had high sleep timing variability (upper third tertile for between day sleep midpoint), 15.3% had insomnia (ISI≥10), 17.3% had excessive daytime sleepiness (ESS ≥10), 21.5% had poor sleep efficiency ( Conclusion Multiple inter-related sleep disturbances, particularly those pertaining to sleep quality and timing, are associated with depression and may be targets for future interventions aimed at improving mood among Hispanics/Latinos. Support HL127307, HL098927, HL125748

Given that sleep-related impairment during the waking period is proposed to play an important role in maintaining insomnia, more research is needed on factors that relate specifically to the daytime symptoms of sleep problems. This study investigated whether trait mindfulness predicts daytime impairment attributed to poor sleep after accounting for deficits in nighttime sleep quantity and quality. In a United States population-based online sample (N = 459), hierarchical multiple regression predicted sleep-related daytime impairment from mindfulness after controlling for demographics, general health status, self-estimated sleep efficiency, and subjective sleep disturbance. Mindfulness displayed robust negative correlations with both nighttime and daytime sleep symptoms. In the full hierarchical model predicting daytime sleep-related impairment, mindfulness explained significant outcome variance after controlling all covariates, including nocturnal sleep symptomology. Trait mindfulness may thus have implications specific to daytime detriments associated with poor sleep, and cultivating mindfulness skills may be a particularly useful strategy for addressing such difficulties.

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a common sleep disorder associated with a myriad of sequelae. OSAHS is effectively treated with continuous positive airway pressure (CPAP) therapy. However, fewer than 50% of patients are compliant with their CPAP therapy prescriptions. The current study sought to explore an integrated, biopsychological approach to CPAP adherence among experienced CPAP users.We performed a retrospective, cross-sectional analysis of a cohort of veterans with a diagnosis of OSAHS (n = 191) who were prescribed CPAP therapy and returned for adherence download at the Miami VA Sleep Clinic. The relationships between biomedical characteristics (e.g., CPAP pressure, self-reported sleepiness, and change in sleep efficiency) and psychological factors (e.g., self-efficacy beliefs and psychological diagnoses) and objectively measured CPAP use were examined to determine whether psychological factors moderated the relationships between biomedical characteristics and CPAP adherence.Hierarchical regression analyses predicting CPAP adherence (adjusting for time since CPAP prescription, age, education, prescribed CPAP pressure, daytime sleepiness, changes in sleep efficiency with CPAP, and psychiatric conditions) revealed the following: (1) CPAP self-efficacy and CPAP pressure were positively related to adherence, and (2) CPAP self-efficacy moderates the relationship between CPAP pressure and CPAP adherence.There was no relationship between CPAP pressure and adherence in individuals with low self-efficacy beliefs. However, for individuals with high self-efficacy beliefs, there was a significant positive relationship between CPAP pressure and adherence. Self-efficacy beliefs appear to be a prime target for focused interventions aimed at improving CPAP adherence among those individuals with higher pressure prescriptions.

Introduction The Insomnia Severity Index is a commonly used instrument to assess the presence of insomnia symptoms as well as an outcome measure following an intervention. Longitudinal measurement invariance is a necessary property of an assessment instrument when it is repeated over time. The validity of conclusions regarding change in the construct ‘insomnia severity’ depend on scale equivalence at each measurement timepoint. Assessment of measurement invariance of the ISI in sleep apnea patients has never been performed. Methods Veterans with sleep apnea (n=654; AHI=36±28; 93% male; age=52±12; BMI=33±6) completed the ISI on the night of their overnight PSG and again when they picked up their PAP device. Invariance was determined by imposing a series of more restrictive equivalence constraints on a 2-factor model of the ISI. The series of constraints tested for configural, weak, strong and strict invariance. Invariance testing was modeled with exploratory structural equation modeling in Mplus (v. 7.0). Results The 2-factor model that emerged from the analysis showed items relating to nighttime symptoms loading on factor 1 and daytime symptoms loading on factor 2. The sleep ‘satisfaction’ item, however, had weak but similar loadings on both factors. The increasingly restrictive constraints imposed on the model revealed no decrement in model fit (RMSEA=.039 to.043; CFI=.987 to .980; TLI=.981-.977; SRMR=.027-.041). Conclusion The ISI met strict criteria for longitudinal measurement invariance demonstrating that it is a valid instrument to be used in repeated measures study designs of insomnia in sleep apnea patients. Change over time on the ISI is not due to the changing measurement characteristics of the ISI but to true changes in the ‘insomnia severity’ construct. Support None

