Identifying gaps in clinical evaluation and treatment of sleep-disordered breathing in women veterans.

PURPOSE: Sleep-disordered breathing (SDB) is a common sleep disorder in veterans; however, limited research exists in women veterans. We sought to estimate patterns of care in terms of evaluation, diagnosis, and treatment among women veterans with factors associated with elevated SDB risk. METHODS: Within one VA healthcare system, women identified through electronic health record data as having one or more factors (e.g., age >50 years, hypertension) associated with SDB, completed telephone screening in preparation for an SDB treatment study and answered questions about prior care related to SDB diagnosis and treatment. RESULTS: Of 319 women, 111 (35%) reported having completed a diagnostic sleep study in the past, of whom 48 (43%) were diagnosed with SDB. Women who completed a diagnostic study were more likely to have hypertension or obesity. Those who were diagnosed with SDB based on the sleep study were more likely to have hypertension, diabetes, or be ≥50 years old. Of the 40 women who received treatment, 37 (93%) received positive airway pressure therapy. Only 9 (24%) had used positive airway pressure therapy in the prior week. Few women received other treatments such as oral appliances or surgery. CONCLUSIONS: Findings support the need for increased attention to identification and management of SDB in women veterans, especially those with conditions associated with elevated SDB risk.

Veterans' Experiences of Support in Managing Comorbid Sleep Apnea and Type 2 Diabetes.

BACKGROUND: Obstructive sleep apnea (OSA) is highly prevalent in patients with Type 2 diabetes, more so in veterans compared with nonveterans. Positive airway pressure is the recommended first-line treatment for OSA. However, adherence to both positive airway pressure and diabetes management regimens can be challenging for older adults. Support from family or friends may improve glucose control or sleep-apnea-related symptoms, yet the evidence is limited when both conditions coexist. OBJECTIVES: This study aimed to describe veterans' experiences of support from family and friends with managing comorbid sleep apnea and Type 2 diabetes. METHODS: We conducted a postal survey of older veterans with OSA and Type 2 diabetes from one healthcare system. Questions include demographic and health-related information, information about sleep apnea and diabetes treatment and education received, related support from family or a friend, perceived benefits of regular positive airway pressure device use on improving sleep health, and perceived benefits of education for family or a friend on sleep apnea and diabetes. Descriptive and bivariate analyses were performed. RESULTS: Of 145 respondents (mean age = 72 years), 43% reported receiving help for Type 2 diabetes from family or a friend. Almost two thirds of the respondents were currently using a positive airway pressure device, of whom 27% received support with device use from family or friends. About one third of veterans perceived family and friends receiving education on treating sleep apnea and diabetes to be very or extremely helpful. Such perceived benefit was higher among those who were married or identified as non-White. Veterans using a positive airway pressure device had lower hemoglobin A1c levels than nonusers. DISCUSSION: Veterans perceived that additional education for the individuals providing support would be beneficial. Future studies could address interventions to increase sleep apnea and Type 2 diabetes knowledge among families and friends of veterans with these comorbid conditions. In addition, patients' adherence to positive airway pressure may be enhanced by support from family and friends.

Values Expressed by Women Veterans Receiving Treatment for Chronic Insomnia Disorder.

