Assisted Relaxation Therapy for Insomnia in Older Adults With Mild Cognitive Impairment: A Pilot Study.

Insomnia symptoms are prevalent in older adults with mild cognitive impairment (MCI) and can pose treatment challenges. We tested the feasibility, acceptability, and preliminary efficacy of assisted relaxation therapy (ART) to improve insomnia symptoms in community-dwelling older adults with MCI. In this pilot RCT, 25 participants were assigned to intervention or control groups for 2 weeks. The final sample (n = 20) consisted of all Black, primarily female (70%) older adults (mean age 69.10; SD = 7.45) with mean Montreal Cognitive Assessment scores of 21.10 (SD = 2.49). Recruitment was timely; attrition was low (80%). Participants were able to use ART (average use 7.00; SD = 5.07 days). Participants in the ART group improved on Insomnia Severity Index (ISI) (- 7.10; 95% CI [-11.63, -2.55]; p = .004) compared to baseline. There were clinically meaningful mean change scores on ISI for the intervention group compared to the control (- 7.10 vs. - 4.33). Results provide justification for testing ART in a fully powered clinical trial.

An mHealth-Facilitated Personalized Intervention for Physical Activity and Sleep in Community-Dwelling Older Adults.

This randomized controlled pilot trial tested the preliminary effect of a 24-week mHealth-facilitated, personalized intervention on physical activity (PA) and sleep in 21 community-dwelling older adults. The intervention included a personalized exercise prescription, training, goal setting, and financial incentives. mHealth strategies, including self-monitoring, motivational messages, activity reminders, and phone coaching, were used to facilitate PA participation. PA and sleep were measured using actigraphy and questionnaires at baseline and 8-, 16-, and 24-week visits. Participants in the intervention group had lower objective PA levels at 24 weeks than at 8 and 16 weeks, although levels of PA remained higher than at baseline. Compared with the control group, the intervention increased PA at 8, 16, and 24 weeks; improved subjective sleep quality at 16 and 24 weeks; and increased actigraphy-measured sleep duration and sleep efficiency at 24 weeks. mHealth PA interventions may benefit PA and sleep in older adults. Strategies for maintaining long-term PA behavioral changes are needed.

Independent associations between sleep duration, gamma gap, and cognitive function among older adults: Results from the NHANES 2013-2014.

This study examined whether gamma gap mediated the association between sleep and cognitive function. Data from NHANES 2013-2014 were used. Three tests were used to measure cognitive function. Sleep was measured by three single questions. Gamma gap was calculated by subtracting albumin from total protein. Participants were 1392 older adults (53.2% females). Approximately 12% reported being told having sleep disorder, 1/3 reported having trouble sleeping, 25.9% had short sleep, and 12.5% had long sleep. Sleep disorders and sleep quality were not associated with cognitive function. Long sleep duration was an independent risk factor of reduced cognitive function on immediate recall, delayed recall, and executive function. Elevated gamma gap was also an independent risk factor of lower cognitive function. In a representative sample of older adults in the US, gamma gap and sleep duration were independent predictors of cognitive function. This study highlights the need for sleep assessment among older adults.

The natural history of insomnia: Does sleep extension differentiate between those that do and do not develop chronic insomnia?

