Objective measures of sleep and dim light melatonin onset in adolescents and young adults with delayed sleep phase disorder compared to healthy controls.

Delayed sleep phase disorder is characterized by a delay in the timing of the major sleep period relative to conventional norms. The sleep period itself has traditionally been described as normal. Nevertheless, it is possible that sleep regulatory mechanism disturbances associated with the disorder may affect sleep duration and/or architecture. Polysomnographic data that may shed light on the issue are scarce. Hence, the aim of this study was to examine polysomnographic measures of sleep in adolescents and young adults with delayed sleep phase disorder, and to compare findings to that of healthy controls. A second aim was to estimate dim light melatonin onset as a marker of circadian rhythm and to investigate the phase angle relationship (time interval) between dim light melatonin onset and the sleep period. Data from 54 adolescents and young adults were analysed, 35 diagnosed with delayed sleep phase disorder and 19 healthy controls. Results show delayed timing of sleep in participants with delayed sleep phase disorder, but once sleep was initiated no group differences in sleep parameters were observed. Dim light melatonin onset was delayed in participants with delayed sleep phase disorder, but no difference in phase angle was observed between the groups. In conclusion, both sleep and dim light melatonin onset were delayed in participants with delayed sleep phase disorder. The sleep period appeared to occur at the same circadian phase in both groups, and once sleep was initiated no differences in sleep parameters were observed.

Development of the Observable Well-Being in Living With Dementia-Scale.

The Observable Well-being in Living with Dementia-Scale was developed to address conceptual and methodological issues in current observational scales for music therapy. Creative interventions may receive lowered scores, as existing instruments rely heavily on verbal behavior. Methods were (1) Systematic review of observational instruments: (2) field work with music therapy and sociable interactions to operationalize the items; (3) field testing assessing feasibility and preliminary psychometric properties; (4) focus groups with experts to investigate content validity; (5) final field test and revision. 2199 OWLS-ratings were conducted in 11 participants. Hypotheses of construct validity and responsiveness were supported (r = .33 -.65). Inter-rater reliability was good (84% agreement between coders, Cohen's Kappa = .82), and intra-rater reliability was excellent (98% agreement, Cohen's Kappa = .98). Focus groups with 8 experts supported the relevance of the items and suggested further refinements to increase comprehensiveness. The final field-tested OWLS showed improved inter-rater reliability and usability.

Obstructive sleep apnea, verbal memory, and executive function in a community-based high-risk population identified by the Berlin Questionnaire Akershus Sleep Apnea Project.

PURPOSE: Cognitive functions in community-dwelling adults at high risk of obstructive sleep apnea have not been described and nor are associations between cognitive functions and obstructive sleep apnea severity fully understood. The study aimed to describe verbal memory and executive function in community-dwelling adults identified by the Berlin Questionnaire and to investigate associations between these cognitive domains and different obstructive sleep apnea severity indicators. METHODS: Among 29,258 age- and gender-stratified persons 30-65 years who received the Berlin Questionnaire by mail, 16,302 (55.7%) responded. From 654 randomly drawn respondents with BQ high risk who were approached for study participation, 290 participants (55.9% males, mean age 48.2 years) were included. Verbal memory was assessed by Rey Auditory Verbal Learning Test and executive function by Stroop test. Obstructive sleep apnea severity indicators were assessed by polysomnography. RESULTS: Mean (standard deviation) verbal learning score was 42.0 (8.9), mean interference time was 31.1 (12.7), median (25th percentile, 75th percentile) apnea-hypopnea index was 7.7 (2.4-22.2), and mean average oxygen saturation was 94.3 (2.0). Verbal learning score was independently associated with average oxygen saturation (ß = 0.721, p = 0.025) in multivariate linear regression models adjusted for putative confounders. Interference time was only related to OSA severity indicators in bivariate analyses. CONCLUSIONS: Verbal memory and executive function impairments were mild in community-dwelling adults at high risk of obstructive sleep apnea. Average oxygen saturation was the indicator of obstructive sleep apnea severity most strongly associated with cognitive function.

Prevalence of cardiovascular risk factors and concentration of C-reactive protein in Type D personality persons without cardiovascular disease.

