Cognitive performance in patients with implantable cardioverter defibrillators: Associations with objective sleep duration, age and anxiety.

Sleep disturbance and anxiety are highly prevalent in patients with implantable cardiac defibrillators (ICDs). There is limited research, however, on the associations between cognitive performance and sleep parameters, age and anxiety. Forty-one patients with ICDs and self-reported sleep disturbance completed 14 days of actigraphy (Mage  = 60.3, SD = 12.3) measuring total sleep time (TST), and a computerized cognitive test battery measuring processing speed and attention (i.e. simple reaction time and symbol digit modality task [SDMT]) and executive function (i.e. flanker task, letter series task and N-back task). Multiple regressions determined whether independent effects of TST, age and anxiety, as well as interactive effects of TST and age, predicted cognitive performance. TST predicted performance on two tasks of executive function (i.e. letter series and N-back task), as well as an attentional vigilance and processing speed task (i.e. SDMT), and this did not depend on patient age. On letter series, N-back and SDMT, longer TST predicted better performance. Increasing age was a predictor of worse performance on SDMT and flanker tasks. No other predictors were associated with task performance. Results show that sleep duration, not anxiety, may be an important predictor of higher-order cognitive functioning and lower-order tasks measuring processing speed and attention in ICD patients, with longer sleep duration showing greater benefit for performance.

Sleep, Psychosocial Functioning, and Device-Specific Adjustment in Patients with Implantable Cardioverter Defibrillators (ICDs).

Rates of sleep disorders and associated adjustment were examined in patients with implantable cardioverter defibrillators (ICDs; n = 42; Mage = 61.57, SD = 12.60). One night of ambulatory polysomnography, 14 days of sleep diaries, and questionnaires (mood, sleepiness, fatigue, device acceptance) were administered. Controlling for ischemia, MANCOVA examined adjustment by sleep diagnosis. Apnea was most common (28.6%), followed by Insomnia (16.7%) and Comorbid Insomnia/Apnea (11.9%). Patients with insomnia reported poorer mood, greater sleepiness, and lower device acceptance than good sleepers; they also demonstrated poorer mood and less ICD device acceptance than patients with sleep apnea. Patients with comorbid insomnia/apnea also exhibited poorer mood and less ICD device acceptance than good sleepers; however, comorbid patients did not significantly differ from insomnia or apnea patients on any measure. Those with disordered sleep (regardless of type) reported greater fatigue than good sleepers. Assessment (and treatment) of difficulties with sleep, mood, fatigue, and device acceptance may be important for the comprehensive clinical management of ICD patients. Further research appears warranted.

Using Telehealth to Deliver Cognitive Behavioral Treatment of Insomnia to a Caregiver of a Person With Alzheimer's Disease.

Cognitive behavioral therapy for Insomnia (CBT-I) is the gold standard treatment for insomnia. There is limited access to qualified providers to deliver CBT-I; moreover, there are patient populations who struggle with access to insomnia care due to limited time and resources. This includes caregivers for persons with Alzheimer's disease, for whom sleep disturbance is a common concern. Utilizing telehealth to deliver CBT-I may be particularly important for vulnerable populations such as caregivers of persons with dementia, as it can offer an accessible, safe, and cost-effective treatment option that can be tailored to meet the needs of a specific population. This case study illustrates the successful implementation of a four-session CBT-I protocol through telehealth with a caregiver of a person with Alzheimer's disease. Given the success of this case and the conditions for psychological care the recent pandemic has created, continued research into the efficacy of sleep-related interventions through telehealth is warranted.

Cognitive, psychomotor and polysomnographic effects of trazodone in primary insomniacs.

Trazodone is prescribed widely as a sleep aid, although it is indicated for depression, not insomnia. Its daytime cognitive and psychomotor effects have not been investigated systematically in insomniacs. The primary goal of this study was to quantify, in primary insomniacs, the hypnotic efficacy of trazodone and subsequent daytime impairments. Sixteen primary insomniacs (mean age 44 years) participated, with insomnia confirmed by overnight polysomnography (sleep efficiency ≤ 85%). Trazodone 50 mg was administered to participants 30 min before bedtime for 7 days in a 3-week, within-subjects, randomized, double-blind, placebo-controlled design. Subjective effects, equilibrium (anterior/posterior body sway), short-term memory, verbal learning, simulated driving and muscle endurance were assessed the morning after days 1 and 7 of drug administration. Sleep was evaluated with overnight polysomnography and modified Multiple Sleep Latency Tests (MSLT) on days 1 and 7. Trazodone produced small but significant impairments of short-term memory, verbal learning, equilibrium and arm muscle endurance across time-points. Relative to placebo across test days, trazodone was associated with fewer night-time awakenings, minutes of Stage 1 sleep and self-reports of difficulty sleeping. On day 7 only, slow wave sleep was greater and objective measures of daytime sleepiness lower with trazodone than with placebo. Although trazodone is efficacious for sleep maintenance difficulties, its associated cognitive and motor impairments may provide a modest caveat to health-care providers.

