Sleep Medicine

People living with HIV (PLWH) had a “mistimed circadian phase” and a shorter night’s sleep compared with HIV-negative individuals with a similar lifestyle, according to findings that suggest both a possible mechanism for increased comorbidities in PLWH and potential solutions.

“It is very well known that sleep problems are common in people living with HIV, and many different reasons for this have been proposed,” coauthor Malcolm von Schantz, PhD, professor of chronobiology at Northumbria University in Newcastle upon Tyne, England, said in an interview. “But the novelty of our findings is the observation of delayed circadian rhythms.”

The mistimed circadian phase in PLWH is linked to later sleep onset and earlier waking and has “important potential implications” for the health and well-being of PLWH, wrote senior author Karine Scheuermaier, MD, from the University of the Witwatersrand, in Johannesburg, South Africa, and coauthors.

Until now, research on sleep in HIV has focused primarily on its homeostatic components, such as sleep duration and staging, rather than on circadian-related aspects, they noted.

“If the lifestyle‐independent circadian misalignment observed in the current study is confirmed to be a constant feature of chronic HIV infection, then it may be a mediator both of poorer sleep health and of poorer physical health in PLWH, which could potentially be alleviated through light therapy or chronobiotic medication or supplements,” they suggested.
 

HIV endemic in study population

The study analyzed a random sample of 187 participants (36 with HIV and 151 without) in the HAALSI (Health and Ageing in Africa: A Longitudinal Study of an INDEPTH Community in South Africa) study, which is part of the Agincourt Health and Socio-demographic Surveillance System.

The study population ranged in age from 45 to 93 years, with an average age of 60.6 years in the HIV-positive group and 68.2 years in the HIV-negative group. Demographic data, Pittsburgh Sleep Quality Index score, and valid actigraphy (measured with an accelerometer for 14 consecutive days) were available for 172 participants (18% with HIV). A subgroup of 51 participants (22% with HIV) also had valid dim light melatonin onset (DLMO) data, a sensitive measure of the internal circadian clock. DLMO was measured for a minimum of 5 consecutive days with hourly saliva sampling between 5 p.m. and 11 p.m. while sitting in a dimly lit room.

In 36 participants (16% with HIV) with both valid actigraphy and DLMO data, circadian phase angle of entrainment was calculated by subtracting DLMO time from habitual sleep-onset time obtained from actigraphy.

After adjustment for age and sex, the study found a slightly later sleep onset (adjusted average delay of 10 minutes), earlier awakening (adjusted average advance of 10 minutes), and shorter sleep duration in PLWH compared with HIV-negative participants.

At the same time, melatonin production in PLWH started more than an hour later on average than in HIV-negative participants, “with half of the HIV+ group having an earlier habitual sleep onset than DLMO time” the authors wrote. In a subgroup of 36 participants with both valid actigraphy and DLMO data, the median circadian phase angle of entrainment was smaller in PLWH (–6 minutes vs. +1 hour 25 minutes in the HIV-negative group).

“Collectively, our data suggest that the sleep phase occurred earlier than what would be biologically optimal among the HIV+ participants,” they added.
 

Asynchrony between bedtime and circadian time

“Ideally, with this delayed timing of circadian phase, they should have delayed their sleep phase (sleep timing) by an equal amount to be sleeping at their optimal biological time,” Dr. Scheuermaier explained. “Their sleep onset was delayed by 12 minutes (statistically significant but biologically not that much) while their circadian phase was delayed by more than an hour.”

Possible consequences of a smaller phase angle of entrainment include difficulty in initiating and maintaining sleep, the authors wrote. “The shorter, potentially mistimed sleep relative to the endogenous circadian cycle observed in this study provides objectively measured evidence supporting the abundant previous subjective reports of poor sleep quality and insomnia in PLWH.”

They noted that a strength of their study is that participants were recruited from rural South Africa, where HIV prevalence is not confined to the so-called “high-risk” groups of gay men, other men who have sex with men, people who inject drugs, and sex workers.

“Behavioral factors associated with belonging to one or more of these groups would be strong potential confounders for studies of sleep and circadian phase,” they explained. “By contrast, in rural southern Africa, the epidemic has been less demographically discriminating ... There are no notable differences in lifestyle between the HIV– and HIV+ individuals in this study. The members of this aging population are mostly beyond retirement age, living quiet, rural lives supported by government remittances and subsistence farming.”
 

Direct evidence warrants further study

The study is “unique” in that it provides “the first direct evidence for potential circadian disturbances in PWLH,” agreed Peng Li, PhD, who was not involved in the study.

“The assessment of dim light melatonin onset in PLWH is a strength of the study; together with actigraphy-based sleep onset assessment, it provides a measure for the phase angle of entrainment,” said Dr. Li, who is research director of the medical biodynamics program, division of sleep and circadian disorders, Brigham and Women’s Hospital, Boston.

But actigraphy has limitations that affect the interpretation of the results, he told this news organization.

“Without the help of sleep diaries, low specificity in assessing sleep using actigraphy has been consistently reported,” he said. “The low specificity means a significant overestimation of sleep. This lowers the value of the reported sleep readouts and limits the validity of sleep onset estimation, especially considering that differences in sleep measures between the two groups are relatively small, compromising the clinical meaning.”

Additionally, he explained that it’s not clear whether sleep onset in the study participants was spontaneous or was “forced” to accommodate routines. “This is a limitation in field study as compared with in-lab studies,” he said.

Dr. Li also pointed to the small sample size and younger age of PLWH, suggesting the study might have benefited from a matched design. Finally, he said the study did not examine gender differences.

“In the general population, it is known that females usually have advanced circadian phase compared to males. ... More rigorous design and analyses based on sex/gender especially in this often-marginalized population are warranted to better inform HIV-specific or general clinical guidelines.”

The study was supported by the Academy of Medical Sciences. The authors did not mention any competing interests. Dr. Li reported grant support from the BrightFocus Foundation. The study is not directly related to this paper. He also receives grant support from the NIH through a Departmental Award, Harvard University Center for AIDS Research and a Pilot Project, HIV and Aging Research Consortium. The projects are on circadian disturbances and cognitive performance in PLWH.

A version of this article first appeared on Medscape.com.

People living with HIV (PLWH) had a “mistimed circadian phase” and a shorter night’s sleep compared with HIV-negative individuals with a similar lifestyle, according to findings that suggest both a possible mechanism for increased comorbidities in PLWH and potential solutions.

“It is very well known that sleep problems are common in people living with HIV, and many different reasons for this have been proposed,” coauthor Malcolm von Schantz, PhD, professor of chronobiology at Northumbria University in Newcastle upon Tyne, England, said in an interview. “But the novelty of our findings is the observation of delayed circadian rhythms.”

The mistimed circadian phase in PLWH is linked to later sleep onset and earlier waking and has “important potential implications” for the health and well-being of PLWH, wrote senior author Karine Scheuermaier, MD, from the University of the Witwatersrand, in Johannesburg, South Africa, and coauthors.

Until now, research on sleep in HIV has focused primarily on its homeostatic components, such as sleep duration and staging, rather than on circadian-related aspects, they noted.

“If the lifestyle‐independent circadian misalignment observed in the current study is confirmed to be a constant feature of chronic HIV infection, then it may be a mediator both of poorer sleep health and of poorer physical health in PLWH, which could potentially be alleviated through light therapy or chronobiotic medication or supplements,” they suggested.
 

HIV endemic in study population

The study analyzed a random sample of 187 participants (36 with HIV and 151 without) in the HAALSI (Health and Ageing in Africa: A Longitudinal Study of an INDEPTH Community in South Africa) study, which is part of the Agincourt Health and Socio-demographic Surveillance System.

The study population ranged in age from 45 to 93 years, with an average age of 60.6 years in the HIV-positive group and 68.2 years in the HIV-negative group. Demographic data, Pittsburgh Sleep Quality Index score, and valid actigraphy (measured with an accelerometer for 14 consecutive days) were available for 172 participants (18% with HIV). A subgroup of 51 participants (22% with HIV) also had valid dim light melatonin onset (DLMO) data, a sensitive measure of the internal circadian clock. DLMO was measured for a minimum of 5 consecutive days with hourly saliva sampling between 5 p.m. and 11 p.m. while sitting in a dimly lit room.

In 36 participants (16% with HIV) with both valid actigraphy and DLMO data, circadian phase angle of entrainment was calculated by subtracting DLMO time from habitual sleep-onset time obtained from actigraphy.

After adjustment for age and sex, the study found a slightly later sleep onset (adjusted average delay of 10 minutes), earlier awakening (adjusted average advance of 10 minutes), and shorter sleep duration in PLWH compared with HIV-negative participants.

At the same time, melatonin production in PLWH started more than an hour later on average than in HIV-negative participants, “with half of the HIV+ group having an earlier habitual sleep onset than DLMO time” the authors wrote. In a subgroup of 36 participants with both valid actigraphy and DLMO data, the median circadian phase angle of entrainment was smaller in PLWH (–6 minutes vs. +1 hour 25 minutes in the HIV-negative group).

“Collectively, our data suggest that the sleep phase occurred earlier than what would be biologically optimal among the HIV+ participants,” they added.
 

Asynchrony between bedtime and circadian time

“Ideally, with this delayed timing of circadian phase, they should have delayed their sleep phase (sleep timing) by an equal amount to be sleeping at their optimal biological time,” Dr. Scheuermaier explained. “Their sleep onset was delayed by 12 minutes (statistically significant but biologically not that much) while their circadian phase was delayed by more than an hour.”

Possible consequences of a smaller phase angle of entrainment include difficulty in initiating and maintaining sleep, the authors wrote. “The shorter, potentially mistimed sleep relative to the endogenous circadian cycle observed in this study provides objectively measured evidence supporting the abundant previous subjective reports of poor sleep quality and insomnia in PLWH.”

They noted that a strength of their study is that participants were recruited from rural South Africa, where HIV prevalence is not confined to the so-called “high-risk” groups of gay men, other men who have sex with men, people who inject drugs, and sex workers.

“Behavioral factors associated with belonging to one or more of these groups would be strong potential confounders for studies of sleep and circadian phase,” they explained. “By contrast, in rural southern Africa, the epidemic has been less demographically discriminating ... There are no notable differences in lifestyle between the HIV– and HIV+ individuals in this study. The members of this aging population are mostly beyond retirement age, living quiet, rural lives supported by government remittances and subsistence farming.”
 

Direct evidence warrants further study

The study is “unique” in that it provides “the first direct evidence for potential circadian disturbances in PWLH,” agreed Peng Li, PhD, who was not involved in the study.

“The assessment of dim light melatonin onset in PLWH is a strength of the study; together with actigraphy-based sleep onset assessment, it provides a measure for the phase angle of entrainment,” said Dr. Li, who is research director of the medical biodynamics program, division of sleep and circadian disorders, Brigham and Women’s Hospital, Boston.

But actigraphy has limitations that affect the interpretation of the results, he told this news organization.

“Without the help of sleep diaries, low specificity in assessing sleep using actigraphy has been consistently reported,” he said. “The low specificity means a significant overestimation of sleep. This lowers the value of the reported sleep readouts and limits the validity of sleep onset estimation, especially considering that differences in sleep measures between the two groups are relatively small, compromising the clinical meaning.”

Additionally, he explained that it’s not clear whether sleep onset in the study participants was spontaneous or was “forced” to accommodate routines. “This is a limitation in field study as compared with in-lab studies,” he said.

Dr. Li also pointed to the small sample size and younger age of PLWH, suggesting the study might have benefited from a matched design. Finally, he said the study did not examine gender differences.

“In the general population, it is known that females usually have advanced circadian phase compared to males. ... More rigorous design and analyses based on sex/gender especially in this often-marginalized population are warranted to better inform HIV-specific or general clinical guidelines.”

The study was supported by the Academy of Medical Sciences. The authors did not mention any competing interests. Dr. Li reported grant support from the BrightFocus Foundation. The study is not directly related to this paper. He also receives grant support from the NIH through a Departmental Award, Harvard University Center for AIDS Research and a Pilot Project, HIV and Aging Research Consortium. The projects are on circadian disturbances and cognitive performance in PLWH.

A version of this article first appeared on Medscape.com.

People living with HIV (PLWH) had a “mistimed circadian phase” and a shorter night’s sleep compared with HIV-negative individuals with a similar lifestyle, according to findings that suggest both a possible mechanism for increased comorbidities in PLWH and potential solutions.

“It is very well known that sleep problems are common in people living with HIV, and many different reasons for this have been proposed,” coauthor Malcolm von Schantz, PhD, professor of chronobiology at Northumbria University in Newcastle upon Tyne, England, said in an interview. “But the novelty of our findings is the observation of delayed circadian rhythms.”

The mistimed circadian phase in PLWH is linked to later sleep onset and earlier waking and has “important potential implications” for the health and well-being of PLWH, wrote senior author Karine Scheuermaier, MD, from the University of the Witwatersrand, in Johannesburg, South Africa, and coauthors.

Until now, research on sleep in HIV has focused primarily on its homeostatic components, such as sleep duration and staging, rather than on circadian-related aspects, they noted.

“If the lifestyle‐independent circadian misalignment observed in the current study is confirmed to be a constant feature of chronic HIV infection, then it may be a mediator both of poorer sleep health and of poorer physical health in PLWH, which could potentially be alleviated through light therapy or chronobiotic medication or supplements,” they suggested.
 

HIV endemic in study population

The study analyzed a random sample of 187 participants (36 with HIV and 151 without) in the HAALSI (Health and Ageing in Africa: A Longitudinal Study of an INDEPTH Community in South Africa) study, which is part of the Agincourt Health and Socio-demographic Surveillance System.

The study population ranged in age from 45 to 93 years, with an average age of 60.6 years in the HIV-positive group and 68.2 years in the HIV-negative group. Demographic data, Pittsburgh Sleep Quality Index score, and valid actigraphy (measured with an accelerometer for 14 consecutive days) were available for 172 participants (18% with HIV). A subgroup of 51 participants (22% with HIV) also had valid dim light melatonin onset (DLMO) data, a sensitive measure of the internal circadian clock. DLMO was measured for a minimum of 5 consecutive days with hourly saliva sampling between 5 p.m. and 11 p.m. while sitting in a dimly lit room.

In 36 participants (16% with HIV) with both valid actigraphy and DLMO data, circadian phase angle of entrainment was calculated by subtracting DLMO time from habitual sleep-onset time obtained from actigraphy.

After adjustment for age and sex, the study found a slightly later sleep onset (adjusted average delay of 10 minutes), earlier awakening (adjusted average advance of 10 minutes), and shorter sleep duration in PLWH compared with HIV-negative participants.