OBJECTIVES: Insomnia may contribute to fewer value-consistent choices and less engagement in meaningful life activities. We sought to identify values commonly expressed by women veterans engaged in a trial testing psychological treatment of insomnia disorder. METHODS: Seventy-four women veterans (mean age = 48.3 [±13] years), meeting DSM-5 diagnostic criteria for insomnia disorder received an acceptance-based behavioral treatment for insomnia. In the first session, participants responded to questions regarding personal values and the impact of insomnia on those values. Responses were categorized into values domains informed by the Bull's Eye Values survey (level 1 categories) and the Valued Living Questionnaire (level 2 categories). RESULTS: Raters reached 100% agreement after independent coding and adjudication. Level 1 value categories in frequency order were: relationships (n = 68), personal care/health (n = 51), work/education (n = 46), pets (n = 12), and leisure (n = 5). The most frequently reported level 2 value categories were: family (other than marriage/parenting; n = 50), parenting (n = 31), work (n = 31), physical health (n = 30), and spirituality (n = 19). The level 1 value categories impacted by insomnia in frequency order were: personal care/health (n = 65), relationships (n = 58), work/education (n = 46), pets (n = 12), and leisure (n = 5). CONCLUSIONS: Women veterans undergoing insomnia treatment highly value relationships and personal care/health, which should be considered patient-centered outcomes of insomnia treatments. CLINICAL TRIALS REGISTRATION: NCT02076165.

Sleep Disruption Due to Stress in Women Veterans: A Comparison between Caregivers and Noncaregivers.

Objective/Background: Sleep problems are common in women and caregiving for an adult is a common role among women. However, the effects of caregiving on sleep and related daytime impairment are poorly understood among women veterans. This study compared stress-related sleep disturbances, insomnia symptoms, and sleep-related daytime impairment between women veterans who were caregivers and those who did not have a caregiving role. Participants: Of 12,225 women veterans who received care in one Veterans Administration Healthcare System, 1,457 completed data on a postal survey (mean age = 51.7 ± 15.9 years). Two hundred forty three (17%) respondents (mean age 53.8 ± 12.7 years) were caregivers for an adult, predominantly for a parent, providing transportation. Methods: The survey included items that addressed insomnia symptoms, total sleep time, sleep-related daytime impairments, caregiving characteristics, self-rated health, pain, stress, body mass index, and demographic information. Results: In adjusted analyses, caregiver status did not directly predict sleep complaints alone. However, in multiple regression analyses, being a caregiver (odds ratio 1.7, p = .001) significantly predicted stress-related sleep disturbance, even after adjusting for age, pain, self-rated health, and other characteristics. Furthermore, being a caregiver (ß = 3.9, p = .031) significantly predicted more symptoms of sleep-related daytime impairment after adjusting for age, pain, self-rated health, and other factors. Conclusions: Compared to noncaregivers, women veterans who were caregivers for an adult were more likely to report stress causing poor sleep, and more daytime impairment due to poor sleep. These findings suggest the need to target stress and other factors when addressing sleep disturbance among women veterans who are caregivers.

Sleep and Caregiving Experiences among Caregivers of Veterans in an Adult Day Health Care Program: A Pilot Study.

OBJECTIVES: This pilot study explored caregivers' attitudes toward core elements of a behavioral sleep intervention for managing sleep problems of older veteran care recipients and the caregivers, as an initial step for developing a dyadic sleep intervention program. METHODS: Five caregivers (all women; age range, 66-75 years) participated in a focus group discussion. Data were collected at one Veterans Affairs, adult day health care program. RESULTS: Caregivers' poor sleep was not necessarily explained by their caregiving responsibility. Caregivers felt that behavioral recommendations regarding sleep compression scheduling, increased indoor physical activity, and outdoor light exposure would be acceptable sleep interventions for themselves and the care recipients. Some challenges to the sleep recommendation were identified and they included limiting naptime of care recipients and change of their current sleep schedule. CONCLUSIONS: Caregivers are receptive to some key components of behavioral approaches to improving sleep. Tailored sleep recommendation strategy is needed to address potential challenges. CLINICAL IMPLICATIONS: If available within clinical care settings or delivered at the patient's home, caregivers of older veterans are likely to engage in behavioral sleep intervention programs.

Measuring Sleep in Vulnerable Older Adults: A Comparison of Subjective and Objective Sleep Measures.