According to the "3P model" of insomnia, the variable that mediates the transition from acute insomnia (AI) to chronic insomnia is "sleep extension" (the behavioural tendency to expand sleep opportunity to compensate for sleep loss). In the present analysis, we sought to evaluate how time in bed (TIB) varies relative to the new onset of AI and chronic insomnia. A total of 1,248 subjects were recruited as good sleepers (GS). Subjects were monitored over 1 year with sleep diaries. State transitions were defined, a priori, for AI, recovered from AI (AI-REC), and for chronic insomnia (AI-CI). Two additional groupings were added based on profiles that were unanticipated: subjects that exhibited persistent poor sleep following AI (AI-PPS [those that neither recovered or developed chronic insomnia]) and subjects that recovered from chronic insomnia (CI-REC). All the groups (GS, AI-REC, AI-CI, AI-PPS and CI-REC) were evaluated for TIB differences with longitudinal mixed effects models. Post hoc analyses for the percentage of the groups that were typed as TIB "restrictors, maintainers, and expanders" were conducted using longitudinal mixed effects models and contingency analyses. Significant differences for pre-post AI TIB were not detected for the insomnia groups. Trends were apparent for the AI-CI group, which suggested that minor increases in TIB occurred weeks before the declared onset of AI. Additionally, it was found that a significantly larger percentage of AI-CI subjects engaged in sleep extension (as compared to GS). The present data suggest that transition from AI to chronic insomnia does not appear to be initiated by sleep extension and the transition may occur before the elapse of 3 months of ≥3 nights of sleep continuity disturbance. Given these findings, it may be that the mismatch between sleep ability and sleep opportunity is perpetuated over time given the failure to "naturally" engage in sleep restriction (as opposed to sleep extension).

Tailored music listening intervention to reduce sleep disturbances in older adults with dementia: Research protocol.

Sleep disruption in older adults living with Alzheimer's disease and related dementias (ADRD) is debilitating and contributes to increased institutionalization, reduced cognitive function, and accelerated disease progression. Furthermore, sleep disruption is linked to poor health outcomes in caregivers, such as decreased quality of life and increased caregiver burden. Given the potentially harmful side effects of pharmacologic treatment, nonpharmacologic approaches, such as music, may provide a safer alternative to reducing sleep disruption in this vulnerable population. A growing body of literature suggests that calming tailored music may improve sleep quality in older adults with memory loss, but its efficacy has not been demonstrated in older adults with ADRD in the community, where most older adults with ADRD live. If shown to be feasible and acceptable, tailored music interventions can then be tested for efficacy in reducing sleep disruption. This protocol details a wait-list randomized controlled trial (NCT04157244), the purpose of which is to test the feasibility, acceptability, and examine the preliminary efficacy of a tailored music listening intervention in older adults with ADRD who report sleep disruption. Music selections will be tailored to the music genre preferences of older adults with ADRD and account for known sleep-inducing properties. The feasibility of processes that is key to the success of the subsequent study will be examined. Preliminary efficacy of the intervention will be assessed using objective (actigraphy) and subjective (proxy-reported) sleep quality measures. In addition, qualitative data will be solicited, examining the acceptability and satisfaction with the intervention by individuals with ADRD.

A personalized behavioral intervention implementing mHealth technologies for older adults: A pilot feasibility study.

Sedentary behavior has been associated with adverse health outcomes such as disturbed sleep in older adults. We conducted a single-group pretest and posttest study to evaluate the feasibility of a personalized behavioral intervention program using mobile health technology in improving physical activity and sleep in older adults. The four-week intervention included: personalized physical activity training, real-time physical activity self-monitoring, interactive prompts and feedback with a smartwatch, phone consultation with an exercise trainer and research team members, and weekly financial incentives for achieving weekly physical activity goals. Eight cognitively intact older adults were recruited and completed the study. Findings suggested that the intervention was feasible in this sample of older adults and provided favorable changes in levels of physical activity during the intervention and at post-intervention. Future studies will include a fully powered trial to evaluate the efficacy of this intervention in sedentary older adults.

Quality of direct oral anticoagulant prescribing in elderly patients with non-valvular atrial fibrillation: results from a large urban health system.