Introduction We aimed to determine if age or sex modifies associations between sleep-disordered breathing (SDB), sleep duration and severe phenotypes of combined SDB/sleep duration with 7-year neurocognitive change (NC) in a diverse sample of U.S. Hispanic/Latinos. Methods We analyzed data of 5,235 adults 50-80 years of age from SOL-INCA, an ancillary to the Hispanic Community Health Study/Study of Latinos that determines the risk factors for NC. The main outcome was NC after a mean follow-up of 7-years on measures of memory (SEVLT sum and SEVLT recall), language (word fluency), processing speed (DSS) and a cognitive impairment screener. We evaluated the effect of baseline SDB (AHI ≥ 15), sleepiness (Epworth Sleepiness Scale, ESS ≥ 10), self-reported sleep duration (i.e. Results Overall, the mean age was 56.0 years, 54.8% females, 62.2% completed high school, 17.3% had SDB, 6.6% had short sleep,and 14.8% had long sleep. Sleep duration and SDB were not associated with NC. There was a significant interaction between agexSDB+sleep duration on delayed recall (F10,599= 2.40, p=0.01) and processing speed (F10,597= 2.55, p=0.01). Combined SDB + short sleep was associated with decline in processing speed (β=-0.6, 95% CI= [-1.2, -0.1], and combined SDB+long sleep was associated with decline in verbal memory (β=-0.9, 95% CI=[-1.7, -0.2] in adults aged ≥ 65 years. There was no association in participants aged Conclusion Age, but not sex, modified the association between SDB and sleep duration with decline on processing speed and verbal memory. Sleep interventions tailored for older adults may be useful in slowing or preventing neurocognitive decline. Support This work is supported by National Institute on Aging (R01AG048642, RF1AG054548, R01AG061022, and R21AG056952).

Introduction: Obstructive sleep apnea (OSA) severity is an independent predictor of cardiovascular disease (CVD) including stroke. Black race has been associated with higher likelihood of CVD morbidity and lower PAP adherence, an unhealthy patient behavior. Data are equivocal for “healthy user” effect: whether a patient’s regular PAP use is associated with physician behavior of optimal CVD prescription regimen. It is unknown if this relationship varies by patient race. We aim to describe whether the association of PAP use with optimal CVD treatment regimen prescription depended on race in veterans with OSA. Methods: We conducted a cross-sectional study of existing PAP users at a VA Medical Center. Data on demographics, medications, comorbidities, and OSA were collected. Optimal CVD medication regimen required prescription of antiplatelet, antihypertensive, and statin. Objective: PAP use was measured by % of days with use ≥ 4 hours. Using logistic regression, we examined whether the association of patient PAP use with physician optimal medication prescription varied by race. The model included race, PAP use, PAP use by race interaction term, and pertinent covariates. Results: A total of 499 veterans (95% male, 38% Black) were included. Two hundred seventy-three veterans (55%) were prescribed an optimal CVD prevention regimen, while 226 (45%) were prescribed a suboptimal regimen. In logistic regression analyses, older age (OR 1.06, 95% CI 1.0-1.1), Black race (OR 1.8, 95% CI 1.1-2.9), higher BMI (OR 1.1, CI 1.1-1.2), and higher Charlson Index (OR 1.3, 95% CI 1.2-1.5), and PAP use by race interaction term were significantly associated with optimal medication regimen prescription. Among white veterans, level of PAP use was not associated to likelihood of optimal CVD prescriptions regimen; However, among Black veterans, those with high levels of PAP use were significantly more likely to be prescribed optimal medication regimen than individuals with low levels of PAP use. Conclusions: A “healthy user” effect was detected for the relationship between patient PAP adherence and physician optimal CVD regimen prescription in Black, but not white, veterans. Longitudinal studies are needed to determine the temporal order of these health behavior associations.