BACKGROUND: Type D personality is associated with poor cardiovascular outcome in patients with coronary or peripheral arterial disease. Whether Type D personality is associated with cardiovascular risk in persons without overt cardiovascular disease remains unknown. We hypothesized that Type D personality is associated with higher prevalence of traditional cardiovascular risk factors and higher concentration of C-reactive protein. DESIGN: Cross-sectional study. METHODS: Type D personality was assessed in 453 participants without cardiovascular disease derived from an epidemiological study of obstructive sleep apnoea. An evaluation of obesity, lipid status, diabetes, blood pressure, heart rate, smoking, leisure-time physical activity and high-sensitivity C-reactive protein was performed. RESULTS: Smoking (43% vs. 21%, P < 0.001) and low leisure-time physical activity (<3 hours/week, 57% vs. 40%, P = 0.003) were more prevalent, and heart rate (mean (standard deviation), 75 (10) vs. 71 (9), P = 0.001) and body mass index was higher (29.8 (6.0) vs. 28.4 (4.5) kg/m2, P = 0.009) in Type D compared to non-Type D participants. The total number of risk factors was significantly higher in Type D than non-Type D participants (3.4 (1.3) vs. 3.0 (1.2), P = 0.004). The concentration of C-reactive protein was higher in participants with Type D personality (median, interquartile range 1.6, 0.7-3.4 vs. 1.1, 0.6-2.6, P = 0.047), although not statistically significant after adjustment for possible mediating factors. CONCLUSIONS: Among participants at high risk of cardiovascular disease, presence of Type D personality was associated with elevated body mass index and unhealthy behaviour such as smoking and low physical activity, which may have mediated the elevated concentration of C-reactive protein.

A Norwegian population-based study on the risk and prevalence of obstructive sleep apnea. The Akershus Sleep Apnea Project (ASAP).

The Berlin Questionnaire (BQ) is a widely used screening tool for obstructive sleep apnea (OSA), but its performance in the general population setting is unknown. The prevalence of OSA in middle-aged adults is not known in Norway. Accordingly, the aims of the current study were to evaluate the utility of the BQ for OSA screening in the general population and to estimate the prevalence of OSA in Norway. The study population consisted of 29,258 subjects (aged 30-65 years, 50% female) who received the BQ by mail. Of these, 16,302 (55.7%) responded. Five-hundred and eighteen subjects were included in the clinical sample and underwent in-hospital polysomnography. Screening properties and prevalence were estimated by a statistical model that adjusted for bias in the sampling procedure. Among the 16,302 respondents, 24.3% (95% confidence interval (CI)=23.6-25.0%) were classified by the BQ to be at high-risk of having OSA. Defining OSA as an apnea-hypopnea index (AHI) ≥5, the positive predictive value of the BQ was estimated to be 61.3%, the negative predictive value 66.2%, the sensitivity 37.2% and the specificity 84.0%. Estimated prevalences of OSA were 16% for AHI≥5 and 8% for AHI≥15. In conclusion, the BQ classified one out of four middle-aged Norwegians to be at high-risk of having OSA, but the screening properties of the BQ were suboptimal. The estimated prevalence of OSA was comparable to previous estimates from general populations in the USA, Australia and Europe.

Sleep problems in general practice: a national survey of assessment and treatment routines of general practitioners in Norway.

The aim of the current national survey of all general practitioners (GPs) practising in Norway was to explore assessment, treatment practice and perceived efficacy of treatment of sleep problems in general practice. A short questionnaire, including self-report measures of the frequency and routines of treatment and assessment of sleep problems, was sent to all 4049 GPs in Norway, of whom 1465 (36.7%) provided valid responses. The prevalence of sleep problems among patients in general practice was estimated to be 11.2%, of which almost two-thirds were believed to be caused by a medical condition. Anamnestic information and blood tests were the most common assessment of sleep problems, whereas GPs rarely referred patients to all-night polysomnographic recording. Sleep hygiene advices were the most commonly used treatment strategy, whereas hypnotics were believed to have the best short-term efficacy. Antidepressives were considered to be the best option for long-term management of sleep problems. About one-third of the patients were prescribed benzodiazepines or 'Z-drugs' for more than 6 months. This study demonstrates that sleep problems are recognized by GPs, but despite evidence that non-pharmacological treatment is superior in the long-term management of insomnia, the current study shows that hypnotics are still considered by GPs to be the most successful treatment.