At the same time, melatonin production in PLWH started more than an hour later on average than in HIV-negative participants, “with half of the HIV+ group having an earlier habitual sleep onset than DLMO time” the authors wrote. In a subgroup of 36 participants with both valid actigraphy and DLMO data, the median circadian phase angle of entrainment was smaller in PLWH (–6 minutes vs. +1 hour 25 minutes in the HIV-negative group).

“Collectively, our data suggest that the sleep phase occurred earlier than what would be biologically optimal among the HIV+ participants,” they added.
 

Asynchrony between bedtime and circadian time

“Ideally, with this delayed timing of circadian phase, they should have delayed their sleep phase (sleep timing) by an equal amount to be sleeping at their optimal biological time,” Dr. Scheuermaier explained. “Their sleep onset was delayed by 12 minutes (statistically significant but biologically not that much) while their circadian phase was delayed by more than an hour.”

Possible consequences of a smaller phase angle of entrainment include difficulty in initiating and maintaining sleep, the authors wrote. “The shorter, potentially mistimed sleep relative to the endogenous circadian cycle observed in this study provides objectively measured evidence supporting the abundant previous subjective reports of poor sleep quality and insomnia in PLWH.”

They noted that a strength of their study is that participants were recruited from rural South Africa, where HIV prevalence is not confined to the so-called “high-risk” groups of gay men, other men who have sex with men, people who inject drugs, and sex workers.

“Behavioral factors associated with belonging to one or more of these groups would be strong potential confounders for studies of sleep and circadian phase,” they explained. “By contrast, in rural southern Africa, the epidemic has been less demographically discriminating ... There are no notable differences in lifestyle between the HIV– and HIV+ individuals in this study. The members of this aging population are mostly beyond retirement age, living quiet, rural lives supported by government remittances and subsistence farming.”
 

Direct evidence warrants further study

The study is “unique” in that it provides “the first direct evidence for potential circadian disturbances in PWLH,” agreed Peng Li, PhD, who was not involved in the study.

“The assessment of dim light melatonin onset in PLWH is a strength of the study; together with actigraphy-based sleep onset assessment, it provides a measure for the phase angle of entrainment,” said Dr. Li, who is research director of the medical biodynamics program, division of sleep and circadian disorders, Brigham and Women’s Hospital, Boston.

But actigraphy has limitations that affect the interpretation of the results, he told this news organization.

“Without the help of sleep diaries, low specificity in assessing sleep using actigraphy has been consistently reported,” he said. “The low specificity means a significant overestimation of sleep. This lowers the value of the reported sleep readouts and limits the validity of sleep onset estimation, especially considering that differences in sleep measures between the two groups are relatively small, compromising the clinical meaning.”

Additionally, he explained that it’s not clear whether sleep onset in the study participants was spontaneous or was “forced” to accommodate routines. “This is a limitation in field study as compared with in-lab studies,” he said.

Dr. Li also pointed to the small sample size and younger age of PLWH, suggesting the study might have benefited from a matched design. Finally, he said the study did not examine gender differences.

“In the general population, it is known that females usually have advanced circadian phase compared to males. ... More rigorous design and analyses based on sex/gender especially in this often-marginalized population are warranted to better inform HIV-specific or general clinical guidelines.”

The study was supported by the Academy of Medical Sciences. The authors did not mention any competing interests. Dr. Li reported grant support from the BrightFocus Foundation. The study is not directly related to this paper. He also receives grant support from the NIH through a Departmental Award, Harvard University Center for AIDS Research and a Pilot Project, HIV and Aging Research Consortium. The projects are on circadian disturbances and cognitive performance in PLWH.

A version of this article first appeared on Medscape.com.

Obstructive sleep apnea (OSA) was associated with both impaired functional performance during exercise and overall worse outcomes in patients with chronic obstructive pulmonary disease (COPD), based on data from 34 adults.

Individuals with COPD are at increased risk for hospital readmissions and disease exacerbations, Patricia Faria Camargo, PhD, of Federal University of São Carlos (Brazil), and colleagues wrote. These patients often have concomitant obstructive sleep apnea, which itself can promote adverse cardiovascular events, but the impact of the overlap of these two conditions on clinical outcomes has not been explored.

In a study published in Heart & Lung, the researchers recruited 17 adults with COPD only and 17 with OSA and COPD. At baseline, patients underwent pulmonary function tests, echocardiography, and polysomnography to confirm their OSA and COPD diagnoses.

The primary endpoint was the impact of OSA on functional performance and cardiac autonomic control in COPD patients, based on measures of heart rate variability and the 6-minute walk test (6MWT). Participants were followed for 1 year, with telephone contacts every 3 months. A secondary endpoint was the number of exacerbations, hospitalizations, and deaths. At baseline, OSA-COPD patients had worse polysomnographic function, compared with COPD patients; they also tended to be older and have higher body mass index, but other demographics were similar between the groups.

Overall, patients in the OSA-COPD group had significantly greater functional impairment, compared with the COPD group (P = .003), as measured by the 6MWT. The OSA-COPD patients also showed significantly worse autonomic response during exercise, compared with the COPD group.

A lower work load during exercise and the interaction between group and time factors suggests that OSA impacts the exercise capacity of COPD patients, the researchers said. Notably, however, neither age nor body mass index was associated with functional performance in the OSA-COPD group.

Patients in the OSA-COPD group also were significantly more likely to experience exacerbations during the study period, compared with the COPD-only group (67.4% vs. 23.5; P = .03). However, the severity of COPD was similar between the groups, which further illustrates that OSA can impair functional performance in COPD patients, the researchers said.

The findings were limited by several factors including the small sample size and restricted collection of follow-up data during the pandemic, the researchers noted. However, the results support previous studies, and suggest that overlapping OSA and COPD produces worse outcomes.

“Future studies can confirm our findings, providing new clinical evidences to the assessment of sleep quality in COPD patients and its implications for the general health status of these individuals, in addition to contributing to more assertive clinical and therapeutic alternative support the need for more research into the mechanisms behind this overlap in larger samples to develop treatment alternatives,” they concluded.

The study was supported by the Federal University of Sao Carlos. The researchers had no financial conflicts to disclose.
 

Obstructive sleep apnea (OSA) was associated with both impaired functional performance during exercise and overall worse outcomes in patients with chronic obstructive pulmonary disease (COPD), based on data from 34 adults.

Individuals with COPD are at increased risk for hospital readmissions and disease exacerbations, Patricia Faria Camargo, PhD, of Federal University of São Carlos (Brazil), and colleagues wrote. These patients often have concomitant obstructive sleep apnea, which itself can promote adverse cardiovascular events, but the impact of the overlap of these two conditions on clinical outcomes has not been explored.

In a study published in Heart & Lung, the researchers recruited 17 adults with COPD only and 17 with OSA and COPD. At baseline, patients underwent pulmonary function tests, echocardiography, and polysomnography to confirm their OSA and COPD diagnoses.

The primary endpoint was the impact of OSA on functional performance and cardiac autonomic control in COPD patients, based on measures of heart rate variability and the 6-minute walk test (6MWT). Participants were followed for 1 year, with telephone contacts every 3 months. A secondary endpoint was the number of exacerbations, hospitalizations, and deaths. At baseline, OSA-COPD patients had worse polysomnographic function, compared with COPD patients; they also tended to be older and have higher body mass index, but other demographics were similar between the groups.

Overall, patients in the OSA-COPD group had significantly greater functional impairment, compared with the COPD group (P = .003), as measured by the 6MWT. The OSA-COPD patients also showed significantly worse autonomic response during exercise, compared with the COPD group.

A lower work load during exercise and the interaction between group and time factors suggests that OSA impacts the exercise capacity of COPD patients, the researchers said. Notably, however, neither age nor body mass index was associated with functional performance in the OSA-COPD group.

Patients in the OSA-COPD group also were significantly more likely to experience exacerbations during the study period, compared with the COPD-only group (67.4% vs. 23.5; P = .03). However, the severity of COPD was similar between the groups, which further illustrates that OSA can impair functional performance in COPD patients, the researchers said.

The findings were limited by several factors including the small sample size and restricted collection of follow-up data during the pandemic, the researchers noted. However, the results support previous studies, and suggest that overlapping OSA and COPD produces worse outcomes.

“Future studies can confirm our findings, providing new clinical evidences to the assessment of sleep quality in COPD patients and its implications for the general health status of these individuals, in addition to contributing to more assertive clinical and therapeutic alternative support the need for more research into the mechanisms behind this overlap in larger samples to develop treatment alternatives,” they concluded.

The study was supported by the Federal University of Sao Carlos. The researchers had no financial conflicts to disclose.
 

Obstructive sleep apnea (OSA) was associated with both impaired functional performance during exercise and overall worse outcomes in patients with chronic obstructive pulmonary disease (COPD), based on data from 34 adults.

Individuals with COPD are at increased risk for hospital readmissions and disease exacerbations, Patricia Faria Camargo, PhD, of Federal University of São Carlos (Brazil), and colleagues wrote. These patients often have concomitant obstructive sleep apnea, which itself can promote adverse cardiovascular events, but the impact of the overlap of these two conditions on clinical outcomes has not been explored.

In a study published in Heart & Lung, the researchers recruited 17 adults with COPD only and 17 with OSA and COPD. At baseline, patients underwent pulmonary function tests, echocardiography, and polysomnography to confirm their OSA and COPD diagnoses.

The primary endpoint was the impact of OSA on functional performance and cardiac autonomic control in COPD patients, based on measures of heart rate variability and the 6-minute walk test (6MWT). Participants were followed for 1 year, with telephone contacts every 3 months. A secondary endpoint was the number of exacerbations, hospitalizations, and deaths. At baseline, OSA-COPD patients had worse polysomnographic function, compared with COPD patients; they also tended to be older and have higher body mass index, but other demographics were similar between the groups.

Overall, patients in the OSA-COPD group had significantly greater functional impairment, compared with the COPD group (P = .003), as measured by the 6MWT. The OSA-COPD patients also showed significantly worse autonomic response during exercise, compared with the COPD group.

A lower work load during exercise and the interaction between group and time factors suggests that OSA impacts the exercise capacity of COPD patients, the researchers said. Notably, however, neither age nor body mass index was associated with functional performance in the OSA-COPD group.

Patients in the OSA-COPD group also were significantly more likely to experience exacerbations during the study period, compared with the COPD-only group (67.4% vs. 23.5; P = .03). However, the severity of COPD was similar between the groups, which further illustrates that OSA can impair functional performance in COPD patients, the researchers said.

The findings were limited by several factors including the small sample size and restricted collection of follow-up data during the pandemic, the researchers noted. However, the results support previous studies, and suggest that overlapping OSA and COPD produces worse outcomes.

“Future studies can confirm our findings, providing new clinical evidences to the assessment of sleep quality in COPD patients and its implications for the general health status of these individuals, in addition to contributing to more assertive clinical and therapeutic alternative support the need for more research into the mechanisms behind this overlap in larger samples to develop treatment alternatives,” they concluded.

The study was supported by the Federal University of Sao Carlos. The researchers had no financial conflicts to disclose.
 

For people with clinically diagnosed “nightmare disorder,” learning to redirect disturbing dreams to more positive ones is usually the return ticket to sleep. 

But for nearly one-third of people, that method – called imagery rehearsal therapy – isn’t effective.

A new study shows that listening to positive sounds while sleeping reduces the frequency of nightmares.

“This is a promising development. It does appear that adding a well-timed sound during REM sleep augments the effect of image rehearsal therapy ... which is a standard and perhaps one of the most effective nonpharmacologic therapies at this time,” said Timothy Morgenthaler, MD, in an interview with CNN. 

Dr. Morgenthaler, who was not involved in this latest study, is lead author of the American Academy of Sleep Medicine’s current guidelines on nightmares.

For the new research, nightmares were defined as “the experience of strong negative emotions occurring usually during REM sleep. They involve images and thoughts of aggression, interpersonal conflict, and failure, and emotions like fear, anger, and sadness.” Nightmare disorder is characterized as having such dreams so frequently that they cause “significant distress or impairment in social, occupational, or other important areas of functioning.” 

Left untreated, nightmare disorder can persist for decades, the authors said.

The study, conducted in Switzerland, enrolled 36 participants with nightmare disorder. All 36 participated in a daytime lesson of imagery rehearsal therapy that taught them to redirect their nightmares to positive dreams. Participants were taught to recall a nightmare, change the negative story line toward a more positive one, and then rehearse the so-called “rewritten dream” during the day.

Half of the participants also had a special sound played while they practiced reimagining their new positive dreams. At night for the following 2 weeks while they slept, the sound was played during their REM cycles.

Those who heard the sound reported significantly fewer nightmares.

“This difference displayed a medium to large effect size and was sustainable at the 3-month follow-up,” the authors reported.

They did note that both groups showed improvement, likely because the lesson to reimagine nightmares into positive dreams is known to be effective. However, the authors allowed that other factors may have contributed in ways their study design could not control.

“The result should be replicated,” Dr. Morgenthaler said. “But I was a bit excited at this new possibility.”

A version of this article first appeared on WebMD.com.

For people with clinically diagnosed “nightmare disorder,” learning to redirect disturbing dreams to more positive ones is usually the return ticket to sleep. 

But for nearly one-third of people, that method – called imagery rehearsal therapy – isn’t effective.

A new study shows that listening to positive sounds while sleeping reduces the frequency of nightmares.

“This is a promising development. It does appear that adding a well-timed sound during REM sleep augments the effect of image rehearsal therapy ... which is a standard and perhaps one of the most effective nonpharmacologic therapies at this time,” said Timothy Morgenthaler, MD, in an interview with CNN. 

Dr. Morgenthaler, who was not involved in this latest study, is lead author of the American Academy of Sleep Medicine’s current guidelines on nightmares.

For the new research, nightmares were defined as “the experience of strong negative emotions occurring usually during REM sleep. They involve images and thoughts of aggression, interpersonal conflict, and failure, and emotions like fear, anger, and sadness.” Nightmare disorder is characterized as having such dreams so frequently that they cause “significant distress or impairment in social, occupational, or other important areas of functioning.” 

Left untreated, nightmare disorder can persist for decades, the authors said.

The study, conducted in Switzerland, enrolled 36 participants with nightmare disorder. All 36 participated in a daytime lesson of imagery rehearsal therapy that taught them to redirect their nightmares to positive dreams. Participants were taught to recall a nightmare, change the negative story line toward a more positive one, and then rehearse the so-called “rewritten dream” during the day.

Half of the participants also had a special sound played while they practiced reimagining their new positive dreams. At night for the following 2 weeks while they slept, the sound was played during their REM cycles.