© 2014 American Academy of Neurology. Objective: We evaluated the association between obstructive sleep apnea (OSA) and neurocognitive function among community-dwelling Hispanic/Latino individuals in the United States. Methods: Cross-sectional analysis of the Hispanic Community Health Study/Study of Latinos middle-aged and older adults, aged 45 to 74 years, with neurocognitive test scores at baseline measurements from 2008 to 2011. Neurocognitive scores were measured using the Word Fluency (WF) Test, the Brief-Spanish English Verbal Learning Test (SEVLT), and the Digit Symbol Substitution (DSS) Test. OSA was defined by the apnea-hypopnea index (AHI). Multivariable linear regression models were fit to evaluate relations between OSA and neurocognitive scores. Results: The analysis consisted of 8,059 participants, mean age of 56 years, 55% women, and 41% with less than high school education. The mean AHI was 9.0 (range 0-142; normal AHI

Poor sleep quality has been linked to inflammatory processes and worse disease outcomes in the context of many chronic illnesses, but less is known in conditions such as chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME). This study examines the relationships between sleep quality, pro-inflammatory cytokines, and CFS/ME symptoms.Sixty women diagnosed with CFS/ME were assessed using the Pittsburgh Sleep Quality Index (PSQI), Fatigue Symptom Inventory (FSI) and Center for Disease Control and Prevention (CDC)-based CFS/ME symptom questionnaires. Circulating plasma pro-inflammatory cytokine levels were measured by ELISA. Multiple regression analyses examined associations between sleep, cytokines and symptoms, controlling for age, education, and body mass index.Poor sleep quality (PSQI global score) was associated with greater pro-inflammatory cytokine levels: interleukin-1β (IL-1β) (β=0.258, p=0.043), IL-6 (β=0.281, p=0.033), and tumor necrosis factor-alpha (TNF-α) (β=0.263, p=0.044). Worse sleep quality related to greater fatigue severity (β=0.395, p=0.003) and fatigue-related interference with daily activities (β=0.464, p0.001), and more severe and frequent CDC-defined core CFS/ME symptoms (β=0.499, p0.001, and β=0.556, p0.001, respectively).Results underscore the importance of managing sleep-related difficulties in this patient population. Further research is needed to identify the etiology of sleep disruptions in CFS/ME and mechanistic factors linking sleep quality to symptom severity and inflammatory processes.

Blunted blood pressure (BP) dipping is an established predictor of adverse cardiovascular outcomes. Although blunted BP dipping is more common in African Americans than whites, the factors contributing to this ethnic difference are not well understood. This study examined the relationships of BP dipping to ethnicity, body mass index (BMI), sleep quality, and fall in sympathetic nervous system (SNS) activity during the sleep-period.On three occasions, 128 participants with untreated high clinic BP (130-159/85-99 mm Hg) underwent assessments of 24-h ambulatory BP (ABP), sleep quality, (evaluated by sleep interview, self-report, actigraphy) and sleep-period fall in sympathetic activity (measured by waking/sleep urinary catecholamine excretion).Compared to whites (n = 72), African Americans (n = 56) exhibited higher sleep-period systolic (SBP) (P = 0.01) and diastolic BP (DBP) (P0.001), blunted SBP dipping (P = 0.01), greater BMI (P = 0.049), and poorer sleep quality (P = 0.02). SBP dipping was correlated with BMI (r = -0.32, P0.001), sleep quality (r = 0.30, P0.001), and sleep-period fall in sympathetic activity (r = 0.30, P0.001). Multiple regression analyses indicated that these three factors were independent determinants of sleep-period SBP dipping; ethnic differences in dipping were attenuated when controlling for these factors.Blunted BP dipping was related to higher BMI, poorer sleep quality, and a lesser decline in sleep-period SNS activity. Although African-American ethnicity also was associated with blunted dipping compared to whites in unadjusted analyses, this ethnic difference was diminished when BMI, sleep quality, and sympathetic activity were taken into account.

Sleep problems are common in persons with dementing illnesses and among the most stressful patient behaviors for caregivers. Although studies have shown differences in sleep across ethnic groups, little information is available on ethnic differences among persons with dementia. The purpose of this study was to investigate possible ethnic differences in sleep problems among patients with Alzheimer dementia.Caregiver reports of 5 sleep- or circadian rhythm-related behavioral problems (behavior disturbance worse in the evening, difficulties falling asleep, frequent awakenings, early awakenings, and excessive daytime sleep) were evaluated in 395 patients who had received a diagnosis of Alzheimer disease after diagnostic evaluation. The average cognitive score of the groups suggested that they could be characterized as having moderately severe impairment. The frequency of sleep problems was then evaluated across subgroups defined by self-reported ethnicity (African American, Hispanic, and non-Hispanic white). As patient and caregiver characteristics may affect caregivers' reports of patients' behaviors, mixed effects regression models were used to adjust for patient and caregiver variables that might affect caregiver reports.Analyses revealed ethnic differences in sleep or circadian rhythm disturbances. African American and Hispanic patients were reported to have more severe sleep disturbances than non-Hispanic whites. After correction for patient and caregiver variables that might have affected caregiver reports, differences between African Americans and others remained.Sleep problems in patients with dementing illnesses are reported by caregivers with differing frequencies across groups of African Americans, Hispanics, and non-Hispanic whites. Clinicians should be aware of these differences in assessing sleep disturbance in patients with dementia as well as the potential effects of patient and caregiver variables on reports of these problems.