Light interventions and sleep, circadian, behavioral, and psychological disturbances in dementia: A systematic review of methods and outcomes.

Dementia is a devastating disease with a global impact, and there is an urgent need for effective interventions to alleviate the accompanying disturbances in behavior, mood, sleep, and circadian rhythms. Bright light treatment (BLT) is a promising non-pharmacological intervention; however, studies have yielded conflicting results. This systematic review provides a comprehensive overview of the effect of BLT in dementia, with a specific focus on how study characteristics might have affected the available results. The included studies were small and comprised time-limited interventions and follow-ups. Light values, adherence to treatment, and time of year were not consistently reported. Varying designs, methods, and population characteristics such as age, gender, dementia diagnosis, circadian phase, and baseline symptoms may have moderated the outcomes and affected review results. The use of crossover designs and too high illumination as placebo lights might have nullified positive effects of BLT. Because some studies had negative outcomes after ambient BLT with high amounts of short wavelengths, more modest light levels should be further investigated. Employing rigorous designs and detailed reporting of intervention characteristics, i.e., the illumination, correlated color temperature, timing, and duration of light utilized, are of utmost importance to establish the optimal treatment approach in this population. Systematic review registration number: PROSPERO CRD42017051004.

How Perceived Pain Influence Sleep and Mood More Than The Reverse: A Novel, Exploratory Study with Patients Awaiting Total Hip Arthroplasty.

Objectives: Attributions about how comorbid symptoms worsen or improve each other are central cognitive components of chronic pain that are shown to facilitate or impede the recovery process. Still, these attributions have been poorly illuminated in chronic pain patients. The present study explored perceptions of how sleep, pain, and mood influence each other in patients awaiting total hip arthroplasty (THA). Design and Methods: In this cross-sectional study, 291 patients (mean age 67.8, 65.3% female) rated 12 statements about how much a given symptom (pain, sleep, mood) changed when another symptom (pain, sleep, mood) worsened or improved on a response scale ranging from much worse (-2) via no change (0) to much better (2). Sleep (Bergen Insomnia Scale), pain (McGill Pain Questionnaire), anxiety and depression (Hospital Anxiety and Depression Scale) were assessed as background variables. Results: Of the patients in the study, 56% reported symptoms indicating insomnia. Anxiety and depression were indicated in 16 and 10%, respectively. Over 80% rated their pain as horrible/unbearable and reported that pain occurred always/daily. When experiencing increased pain, a majority perceived that sleep (90%) and mood (70%) worsened, whilst experiencing reduced pain improved sleep and mood in 50%. Poor sleep increased pain and worsened mood in 45 and 60% of the patients, respectively. Better sleep was perceived to reduce pain and improve mood in 50%. Worsened mood increased pain (46%) and worsened sleep (52%). Improved mood decreased pain and improved sleep in 25 and 35%, respectively. Discussion: In this study, a novel approach was used to investigate perceptions of reciprocal relationships between symptoms. We found that THA patients perceived interrelationships between pain, sleep and mood. These perceived interrelations were stronger when symptoms worsened than when symptoms improved. They also held stronger beliefs about the effect of pain on sleep and mood, than the effect of sleep and mood on pain. Attributions are central in illness perception and ultimately affect illness behavior. For patients who perceive symptoms to interrelate, the door has already been opened to utilize these attributions in treatments aiming to disrupt vicious cycles, hence supporting the use of multimodal treatments.

Prescription trajectories and effect of total hip arthroplasty on the use of analgesics, hypnotics, antidepressants, and anxiolytics: results from a population of total hip arthroplasty patients.

