Sleep in Women with Chronic Pain and Autoimmune Conditions: A Narrative Review.

Chronic pain and sleep disturbances are intricately intertwined. This narrative review provides comments on observations related to pain, stress-immunity, and sleep. Sleep evidence is reviewed from studies of select conditions involving pain (ie, functional somatic syndromes and autoimmune) that are predominant in women. Chronic pain and poor sleep encompass persistent stress-immune activation with systemic inflammation, cellular oxidative stress, and sick behavior indicators that increase morbidity and threaten quality of life. In painful conditions, sleep impairments are nearly ubiquitous, and exaggerated combined effects should not be underestimated or ignored, nor should crucial implications for clinical practice and research.

Sleep and menopause: a narrative review.

OBJECTIVE: Our overall aim-through a narrative review-is to critically profile key extant evidence of menopause-related sleep, mostly from studies published in the last decade. METHODS: We searched the database PubMed using selected Medical Subject Headings for sleep and menopause (n = 588 articles). Using similar headings, we also searched the Cochrane Library (n = 1), Embase (n = 449), Cumulative Index to Nursing and Allied Health Literature (n = 163), Web of Science (n = 506), and PsycINFO (n = 58). Articles deemed most related to the purpose were reviewed. RESULTS: Results were articulated with interpretive comments according to evidence of sleep quality (self-reported) and sleep patterns (polysomnography and actigraphy) impact as related to reproductive aging and in the context of vasomotor symptoms (VMS; self-reported), vasomotor activity (VMA) events (recorded skin conductance), depressed mood, and ovarian hormones. CONCLUSIONS: Predominantly, the menopausal transition conveys poor sleep beyond anticipated age effects. Perceptions of sleep are not necessarily translatable from detectable physical sleep changes and are probably affected by an emotional overlay on symptoms reporting. Sleep quality and pattern changes are mostly manifest in wakefulness indicators, but sleep pattern changes are not striking. Likely contributing are VMS of sufficient frequency/severity and bothersomeness, probably with a sweating component. VMA events influence physical sleep fragmentation but not necessarily extensive sleep loss or sleep architecture changes. Lack of robust connections between perceived and recorded sleep (and VMA) could be influenced by inadequate detection. There is a need for studies of women in well-defined menopausal transition stages who have no sleep problems, accounting for sleep-related disorders, mood, and other symptoms, with attention to VMS dimensions, distribution of VMS during night and day, and advanced measurement of symptoms and physiologic manifestations.

Cognitive behavioral therapy for insomnia comorbid with COPD is feasible with preliminary evidence of positive sleep and fatigue effects.

BACKGROUND: Many people with COPD report difficulties falling asleep or staying asleep, insufficient sleep duration, or nonrestorative sleep. Cognitive behavioral therapy for insomnia (CBT-I) has proved effective not only in people with primary insomnia but also in people with insomnia comorbid with psychiatric and medical illness (eg, depression, cancer, and chronic pain). However, CBT-I has rarely been tested in those with COPD who have disease-related features that interfere with sleep and may lessen the effectiveness of such therapies. The purpose of this study was to determine the feasibility of applying a CBT-I intervention for people with COPD and to assess the impact of CBT-I on insomnia severity and sleep-related outcomes, fatigue, mood, and daytime functioning. METHODS: The study had two phases. In Phase 1, a 6-weekly session CBT-I intervention protocol in participants with COPD was assessed to examine feasibility and acceptability. Phase 2 was a small trial utilizing a prospective two-group pre- and post-test design with random assignment to the six-session CBT-I or a six-session wellness education (WE) program to determine the effects of each intervention, with both interventions being provided by a nurse behavioral sleep medicine specialist. RESULTS: Fourteen participants (five in Phase 1 and nine in Phase 2) completed six sessions of CBT-I and nine participants completed six sessions of WE. Participants indicated that both interventions were acceptable. Significant positive treatment-related effects of the CBT-I intervention were noted for insomnia severity (P = 0.000), global sleep quality (P = 0.002), wake after sleep onset (P = 0.03), sleep efficiency (P = 0.02), fatigue (P = 0.005), and beliefs and attitudes about sleep (P = 0.000). Significant positive effects were noted for depressed mood after WE (P = 0.005). CONCLUSION: Results suggest that using CBT-I in COPD is feasible and the outcomes compare favorably with those obtained in older adults with insomnia in the context of other chronic illnesses.

The symptom cluster experience profile framework.