Sleep disturbances are common among women diagnosed with breast cancer (BCa) [1].Ancoli-Israel et al. [2] showed that sleep disturbances were associated with fatigue and daytime dysfunction prior to adjuvant treatment for the disease. The authors emphasized the importance of understanding sleep patterns before cancer treatment in order to optimally intervene to improve sleep disturbances related to BCa diagnosis. A limitation of the analyses conducted by Ancoli-Israel et al. is the dearth of statistical control for variables such as pain, depression and anxiety that may impact the relationship between sleep and psychosocial and functional outcomes. Determining the independent role of sleep as it relates to symptoms such as fatigue and other quality of life indicators may aid in the identification of specific intervention treatment targets to improve outcomes for cancer patients. The present study examined women with breast cancer in the weeks after surgery (i.e., lumpectomy or mastectomy) and before adjuvant treatment had begun. At this point, physical symptoms and interference in daily life were quite high. Post-surgical issues included reduced satisfaction with physical appearance (particularly the chest), physical sensations (e.g., numbness, tightness, and swelling), reduced energy levels, pain, sleep problems, and decreased quality of life [3–5]. Many of the women in the present study were also preparing to undergo adjuvant treatment (e.g., chemotherapy, radiation, or tamoxifen), and may have been experiencing anticipatory anxiety [6]. Although sleep has been investigated in a similar sample of women with BCa before chemotherapy [2], it has not, to our knowledge, been systematically related to a theoretically derived set of indicators of psychosocial adaptation while controlling for a range of relevant covariates. The current study aimed to (a) determine the frequency of sleep disturbances in women prior to adjuvant therapy for breast cancer, and (b) determine whether greater sleep dysfunction uniquely predicts poorer functional outcomes. With a larger sample than previously studied [2], the current study is powered to examine the unique contribution of sleep to function.

Women with HIV infection report elevated and persisting psychosocial distress, sleep difficulty, and fatigue. The objective of this study was to examine psychosocial distress, sleep difficulty, and fatigue in a group of lower socioeconomic status women co-infected with HIV and HPV (N = 60). After controlling for relevant health behavioral and medical variables, multiple regression analyses indicated that greater psychosocial distress was associated with greater fatigue (p < .01), as well as greater sleep difficulty (p < .01). Sleep difficulty partially mediated the relationship between distress and fatigue (Sobel test, z = 2.39, p = .02). Stress management and sleep-based cognitive behavioral intervention approaches may be useful for treating fatigue in these women, possibly through reductions in psychosocial distress and improvements in sleep quality.

This study consisted of secondary analyses of data from 2 randomized clinical trials to test whether pretherapy cognitions predict CBT outcomes. The sample consisted of 155 primary insomnia patients with sleep maintenance complaints. Of these, 98 were randomized to CBT, 23 were assigned to progressive muscle relaxation training (PMR), and 34 were assigned to a control (sham therapy or wait-list) condition (CON). All patients completed the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS), a sleep-related Self-Efficacy Scale (SES) and nightly sleep diaries for 2 weeks prior to receiving their assigned treatment. They then completed sleep diaries throughout an 8-week acute treatment period and during a 2-week period at a posttherapy follow-up. A subset of the sample (n=67) also completed polysomnography immediately before and after completing their assigned treatment. Preliminary regression analyses conducted with a small subset (n=15) of the patients receiving CBT showed those with relatively high levels of unhelpful sleep-related beliefs (Type 1 patients), as reflected by their pretherapy responses to the DBAS and SES questionnaires, showed markedly greater reductions in nocturnal wakefulness in response to CBT than did those (Type 2 patients) reporting less pronounced sleep-related beliefs. Given these findings, we used the regression equation derived from our initial analyses to dichotomize our entire sample into Type 1 (n=82; 52.9%) and Type 2 (n=73; 47.1%) subgroups. Subsequent comparisons showed CBT-treated Type 1 patients had significantly less wake time after sleep onset during most of the 8-week treatment phase than did the Type 1 and 2 individuals assigned to either PMR or CON. Relative to patients assigned to the PMR and CON conditions, CBT-treated Type 1 patients showed better performance across multiple subjective and objective benchmarks of clinically significant improvement, whereas the CBT-treated Type 2 patients did not. Results suggest that insomnia patients' pretherapy cognitive dispositions predict CBT outcome, and those with a pronounced sense of sleep-related helplessness are best suited for this treatment which targets this cognitive stance.