Total hip arthroplasty (THA) has been shown to reduce pain and improve function. In addition, it is suggested that THA improves sleep and alleviates symptoms of anxiety and depression. Patients with chronic pain are frequent users of analgesic and psychotropic drugs and thereby risk adverse drug events. The impact of THA on such drug use has not been thoroughly investigated. Based on merged data from the Norwegian Prescription Database and the Norwegian Arthroplasty Register, this study sought to investigate redeemed medications in a complete population (N = 39,688) undergoing THA in 2005 to 2011. User rates and redeemed drug volume of analgesics (nonsteroid anti-inflammatory drugs (NSAIDs), opioids, and nonopioids) and psychotropics (hypnotics, anxiolytics, and antidepressants) were calculated for 4 quarters before and 4 quarters after surgery. We analysed preoperative prescription trends (Q1 vs Q4), postoperative prescription (Q4 vs Q5), and long-term effect of surgery (Q4 vs Q8). Before surgery, use of all drug groups increased from Q1 to Q4. Use of opioids, nonopioids, and hypnotics dramatically increased from Q4 to Q5. Long-term (Q4 vs Q8) surgery reduced prescriptions of analgesics, hypnotics, and anxiolytics, but not antidepressants. Overall, the present results extend the positive effects of THA to include reduced reliance on medication to alleviate symptoms.

Type D personality is associated with increased prevalence of ventricular arrhythmias in community-residing persons without coronary heart disease.

BACKGROUND: Type D personality may be a risk factor for poor outcome in patients with cardiovascular disease. The biological mechanisms underlying this association are poorly understood. The objective of the study was to test the hypotheses that Type D personality is associated with biological markers for sympathetic dysregulation. DESIGN: Cross-sectional community-based study. METHODS: Type D personality was evaluated by DS-14 in 450 persons (46% men), aged between 30 and 65 years. From a Holter-recording, (mean length 18.3 hours), long-term heart rate, ventricular arrhythmias, and heart rate variability (HRV) were registered as markers of sympathetic dysregulation. Traditional cardiovascular risk factors, apnoea-hypopnoea index, medication, and anxiety symptoms were adjusted for. RESULTS: Type D persons had higher long-term averaged heart rate (74 vs. 71 beats/min, p = 0.003), but this difference was attenuated and not significant in the multivariate model (p = 0.078)). There was an increased prevalence of complex ventricular ectopy (bigeminy, trigeminy, or non-sustained ventricular tachycardia; 14 vs. 6%, p = 0.005 in multivariate model). HRV indices did not differ significantly between those with or without Type D personality. Anxiety symptoms did not confound these associations. CONCLUSIONS: Type D personality is independently associated with a higher likelihood of ventricular arrhythmias, which may be implicated in the increased cardiovascular risk observed in persons with Type D personality.

Effect of a family-based cognitive behavioural intervention on body mass index, self-esteem and symptoms of depression in children with obesity (aged 7-13): a randomised waiting list controlled trial.

OBJECTIVE: We examined the effect of a 12-week family-based cognitive behavioural weight management programme developed for use in primary care settings. METHODS: The sample consisted of 49 children with obesity (aged 7-13 years; mean ± SD: 10.68 ± 1.24). Families were randomly assigned to immediate start-up of treatment or to a 12-week waiting list condition. Outcome measures were body mass index standard deviation score (BMI SDS), self-esteem, symptoms of depression and blood parameters indicative of cardio-metabolic risk. Assessments were conducted at baseline, post-treatment, post-waiting list and 12 months after treatment termination. RESULTS: The mean reduction for the treatment group was -0.16 BMI SDS units compared with an increase of 0.04 units for the waiting list group (p = .001). For the entire sample, there was a significant post-treatment improvement on BMI SDS (p = .001), all self-esteem measures (p = .001-.041) and symptoms of depression (p = .004). The mean BMI SDS reduction was -0.18 units post-treatment, and it was maintained at 12-month follow-up. Significant reductions were found in blood lipid levels of total cholesterol (p = .03), LDL-cholesterol (p = .005) and HDL-cholesterol (p = .01) at 12-month follow-up. The favourable effect on most of the psychological measures waned from post-treatment to follow-up, but not approaching baseline levels. Boys demonstrated significantly greater reductions in BMI SDS than girls (p = .001), while baseline psychiatric co-morbidity did not influence BMI SDS outcome. CONCLUSIONS: The treatment shows significant and favourable effects on BMI SDS, self-esteem and symptoms of depression compared with a waiting list condition.