Those who heard the sound reported significantly fewer nightmares.

“This difference displayed a medium to large effect size and was sustainable at the 3-month follow-up,” the authors reported.

They did note that both groups showed improvement, likely because the lesson to reimagine nightmares into positive dreams is known to be effective. However, the authors allowed that other factors may have contributed in ways their study design could not control.

“The result should be replicated,” Dr. Morgenthaler said. “But I was a bit excited at this new possibility.”

A version of this article first appeared on WebMD.com.

For people with clinically diagnosed “nightmare disorder,” learning to redirect disturbing dreams to more positive ones is usually the return ticket to sleep. 

But for nearly one-third of people, that method – called imagery rehearsal therapy – isn’t effective.

A new study shows that listening to positive sounds while sleeping reduces the frequency of nightmares.

“This is a promising development. It does appear that adding a well-timed sound during REM sleep augments the effect of image rehearsal therapy ... which is a standard and perhaps one of the most effective nonpharmacologic therapies at this time,” said Timothy Morgenthaler, MD, in an interview with CNN. 

Dr. Morgenthaler, who was not involved in this latest study, is lead author of the American Academy of Sleep Medicine’s current guidelines on nightmares.

For the new research, nightmares were defined as “the experience of strong negative emotions occurring usually during REM sleep. They involve images and thoughts of aggression, interpersonal conflict, and failure, and emotions like fear, anger, and sadness.” Nightmare disorder is characterized as having such dreams so frequently that they cause “significant distress or impairment in social, occupational, or other important areas of functioning.” 

Left untreated, nightmare disorder can persist for decades, the authors said.

The study, conducted in Switzerland, enrolled 36 participants with nightmare disorder. All 36 participated in a daytime lesson of imagery rehearsal therapy that taught them to redirect their nightmares to positive dreams. Participants were taught to recall a nightmare, change the negative story line toward a more positive one, and then rehearse the so-called “rewritten dream” during the day.

Half of the participants also had a special sound played while they practiced reimagining their new positive dreams. At night for the following 2 weeks while they slept, the sound was played during their REM cycles.

Those who heard the sound reported significantly fewer nightmares.

“This difference displayed a medium to large effect size and was sustainable at the 3-month follow-up,” the authors reported.

They did note that both groups showed improvement, likely because the lesson to reimagine nightmares into positive dreams is known to be effective. However, the authors allowed that other factors may have contributed in ways their study design could not control.

“The result should be replicated,” Dr. Morgenthaler said. “But I was a bit excited at this new possibility.”

A version of this article first appeared on WebMD.com.

Undiagnosed atrial fibrillation (AFib) was significantly more common among adults with obstructive sleep apnea (OSA), compared with controls, based on data from 303 individuals.

OSA has become a common chronic disease, and cardiovascular diseases including AFib also are known independent risk factors associated with OSA, Anna Hojager, MD, of Zealand University Hospital, Roskilde, Denmark, and colleagues wrote. Previous studies have shown a significant increase in AFib risk in OSA patients with severe disease, but the prevalence of undiagnosed AFib in OSA patients has not been explored.

In a study published in Sleep Medicine, the researchers enrolled 238 adults with severe OSA (based on apnea-hypopnea index of 15 or higher) and 65 with mild or no OSA (based on an AHI of less than 15). The mean AHI across all participants was 34.2, and ranged from 0.2 to 115.8.

Participants underwent heart rhythm monitoring using a home system or standard ECG for 7 days; they were instructed to carry the device at all times except when showering or sweating heavily. The primary outcome was the detection of AFib, defined as at least one period of 30 seconds or longer with an irregular heart rhythm but without detectable evidence of another diagnosis. Sleep was assessed for one night using a portable sleep monitoring device. All participants were examined at baseline and measured for blood pressure, body mass index, waist-to-hip ratio, and ECG.

Overall, AFib occurred in 21 patients with moderate to severe OSA and 1 patient with mild/no OSA (8.8% vs. 1.5%, P = .045). The majority of patients across both groups had hypertension (66%) and dyslipidemia (77.6%), but the severe OSA group was more likely to be dysregulated and to have unknown prediabetes. Participants who were deemed candidates for anticoagulation therapy were referred for additional treatment. None of the 22 total patients with AFib had heart failure with reduced ejection fraction, and 68.2% had normal ejection fraction and ventricle function.

The researchers noted that no guidelines currently exist for systematic opportunistic screening for comorbidities in OSA patients, although the American Academy of Sleep Medicine recommends patient education as part of a multidisciplinary chronic disease management strategy. The high prevalence of AFib in OSA patients, as seen in the current study, “might warrant a recommendation of screening for paroxysmal [AFib] and could be valuable in the management of modifiable cardiovascular risk factors in patients with OSA,” they wrote.

The study findings were limited by several factors including the observational design and absence of polysomnography to assess OSA, the researchers noted. However, the study has the highest known prevalence of silent AFib in patients with moderate to severe OSA, and supports the value of screening and management for known comorbidities of OSA.

The study received no outside funding. The researchers had no financial conflicts to disclose.
 

Undiagnosed atrial fibrillation (AFib) was significantly more common among adults with obstructive sleep apnea (OSA), compared with controls, based on data from 303 individuals.

OSA has become a common chronic disease, and cardiovascular diseases including AFib also are known independent risk factors associated with OSA, Anna Hojager, MD, of Zealand University Hospital, Roskilde, Denmark, and colleagues wrote. Previous studies have shown a significant increase in AFib risk in OSA patients with severe disease, but the prevalence of undiagnosed AFib in OSA patients has not been explored.

In a study published in Sleep Medicine, the researchers enrolled 238 adults with severe OSA (based on apnea-hypopnea index of 15 or higher) and 65 with mild or no OSA (based on an AHI of less than 15). The mean AHI across all participants was 34.2, and ranged from 0.2 to 115.8.

Participants underwent heart rhythm monitoring using a home system or standard ECG for 7 days; they were instructed to carry the device at all times except when showering or sweating heavily. The primary outcome was the detection of AFib, defined as at least one period of 30 seconds or longer with an irregular heart rhythm but without detectable evidence of another diagnosis. Sleep was assessed for one night using a portable sleep monitoring device. All participants were examined at baseline and measured for blood pressure, body mass index, waist-to-hip ratio, and ECG.

Overall, AFib occurred in 21 patients with moderate to severe OSA and 1 patient with mild/no OSA (8.8% vs. 1.5%, P = .045). The majority of patients across both groups had hypertension (66%) and dyslipidemia (77.6%), but the severe OSA group was more likely to be dysregulated and to have unknown prediabetes. Participants who were deemed candidates for anticoagulation therapy were referred for additional treatment. None of the 22 total patients with AFib had heart failure with reduced ejection fraction, and 68.2% had normal ejection fraction and ventricle function.

The researchers noted that no guidelines currently exist for systematic opportunistic screening for comorbidities in OSA patients, although the American Academy of Sleep Medicine recommends patient education as part of a multidisciplinary chronic disease management strategy. The high prevalence of AFib in OSA patients, as seen in the current study, “might warrant a recommendation of screening for paroxysmal [AFib] and could be valuable in the management of modifiable cardiovascular risk factors in patients with OSA,” they wrote.

The study findings were limited by several factors including the observational design and absence of polysomnography to assess OSA, the researchers noted. However, the study has the highest known prevalence of silent AFib in patients with moderate to severe OSA, and supports the value of screening and management for known comorbidities of OSA.

The study received no outside funding. The researchers had no financial conflicts to disclose.
 

Undiagnosed atrial fibrillation (AFib) was significantly more common among adults with obstructive sleep apnea (OSA), compared with controls, based on data from 303 individuals.

OSA has become a common chronic disease, and cardiovascular diseases including AFib also are known independent risk factors associated with OSA, Anna Hojager, MD, of Zealand University Hospital, Roskilde, Denmark, and colleagues wrote. Previous studies have shown a significant increase in AFib risk in OSA patients with severe disease, but the prevalence of undiagnosed AFib in OSA patients has not been explored.

In a study published in Sleep Medicine, the researchers enrolled 238 adults with severe OSA (based on apnea-hypopnea index of 15 or higher) and 65 with mild or no OSA (based on an AHI of less than 15). The mean AHI across all participants was 34.2, and ranged from 0.2 to 115.8.

Participants underwent heart rhythm monitoring using a home system or standard ECG for 7 days; they were instructed to carry the device at all times except when showering or sweating heavily. The primary outcome was the detection of AFib, defined as at least one period of 30 seconds or longer with an irregular heart rhythm but without detectable evidence of another diagnosis. Sleep was assessed for one night using a portable sleep monitoring device. All participants were examined at baseline and measured for blood pressure, body mass index, waist-to-hip ratio, and ECG.

Overall, AFib occurred in 21 patients with moderate to severe OSA and 1 patient with mild/no OSA (8.8% vs. 1.5%, P = .045). The majority of patients across both groups had hypertension (66%) and dyslipidemia (77.6%), but the severe OSA group was more likely to be dysregulated and to have unknown prediabetes. Participants who were deemed candidates for anticoagulation therapy were referred for additional treatment. None of the 22 total patients with AFib had heart failure with reduced ejection fraction, and 68.2% had normal ejection fraction and ventricle function.

The researchers noted that no guidelines currently exist for systematic opportunistic screening for comorbidities in OSA patients, although the American Academy of Sleep Medicine recommends patient education as part of a multidisciplinary chronic disease management strategy. The high prevalence of AFib in OSA patients, as seen in the current study, “might warrant a recommendation of screening for paroxysmal [AFib] and could be valuable in the management of modifiable cardiovascular risk factors in patients with OSA,” they wrote.

The study findings were limited by several factors including the observational design and absence of polysomnography to assess OSA, the researchers noted. However, the study has the highest known prevalence of silent AFib in patients with moderate to severe OSA, and supports the value of screening and management for known comorbidities of OSA.

The study received no outside funding. The researchers had no financial conflicts to disclose.
 

Who doesn’t love data, especially their own? With that thought in mind, over the years I have owned several activity trackers, including at least two Fitbits, and I frequently check my iPhone to see how far I’ve walked or how many steps I have taken. My most recent acquisition is an Oura (smart ring, third generation), which includes my first sleep tracker.

Sleep trackers are not unique to the Oura Ring; they are included on many of the newer activity trackers and smart watches, but the design and breakdown of daily sleep, activity, and readiness scores are hallmarks of Oura Rings. 

The ring generates data for different phases of sleep, movements, oxygen saturation, disturbances in breathing, heart rate, and heart rate variability. I began to wonder how useful this information would be clinically and whether it might be helpful in either the diagnosis or treatment of sleep disorders.

David Neubauer, MD, is a psychiatrist at the Johns Hopkins Sleep Disorders Center. “Sleep tracking devices are more than just toys but less than medical devices. They do have clinical utility and might show findings that warrant further medical workup,” Dr. Neubauer said. “It is impressive that these devices estimate sleep as well as they do, but there is a problem with how they divide sleep stages that can lead people to believe their sleep is worse than it really is.”

For more than 50 years, he explained, sleep researchers and clinicians have categorized sleep as non–rapid eye movement (NREM) sleep stages 1-4 and REM sleep. More recently, sleep was reorganized to N1, N2, and N3 (which combines the older stages 3 and 4, representing “deep sleep” or “slow wave sleep”) and REM sleep. We normally spend more time in N2 than the other stages. However, the device companies often categorize their sleep estimates as “light sleep,” “deep sleep,” or “REM.” With “light sleep,” they are lumping together N1 and N2 sleep, and this is misleading, said Dr. Neubauer. “Understandably, people often think that there is something wrong if their tracker reports they are spending a lot of time in light sleep, when actually their sleep may be entirely normal.”
 

Sleep tracker validity

A study by Massimiliano de Zambotti, PhD, and colleagues, “The Sleep of the Ring: Comparison of the ŌURA Sleep Tracker Against Polysomnography”, looked at sleep patterns of 41 adolescents and young adults and concluded that the second-generation tracker was accurate in terms of total sleep but underestimated time spent in N3 stage sleep by approximately 20 minutes while overestimating time spent in REM sleep by 17 minutes. They concluded that the ring had potential to be clinically useful but that further studies and validation were needed. 

A larger study of the newest, third-generation Oura tracker, conducted by Altini and Kinnunen at Oura Health, found that the added sensors with the newer-generation ring led to improved accuracy, but they noted that the study was done with a healthy population and might not generalize to clinical populations. 

Fernando Goes, MD, and Matthew Reid, PhD, both at Johns Hopkins, are working on a multicenter study using the Oura Ring and the mindLAMP app to look at the impact of sleep on mood in people with mood disorders as well as healthy controls. Dr. Reid said that “validation of sleep stages takes a hit when the ring is used in people with insomnia. We find it useful for total sleep time, but when you look at sleep architecture, the concordance is only 60%. And oxygen saturation measures are less accurate in people with dark skin.”
 

Clinical uses for sleep trackers

More accurate information might prove reassuring to patients. Dr. Goes added, “One use, for example, might be to help patients to limit or come off of long-term hypnotics with a more benign intervention that incorporates passive monitoring such as that in the Oura Ring. Some patients worry excessively about not being able to sleep, and sleep monitoring data can be helpful to reduce some of these concerns so patients can focus on safer interventions, such as cognitive behavioral therapy for insomnia.” Dr. Reid believes that wearable trackers have potential usefulness in monitoring sleep in patients with insomnia. “In insomnia, sleep state misperception is common. They are hyper-aroused, and they perceive that they are awake when in fact they are sleeping.”

Dr. Goes mentioned another use for sleep trackers in clinical settings: “In our inpatient units, the nurses open the door to look in on patients every hour to monitor and document if they are sleeping. If they look in and the patient isn’t moving, they will ask the patient to raise their hand, which of course is not going to help someone to fall back asleep.” Wearable devices might provide data on sleep without the risk of waking patients every hour through the night.
 

Not medical devices

However, Dr. Neubauer emphasized that current sleep trackers are not medical devices, saying “they may be measuring the same parameters that are measured with medical devices, for example pulse oximetry or sleep states, but there’s no simple answer yet to the question of whether the devices provide reliable data for clinical decision-making.” 

Dr. Neubauer is skeptical about the accuracy of some of the measures the device provides. “I would not use the information from a consumer device to rule out obstructive sleep apnea based on good oxygen saturation numbers. So much depends on the history – snoring, gasping awakenings, reports from bed partners, and daytime sleepiness. These devices do not measure respiratory effort or nasal airflow as sleep studies do. But big drops in oxygen saturation from a consumer device certainly warrant attention for further evaluation.” Dr. Neubauer also noted that the parameters on sleep trackers do not differentiate between central or obstructive sleep apnea and that insurers won’t pay for continuous positive airway pressure to treat sleep apnea without a sleep study. 