Sleep disruption and fatigue are ubiquitous among cancer patients and are sources of stress that may compromise treatment outcomes. Previously, we showed that a cognitive behavioral stress management (CBSM) intervention reduced anxiety and other stress-related processes in women undergoing primary treatment for breast cancer.This study examined secondary outcomes from a CBSM intervention trial for women with early-stage breast cancer to test if CBSM would improve sleep quality and fatigue among these patients at a single site in southern Florida. CBSM-related effects have already been demonstrated for indicators of psychosocial adaptation (e.g., general and cancer-related anxiety).Patients were randomized to CBSM (n= 120) or a 1-day psychoeducation control group (n= 120). The Pittsburgh Sleep Quality Index (PSQI) and Fatigue Symptom Inventory were completed prior to randomization and 6 and 12 months after the baseline assignment.In latent growth analyses, women in CBSM reported greater improvements in PSQI sleep quality scores than controls, although there were no significant differences between conditions on PSQI total scores. Women in CBSM also reported greater reductions in fatigue-related daytime interference than controls, though there were no significant differences in changes in fatigue intensity. Changes in sleep quality were associated with changes in fatigue.Future work may consider integrating sleep and fatigue content into stress management interventions for women with early-stage breast cancer.

Study objectives To examine whether subtypes of continuous positive airway pressure (CPAP) user profiles could be identified, and to determine predictors of CPAP subgroup membership. Design A retrospective, correlational approach was used. Subjects attended clinic where a CPAP download was performed and questionnaires were completed. Additional information was obtained from the electronic medical record. Setting Miami VA Sleep Clinic. Participants Obstructive sleep apnea patients (N = 207). Measurements Three adherence variables comprised the profile: % of nights of CPAP use, % of nights of CPAP use > 4 hours and average nightly use in minutes. Predictors included age, AHI, time since CPAP therapy was initiated, CPAP pressure, residual AHI, BMI, social-cognitive variables, insomnia, sleepiness, and psychiatric and medical comorbidities. Results Latent profile analysis was used to identify CPAP user profiles. Three subgroups were identified and labeled “Non-Adherers,” “Attempters,” and “Adherers”. Non-Adherers (37.6% of the sample) used CPAP for an average of 37 minutes nightly, used CPAP 18.2% of nights and used CPAP > 4 hour 6.2 % of nights. Attempters (32.9%) used CPAP for 156 minutes on average, used CPAP 68.2% of nights and used CPAP > 4 hour 29.3% of nights. Adherers (29.5%) used CPAP for 392 minutes, used CPAP 95.4% of nights and used CPAP >4 hour 86.2% of nights. Self-efficacy, insomnia, AHI, time since CPAP was initiated, and CPAP pressure predicted CPAP subgroup membership. Conclusion Sixty-seven percent of users (Non-Adherers, Attempters) had suboptimal adherence. Understanding CPAP use profiles and their predictors enable identification of those who may require additional intervention to improve adherence.