Novel cardiovascular risk markers in depression: no association between depressive symptoms and osteoprotegerin or adiponectin in persons at high risk for sleep apnea.

BACKGROUND: Inflammation is believed to play a role in the pathogenesis of both cardiovascular disease and depressive disorders. We hypothesized that circulating concentrations of the novel inflammatory and cardiovascular biomarkers osteoprotegerin (OPG) and adiponectin as well as high sensitivity C-reactive protein (hsCRP) are associated with the severity of depressive symptoms and presence of major depressive disorder (MDD). METHODS: In a cross-sectional population-derived study (Akershus Sleep Apnea Project) 520 persons underwent clinical examination and venous blood sampling. Medical history was obtained and the participants completed the Beck Depression Inventory (BDI). Structured clinical interviews for axis-I disorders including MDD were performed in a subgroup of 288 participants. OPG and adiponectin concentrations were determined by in-house time-resolved immunofluorometric assays. RESULTS: Despite significant correlation with hsCRP (r=0.162, p<0.001), the sum-score of BDI did not correlate with OPG or adiponectin levels (r=0.011, p=0.811 and r=0.055, p=0.210, respectively). Neither circulating OPG nor adiponectin differed between persons with (n=34) and without (n=246) MDD (median±interquartile range: 1.18 (0.96-1.49) vs. 1.17 (0.93-1.57) ug/l and 7.26 (5.13-9.91) vs. 7.39 (5.23-11.37) mg/l, respectively). LIMITATIONS: Causal considerations are not possible, and results in the sub-group of diagnosed participants need careful interpretation due to small sample size. CONCLUSIONS: hsCRP was independently associated with depressive symptoms, but no association between depression severity or presence of MDD and OPG- or adiponectin concentrations was observed in community-residing persons at high risk for obstructive sleep apnea.

Circulating cytokine concentrations are not associated with major depressive disorder in a community-based cohort.

OBJECTIVE: The objective was to test the hypotheses that cytokine levels are elevated in community-residing persons at high risk for obstructive sleep apnea with major depressive disorder (MDD) compared to nondepressive persons and that cytokine levels show stronger correlations with somatic than psychological symptoms of depression. METHOD: A case-control study within the cross-sectional Akershus Sleep Apnea Project was performed. Two controls matched for age, gender, metabolic syndrome and obstructive sleep apnea were drawn for each case of MDD. RESULTS: Group comparisons revealed no significant difference in the levels of 17 cytokines [interleukin-1ß, -2,-4, -5, -6, -7, -8, -10, -12(p70), -13 and -17; tumor necrosis factor-α; interferon-γ; granulocyte colony-stimulating factor; granulocyte-monocyte colony-stimulating factor; macrophage chemoattractant protein-1 and monocyte inhibitory protein-1ß] between persons with (n=34) and without MDD (n=68). There was no association between cytokines levels and MDD in multivariate regression analyses. The concentration of interleukin-4 was significantly more positively correlated with psychological than somatic symptoms (r=0.046 vs. -0.143, respectively, P=0.024), while no different correlations were observed for other cytokines. CONCLUSION: The cytokine levels were not elevated in MDD, and cytokine levels were not more strongly associated with somatic than psychological symptoms of depression. The depression-specific effect on inflammation may be weak in community-based samples with prevalent somatic comorbidity.

Sleep disturbances in sexual abuse victims: a systematic review.