Alcohol effects on simulated driving in frequent and infrequent binge drinkers.

OBJECTIVE: Compared with non­bingers, binge drinkers are more likely to drive while intoxicated. The extent to which binge frequency impacts confidence in driving and subsequent driving impairment is unknown. This study compared the effects of an experimenter­delivered alcohol binge on subjective impairment and simulated driving ability in female high­frequency and low­frequency bingers. METHODS: Female drinkers were assigned to high­frequency (n = 30) or low­frequency (n = 30) binge groups based on their Alcohol Use Questionnaire responses. At 30­min intervals within a 2­h period, participants received either a placebo drink (n = 15 per group) or a 0.2 g/kg dose of alcohol (n = 15 per group; cumulative dose 0.8 g/kg). Self­reported impairment, driving confidence, and simulated driving were then measured. RESULTS: Self­reported confidence in driving was significantly lower after alcohol than after placebo in low­frequency but not highfrequency bingers. Self­reported impairment and collisions during simulated driving were significantly greater after alcohol than after placebo in both low­frequency and high­frequency bingers. CONCLUSIONS: The impairing effects of a single alcohol binge on driving ability in women are not influenced by binge frequency. However, high binge frequency may be associated with a less cautious approach to post­binge driving.

A Structured Peer Assessment Method with Regular Reinforcement Promotes Longitudinal Self-Perceived Development of Medical Students' Feedback Skills.

BACKGROUND: Given that training is integral to providing constructive peer feedback, we examined the impact of a regularly reinforced, structured peer assessment method on student-reported feedback abilities throughout a two-year preclinical Communication Skills course. METHODS: Three consecutive 32-student medical school classes were introduced to the Observation-Reaction-Feedback method for providing verbal assessment during Year 1 Communication Skills orientation. In biweekly small-group sessions, students received worksheets reiterating the method and practiced giving verbal feedback to peers. Periodic questionnaires evaluated student perceptions of feedback delivery and the Observation-Reaction-Feedback method. RESULTS: Biweekly reinforcement of the Observation-Reaction-Feedback method encouraged its uptake, which correlated with reports of more constructive, specific feedback. Compared to non-users, students who used the method noted greater improvement in comfort with assessing peers in Year 1 and continued growth of feedback abilities in Year 2. Comfort with providing modifying feedback and verbal feedback increased over the two-year course, while comfort with providing reinforcing feedback and written feedback remained similarly high. Concurrently, student preference for feedback anonymity decreased. CONCLUSIONS: Regular reinforcement of a peer assessment framework can increase student usage of the method, which promotes the expansion of self-reported peer feedback skills over time. These findings support investigation of analogous strategies in other medical education settings. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-021-01242-w.

Loss of laterality in chronic cocaine users: an fMRI investigation of sensorimotor control.

Movement disturbances are often overlooked consequences of chronic cocaine abuse. The purpose of this study was to systematically investigate sensorimotor performance in chronic cocaine users and characterize changes in brain activity among movement-related regions of interest (ROIs) in these users. Functional magnetic resonance imaging data were collected from 14 chronic cocaine users and 15 age- and gender-matched controls. All participants performed a sequential finger-tapping task with their dominant, right hand interleaved with blocks of rest. For each participant, percent signal change from rest was calculated for seven movement-related ROIs in both the left and right hemisphere. Cocaine users had significantly longer reaction times and higher error rates than controls. Whereas the controls used a left-sided network of motor-related brain areas to perform the task, cocaine users activated a less lateralized pattern of brain activity. Users had significantly more activity in the ipsilateral (right) motor and premotor cortical areas, anterior cingulate cortex and the putamen than controls. These data demonstrate that, in addition to the cognitive and affective consequences of chronic cocaine abuse, there are also pronounced alterations in sensorimotor control in these individuals, which are associated with functional alterations throughout movement-related neural networks.

Associations between pain, objective sleep efficiency and cognition in patients with implantable cardioverter defibrillators.