Objective : To evaluate the psychometric properties of the DBAS-10, a recently proposed abbreviated version of the Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS). Population : Two hundred and eleven (69 normal sleepers; 142 insomnia suffers) middle-aged and older adults (age 40–79 years) drawn from two separate cohorts of research volunteers. Method : Volunteers in the first cohort (69 normal sleepers; 69 insomnia sufferers) completed the full DBAS on one occasion. Volunteers in the second cohort (73 insomnia sufferers) completed the full DBAS prior to treatment and at multiple subsequent time points to assess treatment-related changes. A series of statistical tests were conducted with one or both cohorts to investigate the comparability of the DBAS-10 and full DBAS, the internal consistency of each instrument, the factor structure of the DBAS-10, and the validity of this instrument. Results : Statistical findings showed that the DBAS-10 correlated highly with the full DBAS, had respectable internal consistency, effectively discriminated normal sleepers from insomnia sufferers, and detected cognitive changes resulting specifically from CBT intervention. Although factor analysis empirically identified three conceptually meaningful DBAS-10 subscales, the subscale structure varied somewhat from previous factor analytic findings with this instrument. Conclusions : The DBAS-10 generally appears to have very acceptable psychometric properties although subscales previously proposed for this instrument may vary across research populations. Nonetheless, results encourage the use of this instrument in studies concerned with the nature and treatment of sleep-disruptive cognitions.

Persistent primary insomnia (PPI) is a prevalent and potentially serious condition that compromises the functioning, health status, and quality of lives of millions of individuals around the world. This condition is typically perpetuated by a host of psychological and behavioral mechanisms that often require behavioral interventions. Nonetheless, all too commonly, practitioners underestimate the seriousness of this condition or rely too heavily on symptom focused sedative hypnotic therapy for its treatment. Herein we briefly review the epidemiology of PPI and consider the inadequacies of sedative hypnotics for treating this disorder. Subsequently, we provide rationale for the use of behavioral interventions with this condition and we describe the gradual evolution of the currently available behavioral insomnia treatments and consider promising recent developments such as the emergence of cognitive-behavioral and specially tailored, patient-specific approaches. In closing, we consider the potential usefulness of a combined pharmacological/behavioral intervention for PPI and present a number of important research questions to address in future studies of the behavioral insomnia therapies.

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.

Objective The goal of this study was to evaluate how black and white men and women responded physiologically to specific laboratory challenges. Methods Hemodynamic responses to an active coping (evaluated speaking) and two inhibitory-passive coping (mirror tracing, cold pressor) tasks were examined in 138 black and white men and women. Results Significant ethnicity by gender interactions occurred for the evaluated speaking task. Black men responded with lower blood pressure, cardiac output or heart rate, or both, than black women, white men, and white women, who did not differ from each other. Black men, relative to the other subgroups, also reported more inhibitory-passive coping, hostility, and pessimism, and less social support. Whites also responded with greater increases in systolic blood pressure during mirror tracing than blacks. Conclusions These findings indicate that black-white differences in physiological responsivity obtained for men may have limited generalizability for women. The results also suggest that environmental and social factors rather than genetic or constitutional factors may play a role in black-white reactivity differences.

Poor adherence undermines the effectiveness of positive airway pressure (PAP) therapy for sleep apnea. Disparities exist in PAP adherence by race/ethnicity and neighborhood socioeconomic status (SES), but the etiology of these differences is poorly understood. We investigated whether home environmental factors contribute to PAP adherence and whether identified factors explain disparities in adherence by SES.Adult patients with sleep apnea were surveyed at clinic visits about their sleep environment. Medical records were abstracted for demographic data, sleep apnea severity, comorbidities, and objective PAP adherence. We evaluated the association between aspects of home sleep environment with PAP adherence using multivariate linear and logistic regression, and assessed effect modification by SES factors.Participants (n = 119) were diverse, with 44% nonwhite and 35% uninsured/Medicaid. After adjusting for age, sex, race/ethnicity, insurance, neighborhood SES, education, and marital status, participants who endorsed changing sleeping location once per month or more (18%, n = 21) had 77% lower odds of meeting PAP adherence criteria (4 h/night for 70% of nights) and less PAP use (median -11 d/mo, 95% confidence intervals -15.3, -6.5). Frequency of sleeping location change was the only environmental factor surveyed associated with PAP adherence.Frequent change in sleeping location is associated with reduced PAP adherence, independent of sociodemographic factors. This novel finding has implications for physician-patient dialogue. PAP portability considerations in device selection and design may modify adherence and potentially improve treatment outcomes. Prospective investigation is needed to confirm this finding and inform design of possible interventions.