An impressive body of research has investigated whether sexual abuse is associated with sleep disturbances. Across studies there are considerable differences in methods and results. The aim of this paper was to conduct the first systematic review of this area, as well as to clarify existing results and to provide guidelines for future research. We conducted searches in the electronic databases PsycINFO and PubMed up until October 2010 for studies on sleep disturbances in sexually abused samples. Thirty-two studies fulfilled the inclusion criteria (reported empirical data, included sexually abused subjects, employed some form of sleep measurement, English language and published in peer reviewed journals). Across the studies included, sleep disturbances were widespread and more prevalent in sexually abused subjects as compared to in non-abused samples. Symptoms reported more frequently by sexually abused samples included nightmare related distress, sleep paralysis, nightly awakenings, restless sleep, and tiredness. Results were divergent with regards to sleep onset difficulties, nightmare frequency, nocturnal activity, sleep efficiency, and concerning the proportion of each sample reporting sleep disturbances as such. Potential sources of these divergences are examined. Several methodological weaknesses were identified in the included studies. In order to overcome limitations, future researchers are advised to use standardized and objective measurements of sleep, follow-up or longitudinal designs, representative population samples, large sample sizes, adequate comparison groups, as well as comparison groups with other trauma experiences.

Insomnia, nightmare frequency, and nightmare distress in victims of sexual abuse: the role of perceived social support and abuse characteristics.

In this study of victims of sexual abuse, the aim was to investigate the role of perceived social support and abuse characteristics in self-reported insomnia, nightmare frequency, and nightmare distress. Four hundred sixty Norwegian victims of sexual abuse completed a questionnaire assessing perceived social support, abuse characteristics, insomnia, nightmare frequency, and nightmare distress. Results show that higher levels of perceived social support were related to lower scores on all symptom outcome measures. Abuse involving oral, genital, or anal penetration was related to more insomnia symptoms. Longer duration of abuse and threatening conducted by the perpetrator were related to higher nightmare frequency, while threats and abuse involving penetration were related to higher degrees of distress associated with nightmares. In conclusion, the present study provides preliminary data indicating that perceived social support may affect the nature of sleep difficulties in sexual abuse victims. Also, more severe forms of sexual abuse are related to higher levels of sleep difficulties.

The relationship between school day sleep duration and body mass index in Norwegian children (aged 10-12).

OBJECTIVE: To examine the relationship between sleep duration and body mass index (BMI) in Norwegian children (aged 10-12). METHODS: Children and parents of a population of primary school children (N=9 430) were invited to complete a questionnaire containing questions about usual bedtimes, wake-up times, self and parent evaluations of pubertal maturation, parental education and economic status, and parent-reported height and weight of the child. Sixty per cent of parents and children participated. BMI was available for 4 158 children, 44% of the original sample. RESULTS: A U-shaped relationship was found between sleep duration and age- and gender-adjusted BMI. Shorter and longer sleep durations were significantly related to high BMI. The percentage of obesity and overweight was higher in the shortest sleep duration group compared with intermediate sleep durations. Crude logistic regression analyses showed a significant association between early pubertal maturation and both obesity and overweight. Socio-economic status was significantly related to overweight. Short sleep duration showed a significant association with obesity but not with overweight. In an adjusted logistic regression model, short sleep duration was still significantly associated with obesity when controlling for physical maturation and socio-economic status. CONCLUSIONS: High BMI was associated with short and long self and parent-reported duration of sleep. The percentage of obesity/overweight was higher in the shortest sleep duration group than for intermediate sleep durations. Short sleep duration was significantly associated with obesity but not with overweight. Adjusting for physical maturation and socio-economic status, short sleep duration still showed a significant association with obesity.

Patient characteristics and predictors of sleep medication use.

The objective of this study was to investigate the characteristics of sleep medication users, and their satisfaction with treatment and subjective difficulty with quitting the drugs. A representative sample of 5000 adults in Norway was selected to participate in an epidemiologic study. The data were collected through a postal survey in which a total of 2645 (52.9%) participants responded. Weighted logistic regression was used to explore predictors for the drug pattern use. The prevalence of lifetime, current, and chronic use of sleep medications were 18.8, 7.9, and 4.2%. The use was associated with low socioeconomic status, older age, female sex, and frequent symptoms of sleep disorders, anxiety, and depression. Older age and low perceived control over sleep were the strongest predictors for use and difficulty in quitting sleep medications. Among responders who had ever used sleep medications, 80.3% would prefer a nonpharmacological treatment alternative. It is concluded that consumption of sleep medications is widespread in Norway, and that perception of control over sleep may play a significant role in the drug pattern use. Nonpharmacological treatment is to a small extent implemented in the health care sector.