OBJECTIVES: This study compared subjective (questionnaire) and objective (actigraphy) sleep assessments, and examined agreement between these methods, in vulnerable older adults participating in a Veterans Administration Adult Day Health Care (ADHC) program. METHODS: 59 ADHC participants (95% male, mean age = 78 years) completed sleep questionnaires and 72 continuous hours of wrist actigraphy. Linear regression was used to examine agreement between methods and explore discrepancies in subjective/objective measures. RESULTS: Disturbed sleep was common, yet there was no agreement between subjective and objective sleep assessment methods. Compared with objective measures, one-half of participants reported worse sleep efficiency (SE) on questionnaires while one-quarter over-estimated SE. Participants reporting worse pain had a greater discrepancy between subjective and objective SE. CONCLUSIONS: Vulnerable older adults demonstrated unique patterns of reporting sleep quality when comparing subjective and objective methods. Additional research is needed to better understand how vulnerable older adults evaluate sleep problems. CLINICAL IMPLICATIONS: Objective and subjective sleep measures may represent unique and equally important constructs in this population. Clinicians should consider utilizing both objective and subjective sleep measures to identify individuals who may benefit from behavioral sleep treatments, and future research is needed to develop and validate appropriate sleep assessments for vulnerable older adults.

Novel treatment based on acceptance and commitment therapy versus cognitive behavioral therapy for insomnia: A randomized comparative effectiveness trial in women veterans.

OBJECTIVE: This randomized comparative effectiveness trial evaluated a novel insomnia treatment using acceptance and commitment therapy (ACT) among women veterans. Participants received either the acceptance and the behavioral changes to treat insomnia (ABC-I) or cognitive behavioral therapy for insomnia (CBT-I). The primary objectives were to determine whether ABC-I was noninferior to CBT-I in improving sleep and to test whether ABC-I resulted in higher treatment completion and adherence versus CBT-I. METHOD: One hundred forty-nine women veterans with insomnia disorder (Mage = 48.0 years) received ABC-I or CBT-I. The main sleep outcomes were Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), and sleep efficiency (SE) by actigraphy (objective) and sleep diary (subjective). Measures were collected at baseline, immediate posttreatment, and 3-month posttreatment follow-up. Treatment completion and adherence were assessed during the interventions. RESULTS: Both interventions improved all sleep outcomes from baseline to immediate posttreatment and 3-month posttreatment follow-up. At immediate posttreatment, ABC-I was statically noninferior for sleep diary SE and objective SE, but noninferiority was not statistically confirmed for ISI or PSQI total scores. At 3-month posttreatment follow-up, ABC-I was noninferior for all four of the key outcome variables. There was not a statistically significant difference between the number of participants who discontinued CBT-I (11%) versus ABC-I (18%; p = .248) before completing treatment. ABC-I was superior to CBT-I for some adherence metrics. CONCLUSIONS: Overall, ABC-I was similar in effectiveness compared to CBT-I for the treatment of insomnia and may improve adherence to some behavioral elements of treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A longitudinal study of poor sleep after inpatient post-acute rehabilitation: the role of depression and pre-illness sleep quality.

OBJECTIVES: To explore the unique impact of poor sleep and symptoms of depression on sleep quality for up to 1 year after inpatient post-acute rehabilitation among older adults. DESIGN: Prospective longitudinal cohort study. SETTING: Two inpatient post-acute rehabilitation facilities. PARTICIPANTS: A total of 245 individuals older than 65 years (mean age = 80 years, 38% women). INTERVENTIONS: None. MEASUREMENTS: Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI) during the post-acute care stay twice to evaluate pre-illness sleep quality and sleep quality during the post-acute care stay, and again at 3-, 6-, 9-, and 12-month follow-up. Demographics, symptoms of depression, cognitive functioning, and comorbidities were also assessed. RESULTS: Across time points, sleep was significantly disturbed for many individuals. Nested regression models predicting PSQI total score at 3, 6, 9, and 12 months showed that variables entered in Block 1 (age, gender, cognitive functioning, and comorbidities) were significant predictors of poor sleep at 6-month follow-up but not at 3-, 9-, or 12-month follow-up. Depression (Block 2) and pre-illness PSQI total score (Block 3) were significant predictors of PSQI total score at all follow-up time points. PSQI total score during post-acute care (Block 4) explained a significant proportion of variance only at the 3-month follow-up. CONCLUSIONS: This study confirms that chronic poor sleep is common among older adults during post-acute rehabilitation and resolution of sleep disturbance after acute health events may be a lengthy process. Our findings expand understanding of the role of depressive symptoms and preexisting sleep complaints in predicting poor sleep over time among these vulnerable older adults.