Previous studies of the reproducibility of blood pressure (BP) dipping have yielded inconsistent results. Few have examined factors that may influence day-to-day differences in dipping. Ambulatory BP monitoring was performed on three occasions, approximately 1 week apart, in 115 untreated adult subjects with elevated clinic BPs. The mean ± standard deviation BP dip was 18 ± 7/15 ± 5 mm Hg (sleep/awake BP ratio = 0.87 ± 0.05/0.82 ± 0.06), with a median (interquartile range) day-to-day variation of 5.2 (3.1-8.1)/4.3 (2.8-5.6) mm Hg. There was no decrease in variability with successive measurements. The reproducibility coefficient (5.6 [95% confidence interval, 5.1-6.1] mm Hg) was greater and the intraclass correlation coefficient (0.53 [95% confidence interval, 0.42-0.63]) was smaller for the systolic dip than for 24-hour or awake systolic BPs, suggesting greater day-to-day variability in dipping. Variability in systolic dipping was greater in subjects with higher awake BP, but was not related to age, gender, race, or body mass index. Within individuals, day-to-day variations in dipping were related to variations in the fragmentation index (P .001), a measure of sleep quality. Although mean 24-hour and awake BPs were relatively stable over repeated monitoring days, our study confirms substantial variability in BP dipping. Day-to-day differences in dipping are related to sleep quality.

Background: Sleep disorders are associated with stroke and may vary among elderly Hispanics, Blacks and Whites. We evaluated differences in sleep symptoms by race-ethnicity in an elderly population-based urban community sample. Methods: Snoring, daytime sleepiness and reported sleep duration were ascertained by standardized interviews as a part of the Northern Manhattan Study, a prospective cohort study of vascular risk factors and stroke risk in a multi-ethnic urban population. Sleep symptoms were compared amongst race-ethnic groups using logistic regression models. Results: A total of 1,964 stroke-free participants completed sleep questionnaires. The mean age was 75 ± 9 years, with 37% men, with 60% Hispanics, 21% Blacks and 19% Whites. In models adjusted for demographic and vascular risk factors, Hispanics had increased odds of frequent snoring (odds ratio, OR: 3.6, 95% confidence interval, CI: 2.3–5.8) and daytime sleepiness (OR: 2.8, 95% CI: 1.7–4.5) compared to White participants. Hispanics were more likely to report long sleep (≧9 h of sleep, OR: 1.8, 95% CI: 1.1–3.1). There was no difference in sleep symptoms between Black and White participants. Conclusion: In this cross-sectional analysis among an elderly community cohort, snoring, sleepiness and long sleep duration were more common in Hispanics. Sleep symptoms may be surrogate markers for an underlying sleep disorder which may be associated with an elevated risk of stroke and may be modified by clinical intervention.

Background There is limited data on chronic insomnia in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans, in whom post-traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) often co-exist. Our aim was to compare sleep characteristics of three groups of OEF/OIF veterans: (1) healthy sleepers (HS), (2) those with insomnia associated with PTSD and mTBI (PTSD–mTBI), and (3) those with insomnia associated with PTSD alone. Methods Consecutive veterans with insomnia complaints (>6 months) were recruited over 6 months from the Miami VA Post Deployment clinic. Participants completed a sleep disorders clinical interview, medical history, and questionnaires about insomnia, sleepiness, pain, fatigue, depression, PTSD, and health-related quality of life. They underwent polysomnography (PSG) with 2 weeks of actigraphy (ACT) and sleep diaries. Results There were no differences in demographics or most questionnaire responses between PTSD and PTSD–mTBI groups. Subjective daytime sleepiness was significantly greater in PTSD–mTBI subjects compared with HS and PTSD participants. Significant co-morbid sleep disorders were noted in insomnia patients. PSG and ACT wake after sleep onset was significantly shorter in PTSD–mTBI subjects as compared with PTSD participants. Conclusion Insomnia patients with PTSD–mTBI were subjectively sleepier despite spending less time awake during the night than PTSD subjects, possibly as a consequence of head trauma.