I enjoy looking at the data, even knowing that they are not entirely accurate. As future renditions of these multisensor devices become more specific and sensitive, I predict that they will take on a role in the diagnosis and treatment of sleep disorders, and we may find more clinical uses for these devices. For now, I’m off to get more exercise, at the suggestion of my tracker!

Dinah Miller, MD, is assistant professor of psychiatry and behavioral sciences, Johns Hopkins Medicine, Baltimore.

A version of this article first appeared on Medscape.com.

Who doesn’t love data, especially their own? With that thought in mind, over the years I have owned several activity trackers, including at least two Fitbits, and I frequently check my iPhone to see how far I’ve walked or how many steps I have taken. My most recent acquisition is an Oura (smart ring, third generation), which includes my first sleep tracker.

Sleep trackers are not unique to the Oura Ring; they are included on many of the newer activity trackers and smart watches, but the design and breakdown of daily sleep, activity, and readiness scores are hallmarks of Oura Rings. 

The ring generates data for different phases of sleep, movements, oxygen saturation, disturbances in breathing, heart rate, and heart rate variability. I began to wonder how useful this information would be clinically and whether it might be helpful in either the diagnosis or treatment of sleep disorders.

David Neubauer, MD, is a psychiatrist at the Johns Hopkins Sleep Disorders Center. “Sleep tracking devices are more than just toys but less than medical devices. They do have clinical utility and might show findings that warrant further medical workup,” Dr. Neubauer said. “It is impressive that these devices estimate sleep as well as they do, but there is a problem with how they divide sleep stages that can lead people to believe their sleep is worse than it really is.”

For more than 50 years, he explained, sleep researchers and clinicians have categorized sleep as non–rapid eye movement (NREM) sleep stages 1-4 and REM sleep. More recently, sleep was reorganized to N1, N2, and N3 (which combines the older stages 3 and 4, representing “deep sleep” or “slow wave sleep”) and REM sleep. We normally spend more time in N2 than the other stages. However, the device companies often categorize their sleep estimates as “light sleep,” “deep sleep,” or “REM.” With “light sleep,” they are lumping together N1 and N2 sleep, and this is misleading, said Dr. Neubauer. “Understandably, people often think that there is something wrong if their tracker reports they are spending a lot of time in light sleep, when actually their sleep may be entirely normal.”
 

Sleep tracker validity

A study by Massimiliano de Zambotti, PhD, and colleagues, “The Sleep of the Ring: Comparison of the ŌURA Sleep Tracker Against Polysomnography”, looked at sleep patterns of 41 adolescents and young adults and concluded that the second-generation tracker was accurate in terms of total sleep but underestimated time spent in N3 stage sleep by approximately 20 minutes while overestimating time spent in REM sleep by 17 minutes. They concluded that the ring had potential to be clinically useful but that further studies and validation were needed. 

A larger study of the newest, third-generation Oura tracker, conducted by Altini and Kinnunen at Oura Health, found that the added sensors with the newer-generation ring led to improved accuracy, but they noted that the study was done with a healthy population and might not generalize to clinical populations. 

Fernando Goes, MD, and Matthew Reid, PhD, both at Johns Hopkins, are working on a multicenter study using the Oura Ring and the mindLAMP app to look at the impact of sleep on mood in people with mood disorders as well as healthy controls. Dr. Reid said that “validation of sleep stages takes a hit when the ring is used in people with insomnia. We find it useful for total sleep time, but when you look at sleep architecture, the concordance is only 60%. And oxygen saturation measures are less accurate in people with dark skin.”
 

Clinical uses for sleep trackers

More accurate information might prove reassuring to patients. Dr. Goes added, “One use, for example, might be to help patients to limit or come off of long-term hypnotics with a more benign intervention that incorporates passive monitoring such as that in the Oura Ring. Some patients worry excessively about not being able to sleep, and sleep monitoring data can be helpful to reduce some of these concerns so patients can focus on safer interventions, such as cognitive behavioral therapy for insomnia.” Dr. Reid believes that wearable trackers have potential usefulness in monitoring sleep in patients with insomnia. “In insomnia, sleep state misperception is common. They are hyper-aroused, and they perceive that they are awake when in fact they are sleeping.”

Dr. Goes mentioned another use for sleep trackers in clinical settings: “In our inpatient units, the nurses open the door to look in on patients every hour to monitor and document if they are sleeping. If they look in and the patient isn’t moving, they will ask the patient to raise their hand, which of course is not going to help someone to fall back asleep.” Wearable devices might provide data on sleep without the risk of waking patients every hour through the night.
 

Not medical devices

However, Dr. Neubauer emphasized that current sleep trackers are not medical devices, saying “they may be measuring the same parameters that are measured with medical devices, for example pulse oximetry or sleep states, but there’s no simple answer yet to the question of whether the devices provide reliable data for clinical decision-making.” 

Dr. Neubauer is skeptical about the accuracy of some of the measures the device provides. “I would not use the information from a consumer device to rule out obstructive sleep apnea based on good oxygen saturation numbers. So much depends on the history – snoring, gasping awakenings, reports from bed partners, and daytime sleepiness. These devices do not measure respiratory effort or nasal airflow as sleep studies do. But big drops in oxygen saturation from a consumer device certainly warrant attention for further evaluation.” Dr. Neubauer also noted that the parameters on sleep trackers do not differentiate between central or obstructive sleep apnea and that insurers won’t pay for continuous positive airway pressure to treat sleep apnea without a sleep study. 

I enjoy looking at the data, even knowing that they are not entirely accurate. As future renditions of these multisensor devices become more specific and sensitive, I predict that they will take on a role in the diagnosis and treatment of sleep disorders, and we may find more clinical uses for these devices. For now, I’m off to get more exercise, at the suggestion of my tracker!

Dinah Miller, MD, is assistant professor of psychiatry and behavioral sciences, Johns Hopkins Medicine, Baltimore.

A version of this article first appeared on Medscape.com.

Who doesn’t love data, especially their own? With that thought in mind, over the years I have owned several activity trackers, including at least two Fitbits, and I frequently check my iPhone to see how far I’ve walked or how many steps I have taken. My most recent acquisition is an Oura (smart ring, third generation), which includes my first sleep tracker.

Sleep trackers are not unique to the Oura Ring; they are included on many of the newer activity trackers and smart watches, but the design and breakdown of daily sleep, activity, and readiness scores are hallmarks of Oura Rings. 

The ring generates data for different phases of sleep, movements, oxygen saturation, disturbances in breathing, heart rate, and heart rate variability. I began to wonder how useful this information would be clinically and whether it might be helpful in either the diagnosis or treatment of sleep disorders.

David Neubauer, MD, is a psychiatrist at the Johns Hopkins Sleep Disorders Center. “Sleep tracking devices are more than just toys but less than medical devices. They do have clinical utility and might show findings that warrant further medical workup,” Dr. Neubauer said. “It is impressive that these devices estimate sleep as well as they do, but there is a problem with how they divide sleep stages that can lead people to believe their sleep is worse than it really is.”

For more than 50 years, he explained, sleep researchers and clinicians have categorized sleep as non–rapid eye movement (NREM) sleep stages 1-4 and REM sleep. More recently, sleep was reorganized to N1, N2, and N3 (which combines the older stages 3 and 4, representing “deep sleep” or “slow wave sleep”) and REM sleep. We normally spend more time in N2 than the other stages. However, the device companies often categorize their sleep estimates as “light sleep,” “deep sleep,” or “REM.” With “light sleep,” they are lumping together N1 and N2 sleep, and this is misleading, said Dr. Neubauer. “Understandably, people often think that there is something wrong if their tracker reports they are spending a lot of time in light sleep, when actually their sleep may be entirely normal.”
 

Sleep tracker validity

A study by Massimiliano de Zambotti, PhD, and colleagues, “The Sleep of the Ring: Comparison of the ŌURA Sleep Tracker Against Polysomnography”, looked at sleep patterns of 41 adolescents and young adults and concluded that the second-generation tracker was accurate in terms of total sleep but underestimated time spent in N3 stage sleep by approximately 20 minutes while overestimating time spent in REM sleep by 17 minutes. They concluded that the ring had potential to be clinically useful but that further studies and validation were needed. 

A larger study of the newest, third-generation Oura tracker, conducted by Altini and Kinnunen at Oura Health, found that the added sensors with the newer-generation ring led to improved accuracy, but they noted that the study was done with a healthy population and might not generalize to clinical populations. 

Fernando Goes, MD, and Matthew Reid, PhD, both at Johns Hopkins, are working on a multicenter study using the Oura Ring and the mindLAMP app to look at the impact of sleep on mood in people with mood disorders as well as healthy controls. Dr. Reid said that “validation of sleep stages takes a hit when the ring is used in people with insomnia. We find it useful for total sleep time, but when you look at sleep architecture, the concordance is only 60%. And oxygen saturation measures are less accurate in people with dark skin.”
 

Clinical uses for sleep trackers

More accurate information might prove reassuring to patients. Dr. Goes added, “One use, for example, might be to help patients to limit or come off of long-term hypnotics with a more benign intervention that incorporates passive monitoring such as that in the Oura Ring. Some patients worry excessively about not being able to sleep, and sleep monitoring data can be helpful to reduce some of these concerns so patients can focus on safer interventions, such as cognitive behavioral therapy for insomnia.” Dr. Reid believes that wearable trackers have potential usefulness in monitoring sleep in patients with insomnia. “In insomnia, sleep state misperception is common. They are hyper-aroused, and they perceive that they are awake when in fact they are sleeping.”

Dr. Goes mentioned another use for sleep trackers in clinical settings: “In our inpatient units, the nurses open the door to look in on patients every hour to monitor and document if they are sleeping. If they look in and the patient isn’t moving, they will ask the patient to raise their hand, which of course is not going to help someone to fall back asleep.” Wearable devices might provide data on sleep without the risk of waking patients every hour through the night.
 

Not medical devices

However, Dr. Neubauer emphasized that current sleep trackers are not medical devices, saying “they may be measuring the same parameters that are measured with medical devices, for example pulse oximetry or sleep states, but there’s no simple answer yet to the question of whether the devices provide reliable data for clinical decision-making.” 

Dr. Neubauer is skeptical about the accuracy of some of the measures the device provides. “I would not use the information from a consumer device to rule out obstructive sleep apnea based on good oxygen saturation numbers. So much depends on the history – snoring, gasping awakenings, reports from bed partners, and daytime sleepiness. These devices do not measure respiratory effort or nasal airflow as sleep studies do. But big drops in oxygen saturation from a consumer device certainly warrant attention for further evaluation.” Dr. Neubauer also noted that the parameters on sleep trackers do not differentiate between central or obstructive sleep apnea and that insurers won’t pay for continuous positive airway pressure to treat sleep apnea without a sleep study. 

I enjoy looking at the data, even knowing that they are not entirely accurate. As future renditions of these multisensor devices become more specific and sensitive, I predict that they will take on a role in the diagnosis and treatment of sleep disorders, and we may find more clinical uses for these devices. For now, I’m off to get more exercise, at the suggestion of my tracker!

Dinah Miller, MD, is assistant professor of psychiatry and behavioral sciences, Johns Hopkins Medicine, Baltimore.

A version of this article first appeared on Medscape.com.

While trials of various interventions for obstructive sleep apnea and insomnia were effective, there was a strong suggestion that tailoring them according to the race/gender of the target populations strengthens engagement and improvements, according to a presentation by Dayna A. Johnson, PhD, MPH, at the annual meeting of the American College of Chest Physicians (CHEST).

Dr. Johnson, assistant professor at Emory University in Atlanta, stated that determinants of sleep disparities are multifactorial across the lifespan, from in utero to aging, but it was also important to focus on social determinants of poor sleep.

The complexity of factors, she said, calls for multilevel interventions beyond screening and treatment. Racism and discrimination come into play, especially with regard to anxiety and stress, In addition, neighborhood factors including safety, noise and light pollution, ventilation, and thermal comfort come into play.

Dr. Johnson cited the example of parents who work multiple jobs to provide for their families: “Minimum wage is not a livable wage, and parents may not be available to ensure that children have consistent bedtimes.” Interventions, she added, may have to be at the neighborhood level, including placing sleep specialists in the local neighborhood “where the need is.” Cleaning up a neighborhood reduces crime and overall health, while light shielding in public housing can lower light pollution.

Observing that African Americans have higher rates of obstructive sleep apnea, Dr. Johnson and colleagues designed a screening tool specifically for African Americans with five prediction models with increasing levels of factor measurements (from 4 to 10). The prediction accuracy across the models ascended in lockstep with the number of measures from 74.0% to 76.1%, with the simplest model including only age, body mass index, male sex, and snoring. The latter model added witnessed apneas, high depressive symptoms, two measures of waist and neck size, and sleepiness. Dr. Johnson pointed out that accuracy for well-established predictive models is notably lower: STOP-Bang score ranges from 56% to 66%; NoSAS ranges from 58% to 66% and the HCHS prediction model accuracy is 70%. Dr. Johnson said that a Latino model they developed was more accurate than the traditional models, but not as accurate as their model for African Americans.

Turning to specific interventions, and underscoring higher levels of stress and anxiety among African American and Hispanic populations, Dr. Johnson cited MINDS (Mindfulness Intervention to Improve Sleep and Reduce Diabetes Risk Among a Diverse Sample in Atlanta), her study at Emory University of mindfulness meditation. Although prior studies have confirmed sleep benefits of mindfulness meditation, studies tailored for African American or Hispanic populations have been lacking.

The MINDS pilot study investigators enrolled 17 individuals (mostly women, with a mixture of racial and ethnic groups comprising Black, White, Asian and Hispanic patients) with poor sleep quality as measured by the Pittsburgh Sleep Quality Index (PSQI). Most patients, Dr. Johnson said, were overweight. Because of COVID restrictions on clinic visits, the diabetes portion of the study was dropped. All participants received at least 3 days of instruction on mindfulness meditation, on dealing with stress and anxiety, and on optimum sleep health practices. While PSQI scores higher than 5 are considered to indicate poor sleep quality, the mean PSQI score at study outset in MINDS was 9.2, she stated.

After 30 days of the intervention, stress (on a perceived stress scale) was improved, as were PSQI scores and actigraphy measures of sleep duration, efficiency and wakefulness after sleep onset, Dr. Johnson reported. “Participants found the mindfulness app to be acceptable and appropriate, and to reduce time to falling asleep,” Dr. Johnson said.