Sleep disturbance among older adults in assisted living facilities.

OBJECTIVES: To evaluate whether objectively and subjectively measured sleep disturbances persist among older adults in assisted living facilities (ALFs) and to identify predictors of sleep disturbance in this setting. DESIGN: Prospective, observational cohort study. SETTING AND PARTICIPANTS: A total of 121 residents, age ≥ 65 years, in 18 ALFs in the Los Angeles area. MEASUREMENTS: Objective (actigraphy) and subjective (Pittsburgh Sleep Quality Index) sleep measures were collected at baseline and 3- and 6-month follow-up. Predictors of baseline sleep disturbance tested in bivariate analyses and multiple regression models included demographics, Mini-Mental State Examination score, number of comorbidities, nighttime sedating medication use, functional status (activities of daily living; instrumental activities of daily living), restless legs syndrome, and sleep apnea risk. RESULTS: Objective and subjective sleep measures were similar at baseline and 3- and 6-month follow-up (objective nighttime total sleep [hours] 6.3, 6.5, and 6.4; objective nighttime percent sleep 77.2, 77.7, and 78.3; and Pittsburgh Sleep Quality Index total score 8.0, 7.8, and 7.7, respectively). The mean baseline nighttime percent sleep decreased by 2% for each additional unit increase in baseline comorbid conditions (measured as the number of conditions), and increased by 4.5% for each additional unit increase in baseline activities of daily living (measured as the number of activities of daily living), in a multiple regression model. CONCLUSIONS: In this study, we found that objectively and subjectively measured sleep disturbances are persistent among ALF residents and are related to a greater number of comorbidities and poorer functional status at baseline. Interventions are needed to improve sleep in this setting.

Actigraphy prior to Multiple Sleep Latency Test: nighttime total sleep time predicts sleep-onset latency.

STUDY OBJECTIVES: To evaluate the clinical utility of actigraphy as compared with sleep questionnaires prior to the Multiple Sleep Latency Test (MSLT) in a sleep disorders clinic population. METHODS: Twenty-eight clinically referred participants (mean age: 42.3 ± 18.8 years) completed the study protocol. On day 1, participants completed the following questionnaires: Epworth Sleepiness Scale (ESS), Insomnia Severity Index, Pittsburgh Sleep Quality Index (PSQI), Visual Analog Scale (affect, vigor), Patient Health Questionnaire, and Multidimensional Fatigue Symptom Inventory-Short Form. On days 1-8, participants wore an actigraph and completed a sleep diary to assess mean nighttime and mean daytime total sleep time and sleep efficiency or sleep percentage. On day 9, participants repeated the ESS and completed an MSLT. Correlations assessed mean MSLT sleep-onset latency (MSLT-SOL) vs actigraphy, sleep diary, and questionnaires. Chi-square analyses assessed abnormal MSLT-SOL (≤ 8 minutes) or daytime sleepiness (ESS ≥ 10) and referral question (ie, sleep-disordered breathing vs hypersomnolence disorder). RESULTS: Mean MSLT-SOL was correlated with nighttime total sleep time assessed via both actigraphy and diary, but not with questionnaires. Significant correlations emerged for ESS score on day 1 vs 9, actigraphy vs sleep diary mean nighttime total sleep time, and PSQI vs mean sleep diary sleep efficiency. There was no significant relationship between mean MSLT-SOL and referral question. CONCLUSIONS: Our finding that total sleep time measured by actigraphy was associated with MSLT-SOL suggests it is useful in informing the interpretation of MSLT findings; however, it does not appear to be a viable substitute for MSLT for the measurement of objective sleepiness in clinical settings. CITATION: Kelly MR, Zeidler MR, DeCruz S, et al. Actigraphy prior to Multiple Sleep Latency Test: nighttime total sleep time predicts sleep-onset latency. J Clin Sleep Med. 2022;18(1):161-170.