INTRODUCTION: Patients with implantable cardioverter defibrillators (ICDs) frequently experience sleep disruption. Prior work shows associations between objective (actigraphic) sleep and cognition in these patients, but whether pain affects associations between measures of sleep fragmentation (eg, sleep efficiency, SE) and cognition is unknown. The present study examined independent and interactive associations between objective SE and pain on cognitive performance in patients with ICDs. METHODS: A total of 37 patients with ICDs (Mage = 60.0, SD = 12.4) and self-reported sleep disturbance completed 14 days of actigraphy. Average SE was computed [(average total sleep time/average time in bed) × 100%]. Patients completed the Short Form 36 Health Survey pain section, and computerized tasks measuring executive functioning (letter series, N-Back task), sustained attention/processing speed (symbol digit modalities test, SDMT), and simple reaction time. Multiple linear regressions examined whether SE independently predicted or interacted with pain ratings to predict cognitive performance. RESULTS: SE interacted with pain to predict SDMT performance, accounting for 12% unique variance. In patients reporting worse pain, higher SE was associated with better SDMT performance. Similar patterns of association on SDMT were not observed in patients with average or low pain. SE and pain ratings did not independently predict SDMT performance. Performance on other cognitive tasks was not associated with any predictors. CONCLUSION: Better sleep efficiency may play an important role in improving sustained attention/processing speed in patients with ICDs and perceived severe pain. Future research should examine whether interventions aimed at improving sleep fragmentation provide benefit to lower order cognition, particularly in patients with worse pain.

The COVID-19 Crisis: A Mental Health Perspective and Response Using Telemedicine.

With the outbreak of COVID-19, patients and providers were forced to isolate and become innovative in ways to continue exceptional patient care. The Cleveland Clinic went from mostly in-person medical appointments to all virtual/telemedicine care in about 2 weeks' time. In this piece, we show specifically the thought process and our conversion of the Mellen Center for Multiple Sclerosis Behavioral Medicine to ensure that our patients still receive exceptional care and patient experience. Additionally, we discuss the importance of innovating the training and supervision of postdoctoral trainees using telepsychology and virtual options.

Changes in Sleep Predict Changes in Affect in Older Caregivers of Individuals with Alzheimer's Dementia: A Multilevel Model Approach.

OBJECTIVES: Understanding predictors of older dementia caregivers' mood could provide insight into potential treatments which may delay institutionalization of their care recipient. Research with older noncaregivers has shown that nights characterized by better subjective sleep were associated with days characterized by higher positive and lower negative affect, and vice versa. Examining daily relationships is important, as sleep and affect are state-like behaviors that fluctuate within individuals, across time. This study was a preliminary examination of whether a sample with a greater proportion of older dementia caregivers exhibits similar daily sleep/affect associations. METHODS: Sleep diaries, actigraphy, and affect data were collected concurrently for 7 days in 55 community-dwelling, dementia caregivers (M = 62.80 years, SD = 12.21; 77.8% female). Sleep and affect were examined within- (day-to-day level) and between-persons (mean level). RESULTS: Findings for older noncaregivers were replicated for negative affect only. Specifically, nights characterized by better subjective sleep were characterized by lower negative affect, and vice versa. DISCUSSION: Examining older caregivers' daily sleep/affect association is important, because caregiving-related awakenings are unavoidable, often unpredictable, and can impact mood. Future research is needed to examine whether regularization in awakenings and/or negative affect represent important secondary, or even target, treatment outcomes for this vulnerable population.

Measuring Treatment Outcomes in Comorbid Insomnia and Fibromyalgia: Concordance of Subjective and Objective Assessments.

STUDY OBJECTIVES: In insomnia, actigraphy tends to underestimate wake time compared to diaries and PSG. When chronic pain co-occurs with insomnia, sleep may be more fragmented, including more movement and arousals. However, individuals may not be consciously aware of these arousals. We examined the baseline concordance of diaries, actigraphy, and PSG as well as the ability of each assessment method to detect changes in sleep following cognitive behavioral therapy for insomnia (CBT-I). METHODS: Adults with insomnia and fibromyalgia (n = 113) were randomized to CBT-I, CBT for pain, or waitlist control. At baseline and posttreatment, participants completed one night of PSG and two weeks of diaries/actigraphy. RESULTS: At baseline, objective measures estimated lower SOL, higher TST, and higher SE than diaries (ps < 0.05). Compared to PSG, actigraphic estimates were higher for SOL and lower for WASO (ps < 0.05). Repeated measures ANOVAs were conducted for the CBT-I group (n = 15), and significant method by time interactions indicated that the assessment methods differed in their sensitivity to detect treatment-related changes. PSG values did not change significantly for any sleep parameters. However, diaries showed improvements in SOL, WASO, and SE, and actigraphy also detected the WASO and SE improvements (ps < 0.05). CONCLUSIONS: Actigraphy was generally more concordant with PSG than with diaries, which are the recommended assessment for diagnosing insomnia. However, actigraphy showed greater sensitivity to treatment-related changes than PSG; PSG failed to detect any improvements, but actigraphy demonstrated changes in WASO and SE, which were also found with diaries. In comorbid insomnia/fibromyalgia, actigraphy may therefore have utility in measuring treatment outcomes.