Qualitative data gathered post intervention from four focus groups (two to six participants in each; 1-1.5 hours in length), revealed general acceptability of the MINDS app. It showed also that among those with 50% or more adherence to the intervention, time to falling asleep was reduced, as were sleep awakenings at night. The most striking finding, Dr. Johnson said, was that individuals from among racial/ethnic minorities expressed appreciation of the diversity of the meditation instructors, and said that they preferred instruction from a person of their own race and sex. Findings would be even more striking with a larger sample size, Dr. Johnson speculated.

Citing TASHE (Tailored Approach to Sleep Health Education), a further observational study on obstructive sleep apnea knowledge conducted at New York University, Dr. Johnson addressed the fact that current messages are not tailored to race/ethnic minorities with low-to-moderate symptom knowledge. Also, a 3-arm randomized clinical trial of Internet-delivered treatment (Sleep Healthy or SHUTI) with a version revised for Black women (SHUTI-BWHS) showed findings similar to those of other studies cited and suggested: “Tailoring may be necessary to increase uptake and sustainability and to improve sleep among racial/ethnic minorities.”

Dr. Johnson noted, in closing, that Black/African American individuals have higher risk for obstructive sleep apnea than that of their White counterparts and lower rates of screening for treatment.

Dr. Johnson’s research was funded by the National Institutes of Health; National Heart, Lung, and Blood Institute; Woodruff Health Sciences Center; Synergy Award; Rollins School of Public Health Dean’s Pilot and Innovation Award; and Georgia Center for Diabetes Translation Research Pilot and Feasibility award program. She reported no relevant conflicts.

While trials of various interventions for obstructive sleep apnea and insomnia were effective, there was a strong suggestion that tailoring them according to the race/gender of the target populations strengthens engagement and improvements, according to a presentation by Dayna A. Johnson, PhD, MPH, at the annual meeting of the American College of Chest Physicians (CHEST).

Dr. Johnson, assistant professor at Emory University in Atlanta, stated that determinants of sleep disparities are multifactorial across the lifespan, from in utero to aging, but it was also important to focus on social determinants of poor sleep.

The complexity of factors, she said, calls for multilevel interventions beyond screening and treatment. Racism and discrimination come into play, especially with regard to anxiety and stress, In addition, neighborhood factors including safety, noise and light pollution, ventilation, and thermal comfort come into play.

Dr. Johnson cited the example of parents who work multiple jobs to provide for their families: “Minimum wage is not a livable wage, and parents may not be available to ensure that children have consistent bedtimes.” Interventions, she added, may have to be at the neighborhood level, including placing sleep specialists in the local neighborhood “where the need is.” Cleaning up a neighborhood reduces crime and overall health, while light shielding in public housing can lower light pollution.

Observing that African Americans have higher rates of obstructive sleep apnea, Dr. Johnson and colleagues designed a screening tool specifically for African Americans with five prediction models with increasing levels of factor measurements (from 4 to 10). The prediction accuracy across the models ascended in lockstep with the number of measures from 74.0% to 76.1%, with the simplest model including only age, body mass index, male sex, and snoring. The latter model added witnessed apneas, high depressive symptoms, two measures of waist and neck size, and sleepiness. Dr. Johnson pointed out that accuracy for well-established predictive models is notably lower: STOP-Bang score ranges from 56% to 66%; NoSAS ranges from 58% to 66% and the HCHS prediction model accuracy is 70%. Dr. Johnson said that a Latino model they developed was more accurate than the traditional models, but not as accurate as their model for African Americans.

Turning to specific interventions, and underscoring higher levels of stress and anxiety among African American and Hispanic populations, Dr. Johnson cited MINDS (Mindfulness Intervention to Improve Sleep and Reduce Diabetes Risk Among a Diverse Sample in Atlanta), her study at Emory University of mindfulness meditation. Although prior studies have confirmed sleep benefits of mindfulness meditation, studies tailored for African American or Hispanic populations have been lacking.

The MINDS pilot study investigators enrolled 17 individuals (mostly women, with a mixture of racial and ethnic groups comprising Black, White, Asian and Hispanic patients) with poor sleep quality as measured by the Pittsburgh Sleep Quality Index (PSQI). Most patients, Dr. Johnson said, were overweight. Because of COVID restrictions on clinic visits, the diabetes portion of the study was dropped. All participants received at least 3 days of instruction on mindfulness meditation, on dealing with stress and anxiety, and on optimum sleep health practices. While PSQI scores higher than 5 are considered to indicate poor sleep quality, the mean PSQI score at study outset in MINDS was 9.2, she stated.

After 30 days of the intervention, stress (on a perceived stress scale) was improved, as were PSQI scores and actigraphy measures of sleep duration, efficiency and wakefulness after sleep onset, Dr. Johnson reported. “Participants found the mindfulness app to be acceptable and appropriate, and to reduce time to falling asleep,” Dr. Johnson said.

Qualitative data gathered post intervention from four focus groups (two to six participants in each; 1-1.5 hours in length), revealed general acceptability of the MINDS app. It showed also that among those with 50% or more adherence to the intervention, time to falling asleep was reduced, as were sleep awakenings at night. The most striking finding, Dr. Johnson said, was that individuals from among racial/ethnic minorities expressed appreciation of the diversity of the meditation instructors, and said that they preferred instruction from a person of their own race and sex. Findings would be even more striking with a larger sample size, Dr. Johnson speculated.

Citing TASHE (Tailored Approach to Sleep Health Education), a further observational study on obstructive sleep apnea knowledge conducted at New York University, Dr. Johnson addressed the fact that current messages are not tailored to race/ethnic minorities with low-to-moderate symptom knowledge. Also, a 3-arm randomized clinical trial of Internet-delivered treatment (Sleep Healthy or SHUTI) with a version revised for Black women (SHUTI-BWHS) showed findings similar to those of other studies cited and suggested: “Tailoring may be necessary to increase uptake and sustainability and to improve sleep among racial/ethnic minorities.”

Dr. Johnson noted, in closing, that Black/African American individuals have higher risk for obstructive sleep apnea than that of their White counterparts and lower rates of screening for treatment.

Dr. Johnson’s research was funded by the National Institutes of Health; National Heart, Lung, and Blood Institute; Woodruff Health Sciences Center; Synergy Award; Rollins School of Public Health Dean’s Pilot and Innovation Award; and Georgia Center for Diabetes Translation Research Pilot and Feasibility award program. She reported no relevant conflicts.

While trials of various interventions for obstructive sleep apnea and insomnia were effective, there was a strong suggestion that tailoring them according to the race/gender of the target populations strengthens engagement and improvements, according to a presentation by Dayna A. Johnson, PhD, MPH, at the annual meeting of the American College of Chest Physicians (CHEST).

Dr. Johnson, assistant professor at Emory University in Atlanta, stated that determinants of sleep disparities are multifactorial across the lifespan, from in utero to aging, but it was also important to focus on social determinants of poor sleep.

The complexity of factors, she said, calls for multilevel interventions beyond screening and treatment. Racism and discrimination come into play, especially with regard to anxiety and stress, In addition, neighborhood factors including safety, noise and light pollution, ventilation, and thermal comfort come into play.

Dr. Johnson cited the example of parents who work multiple jobs to provide for their families: “Minimum wage is not a livable wage, and parents may not be available to ensure that children have consistent bedtimes.” Interventions, she added, may have to be at the neighborhood level, including placing sleep specialists in the local neighborhood “where the need is.” Cleaning up a neighborhood reduces crime and overall health, while light shielding in public housing can lower light pollution.

Observing that African Americans have higher rates of obstructive sleep apnea, Dr. Johnson and colleagues designed a screening tool specifically for African Americans with five prediction models with increasing levels of factor measurements (from 4 to 10). The prediction accuracy across the models ascended in lockstep with the number of measures from 74.0% to 76.1%, with the simplest model including only age, body mass index, male sex, and snoring. The latter model added witnessed apneas, high depressive symptoms, two measures of waist and neck size, and sleepiness. Dr. Johnson pointed out that accuracy for well-established predictive models is notably lower: STOP-Bang score ranges from 56% to 66%; NoSAS ranges from 58% to 66% and the HCHS prediction model accuracy is 70%. Dr. Johnson said that a Latino model they developed was more accurate than the traditional models, but not as accurate as their model for African Americans.

Turning to specific interventions, and underscoring higher levels of stress and anxiety among African American and Hispanic populations, Dr. Johnson cited MINDS (Mindfulness Intervention to Improve Sleep and Reduce Diabetes Risk Among a Diverse Sample in Atlanta), her study at Emory University of mindfulness meditation. Although prior studies have confirmed sleep benefits of mindfulness meditation, studies tailored for African American or Hispanic populations have been lacking.

The MINDS pilot study investigators enrolled 17 individuals (mostly women, with a mixture of racial and ethnic groups comprising Black, White, Asian and Hispanic patients) with poor sleep quality as measured by the Pittsburgh Sleep Quality Index (PSQI). Most patients, Dr. Johnson said, were overweight. Because of COVID restrictions on clinic visits, the diabetes portion of the study was dropped. All participants received at least 3 days of instruction on mindfulness meditation, on dealing with stress and anxiety, and on optimum sleep health practices. While PSQI scores higher than 5 are considered to indicate poor sleep quality, the mean PSQI score at study outset in MINDS was 9.2, she stated.

After 30 days of the intervention, stress (on a perceived stress scale) was improved, as were PSQI scores and actigraphy measures of sleep duration, efficiency and wakefulness after sleep onset, Dr. Johnson reported. “Participants found the mindfulness app to be acceptable and appropriate, and to reduce time to falling asleep,” Dr. Johnson said.

Qualitative data gathered post intervention from four focus groups (two to six participants in each; 1-1.5 hours in length), revealed general acceptability of the MINDS app. It showed also that among those with 50% or more adherence to the intervention, time to falling asleep was reduced, as were sleep awakenings at night. The most striking finding, Dr. Johnson said, was that individuals from among racial/ethnic minorities expressed appreciation of the diversity of the meditation instructors, and said that they preferred instruction from a person of their own race and sex. Findings would be even more striking with a larger sample size, Dr. Johnson speculated.

Citing TASHE (Tailored Approach to Sleep Health Education), a further observational study on obstructive sleep apnea knowledge conducted at New York University, Dr. Johnson addressed the fact that current messages are not tailored to race/ethnic minorities with low-to-moderate symptom knowledge. Also, a 3-arm randomized clinical trial of Internet-delivered treatment (Sleep Healthy or SHUTI) with a version revised for Black women (SHUTI-BWHS) showed findings similar to those of other studies cited and suggested: “Tailoring may be necessary to increase uptake and sustainability and to improve sleep among racial/ethnic minorities.”

Dr. Johnson noted, in closing, that Black/African American individuals have higher risk for obstructive sleep apnea than that of their White counterparts and lower rates of screening for treatment.

Dr. Johnson’s research was funded by the National Institutes of Health; National Heart, Lung, and Blood Institute; Woodruff Health Sciences Center; Synergy Award; Rollins School of Public Health Dean’s Pilot and Innovation Award; and Georgia Center for Diabetes Translation Research Pilot and Feasibility award program. She reported no relevant conflicts.

Cardiovascular health (CVH) scores that include sleep predicted CV disease risk among older U.S. adults, supporting the American Heart Association’s recent inclusion of sleep in its own checklist.

Sleep duration is now considered “an essential component for ideal heart and brain health,” according to the AHA’s updated checklist, now called Life’s Essential 8. “Our study is the first to show that sleep metrics add independent predictive value for CVD events over and above the original seven cardiovascular health metrics, providing support for updating the guidelines from Life’s Simple 7 (LS7) to Life’s Essential 8,” lead author Nour Makarem, PhD, of the Mailman School of Public Health at Columbia University Irving Medical Center, New York, said in an interview.

For the study, her team compared four versions of LS7 checklists that included sleep in relation to cardiovascular disease (CVD) risk.

“CVH scores that included sleep duration alone as a measure of overall sleep health, as well as scores that included multiple dimensions of sleep health (that is, sleep duration, efficiency, and regularity, daytime sleepiness, and sleep disorders), were both predictive of future CVD,” she said.

Study participants scoring in the highest tertile of the CVH checklists that included sleep had up to a 47% lower CVD risk.

Sleeping 7 hours or more but less than 9 hours nightly was considered “ideal,” according to the study, which was published online  in the Journal of the American Heart Association.
 

Lower the odds

Dr. Makarem and colleagues analyzed data from participants in the Multi-Ethnic Study of Atherosclerosis (MESA) sleep study using overnight polysomnography, 7-day wrist actigraphy, validated questionnaires, and outcomes. They used the data to evaluate the four iterations of an expanded LS7 score:

• Score 1 included sleep duration;
• Score 2 included sleep characteristics linked to CVD in the literature (sleep duration, insomnia, daytime sleepiness, and obstructive sleep apnea [OSA]);
• Score 3 included sleep characteristics associated with CVD in MESA (sleep duration and efficiency, daytime sleepiness, and OSA); and
• Score 4, also based on CVD in MESA, included sleep regularity.

Among 1,920 participants (mean age 69 years; 54% women; 40%, White individuals), the mean LS7 score was 7.3, and the means of the alternate CVH scores that included sleep ranged from 7.4 to 7.8 (scores range from 0 to 14, with higher scores indicating better CVH).

On actigraphy, 63% of participants slept less than 7 hours; 30% slept less than 6 hours; 39% had high night-to-night variability in sleep duration; and 25% had high variability in sleep onset timing.

Overall, 10% had sleep efficiency less than 85%; 14% had excessive daytime sleepiness; 36% had high insomnia symptoms; and 47% had moderate to severe OSA. Short-duration sleepers also had a higher prevalence of overweight/obesity, diabetes, and hypertension and had lower mean LS7 scores.

During a mean follow-up of 4.4 years, 95 prevalent CVD events and 93 incident cases occurred.

Higher scores on all four expanded versions were related to lower odds of having CVD. Participants in the highest versus the lowest tertile of the LS7 score had 75% lower CVD odds (odds ratio, 0.25). Similarly, those in the highest versus the lowest tertile of CVH scores 1 and 2 had 71% and 80% lower odds of prevalent CVD (OR, 0.29 and OR, 0.20), respectively.

Overall, participants in the highest versus lowest tertile of the LS7 score and all CVH scores had up to 80% lower odds of prevalent CVD; those in the highest versus lowest tertile of CVH score 1, which included sleep duration, and CVH score 4, which included multidimensional sleep health, had 43% and 47% lower incident CVD risk (hazard ratios, 0.57 and 0.53), respectively.

The LS7 score alone was not significantly associated with CVD incidence (HR, 0.62).

“Clinicians should ask patients about their sleep health and emphasize the importance of prioritizing sleep for heart disease prevention,” Dr. Makarem said.
 