Benefits of Cognitive Behavioral Therapy for Insomnia for Women Veterans with and without Probable Post-Traumatic Stress Disorder.

OBJECTIVE: This study compared the benefits of cognitive-behavioral therapy for insomnia for sleep, mental health symptoms, and quality of life (QoL) in a sample of women veterans with and without probable post-traumatic stress disorder (PTSD) comorbid with insomnia disorder. METHODS: Seventy-three women veterans (30 with probable PTSD) received a manual-based 5-week cognitive-behavioral therapy for insomnia treatment as part of a behavioral sleep intervention study. Measures were completed at baseline, post-treatment, and 3-month follow-up. Sleep measures included the Insomnia Severity Index, Pittsburgh Sleep Quality Index, sleep efficiency measured by actigraphy, and sleep efficiency and total sleep time measured by sleep diary. Mental health measures included the PTSD Checklist-5, nightmares per week, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7 scale. QoL was measured with the Short Form-12. Linear mixed models compared changes over time across groups. Independent t tests examined PTSD symptom changes in women veterans with probable PTSD. RESULTS: Both groups demonstrated improvements across sleep (ps < .001-.040), mental health symptoms (ps < .001), and QoL measures (ps < .001). The probable PTSD group reported greater improvements in diary sleep efficiency (p = .046) and nightmares per week (p = .001) at post-treatment and in total sleep time (p = .029) and nightmares per week (p = .006) at follow-up. Most participants with probable PTSD experienced clinically significant reductions in PTSD symptoms at post-treatment (66.7%) and follow-up (60.0%). Significant reductions in intrusive and arousal/reactivity symptoms were maintained at follow-up. CONCLUSIONS: Cognitive-behavioral therapy for insomnia improves insomnia, mental health symptoms, and QoL among women veterans, with greater improvement in those with probable PTSD.

Development of a dyadic sleep intervention for Alzheimer's disease patients and their caregivers.

PURPOSE: This study aimed to refine a behavioral sleep intervention program targeting patients with Alzheimer's disease and their caregivers. METHODS: In this case series, key components of the sleep program were built upon previous intervention studies of patients with cognitive impairment/dementia. The intervention consisted of five weekly sessions covering sleep hygiene, sleep compression, stimulus control, daily walking/light exposure, relaxation/mindfulness, and caregiver training to manage patients' behavioral problems. The materials and structure were iteratively refined based on feedback from caregivers and sleep educators. Sleep diaries were used to evaluate sleep outcomes. RESULTS: Five out of six enrolled dyads completed the sessions. Several revisions were made during testing: the last session was changed from telephone to in-person; some components (e.g., sleep scheduling, mindfulness) were rearranged within or across sessions; sleep educator guidelines for sleep scheduling, light exposure, and walking were revised. After the fifth dyad, no additional issues were identified by the caregiver or the sleep educator. Four patients and three caregivers had improved sleep at the last session. CONCLUSIONS: The iterative refinement process was successful in finalizing the intervention program, with evidence of sleep improvements. Formal pilot testing of the program will provide further information on feasibility and effectiveness.IMPLICATIONS FOR REHABILITATIONOur dyadic behavioral sleep program can be tailored to various types of sleep problems among patients with Alzheimer's disease and their family caregivers, with the goal of improving daytime function by reducing sleep disturbances at night.Caregiver training and participation of both members of the dyad in sleep management may benefit the patients' sleep and other health outcomes, reduce caregiver stress and burden, and ultimately delay or prevent institutionalization of Alzheimer's disease patients.