PURPOSE/OBJECTIVES: To present the novel Symptom Cluster Experience Profile (SCEP) framework for guiding symptom research in adult survivors of childhood cancers and other subgroups at risk for high symptom burden. DATA SOURCES: Empirically derived model of symptom cluster experience profiles, existing theoretical frameworks, and data-based literature on symptoms and quality of life in adult survivors of childhood cancers. DATA SYNTHESIS: In a previous study, the authors generated a preliminary model to characterize subgroups of adult survivors of childhood cancers with high-risk symptom cluster profiles. The authors developed the SCEP framework, which depicts symptom cluster experiences as subgroup-specific profiles that are driven by multiple sets of risk and protective factors. The risk and protective factors may directly and indirectly contribute to or alleviate symptoms through their effects on systemic stress. Systemic stress instigates and sustains the symptom experience that, in turn, is expressed through negative diffusion into other components of quality of life, such as functional status, general health perceptions, and overall quality of life. CONCLUSIONS: The SCEP framework is an initial approach to unbundle the complex heterogeneity that underlies the clustering of symptoms. By measuring a wide range of risk and protective factors in future studies of adult survivors of childhood cancers and other subgroups at risk for high symptom burden, further development and validation of the SCEP framework will occur. IMPLICATIONS FOR NURSING: The SCEP framework can be used to specify mechanisms underlying symptom cluster profiles and derive interventions targeted to high-risk symptom profiles. Findings from future studies can be translated to risk-based surveillance and symptom management clinical practice guidelines.

Self-reported medication and herb/supplement use by women with and without fibromyalgia.

METHODS: Using a telephone survey of 434 women who self-reported having and 198 women, who denied having fibromyalgia (FM) (aged 18-80 years), we compared women on self-reported number, major types, and effectiveness of currently taken conventional medications and herbs/supplements. RESULTS: Ninety-three percent of women with FM reported taking at least one medication (1855 total, 499 types, on average 4.6 per person) compared with 56% of women without FM (269 total, 172 types, 1.4 per person on average). Half (n = 217) of the women with FM reported taking antidepressant drugs; more reported selective serotonin reuptake inhibitors (SSRI)-type with moderate effectiveness than tricyclic amines deemed to have strong effectiveness. Few were taking dual uptake inhibitors or the now approved pregabalin. Nearly 30% reported taking nonsteroidal anti-inflammatory drugs (NSAID), which have weak efficacy evidence. Less than 8% of controls reported taking either antidepressants or NSAID. Having FM was associated with these medications plus guaifenesen, anticonvulsants, muscle relaxants, narcotics, other analgesics, and benzodiazepines. Highest effectiveness scores were for opioid narcotics and guaifenesin. Forty-three percent of women with FM reported taking at least one herb/supplement compared with 23% of control women. The most common types were omega esterified fatty acids, glucosamine, and gingko. No particular type distinguished between the groups. Both groups tended to rate overall effectiveness lower for herbs/supplements than for conventional medications. CONCLUSIONS: Substantial numbers of women with FM were taking pain medications that often lacked evidence for effectiveness. The variety of medications being taken by women with FM compared with women without FM indicates that there are few medications that consistently provide symptom alleviation for this condition.

Women's health issues with fibromyalgia syndrome.

BACKGROUND: Fibromyalgia syndrome (FMS) involves multiple sensory, somatic, and cognitive symptoms that are bound to affect or be affected by physical and mental health status and behavioral components of daily life. METHODS: From a telephone survey of 442 women with and 205 women without FMS as volunteers, data were compared on (1) general health status, (2) reproductive and sleep-related diagnoses, and (3) lifestyle health behaviors. RESULTS: All multiple or logistics regression analyses for group differences were controlled for age, body mass index (BMI), race, employment status, marital status, having a college degree, low household income, and having ever been diagnosed with depression, with a Bonferroni p value correction for multiple indicators. Accordingly, FMS negatively impacted both perceived physical and mental health status, although relatively more so for physical (p < 0.017). Women with FMS were more likely to have had reproductive health or sleep-related diagnoses, including premenstrual syndrome, dysmenorrhea, breast cysts, bladder cystitis, sleep apnea, restless leg syndrome, and abnormal leg movements (p < 0.0125). They were calculated to use less than half as many calories per week as control women (689 +/- 1293 vs. 1499 +/- 1584 kcal/week, p < 0.05) and had more sleep pattern difficulties (p < 0.0125), more negative changes in sexual function (greater odds for 5 of 10 indicators at p < 0.005), and lower alcohol use (odds ratio = 0.39, p < 0.05). CONCLUSIONS: Patients with FMS deserve careful assessment for reproductive conditions and sleep-related functional disorders. Besides more research into mechanisms underlying symptoms, intervention testing specifically to alleviate sleep problems, low physical activity levels, and sexual dysfunction should be paramount.

Decreased sleep spindles and spindle activity in midlife women with fibromyalgia and pain.