Sleep ‘devalued’

“The sleep field has been fighting to get more sleep education into medical education for decades,” AHA volunteer expert Michael A. Grandner, PhD, Director of the Sleep & Health Research Program and of the Behavioral Sleep Medicine Clinic at the University of Arizona College of Medicine, Tucson, said in an interview.

“To my knowledge, there still is not a lot of attention given to it, partly because the culture in medical school and among residents is one of not sleeping,” said Dr. Grandner, who was not involved in the study. “The culture among physicians is ‘Who needs sleep? I function fine without it.’ ”

“Sleep made it to the checklist because it is a biological requirement for human life,” he noted. “We sleep for the same reason we breathe and drink. It’s an imperative. Yet we live in a society that devalues sleep.”

It’s “extremely unusual” for a doctor to ask a patient how they’re sleeping, he said. “It’s also pretty unusual to have sleep-related conversations between doctors and patients, especially in the context of health, not just, ‘Hey, doc, I can’t sleep, throw me a pill.’”

Clinicians should be asking every patient about how they’re sleeping at every visit, Dr. Grandner said. “It’s now part of the official definition of heart health. Just like you would be remiss if you didn’t ask about smoking or test blood pressure, you’d be missing something important by not asking about sleep – something that has similar billing to diet, exercise, blood pressure, and all the other ‘essentials.’ ”

No commercial funding or conflicts of interest were declared.

A version of this article first appeared on Medscape.com.

Cardiovascular health (CVH) scores that include sleep predicted CV disease risk among older U.S. adults, supporting the American Heart Association’s recent inclusion of sleep in its own checklist.

Sleep duration is now considered “an essential component for ideal heart and brain health,” according to the AHA’s updated checklist, now called Life’s Essential 8. “Our study is the first to show that sleep metrics add independent predictive value for CVD events over and above the original seven cardiovascular health metrics, providing support for updating the guidelines from Life’s Simple 7 (LS7) to Life’s Essential 8,” lead author Nour Makarem, PhD, of the Mailman School of Public Health at Columbia University Irving Medical Center, New York, said in an interview.

For the study, her team compared four versions of LS7 checklists that included sleep in relation to cardiovascular disease (CVD) risk.

“CVH scores that included sleep duration alone as a measure of overall sleep health, as well as scores that included multiple dimensions of sleep health (that is, sleep duration, efficiency, and regularity, daytime sleepiness, and sleep disorders), were both predictive of future CVD,” she said.

Study participants scoring in the highest tertile of the CVH checklists that included sleep had up to a 47% lower CVD risk.

Sleeping 7 hours or more but less than 9 hours nightly was considered “ideal,” according to the study, which was published online  in the Journal of the American Heart Association.
 

Lower the odds

Dr. Makarem and colleagues analyzed data from participants in the Multi-Ethnic Study of Atherosclerosis (MESA) sleep study using overnight polysomnography, 7-day wrist actigraphy, validated questionnaires, and outcomes. They used the data to evaluate the four iterations of an expanded LS7 score:

• Score 1 included sleep duration;
• Score 2 included sleep characteristics linked to CVD in the literature (sleep duration, insomnia, daytime sleepiness, and obstructive sleep apnea [OSA]);
• Score 3 included sleep characteristics associated with CVD in MESA (sleep duration and efficiency, daytime sleepiness, and OSA); and
• Score 4, also based on CVD in MESA, included sleep regularity.

Among 1,920 participants (mean age 69 years; 54% women; 40%, White individuals), the mean LS7 score was 7.3, and the means of the alternate CVH scores that included sleep ranged from 7.4 to 7.8 (scores range from 0 to 14, with higher scores indicating better CVH).

On actigraphy, 63% of participants slept less than 7 hours; 30% slept less than 6 hours; 39% had high night-to-night variability in sleep duration; and 25% had high variability in sleep onset timing.

Overall, 10% had sleep efficiency less than 85%; 14% had excessive daytime sleepiness; 36% had high insomnia symptoms; and 47% had moderate to severe OSA. Short-duration sleepers also had a higher prevalence of overweight/obesity, diabetes, and hypertension and had lower mean LS7 scores.

During a mean follow-up of 4.4 years, 95 prevalent CVD events and 93 incident cases occurred.

Higher scores on all four expanded versions were related to lower odds of having CVD. Participants in the highest versus the lowest tertile of the LS7 score had 75% lower CVD odds (odds ratio, 0.25). Similarly, those in the highest versus the lowest tertile of CVH scores 1 and 2 had 71% and 80% lower odds of prevalent CVD (OR, 0.29 and OR, 0.20), respectively.

Overall, participants in the highest versus lowest tertile of the LS7 score and all CVH scores had up to 80% lower odds of prevalent CVD; those in the highest versus lowest tertile of CVH score 1, which included sleep duration, and CVH score 4, which included multidimensional sleep health, had 43% and 47% lower incident CVD risk (hazard ratios, 0.57 and 0.53), respectively.

The LS7 score alone was not significantly associated with CVD incidence (HR, 0.62).

“Clinicians should ask patients about their sleep health and emphasize the importance of prioritizing sleep for heart disease prevention,” Dr. Makarem said.
 

Sleep ‘devalued’

“The sleep field has been fighting to get more sleep education into medical education for decades,” AHA volunteer expert Michael A. Grandner, PhD, Director of the Sleep & Health Research Program and of the Behavioral Sleep Medicine Clinic at the University of Arizona College of Medicine, Tucson, said in an interview.

“To my knowledge, there still is not a lot of attention given to it, partly because the culture in medical school and among residents is one of not sleeping,” said Dr. Grandner, who was not involved in the study. “The culture among physicians is ‘Who needs sleep? I function fine without it.’ ”

“Sleep made it to the checklist because it is a biological requirement for human life,” he noted. “We sleep for the same reason we breathe and drink. It’s an imperative. Yet we live in a society that devalues sleep.”

It’s “extremely unusual” for a doctor to ask a patient how they’re sleeping, he said. “It’s also pretty unusual to have sleep-related conversations between doctors and patients, especially in the context of health, not just, ‘Hey, doc, I can’t sleep, throw me a pill.’”

Clinicians should be asking every patient about how they’re sleeping at every visit, Dr. Grandner said. “It’s now part of the official definition of heart health. Just like you would be remiss if you didn’t ask about smoking or test blood pressure, you’d be missing something important by not asking about sleep – something that has similar billing to diet, exercise, blood pressure, and all the other ‘essentials.’ ”

No commercial funding or conflicts of interest were declared.

A version of this article first appeared on Medscape.com.

Cardiovascular health (CVH) scores that include sleep predicted CV disease risk among older U.S. adults, supporting the American Heart Association’s recent inclusion of sleep in its own checklist.

Sleep duration is now considered “an essential component for ideal heart and brain health,” according to the AHA’s updated checklist, now called Life’s Essential 8. “Our study is the first to show that sleep metrics add independent predictive value for CVD events over and above the original seven cardiovascular health metrics, providing support for updating the guidelines from Life’s Simple 7 (LS7) to Life’s Essential 8,” lead author Nour Makarem, PhD, of the Mailman School of Public Health at Columbia University Irving Medical Center, New York, said in an interview.

For the study, her team compared four versions of LS7 checklists that included sleep in relation to cardiovascular disease (CVD) risk.

“CVH scores that included sleep duration alone as a measure of overall sleep health, as well as scores that included multiple dimensions of sleep health (that is, sleep duration, efficiency, and regularity, daytime sleepiness, and sleep disorders), were both predictive of future CVD,” she said.

Study participants scoring in the highest tertile of the CVH checklists that included sleep had up to a 47% lower CVD risk.

Sleeping 7 hours or more but less than 9 hours nightly was considered “ideal,” according to the study, which was published online  in the Journal of the American Heart Association.
 

Lower the odds

Dr. Makarem and colleagues analyzed data from participants in the Multi-Ethnic Study of Atherosclerosis (MESA) sleep study using overnight polysomnography, 7-day wrist actigraphy, validated questionnaires, and outcomes. They used the data to evaluate the four iterations of an expanded LS7 score:

• Score 1 included sleep duration;
• Score 2 included sleep characteristics linked to CVD in the literature (sleep duration, insomnia, daytime sleepiness, and obstructive sleep apnea [OSA]);
• Score 3 included sleep characteristics associated with CVD in MESA (sleep duration and efficiency, daytime sleepiness, and OSA); and
• Score 4, also based on CVD in MESA, included sleep regularity.

Among 1,920 participants (mean age 69 years; 54% women; 40%, White individuals), the mean LS7 score was 7.3, and the means of the alternate CVH scores that included sleep ranged from 7.4 to 7.8 (scores range from 0 to 14, with higher scores indicating better CVH).

On actigraphy, 63% of participants slept less than 7 hours; 30% slept less than 6 hours; 39% had high night-to-night variability in sleep duration; and 25% had high variability in sleep onset timing.

Overall, 10% had sleep efficiency less than 85%; 14% had excessive daytime sleepiness; 36% had high insomnia symptoms; and 47% had moderate to severe OSA. Short-duration sleepers also had a higher prevalence of overweight/obesity, diabetes, and hypertension and had lower mean LS7 scores.

During a mean follow-up of 4.4 years, 95 prevalent CVD events and 93 incident cases occurred.

Higher scores on all four expanded versions were related to lower odds of having CVD. Participants in the highest versus the lowest tertile of the LS7 score had 75% lower CVD odds (odds ratio, 0.25). Similarly, those in the highest versus the lowest tertile of CVH scores 1 and 2 had 71% and 80% lower odds of prevalent CVD (OR, 0.29 and OR, 0.20), respectively.

Overall, participants in the highest versus lowest tertile of the LS7 score and all CVH scores had up to 80% lower odds of prevalent CVD; those in the highest versus lowest tertile of CVH score 1, which included sleep duration, and CVH score 4, which included multidimensional sleep health, had 43% and 47% lower incident CVD risk (hazard ratios, 0.57 and 0.53), respectively.

The LS7 score alone was not significantly associated with CVD incidence (HR, 0.62).

“Clinicians should ask patients about their sleep health and emphasize the importance of prioritizing sleep for heart disease prevention,” Dr. Makarem said.
 

Sleep ‘devalued’

“The sleep field has been fighting to get more sleep education into medical education for decades,” AHA volunteer expert Michael A. Grandner, PhD, Director of the Sleep & Health Research Program and of the Behavioral Sleep Medicine Clinic at the University of Arizona College of Medicine, Tucson, said in an interview.

“To my knowledge, there still is not a lot of attention given to it, partly because the culture in medical school and among residents is one of not sleeping,” said Dr. Grandner, who was not involved in the study. “The culture among physicians is ‘Who needs sleep? I function fine without it.’ ”

“Sleep made it to the checklist because it is a biological requirement for human life,” he noted. “We sleep for the same reason we breathe and drink. It’s an imperative. Yet we live in a society that devalues sleep.”

It’s “extremely unusual” for a doctor to ask a patient how they’re sleeping, he said. “It’s also pretty unusual to have sleep-related conversations between doctors and patients, especially in the context of health, not just, ‘Hey, doc, I can’t sleep, throw me a pill.’”

Clinicians should be asking every patient about how they’re sleeping at every visit, Dr. Grandner said. “It’s now part of the official definition of heart health. Just like you would be remiss if you didn’t ask about smoking or test blood pressure, you’d be missing something important by not asking about sleep – something that has similar billing to diet, exercise, blood pressure, and all the other ‘essentials.’ ”

No commercial funding or conflicts of interest were declared.

A version of this article first appeared on Medscape.com.

Individuals who are middle-aged and older and who sleep 5 hours or less a night may be at risk for an array of serious and chronic health conditions, ranging from heart disease to cancer, results of a large study show.

Researchers at University College London and Université Paris Cité found that beginning at age 50, those who slept 5 hours or fewer a night had a 30% higher risk of developing multiple chronic diseases over time than those who slept at least 7 hours a night. By the time the participants were aged 70 years, that risk had increased to 40%.

Diseases for which there was a higher risk included diabetes, cancer, coronary heart disease, stroke, heart failure, chronic obstructive pulmonary disease, chronic kidney disease, liver disease, depression, dementia, Parkinson’s disease, and arthritis.

“It is important to take care of our sleep,” lead investigator Séverine Sabia, PhD, said in an interview. Dr. Sabia is a researcher and epidemiologist at Université Paris Cité and INSERM in Paris, and the University College London.

She noted that the source of the sleep problem must be addressed, but in cases in which there is no medical reason for sleep paucity, “healthy sleep habits are a must. These include keeping a regular sleep schedule, a healthy lifestyle – physical activity and light exposure during the day, and a light dinner – and avoidance of screens for a half hour before sleep.”

The study was published online in PLOS Medicine.
 

Risk of multiple chronic diseases

Prior research suggests that sleeping for 5 hours or less or 9 hours or more is associated with cancer and cardiovascular disease (CVD).

For the current study, Dr. Sabia and her team asked nearly 8,000 civil servants in the United Kingdom as part of the Whitehall II cohort study to report the amount of sleep they received beginning at age 50 every 4 to 5 years for the next 25 years. Study participants were free of chronic disease at age 50 and were mostly male (67.5%) and White (90%).

The investigators found that at age 50, those who slept 5 hours or less were 30% more likely to be diagnosed with multiple chronic diseases over time, (hazard ratio, 1.30; 95% confidence interval, 1.12-1.50; P < .001) compared with their peers who slept 7 hours.

At age 60, those who slept 5 hours or less had a 32% greater risk of developing more than one chronic disease (HR, 1.32; 95% CI, 1.13-1.55; P < .001), and by age 70, this risk increased to 40% compared with their peers who slept 7 hours a night (HR, 1.40; 95% CI, 1.16-1.68; P < .001).

For participants who slept 9 or more hours per night, only those aged 60 (HR, 1.54; 95% CI, 1.15-2.06; P = .003) and 70 (HR, 1.51; 95% CI, 1.10-2.08; P = .010) were at increased risk of developing more than one chronic disease.

Dr. Sabia noted that previous studies have shown that those who slept less than 5 hours a night were more likely to develop diabetes, hypertension, CVD, or dementia. “However, chronic diseases often coexist, particularly at older ages, and it remains unclear how sleep duration may be associated with risk of multimorbidity,” she said. She noted that several biological hypotheses have been proposed as underlying the association.

“Sleep is important for the regulation of several body functions, such as metabolic, endocrine, and inflammatory regulation over the day, that in turn, when dysregulated, may contribute to increased risk of several chronic conditions.”