Sleep apnea in women veterans: results of a national survey of VA health care users.

STUDY OBJECTIVES: The goals of this study were to estimate rates of undiagnosed, diagnosed, and treated sleep apnea in women veterans and to identify factors associated with diagnosis and treatment of sleep apnea in this population. METHODS: A large nationwide postal survey was sent to a random sample of 4,000 women veterans who had received health care at a Veterans Health Administration (VA) facility in the previous 6 months. A total of 1,498 surveys were completed. Survey items used for the current analyses included: demographics; sleep apnea risk, diagnostic status, and treatment; symptoms of other sleep disorders (eg, insomnia); mental health symptoms; and comorbidities. RESULTS: Among responders, 13% of women reported a prior sleep apnea diagnosis. Among women who reported a diagnosis of sleep apnea, 65% reported using positive airway pressure therapy. A sleep apnea diagnosis was associated with older age, higher BMI, non-Hispanic African American/Black racial/ethnic identity, being unemployed, other sleep disorder symptoms (eg, insomnia), depression and post-traumatic stress disorder symptoms, and multimorbidity. Among women without a sleep apnea diagnosis, 43% scored as "high risk" on the STOP (snoring, tiredness, observed apneas, blood pressure) questionnaire. High risk scores were associated with older age, higher BMI, African American/Black identity, other sleep disorder symptoms (eg, insomnia), mental health symptoms, and multimorbidity. Only BMI differed between women using vs not using positive airway pressure therapy. CONCLUSIONS: Women veterans with diagnosed sleep apnea were commonly treated with positive airway pressure therapy, which is standard first-line treatment; however, many undiagnosed women were at high risk. Efforts to increase screening, diagnosis, and treatment of sleep apnea in women with comorbid mental and physical health conditions are needed.

Development of a fall prevention survey to determine educational needs for primary care providers.

Quality indicators are standardized measures of health care quality. We designed a survey to assess how knowledge, attitude, and organizational practices might affect healthcare provider behaviors in meeting quality indicators for fall prevention to plan curricula for a continuing educational intervention. The survey was pilot tested in the Veterans Affairs (VA) in a small stratified sample. Some items that had been previously used in assessments for continuing education among community physicians were not well matched to the VA practice environment or to midlevel clinicians, suggesting that instruments need to be adapted for relevance to the health care setting as well as discipline.

Effect of testing procedures on gait speed measurement: A systematic review.

BACKGROUND: Although gait speed is a widely used measure in older people, testing methods are highly variable. We conducted a systematic review to investigate the influence of testing procedures on resulting gait speed. METHODS: We followed the PRISMA checklist for this systematic review. Two independent reviewers screened Pubmed and Embase for publications on pairwise comparisons of testing procedures of usual gait speed. Descriptives were abstracted from the included publications using a predefined extraction tool by two independent reviewers. We defined the cut-off for the minimal clinically imporant diffence in gait speed as 0.1 m/sec. RESULTS: Of a total of 2109 records identified for screening, 29 reports on 53 pairwise comparisons were analyzed. The median (range) difference in gait speed for dynamic versus static start was 0.06 (-0.02 to 0.35) m/sec (14 reports); for longer versus shorter test distance 0.04 (-0.05 to 0.23) m/sec (14 reports); for automatic versus manual timing 0.00 (-0.05 to 0.07) m/sec (12 reports), for hard versus soft surfaces -0.11 (-0.18 to 0.08) m/sec (six reports), and electronic walkways versus usual walk test 0.04 (-0.08 to 0.14) m/sec (seven reports), respectively. No report compared the effect of finishing procedures. CONCLUSIONS: The type of starting procedure, the length of the test distance, and the surface of the walkway may have a clinically relevant impact on measured gait speed. Manual timing resulted in statistically significant differences of measured gait speed as compared to automatic timing, but was below the level of clinical importance. These results emphasize that it is key to use a strictly standardized method for obtaining a reliable and valid measurement of gait speed.