Non-valvular atrial fibrillation (NVAF) is common in older adults. Oral anticoagulation is indicated to reduce the risk of stroke and systemic embolism, but it also poses a risk of bleeding, particularly in the elderly. Direct oral anticoagulants (DOACs) provide an alternative to warfarin and their use in the treatment of AF is growing. We conducted a retrospective cohort study to assess the quality of DOAC prescribing in elderly patients with NVAF in a large academic health system and to compare practice with consensus best practice recommendations. We searched the electronic medical record for patients ≥ 65 years of age who were newly initiated on a DOAC for AF from January 2013 through December 2015. Patient and provider characteristics, baseline laboratory investigations, concomitant medications, and interval to first follow-up were recorded. 192 patients met eligibility criteria. The most commonly prescribed DOACs were rivaroxaban (65%) and apixaban (26%). Despite consensus recommendations that patients have a baseline creatinine, complete blood cell count, and coagulation studies prior to DOAC initiation, these tests were not performed in 18, 31, and 67% of patients, respectively. Consensus recommendations also suggest a follow-up visit within 1 month of DOAC initiation. However, only 39% of patients had a return visit within 6 weeks and 43% did not have follow-up within 12 weeks. DOAC prescribing in elderly patients with NVAF frequently fell short of quality standards. Interventions to enhance the quality of DOAC prescribing in this high-risk population are needed.

Impact of Alzheimer disease patients' sleep disturbances on their caregivers.

Sleep disturbance symptoms are common in persons living with Alzheimer disease (AD). However little is known about the impact of sleep disturbance symptoms in patients living with AD on caregiver burden and quality of life (QOL). The aims of this study were to determine the prevalence of symptoms of disturbed sleep in patients with AD, identify the care-recipient sleep disturbance symptoms that predict caregiver burden and QoL, and determine how care-recipient sleep disturbance symptoms compare to other caregiver and patient characteristics when predicting caregiver QoL. Caregiver burden was assessed using the Screen for Caregiver Burden. Sixty percent of the care-recipients had at least one sleep symptom. In 130 caregiver/patient dyads, nocturnal awakenings, nocturnal wandering, and snoring predicted caregiver burden. Multivariate modeling demonstrated that caregiver burden, caregiver physical and mental health, and caregiver depression were predictors of overall caregiver QoL. Treating disturbed sleep in care-recipients and caregiver mental health symptoms could have important public health impact by improving the lives of the caregiving dyad.

The development of a questionnaire to assess sleep-related practices, beliefs, and attitudes.

There are no established questionnaires that evaluate habitual sleep practices in the context of beliefs and attitudes about sleep. This study describes an effort to develop and evaluate a questionnaire that assesses habitual sleep; behaviors associated with sleep and potential sleep problems; sleep hygiene; social and environmental determinants of sleep; beliefs and attitudes about sleep as it relates to health, safety, and functioning; and knowledge about sleep. A total of 124 participants completed the final questionnaire. Overall, the questionnaire and subscales demonstrated moderate internal consistency, and concurrent and divergent validity were demonstrated by comparing various subscales to existing measures. Future studies may utilize the descriptive data to determine the role of behavioral, social, and environmental determinants of healthy sleep.

Limits of the Epworth Sleepiness Scale in older adults.

PURPOSE: Excessive daytime sleepiness (EDS) in older adults is associated with obstructive sleep apnea, falls, reduced quality of life, and mortality. The Epworth Sleepiness Scale (ESS) is widely used to assess sleepiness. However, EDS assessment with the ESS may not be accurate in older adults. We aimed to (1) describe the responsiveness of nondemented older subjects to the ESS and (2) compare the self-report ESS scores to those of close relatives (CR) proxy and identify factors influencing any discrepancies between them. METHODS: This is a cross-sectional observational study including 104 independently living nondemented older subjects with daytime sleepiness complaints and 104 nondemented CRs. Cognitive tests (Mini-Mental State Examination) and the ESS were completed separately by subjects and CRs to assess the subject's daytime sleepiness. RESULTS: Almost 60 % of subjects and CRs were not able to answer at least one question on the ESS. Despite the fact that all subjects complained of EDS, only 24 % of them had an abnormal ESS score (>10). Subjects rated their sleepiness lower (7.10 ± 4.31) than their CR proxy did (9.70 ± 5.14) (p < 0.0001). In multivariate analysis, an increase in age and a decrease in cognitive status of the subjects appeared related to the difference in ESS between subject and CR. CONCLUSIONS: The majority of older adults were not able to answer all of the ESS items. The ESS may underestimate sleepiness severity in older subjects. Despite EDS complaints in all subjects, only one quarter of them had a pathological ESS score.