OBJECTIVES: To compare sleep-spindle incidence (number of spindles per minute of non-rapid eye movement [NREM] stage 2 sleep) and duration, spindle wave time (seconds per epoch in NREM stage 2 sleep), spindle frequency activity, and pain measures (pressure pain threshold, number of tender points, skinfold tenderness) between midlife women with fibromyalgia (FM) and moderate to high pain to a control group of sedentary women without pain. A second goal was to explore the extent to which pain pressure thresholds, age, and depression explain the variance in spindle incidence. DESIGN: A cross-sectional descriptive study. SETTING: A university-based sleep research laboratory and a referral clinic for chronic fatigue and pain. PARTICIPANTS: Thirty-seven medication-free women with FM (mean age, 44.9 +/- 8 years) and 30 women with self-reported good sleep and no pain (mean age, 44.1 +/- 7.7 years) completed a psychiatric interview and the Beck Depression Inventory prior to 2 consecutive nights of polysomnography, with pain measures obtained in the morning. Time domain analysis of spindle incidence and spectral analysis of spindle frequency activity were conducted on night 2 of polysomnography recordings. INTERVENTIONS: NA. RESULTS: Women with FM had fewer mean spindles per minute of NREM stage 2 sleep and lower mean spindle time per epoch of NREM stage 2 sleep (both P values < .02), but mean spindle duration, although slightly shorter, was not statistically significantly different (P < .06) compared to control women. Women with FM had a lower mean pressure pain threshold, a higher average number of positive tender points, and higher skinfold tenderness compared to control women (all P values < .001). Group differences in spindle frequency activity were found after controlling for age, depression, and psychiatric diagnosis in a general linear model (P < .02). One-way analysis of variance revealed significantly lower spindle activity in the 3 frequency bins (12-12.5 Hz, 13-13.5 Hz, 14-14.5 Hz) at C3 (all P values < .04), Fz (all P values < .02), and Cz (all P values < .02). Finally, after controlling for age and depression, pain pressure threshold significantly predicted spindles per minute and spindle time per epoch of NREM stage 2 sleep (r2 = .26; P < .001). CONCLUSIONS: Women with FM and pain have fewer sleep spindles and reduced electroencephalogram power in spindle frequency activity compared to control women of similar age. These data imply that some aspect of thalamocortical mechanisms of spindle generation might be impaired in FM.

Variations in sleep hygiene practices of women with and without insomnia.

Sleep hygiene education is a basic component of behavioral treatment for chronic insomnia, yet the actual sleep hygiene practices of people with insomnia have not been well documented. In this descriptive secondary analysis, midlife women ages 41-55 years with either chronic insomnia (n = 92) or good sleep (n = 29) kept diaries of sleep perceptions and sleep hygiene practices during 6 nights of somnographic monitoring at home. In both groups few reported smoking cigarettes (<10%), most drank caffeine (>80%), and many averaged 30 min of exercise per day ( approximately 50%). Very few in either group (<10%) had regular (<30 min variation) bedtimes or getting-up times. Compared to women with good sleep, those with insomnia reported drinking less caffeine per day, being more abstinent from alcohol, and having smaller variations in day-to-day alcohol intake and bedtimes. Although some women with insomnia limit or refrain from caffeine and alcohol intake, many have not optimized behaviors believed to help prevent or modulate insomnia.

Lifestyle practices and nocturnal sleep in midlife women with and without insomnia.

Relationships between common lifestyle practices important to sleep hygiene (e.g., smoking cigarettes, drinking alcohol, ingesting caffeine, exercising, bed times, getting-up times) and nocturnal sleep have not been documented for women with insomnia in their home environments. This community-based sample of 121 women, ages 40 to 55 years, included 92 women who had experienced insomnia for at least 3 months and 29 women with good-quality sleep. Women recorded lifestyle practices and sleep perceptions (time to fall asleep, awakenings during sleep, feeling rested after sleeping, and overall sleep quality) in diaries while undergoing 6 nights of somnographic sleep monitoring at home. Compared to women with good-quality sleep, women with insomnia reported greater night-to-night variation in perceived sleep variables, poorer overall sleep quality (M = 2.8, SD = 0.7 vs. M = 1.9, SD = 0.5, P < 0.05), and longer times to fall asleep (M = 25 min, SD = 14.2 vs. M= 12.9 min, SD = 5.8, P < 0.05). Correlations between mean individual lifestyle practice scores and mean perceived or somnographic sleep variables were low, ranging from 0 to 0.20. An aggregated sleep hygiene practice score was not associated with either perceived or somnographic sleep variables. Regression analysis using dummy variables showed that combinations of alcohol, caffeine, exercise, smoking, and history of physical disease explained 9% to 19% of variance in perceived or somnographic sleep variables. Lifestyle practices, and combinations thereof, do warrant consideration when assessing or treating insomnia, but these data fail to support a dominant relationship between lifestyle practices and either perceived or somnographic sleep variables.