Insomnia Disorder Among Older Veterans: Results of a Postal Survey.

STUDY OBJECTIVES: To estimate the prevalence of insomnia disorder among older veterans and to study relationships among age and self-rated health, with insomnia disorder, self-reported sleep duration and sleep efficiency. METHODS: A cross-sectional postal survey of community-dwelling older veterans (older than 60 years) seen at one VA Healthcare System in the prior 18 months was performed, which was constructed to align with the general diagnostic criteria for insomnia disorder (International Classification of Sleep Disorders, Second Edition [ICSD-2]). The survey also queried self-reported sleep duration, bedtime, and wake time, which were used to calculate sleep efficiency. The survey also asked about race/ethnicity and self-rated health (using the general health item from the Short Form-36). RESULTS: A completed survey was returned by 4,717 individuals (51.9% response rate; mean age 74.1 years). Of those, 2,249 (47.7%) met ICSD-2 diagnostic criteria for insomnia disorder. In logistic regression analyses, insomnia disorder was more likely among younger age categories (odds ratios [OR] 1.4-2.5) and in those with worse self-rated health (OR 2.1-14.4). Both total nocturnal sleep time and time in bed increased with older age (all P < .001), whereas sleep efficiency did not differ. Worse self-rated health was associated with shorter total nocturnal sleep time, more time in bed, and lower (worse) sleep efficiency. CONCLUSIONS: Results of the postal survey suggest that almost half of community-dwelling older veterans have insomnia disorder, which was more common in young-old and among those with worse self-rated health. Additional work is needed to address the high burden of insomnia among older adults, including those with poor health.

More daytime sleeping predicts less functional recovery among older people undergoing inpatient post-acute rehabilitation.

STUDY OBJECTIVES: To study the association between sleep/wake patterns among older adults during inpatient post-acute rehabilitation and their immediate and long-term functional recovery DESIGN: Prospective, observational cohort study. SETTING: Two inpatient post-acute rehabilitation sites (one community and one Veterans Administration). PARTICIPANTS: Older patients (aged > or = 65 years, N = 245) admitted for inpatient post-acute rehabilitation. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Based on 7-day wrist actigraphy during the rehabilitation stay, mean nighttime percent sleep was only 52.2% and mean daytime percent sleep was 15.8% (16.3% based on structured behavioral observations). Using the Pittsburgh Sleep Quality Index (PSQI), participants reported their sleep was worse during rehabilitation compared to their premorbid sleep. Functional recovery between admission and discharge from rehabilitation (measured by the motor component of the Functional Independence Measure) was not significantly associated with reported sleep quality (PSQI scores) or actigraphically measured nighttime sleep. However, more daytime percent sleep (estimated by actigraphy and observations) during the rehabilitation stay was associated with less functional recovery from admission to discharge, even after adjusting for other significant predictors of functional recovery (mental status, hours of rehabilitation therapy received, rehospitalization, and reason for admission; adjusted R2= 0.267, P < 0.0001). More daytime sleeping during rehabilitation remained a significant predictor of less functional recovery in adjusted analyses at 3-month follow-up. CONCLUSIONS: Sleep disturbance is common among older people undergoing inpatient post-acute rehabilitation. These data suggest that more daytime sleeping during the rehabilitation stay is associated with less functional recovery for up to three months after admission for rehabilitation.

Sleep in assisted living facility residents versus home-dwelling older adults.