The authors acknowledge several study limitations, including the fact that the data were obtained via participant self-reports, which may be affected by reporting bias. There was also a lack of diversity within the study sample, as the civil servants were mostly male and White. In addition to this, the investigators note that the study population of British civil servants tended to be healthier than the general population.
 

Chicken or egg?

Commenting on the findings for this article, Charlene Gamaldo, MD, urged caution in interpreting the findings. She noted that self-reporting of sleep has been established as “potentially problematic” because it doesn’t always correlate with actual sleep.

Dr. Gamaldo, who is professor of neurology and psychiatry at Johns Hopkins University in Baltimore and the medical director of the JHU Center for Sleep and Wellness, said previous studies have shown that underestimation of sleep can occur among those suffering with insomnia and that overestimation can be seen among individuals with behaviorally based chronic, insufficient sleep.

Dr. Gamaldo also raised the issue of sleep quality.

“Getting 5 hours of high-quality sleep is less worrisome than one getting 8 hours of terrible-quality, based on untreated sleep apnea, for instance,” she noted.

In addition, she pointed out that chronic health problems can interrupt sleep. “Which is the chicken, and which is the egg?” she asked.

“For me, the take-home of current literature and supported by this paper is that individuals with sleep quality complaints, short duration, or related impact in daytime function should address them with their treating provider to assess for the underlying cause.

“Those sleeping under 5 hours without complaints should consider whether 5 hours really represents the amount of sleep they need to wake rested and function at their best. If answer is no, they should prioritize getting more sleep,” she concluded.

The study was funded by the National Institute on Aging, the National Institute of Health, the UK Research Medical Council, the British Heart Foundation, the Wellcome Trust, and the French National Research Agency. The investigators and Dr. Gamaldo report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Individuals who are middle-aged and older and who sleep 5 hours or less a night may be at risk for an array of serious and chronic health conditions, ranging from heart disease to cancer, results of a large study show.

Researchers at University College London and Université Paris Cité found that beginning at age 50, those who slept 5 hours or fewer a night had a 30% higher risk of developing multiple chronic diseases over time than those who slept at least 7 hours a night. By the time the participants were aged 70 years, that risk had increased to 40%.

Diseases for which there was a higher risk included diabetes, cancer, coronary heart disease, stroke, heart failure, chronic obstructive pulmonary disease, chronic kidney disease, liver disease, depression, dementia, Parkinson’s disease, and arthritis.

“It is important to take care of our sleep,” lead investigator Séverine Sabia, PhD, said in an interview. Dr. Sabia is a researcher and epidemiologist at Université Paris Cité and INSERM in Paris, and the University College London.

She noted that the source of the sleep problem must be addressed, but in cases in which there is no medical reason for sleep paucity, “healthy sleep habits are a must. These include keeping a regular sleep schedule, a healthy lifestyle – physical activity and light exposure during the day, and a light dinner – and avoidance of screens for a half hour before sleep.”

The study was published online in PLOS Medicine.
 

Risk of multiple chronic diseases

Prior research suggests that sleeping for 5 hours or less or 9 hours or more is associated with cancer and cardiovascular disease (CVD).

For the current study, Dr. Sabia and her team asked nearly 8,000 civil servants in the United Kingdom as part of the Whitehall II cohort study to report the amount of sleep they received beginning at age 50 every 4 to 5 years for the next 25 years. Study participants were free of chronic disease at age 50 and were mostly male (67.5%) and White (90%).

The investigators found that at age 50, those who slept 5 hours or less were 30% more likely to be diagnosed with multiple chronic diseases over time, (hazard ratio, 1.30; 95% confidence interval, 1.12-1.50; P < .001) compared with their peers who slept 7 hours.

At age 60, those who slept 5 hours or less had a 32% greater risk of developing more than one chronic disease (HR, 1.32; 95% CI, 1.13-1.55; P < .001), and by age 70, this risk increased to 40% compared with their peers who slept 7 hours a night (HR, 1.40; 95% CI, 1.16-1.68; P < .001).

For participants who slept 9 or more hours per night, only those aged 60 (HR, 1.54; 95% CI, 1.15-2.06; P = .003) and 70 (HR, 1.51; 95% CI, 1.10-2.08; P = .010) were at increased risk of developing more than one chronic disease.

Dr. Sabia noted that previous studies have shown that those who slept less than 5 hours a night were more likely to develop diabetes, hypertension, CVD, or dementia. “However, chronic diseases often coexist, particularly at older ages, and it remains unclear how sleep duration may be associated with risk of multimorbidity,” she said. She noted that several biological hypotheses have been proposed as underlying the association.

“Sleep is important for the regulation of several body functions, such as metabolic, endocrine, and inflammatory regulation over the day, that in turn, when dysregulated, may contribute to increased risk of several chronic conditions.”

The authors acknowledge several study limitations, including the fact that the data were obtained via participant self-reports, which may be affected by reporting bias. There was also a lack of diversity within the study sample, as the civil servants were mostly male and White. In addition to this, the investigators note that the study population of British civil servants tended to be healthier than the general population.
 

Chicken or egg?

Commenting on the findings for this article, Charlene Gamaldo, MD, urged caution in interpreting the findings. She noted that self-reporting of sleep has been established as “potentially problematic” because it doesn’t always correlate with actual sleep.

Dr. Gamaldo, who is professor of neurology and psychiatry at Johns Hopkins University in Baltimore and the medical director of the JHU Center for Sleep and Wellness, said previous studies have shown that underestimation of sleep can occur among those suffering with insomnia and that overestimation can be seen among individuals with behaviorally based chronic, insufficient sleep.

Dr. Gamaldo also raised the issue of sleep quality.

“Getting 5 hours of high-quality sleep is less worrisome than one getting 8 hours of terrible-quality, based on untreated sleep apnea, for instance,” she noted.

In addition, she pointed out that chronic health problems can interrupt sleep. “Which is the chicken, and which is the egg?” she asked.

“For me, the take-home of current literature and supported by this paper is that individuals with sleep quality complaints, short duration, or related impact in daytime function should address them with their treating provider to assess for the underlying cause.

“Those sleeping under 5 hours without complaints should consider whether 5 hours really represents the amount of sleep they need to wake rested and function at their best. If answer is no, they should prioritize getting more sleep,” she concluded.

The study was funded by the National Institute on Aging, the National Institute of Health, the UK Research Medical Council, the British Heart Foundation, the Wellcome Trust, and the French National Research Agency. The investigators and Dr. Gamaldo report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Individuals who are middle-aged and older and who sleep 5 hours or less a night may be at risk for an array of serious and chronic health conditions, ranging from heart disease to cancer, results of a large study show.

Researchers at University College London and Université Paris Cité found that beginning at age 50, those who slept 5 hours or fewer a night had a 30% higher risk of developing multiple chronic diseases over time than those who slept at least 7 hours a night. By the time the participants were aged 70 years, that risk had increased to 40%.

Diseases for which there was a higher risk included diabetes, cancer, coronary heart disease, stroke, heart failure, chronic obstructive pulmonary disease, chronic kidney disease, liver disease, depression, dementia, Parkinson’s disease, and arthritis.

“It is important to take care of our sleep,” lead investigator Séverine Sabia, PhD, said in an interview. Dr. Sabia is a researcher and epidemiologist at Université Paris Cité and INSERM in Paris, and the University College London.

She noted that the source of the sleep problem must be addressed, but in cases in which there is no medical reason for sleep paucity, “healthy sleep habits are a must. These include keeping a regular sleep schedule, a healthy lifestyle – physical activity and light exposure during the day, and a light dinner – and avoidance of screens for a half hour before sleep.”

The study was published online in PLOS Medicine.
 

Risk of multiple chronic diseases

Prior research suggests that sleeping for 5 hours or less or 9 hours or more is associated with cancer and cardiovascular disease (CVD).

For the current study, Dr. Sabia and her team asked nearly 8,000 civil servants in the United Kingdom as part of the Whitehall II cohort study to report the amount of sleep they received beginning at age 50 every 4 to 5 years for the next 25 years. Study participants were free of chronic disease at age 50 and were mostly male (67.5%) and White (90%).

The investigators found that at age 50, those who slept 5 hours or less were 30% more likely to be diagnosed with multiple chronic diseases over time, (hazard ratio, 1.30; 95% confidence interval, 1.12-1.50; P < .001) compared with their peers who slept 7 hours.

At age 60, those who slept 5 hours or less had a 32% greater risk of developing more than one chronic disease (HR, 1.32; 95% CI, 1.13-1.55; P < .001), and by age 70, this risk increased to 40% compared with their peers who slept 7 hours a night (HR, 1.40; 95% CI, 1.16-1.68; P < .001).

For participants who slept 9 or more hours per night, only those aged 60 (HR, 1.54; 95% CI, 1.15-2.06; P = .003) and 70 (HR, 1.51; 95% CI, 1.10-2.08; P = .010) were at increased risk of developing more than one chronic disease.

Dr. Sabia noted that previous studies have shown that those who slept less than 5 hours a night were more likely to develop diabetes, hypertension, CVD, or dementia. “However, chronic diseases often coexist, particularly at older ages, and it remains unclear how sleep duration may be associated with risk of multimorbidity,” she said. She noted that several biological hypotheses have been proposed as underlying the association.

“Sleep is important for the regulation of several body functions, such as metabolic, endocrine, and inflammatory regulation over the day, that in turn, when dysregulated, may contribute to increased risk of several chronic conditions.”

The authors acknowledge several study limitations, including the fact that the data were obtained via participant self-reports, which may be affected by reporting bias. There was also a lack of diversity within the study sample, as the civil servants were mostly male and White. In addition to this, the investigators note that the study population of British civil servants tended to be healthier than the general population.
 

Chicken or egg?

Commenting on the findings for this article, Charlene Gamaldo, MD, urged caution in interpreting the findings. She noted that self-reporting of sleep has been established as “potentially problematic” because it doesn’t always correlate with actual sleep.

Dr. Gamaldo, who is professor of neurology and psychiatry at Johns Hopkins University in Baltimore and the medical director of the JHU Center for Sleep and Wellness, said previous studies have shown that underestimation of sleep can occur among those suffering with insomnia and that overestimation can be seen among individuals with behaviorally based chronic, insufficient sleep.

Dr. Gamaldo also raised the issue of sleep quality.

“Getting 5 hours of high-quality sleep is less worrisome than one getting 8 hours of terrible-quality, based on untreated sleep apnea, for instance,” she noted.

In addition, she pointed out that chronic health problems can interrupt sleep. “Which is the chicken, and which is the egg?” she asked.

“For me, the take-home of current literature and supported by this paper is that individuals with sleep quality complaints, short duration, or related impact in daytime function should address them with their treating provider to assess for the underlying cause.

“Those sleeping under 5 hours without complaints should consider whether 5 hours really represents the amount of sleep they need to wake rested and function at their best. If answer is no, they should prioritize getting more sleep,” she concluded.

The study was funded by the National Institute on Aging, the National Institute of Health, the UK Research Medical Council, the British Heart Foundation, the Wellcome Trust, and the French National Research Agency. The investigators and Dr. Gamaldo report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Mental health symptoms at the time of admission to an inpatient psychiatric hospital were significantly more severe during the COVID-19 pandemic compared to the time before the pandemic, based on data from more than 500 individuals.

“Those with preexisting mental health conditions may be particularly vulnerable to these effects because they are more susceptible to experiencing high levels of stress during a crisis and are more likely to experience isolation/despair during confinement compared to the general population,” wrote Danna Ramirez of The Menninger Clinic, Houston, and colleagues.

In a study published in Psychiatry Research , the investigators compared data from 142 adolescents aged 12-17 years and 470 adults aged 18-79 years who were admitted to an inpatient psychiatric hospital in Houston. Of these, 65 adolescents and 235 adults were admitted before the pandemic, and 77 adolescents and 235 adults were admitted during the pandemic.

Clinical outcomes were scores on the Generalized Anxiety Disorder Scale (GAD-7), the Patient Health Questionnaire (PHQ-9), the Patient Health Questionnaire for Adolescents (PHQ-A), the Difficulties in Emotion Regulation Scale–Short Form (DERS-SF), the World Health Organization Disability Assessment Scale (WHODAS), the World Health Organization Alcohol, Smoking, and Substance Involvement Screening Test (WHOASSIST), the Pittsburgh Sleep Quality Index (PSQI), the Disturbing Dream and Nightmare Severity Index (DDNSI), and the Suicide Behaviors Questionnaire–Revised (SBQ-R).

Overall, adults admitted during the pandemic had significantly higher levels of anxiety, depression, emotional dysregulation, and disability (P < .001 for all) as well as nightmares (P = .013) compared to those admitted prior to the pandemic.

Among adolescents, measures of anxiety, depression, and sleep quality were significantly higher at admission during the pandemic compared to prior to the pandemic (P = .005, P = .005, and P = .011, respectively)

Reasons for the increase in symptom severity remain unclear, but include the possibility that individuals with preexisting mental illness simply became more ill; or that individuals with symptoms delayed hospital admission out of fear of exposure to COVID-19, which resulted in more severe symptoms at admission, the researchers wrote in their discussion.

The findings were limited by several factors, including the primarily White population and the reliance on self-reports, the researchers noted. Another limitation was the lack of differentiation between patients who may have had COVID-19 before hospitalization and those who did not, so the researchers could not determine whether the virus itself played a biological role in symptom severity.

However, the results support data from previous studies and identify increased psychiatry symptom severity for patients admitted for inpatient psychiatry care during the pandemic, they said. Although resources are scarce, the findings emphasize that mental health needs, especially for those with preexisting conditions, should not be overlooked, and continuity and expansion of access to mental health care for all should be prioritized, they concluded.

The study was supported by The Menninger Clinic and The Menninger Clinic Foundation. The researchers had no financial conflicts to disclose.

Mental health symptoms at the time of admission to an inpatient psychiatric hospital were significantly more severe during the COVID-19 pandemic compared to the time before the pandemic, based on data from more than 500 individuals.

“Those with preexisting mental health conditions may be particularly vulnerable to these effects because they are more susceptible to experiencing high levels of stress during a crisis and are more likely to experience isolation/despair during confinement compared to the general population,” wrote Danna Ramirez of The Menninger Clinic, Houston, and colleagues.

In a study published in Psychiatry Research , the investigators compared data from 142 adolescents aged 12-17 years and 470 adults aged 18-79 years who were admitted to an inpatient psychiatric hospital in Houston. Of these, 65 adolescents and 235 adults were admitted before the pandemic, and 77 adolescents and 235 adults were admitted during the pandemic.