Background Sleep-disordered breathing is a risk factor for stroke, but its association with subclinical atherosclerosis remains controversial. Snoring and insomnia are frequently comorbid with sleep-disordered breathing and may contribute to stroke. Data on the relationship between snoring and insomnia with atherosclerotic disease are sparse. We investigated the relationship between markers of subclinical atherosclerosis, insomnia, snoring, and carotid intima-media thickness, in the Northern Manhattan Study. Methods A group of 1605 participants (mean age 65±8 years; 40% men; 61% Hispanic, 19% black, 20% white) who had carotid intima–media thickness measurements performed was assessed for self-reported sleep habits. Habitual snoring was defined as self-reported snoring greater than four times per week. Presence of insomnia was based on three items extracted from the Hamilton Rating Scale for Depression. Carotid intima–media thickness was expressed as a mean composite measure of intima–media thickness in the carotid bifurcation, common, and internal carotid artery. Multivariate linear regression models were used to identify associations between snoring, insomnia, and carotid intima–media thickness. Results Habitual snoring was present in 29% of the subjects and insomnia in 26%. There was a higher prevalence of self-reported snoring (84%) and insomnia (66%) among Hispanics than non-Hispanics. The mean total carotid intima–media thickness was 0.95±0.09 mm; among those with self-reported snoring was 0.94±0.09 mm; and among those with insomnia was 0.95±0.08 mm. After controlling for age, gender, race-ethnicity, body mass index and cardiovascular risk factors, snoring ( P = 0.986) and insomnia ( P = 0.829) were not significantly associated with increased carotid intima–media thickness. Conclusion Snoring and insomnia were not significantly associated with subclinical atherosclerosis in this population-based community cohort.

Subject objective To determine the optimal number of therapist-guided Cognitive-Behavioral Insomnia Therapy (CBT) sessions required for treating primary sleep-maintenance insomnia. Design and setting Randomized, parallel-group, clinical trial at a single academic medical center. Outpatient treatment lasted 8 weeks with final follow-up conducted at 6 months. Participants 86 adults (43 women; mean age 55.4 +/- 9.7 years) with primary sleep-maintenance insomnia (nightly mean wake time after sleep onset [WASO] = 93.4 +/- 44.5 minutes). Interventions One (week 1), 2 (weeks 1 and 5), 4 (biweekly), or 8 (weekly) individual CBT sessions scheduled over an 8-week treatment phase, compared with an 8-week no-treatment waiting period (WL). Measurement Sleep diary and actigraphy measures of total sleep time, onset latency, WASO, total wake time, and sleep efficiency, as well as questionnaire measures of global insomnia symptoms, sleep related self-efficacy, and mood. Results Statistical tests of subjective/objective sleep measures favored the 1- and 4-session CBT doses over the other CBT doses and WL control. However, comparisons of pretreatment data with data acquired at the 6-month follow-up showed only the 4-session group showed significant long-term improvements in objective wake time and sleep efficiency measures. Additionally, 58.3% of the patients receiving 4 CBT sessions met criteria for clinically significant improvement by the end of treatment compared to 43.8% of those receiving 1 CBT session, 22.2% of those provided 2 sessions, 35.3% of those receiving 8 sessions, and 9.1% of those in the control condition. Conclusion Findings suggest that 4 individual, biweekly sessions represents the optimal dosing for the CBT intervention tested. Additional dose-response studies are warranted to test CBT models that contain additional treatment components or are delivered via group therapy.

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.

To determine whether the frequency spectrum of the sleep EEG is a physiologic correlate of 1) the degree to which individuals with persistent primary insomnia (PPI) underestimate their sleep time compared with the traditionally scored polysomnogram (PSG) and 2) the sleep complaints in PPI subjects who have relatively long traditionally scored PSG sleep times and relatively greater underestimation of sleep time.We compared EEG frequency spectra from REM and NREM sleep in PPI subjects subtyped as subjective insomnia sufferers (those with relatively long total sleep time and relative underestimation of sleep time compared with PSG), and objective insomnia sufferers (those with relatively short PSG total sleep time) with EEG frequency spectra in normals. We also studied the correlation between these indices and the degree of underestimation of sleep. Further, we determined the degree to which sleep EEG indexes related to sleep complaints.Duke University Medical Center Sleep Laboratory.Normal (N=20), subjective insomnia (N=12), and objective insomnia (N=18) subjects.N/A.Lower delta and greater alpha, sigma, and beta NREM EEG activity were found in the patients with subjective insomnia but not those with objective insomnia, compared with the normal subjects. These results were robust to changes in the subtyping criteria. No effects were found for REM spectral indexes. Less delta non- REM EEG activity predicted greater deviation between subjective and PSG estimates of sleep time across all subjects. For the subjective insomnia subjects, diminished low-frequency and elevated higher frequency non- REM EEG activity was associated with their sleep complaints.NREM EEG frequency spectral indexes appear to be physiologic correlates of sleep complaints in patients with subjective insomnia and may reflect heightened arousal during sleep.