BACKGROUND: Sleep problems among assisted living facility (ALF) residents are not well understood, and sleep-related differences between ALF residents and home-dwelling older adults have not been examined. METHODS: We compared sleep patterns in 19 ALF residents to sleep patterns in 19 matched home-dwelling older people (age > or =65 years). All were participating in the follow-up portion of a longitudinal study of sleep and functional outcomes following post-acute rehabilitation. Sleep was assessed with the Pittsburgh Sleep Quality Index and 1 week of wrist actigraphy. RESULTS: By actigraphy, ALF residents awoke earlier in the morning and exhibited more nighttime awakenings compared to home-dwelling participants (06:50 hours +/- 1:29 hours vs 07:51 hours +/- 1:19 hours and 19.5 +/- 8.5 vs 12.9 +/- 11.4 awakenings, respectively). CONCLUSIONS: Larger studies are needed to confirm these initial findings that ALF residents have more disrupted sleep than do home-dwelling older persons, and to examine the functional and health consequences of poor sleep among ALF residents.

A randomized trial of a screening, case finding, and referral system for older veterans in primary care.

OBJECTIVES: To test whether a system of screening, assessment, referral, and follow-up provided within primary care for high-risk older outpatients improves recognition of geriatric conditions and healthcare outcomes. DESIGN: Controlled clinical trial with 3-year follow-up; intervention versus control group allocation based on practice group assignment. SETTING: Department of Veterans Affairs (VA) ambulatory care center. PARTICIPANTS: Seven hundred ninety-two community-dwelling patients aged 65 and older identified by postal screening survey. INTERVENTION: The intervention combined a structured telephone geriatric assessment by a physician assistant, individualized referrals and recommendations, selected referral to outpatient geriatric assessment, and ongoing telephone case management. MEASUREMENTS: Main outcomes were VA medical record evidence of recognition and evaluation of target geriatric conditions (depression, cognitive impairment, urinary incontinence, falls, functional impairment), functional status (Functional Status Questionnaire, FSQ), and hospitalization (VA databases and self-reported non-VA usage). RESULTS: Intervention participants were more likely to have target conditions recognized, evaluated, and referred to specialized services within 12 months of enrollment, although there were no significant differences in FSQ scores or acute hospitalization between intervention and control groups at 1, 2, or 3 years follow-up. Subgroup analyses suggested improvements in depression symptoms and functional impairment at 1-year follow-up in intervention participants with these problems at baseline, but these findings were not evident at later follow-up. CONCLUSION: The intervention increased recognition and evaluation of target geriatric conditions but did not improve functional status or decrease hospitalization. Innovative screening methods can identify older people in need of geriatric services, but achieving measurable improvement in functional status or hospitalization rates will likely require a more-intensive intervention than a program involving primarily unsolicited referrals and short-term consultations.

A multicomponent nonpharmacological intervention improves activity rhythms among nursing home residents with disrupted sleep/wake patterns.

BACKGROUND: Sleep and circadian rhythms are disrupted among many nursing home (NH) residents. We examined the impact of a multicomponent nonpharmacological intervention on 24-hour rest/activity rhythms among long-stay NH residents. METHODS: The study was a randomized controlled trial in which, following a 3-day baseline, participants received 5 days of either usual care (control condition) or the active intervention. The intervention combined increased exposure to outdoor bright light, efforts to keep residents out of bed during the day, structured physical activity, institution of a bedtime routine, and efforts to reduce nighttime noise and light in residents' rooms. For 100 residents with baseline and follow-up wrist actigraphy data (mean age = 87 years; 76% women), rest/activity rhythms were modeled to determine the rhythm acrophase (peak time), nadir (trough time), midline estimating statistic of rhythm (MESOR) (midpoint), amplitude (height of peak), slope, and the rest period/active period ratio (alpha). RESULTS: The intervention led to an increase in the duration of the "active" portion of the rhythm, which was primarily accounted for by a shift in the rest/activity rhythm rise to an earlier time. Findings persisted when analyses were adjusted for age, cognitive functioning, medical comorbidities, and behavioral disturbances. CONCLUSIONS: These findings suggest that the intervention may effectively improve the robustness of rest/activity rhythms in NH residents. Further research is needed to examine the impact of similar interventions on other measures of circadian rhythms (e.g., body temperature, melatonin) among NH residents.