Sleep-related behaviors and beliefs associated with race/ethnicity in women.

Explore how social factors influence sleep, especially sleep-related beliefs and behaviors. Sleep complaints, sleep hygiene behaviors, and beliefs about sleep were studied in 65 black/African American and white/European American women. Differences were found for snoring and discrepancy between sleep duration and need. Sleep behaviors differed across groups for napping, methods for coping with sleep difficulties, and nonsleep behaviors in bed. Beliefs also distinguished groups, with differences in motivation for sleep and beliefs about sleep being important for health and functioning. These findings have important public health implications in terms of developing effective sleep education interventions that include consideration of cultural aspects.

A randomized controlled trial to test a behavioral sleep intervention to improve insomnia symptoms in older adults with mild cognitive impairment: Multicomponent Behavioral Sleep Intervention (MBSI) protocol.

BACKGROUND: Insomnia symptoms in older adults with mild cognitive impairment represent a significant public health burden in terms of impaired quality of life, risks from untreated insomnia, and adverse effects from pharmaceutical insomnia treatment. To address current limitations in the most effective non-pharmacological treatments for insomnia in older adults with mild cognitive impairment, we are conducting a randomized pilot study to test a brief (4- week), tablet-based, personalized, multicomponent behavioral sleep intervention (MBSI) for insomnia, compared to a sleep education control, in a sample of older adults with mild cognitive impairment. METHODS: Participants will be randomized in a 1:1 ratio to intervention or control group. Both groups will complete three virtual study data collection visits: baseline, 4-week post-intervention, and 12-week post-intervention follow-up. Key components of the 4-week intervention include sleep hygiene education, stimulating meaningful activity during the day and promoting relaxation therapy at night. We will determine preliminary immediate (4-week) and sustained efficacy (12-week) of MBSI compared to sleep education on sleep related outcomes and health related quality of life. Additionally, we will explore mechanisms by which the intervention affects sleep and health related quality of life using standardized questionnaires and inflammatory biomarkers. RESULTS: (N/A). DISCUSSION: The findings of the proposed project will inform future, larger scale clinical trials and may provide a novel and innovative way for older adults with mild cognitive impairment to achieve better sleep and health-related quality of life outcomes.

Religion, Spirituality, and Coping During the Pandemic: Perspectives of Dementia Caregivers.

Religious and spiritual (R/S) practices support individuals during difficult situations. The COVID-19 social distancing restrictions may have limited access to R/S practices for older adults with Alzheimer's disease related dementia (ADRD) and their caregivers, affecting coping and well-being. This qualitative study explored the impact of social distancing on R/S practices and coping in ADRD-caregiver dyads from the perspective of caregivers. Interviews were conducted with 11 family caregivers of older adults with ADRD residing in nursing homes (n = 4) or private homes (n = 7). Caregivers continued individual and started virtual R/S practices which improved their ability to cope. However, organized R/S practices were unavailable for those with ADRD, but they used prayer and read religious texts which noticeably improved their mood. Healthcare professionals' sharing of individual and community R/S resources available for ADRD-caregiver dyads could decrease anxiety and agitation, while improving their ability to cope with increased isolation.

Melatonin pharmacokinetics following two different oral surge-sustained release doses in older adults.