Clinical outcomes were scores on the Generalized Anxiety Disorder Scale (GAD-7), the Patient Health Questionnaire (PHQ-9), the Patient Health Questionnaire for Adolescents (PHQ-A), the Difficulties in Emotion Regulation Scale–Short Form (DERS-SF), the World Health Organization Disability Assessment Scale (WHODAS), the World Health Organization Alcohol, Smoking, and Substance Involvement Screening Test (WHOASSIST), the Pittsburgh Sleep Quality Index (PSQI), the Disturbing Dream and Nightmare Severity Index (DDNSI), and the Suicide Behaviors Questionnaire–Revised (SBQ-R).

Overall, adults admitted during the pandemic had significantly higher levels of anxiety, depression, emotional dysregulation, and disability (P < .001 for all) as well as nightmares (P = .013) compared to those admitted prior to the pandemic.

Among adolescents, measures of anxiety, depression, and sleep quality were significantly higher at admission during the pandemic compared to prior to the pandemic (P = .005, P = .005, and P = .011, respectively)

Reasons for the increase in symptom severity remain unclear, but include the possibility that individuals with preexisting mental illness simply became more ill; or that individuals with symptoms delayed hospital admission out of fear of exposure to COVID-19, which resulted in more severe symptoms at admission, the researchers wrote in their discussion.

The findings were limited by several factors, including the primarily White population and the reliance on self-reports, the researchers noted. Another limitation was the lack of differentiation between patients who may have had COVID-19 before hospitalization and those who did not, so the researchers could not determine whether the virus itself played a biological role in symptom severity.

However, the results support data from previous studies and identify increased psychiatry symptom severity for patients admitted for inpatient psychiatry care during the pandemic, they said. Although resources are scarce, the findings emphasize that mental health needs, especially for those with preexisting conditions, should not be overlooked, and continuity and expansion of access to mental health care for all should be prioritized, they concluded.

The study was supported by The Menninger Clinic and The Menninger Clinic Foundation. The researchers had no financial conflicts to disclose.

Mental health symptoms at the time of admission to an inpatient psychiatric hospital were significantly more severe during the COVID-19 pandemic compared to the time before the pandemic, based on data from more than 500 individuals.

“Those with preexisting mental health conditions may be particularly vulnerable to these effects because they are more susceptible to experiencing high levels of stress during a crisis and are more likely to experience isolation/despair during confinement compared to the general population,” wrote Danna Ramirez of The Menninger Clinic, Houston, and colleagues.

In a study published in Psychiatry Research , the investigators compared data from 142 adolescents aged 12-17 years and 470 adults aged 18-79 years who were admitted to an inpatient psychiatric hospital in Houston. Of these, 65 adolescents and 235 adults were admitted before the pandemic, and 77 adolescents and 235 adults were admitted during the pandemic.

Clinical outcomes were scores on the Generalized Anxiety Disorder Scale (GAD-7), the Patient Health Questionnaire (PHQ-9), the Patient Health Questionnaire for Adolescents (PHQ-A), the Difficulties in Emotion Regulation Scale–Short Form (DERS-SF), the World Health Organization Disability Assessment Scale (WHODAS), the World Health Organization Alcohol, Smoking, and Substance Involvement Screening Test (WHOASSIST), the Pittsburgh Sleep Quality Index (PSQI), the Disturbing Dream and Nightmare Severity Index (DDNSI), and the Suicide Behaviors Questionnaire–Revised (SBQ-R).

Overall, adults admitted during the pandemic had significantly higher levels of anxiety, depression, emotional dysregulation, and disability (P < .001 for all) as well as nightmares (P = .013) compared to those admitted prior to the pandemic.

Among adolescents, measures of anxiety, depression, and sleep quality were significantly higher at admission during the pandemic compared to prior to the pandemic (P = .005, P = .005, and P = .011, respectively)

Reasons for the increase in symptom severity remain unclear, but include the possibility that individuals with preexisting mental illness simply became more ill; or that individuals with symptoms delayed hospital admission out of fear of exposure to COVID-19, which resulted in more severe symptoms at admission, the researchers wrote in their discussion.

The findings were limited by several factors, including the primarily White population and the reliance on self-reports, the researchers noted. Another limitation was the lack of differentiation between patients who may have had COVID-19 before hospitalization and those who did not, so the researchers could not determine whether the virus itself played a biological role in symptom severity.

However, the results support data from previous studies and identify increased psychiatry symptom severity for patients admitted for inpatient psychiatry care during the pandemic, they said. Although resources are scarce, the findings emphasize that mental health needs, especially for those with preexisting conditions, should not be overlooked, and continuity and expansion of access to mental health care for all should be prioritized, they concluded.

The study was supported by The Menninger Clinic and The Menninger Clinic Foundation. The researchers had no financial conflicts to disclose.

A stuffed animal, aromatherapy, a night light. A kit containing these and other items can help children in foster care who have experienced trauma sleep more soundly, a critical step in helping them cope with their emotional distress. 

In a new study, researchers at the Children’s Hospital of Philadelphia reported that sleep kits specially tailored to foster children appeared to be helpful in most cases. The kits can be distributed by pediatricians in the office or clinic setting.

“Children who have experienced trauma can have issues with behavior, it can impact their school, and they have difficulties sleeping,” said Kristine Fortin, MD, MPH, director of the fostering health program at Safe Place: Center for Child Protection and Health at CHOP. “I thought, what could a pediatrician do in the office in one visit to help children with sleep?”

Dr. Fortin and colleagues designed sleep kits for both younger children and adolescents.

The version for teenagers contained a sound machine, aromatherapy spray, and a sleep mask. The kits for younger children contained matching stuffed toys to share with someone they felt connected to, and a rechargeable night-light. All kits included written materials about sleep hygiene, a journal, and directions for downloading a free age-appropriate relaxation app for belly breathing or a PTSD Coach app from the Department of Veterans Affairs to manage symptoms of trauma.

In a pilot study presented at the annual meeting of the American Academy of Pediatrics, Dr. Fortin and colleagues surveyed caregivers in foster homes about their use of the kits.

Of the 20 foster parents who responded to the survey, 11 said the kits helped “very much,” 5 others reported they helped “somewhat,” another 2 reported no improvements in sleep, and 2 said they didn’t know the effect. The children for whom results were unknown moved from the home without the sleep kit or had difficulties communicating with the foster parents, resulting in incomplete assessment, according to the researchers. 

Night-lights were used most in the kits, followed by the stuffed toys, sound machines, and sleep journals.

Dr. Fortin said existing resources like sleep therapy or medication can be costly or difficult to find, and many pediatricians don’t have enough time during wellness visits to address symptoms like sleep deprivation. She said the sleep kits could be an alternative to other forms of sleep therapy. “If these sleep kits were effective, and could really help them sleep, then maybe less children would need something like medication.”

Dr. Fortin said the kits her group has designed are tailored specifically for children with symptoms of trauma, or with difficult emotions associated with foster care.

“We’ve tried to design something that can be really practical and easy to use in a pediatric visit, where there’s a lot of written information that can be discussed with the child and their family,” Dr. Fortin said.

She added that she would like to see clinicians give out the sleep kits during in-office visits.

“These sleep issues are common in foster children,” she said. “We felt it was important to do an intervention.”

Kristina Lenker, PhD, a sleep psychologist at Penn State Health, Hershey, said children in foster care often struggle with falling or staying asleep, an inability to sleep alone, nightmares, and bed wetting.

“Sleep kits can be particularly helpful for these children, given how they can help caregivers to provide a safe sleep environment and predictable routine, and send messages of safety and comfort at bedtime, with tangible objects, and enable children to feel a sense of control,” she said.

Charitable organizations like Pajama Program and Sleeping Children Around the World provide sleep kits to children from underserved backgrounds. But Candice Alfano, PhD, director of the University of Houston’s Sleep and Anxiety Center of Houston, said the CHOP kits are the first to specifically target sleeping difficulties in foster children.

“Sleep is a largely neglected yet essential area of health, development, and well-being in this highly-vulnerable population of youth, so I am very excited to see this work being done,” Dr. Alfano said in an interview.

Dr. Fortin and Dr. Lenker reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A stuffed animal, aromatherapy, a night light. A kit containing these and other items can help children in foster care who have experienced trauma sleep more soundly, a critical step in helping them cope with their emotional distress. 

In a new study, researchers at the Children’s Hospital of Philadelphia reported that sleep kits specially tailored to foster children appeared to be helpful in most cases. The kits can be distributed by pediatricians in the office or clinic setting.

“Children who have experienced trauma can have issues with behavior, it can impact their school, and they have difficulties sleeping,” said Kristine Fortin, MD, MPH, director of the fostering health program at Safe Place: Center for Child Protection and Health at CHOP. “I thought, what could a pediatrician do in the office in one visit to help children with sleep?”

Dr. Fortin and colleagues designed sleep kits for both younger children and adolescents.

The version for teenagers contained a sound machine, aromatherapy spray, and a sleep mask. The kits for younger children contained matching stuffed toys to share with someone they felt connected to, and a rechargeable night-light. All kits included written materials about sleep hygiene, a journal, and directions for downloading a free age-appropriate relaxation app for belly breathing or a PTSD Coach app from the Department of Veterans Affairs to manage symptoms of trauma.

In a pilot study presented at the annual meeting of the American Academy of Pediatrics, Dr. Fortin and colleagues surveyed caregivers in foster homes about their use of the kits.

Of the 20 foster parents who responded to the survey, 11 said the kits helped “very much,” 5 others reported they helped “somewhat,” another 2 reported no improvements in sleep, and 2 said they didn’t know the effect. The children for whom results were unknown moved from the home without the sleep kit or had difficulties communicating with the foster parents, resulting in incomplete assessment, according to the researchers. 

Night-lights were used most in the kits, followed by the stuffed toys, sound machines, and sleep journals.

Dr. Fortin said existing resources like sleep therapy or medication can be costly or difficult to find, and many pediatricians don’t have enough time during wellness visits to address symptoms like sleep deprivation. She said the sleep kits could be an alternative to other forms of sleep therapy. “If these sleep kits were effective, and could really help them sleep, then maybe less children would need something like medication.”

Dr. Fortin said the kits her group has designed are tailored specifically for children with symptoms of trauma, or with difficult emotions associated with foster care.

“We’ve tried to design something that can be really practical and easy to use in a pediatric visit, where there’s a lot of written information that can be discussed with the child and their family,” Dr. Fortin said.

She added that she would like to see clinicians give out the sleep kits during in-office visits.

“These sleep issues are common in foster children,” she said. “We felt it was important to do an intervention.”

Kristina Lenker, PhD, a sleep psychologist at Penn State Health, Hershey, said children in foster care often struggle with falling or staying asleep, an inability to sleep alone, nightmares, and bed wetting.

“Sleep kits can be particularly helpful for these children, given how they can help caregivers to provide a safe sleep environment and predictable routine, and send messages of safety and comfort at bedtime, with tangible objects, and enable children to feel a sense of control,” she said.

Charitable organizations like Pajama Program and Sleeping Children Around the World provide sleep kits to children from underserved backgrounds. But Candice Alfano, PhD, director of the University of Houston’s Sleep and Anxiety Center of Houston, said the CHOP kits are the first to specifically target sleeping difficulties in foster children.

“Sleep is a largely neglected yet essential area of health, development, and well-being in this highly-vulnerable population of youth, so I am very excited to see this work being done,” Dr. Alfano said in an interview.

Dr. Fortin and Dr. Lenker reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A stuffed animal, aromatherapy, a night light. A kit containing these and other items can help children in foster care who have experienced trauma sleep more soundly, a critical step in helping them cope with their emotional distress. 

In a new study, researchers at the Children’s Hospital of Philadelphia reported that sleep kits specially tailored to foster children appeared to be helpful in most cases. The kits can be distributed by pediatricians in the office or clinic setting.

“Children who have experienced trauma can have issues with behavior, it can impact their school, and they have difficulties sleeping,” said Kristine Fortin, MD, MPH, director of the fostering health program at Safe Place: Center for Child Protection and Health at CHOP. “I thought, what could a pediatrician do in the office in one visit to help children with sleep?”

Dr. Fortin and colleagues designed sleep kits for both younger children and adolescents.

The version for teenagers contained a sound machine, aromatherapy spray, and a sleep mask. The kits for younger children contained matching stuffed toys to share with someone they felt connected to, and a rechargeable night-light. All kits included written materials about sleep hygiene, a journal, and directions for downloading a free age-appropriate relaxation app for belly breathing or a PTSD Coach app from the Department of Veterans Affairs to manage symptoms of trauma.

In a pilot study presented at the annual meeting of the American Academy of Pediatrics, Dr. Fortin and colleagues surveyed caregivers in foster homes about their use of the kits.

Of the 20 foster parents who responded to the survey, 11 said the kits helped “very much,” 5 others reported they helped “somewhat,” another 2 reported no improvements in sleep, and 2 said they didn’t know the effect. The children for whom results were unknown moved from the home without the sleep kit or had difficulties communicating with the foster parents, resulting in incomplete assessment, according to the researchers. 

Night-lights were used most in the kits, followed by the stuffed toys, sound machines, and sleep journals.

Dr. Fortin said existing resources like sleep therapy or medication can be costly or difficult to find, and many pediatricians don’t have enough time during wellness visits to address symptoms like sleep deprivation. She said the sleep kits could be an alternative to other forms of sleep therapy. “If these sleep kits were effective, and could really help them sleep, then maybe less children would need something like medication.”

Dr. Fortin said the kits her group has designed are tailored specifically for children with symptoms of trauma, or with difficult emotions associated with foster care.

“We’ve tried to design something that can be really practical and easy to use in a pediatric visit, where there’s a lot of written information that can be discussed with the child and their family,” Dr. Fortin said.

She added that she would like to see clinicians give out the sleep kits during in-office visits.

“These sleep issues are common in foster children,” she said. “We felt it was important to do an intervention.”

Kristina Lenker, PhD, a sleep psychologist at Penn State Health, Hershey, said children in foster care often struggle with falling or staying asleep, an inability to sleep alone, nightmares, and bed wetting.

“Sleep kits can be particularly helpful for these children, given how they can help caregivers to provide a safe sleep environment and predictable routine, and send messages of safety and comfort at bedtime, with tangible objects, and enable children to feel a sense of control,” she said.

Charitable organizations like Pajama Program and Sleeping Children Around the World provide sleep kits to children from underserved backgrounds. But Candice Alfano, PhD, director of the University of Houston’s Sleep and Anxiety Center of Houston, said the CHOP kits are the first to specifically target sleeping difficulties in foster children.

“Sleep is a largely neglected yet essential area of health, development, and well-being in this highly-vulnerable population of youth, so I am very excited to see this work being done,” Dr. Alfano said in an interview.

Dr. Fortin and Dr. Lenker reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.