Melatonin is increasingly used for the treatment of sleep disorders. Surge-sustained formulations consisting of combined immediate release and controlled release dosing may mimic the endogenous melatonin physiologic profile. However, relatively little is known about the pharmacokinetic properties of low-dose (<0.5mg) and high-dose (>2mg) melatonin in a combined immediate release/controlled release dose, especially in older adults who may also exhibit altered melatonin disposition. To assess this, we conducted a randomized, double-blind, placebo-controlled study of low-dose (0.4mg) and high-dose (4.0mg) melatonin (25% immediate release+75% controlled release) in 27 older adults with insomnia complaints and low endogenous melatonin levels to determine whether melatonin pharmacokinetic properties differ between these two doses. The time to maximum level (1.3hrs versus 1.5hrs), elimination half-life (1.8hrs versus 2.1hrs), and apparent total clearance (379L/hr versus 478L/hr) did not differ significantly between the low- and high-dose arms, respectively. The maximum concentration was 405 ±93pg/mL for the low-dose arm and 3999±700pg/mL for the high-dose arm, both of which are substantially higher than physiologic melatonin levels for this age group. In addition, subjects in the high-dose arm maintained melatonin levels >50pg/mL for an average of 10hrs, which could result in elevated melatonin levels beyond the typical sleep period. Renal and liver function parameters remained stable after 6wks of treatment. The linear pharmacokinetic behavior of melatonin observed in the elderly can form the basis for future studies exploring a wider range of dosing scenarios to establish exposure-response relationships for melatonin-mediated sleep outcomes.

Perceived racial discrimination as an independent predictor of sleep disturbance and daytime fatigue.

Perceived discrimination is a potential cause of racial and ethnic disparities in health. Disturbed sleep may serve as a mechanism linking perceived racism with health consequences. This study investigates data from 7,148 adults from Michigan and Wisconsin who participated in the 2006 Behavioral Risk Factor Surveillance System. Hierarchical logistic regression analyses explored associations between perceived racial discrimination and self-reported sleep disturbance and daytime fatigue. Sleep disturbance and daytime fatigue were reported in 19% and 21% of the sample, respectively. Black/African American respondents (21%) report perceiving worse experiences, compared to people of other races, when seeking health care at higher rates than non-Hispanic White respondents (3%). Results from logistic regression models show that perceived racial discrimination is associated with increased risks of sleep disturbance (odds ratio [OR] = 2.62, p < .0001) and daytime fatigue (OR = 2.07, p < .0001). After adjustment for all covariates, perceived discrimination remains a significant predictor of sleep disturbance (OR = 1.60, p = .04). The interaction between perceived racism and race (Black/African American vs. non-Hispanic White) was nonsignificant. This population-based research adds to the growing body of data, suggesting that perceived racism may impact health via its influence on sleep-wake behaviors.

Sleep in Normal Aging.

Sleep is a key determinant of healthy and cognitive aging. Sleep patterns change with aging, independent of other factors, and include advanced sleep timing, shortened nocturnal sleep duration, increased frequency of daytime naps, increased number of nocturnal awakenings and time spent awake during the night, and decreased slow-wave sleep. The sleep-related hormone secretion changes with aging. Most changes seem to occur between young and middle adulthood; sleep parameters remain largely unchanged among healthy older adults. The circadian system and sleep homeostatic mechanisms become less robust with normal aging. The causes of sleep disturbances in older adults are multifactorial.

Recruiting Persons with Dementia and Caregivers in a Clinical Trial: Dyads Perceptions.

Recruitment for dementia research is challenging and costly. Using Ajzen's Theory of Planned Behavior we explored attitudes, perceived norms, and perceived behavioral control of persons living with dementia (PLWD) and their caregivers who participated in one clinical trial to better understand factors that influence dyads' decisions to enroll. We conducted semi-structured telephone interviews with 12 PLWD and 9 caregivers and utilized directed content analysis. Categories connected with positive attitudes about study enrollment were personal desires of wanting to learn and in-person meetings with knowledgeable staff. Additionally, participants said the money always helps in terms of the financial incentive. Participants reported enrolling to support another person (perceived norm). Study requirements were thought to be easy (perceived behavioral control). Participants highlighted the importance of flexible scheduling and study tasks being completed at their home. Findings can inform future recruitment efforts and should be investigated as effective recruitment methods in other clinical trials.

"Please Don't Forget Us": A Descriptive Qualitative Study of Caregivers of Older Adults With Alzheimer's Disease and Related Dementias During the COVID-19 Pandemic.

The current descriptive qualitative study explored the perceived impact of the coronavirus disease 2019 pandemic on sleep disturbances and nighttime agitation; the reported use of antipsychotics and other sedating medications; and the overall well-being of older adults with Alzheimer's disease and related dementias (ADRD) and their caregivers. One investigator conducted in-depth, phone interviews with caregivers of nursing home residents with ADRD (four family caregivers [FCs], three nurse practitioners [NPs]) and seven FCs of older adults with ADRD who lived with them at home. Caregivers described multiple sleep disturbances. Nighttime agitation symptoms were perceived to continue or worsen, and sedating medications and nonpharmacological interventions were required. Adverse impacts on reported well-being were significant, and impacts were grouped into emotional, social, and physical themes. Caregivers said, "Please don't forget us," and requested telehealth support for those at home and technology and human resources for nursing homes to reduce adverse impacts. [Research in Gerontological Nursing, 15(5), 217-228.].

Case-control study of subjective and objective differences in sleep patterns in older adults with insomnia symptoms.

Older adults have high prevalence rates of insomnia symptoms, yet it is unclear if these insomnia symptoms are associated with objective impairments in sleep. We hypothesized that insomnia complaints in older adults would be associated with objective differences in sleep compared with those without insomnia complaints. To test this hypothesis, we conducted a cross-sectional study in which older adults with insomnia complaints (cases, n=100) were compared with older adults without insomnia complaints (controls, n=100) using dual-night in-lab nocturnal polysomnography, study questionnaires and 7 days of at-home actigraphy and sleep diaries. Cases were noted to have reduced objective total sleep time compared with controls (25.8 ± 8.56 min, P=0.003). This was largely due to increased wakefulness after sleep onset, and not increased sleep latency. When participants with sleep-related breathing disorder or periodic limb movement disorder were excluded, the polysomnography total sleep time difference became even larger. Cases also had reduced slow-wave sleep (5.10 ± 1.38 min versus 10.57 ± 2.29 min, effect size -0.29, P=0.04). When comparing self-reported sleep latency and sleep efficiency with objective polysomnographic findings, cases demonstrated low, but statistically significant correlations, while no such correlations were observed in controls. Cases tended to underestimate their sleep efficiency by 1.6% (±18.4%), while controls overestimated their sleep efficiency by 12.4% (±14.5%). In conclusion, we noted that older adults with insomnia complaints have significant differences in several objective sleep findings relative to controls, suggesting that insomnia complaints in older adults are associated with objective impairments in sleep.

Primary care provider evaluation and management of insomnia.

STUDY OBJECTIVES: To evaluate the type and extent of information collected from patients with insomnia during their first office encounter for insomnia and the prescribing therapies of primary care providers during this initial encounter. METHODS: This study was a retrospective chart review of randomly selected patients who had a primary care provider office visit at any clinic affiliated with a university medical system between March 1, 2013, and March 1, 2016. Demographic and clinical information was abstracted for analysis. RESULTS: Our sample (n = 200) was primarily female (63.5%), White (69%), middle-aged (ages 44.6 ± 15.1 years) adults. Most (68.5%) encounter notes did not have significant information related to insomnia risk factors and symptoms (< 50% of the notes). When examining comorbidities, we found that younger patients (<45 years old) were more likely to have anxiety linked to insomnia (P = .025), whereas older patients (≥45) were less likely to have any identified comorbidities associated with insomnia (P = .009). Only 5.0% of patients with insomnia were referred for cognitive-behavioral therapy for insomnia, whereas 51.5% of patients were prescribed sleep medications. The younger cohort was statistically more likely to receive sleep hygiene or cognitive-behavioral therapy for insomnia as a treatment option in comparison to the older cohort (P = .01 and P = .04, respectively). CONCLUSIONS: Progress notes from primary care providers tend to have a paucity of information on insomnia symptoms and related comorbidities. Medications are often prescribed as the first-line treatment for insomnia. Cognitive-behavioral therapy for insomnia remains underutilized despite robust evidence suggesting that cognitive-behavioral therapy for insomnia is a safe and effective treatment for insomnia.