Impact of the sleep apnea management group clinic on positive airway pressure adherence.

BACKGROUND: Positive airway pressure (PAP) adherence is critical for managing obstructive sleep apnea (OSA). We postulate that group-based Sleep Apnea Management (SAM) clinic, which harnesses the benefits of providing mutual support as well as facilitates access to system-based resources and education, will confer improvements in PAP adherence. METHODS: Data from SAM clinic attendees from January 2017 to June 2018 were retrospectively analyzed. Adherence data at SAM baseline visit and 1-3 months follow-up were collected. Average PAP usage from all-days and days used were analyzed along with demographics, co-morbidities, and Epworth Sleepiness Scale. Adherence was defined as >4 hours a night for ≥70% of nights over a 30-day period. Key structural elements of the SAM group clinic model were co-presence of the OSA care team members and peer group support. Key efficiency elements were group education and the prompt-to-patient multidisciplinary troubleshooting adherence barriers. RESULTS: Of 110 SAM clinic attendees, average age was 60.9±12.7 years, 53% were men, and 46% Caucasian. At baseline, the mean for average-all-days usage was 4.2 hours, mean average-days-used usage was 5.2 hours, and mean percentage-of-days usage ≥4 hours was 57%. At follow-up, the mean average-all-days usage increased 1.2 hours (p<0.001), mean average-days-used usage increased 0.8 hours (p<0.001), and the mean percentage-of-days with usage ≥4 hours increased 16% (p<0.001). At baseline, 46% of patients met criteria for adherence, which increased to 66% at follow-up. CONCLUSION: In this study, after the SAM clinic, all PAP adherence parameters improved significantly. This observational study serves as a proof of concept study for future trials pertaining to group clinic in managing PAP adherence in OSA.

Sleep disturbance predicts future health status after stroke.

STUDY OBJECTIVES: We evaluated factors associated with the presence of sleep disturbance in patients with stroke and whether sleep disturbance predicted change in other patient-reported domains of health over time. METHODS: Observational cohort study of 2,190 patients with stroke seen in a cerebrovascular clinic February 17, 2015 to July 5, 2017 who completed patient-reported outcome measures (PROMs) at ≥ 1 visit, including the Patient Health Questionnaire-9 depression screen, Quality of Life in Neurological Disorders (NeuroQoL) cognitive function and Patient-Reported Outcomes Information Measurement System (PROMIS) sleep disturbance, fatigue, anxiety, social role satisfaction, physical function, and pain interference. Separate multivariable models were constructed with PROMIS sleep disturbance as the dependent variable. Covariates included clinical and demographic variables, the Patient Health Questionnaire-9 depression screen scored on the PROMIS metric, and 1 of the 6 other PROMs. Among the 476 patients with ≥ 2 visits, linear regression models were constructed to determine the association of baseline sleep disturbance with follow-up PROMs after adjustment for the corresponding baseline PROMIS/NeuroQol scores, depression score, and clinical variables. RESULTS: Younger age and all PROM scores were associated with sleep disturbance; depression had the greatest association among PROMs (beta estimate 0.53, 95% confidence interval, 0.49, 0.57), physical function had the least (-0.06, 95% confidence interval, -0.11, -0.01). Baseline PROMIS sleep disturbance score was associated with worse adjusted follow-up scores for depression, fatigue, social role satisfaction, and physical function. CONCLUSIONS: Younger age and all 8 PROMs were associated with sleep disturbance in patients with stroke. The degree of sleep disturbance predicted future patient-reported outcomes for multiple domains of health. Further study is warranted to determine if interventions shown to improve sleep symptoms will also improve other outcomes.

Sleep-related symptoms in patients with mild stroke.

STUDY OBJECTIVES: Treatable sleep-related conditions are frequent in stroke patients, although their prevalence across stroke types and ideal method for screening is not clear. The objectives of this study were to evaluate the prevalence of sleep disturbance across different stroke types and identify approaches to the collection of sleep-related measures in clinical practice. METHODS: We performed an observational cohort study of 2,213 patients with ischemic stroke, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), or transient ischemic attack seen in a cerebrovascular clinic February 17, 2015 through July 5, 2017 who completed at least one of the following sleep-related questionnaires: Patient-Reported Outcomes Measurement Information System (PROMIS) sleep disturbance, Insomnia Severity Index (ISI), Sleep Apnea Probability Scale (SAPS), and sleep duration. Prevalence of abnormal scores were calculated using the following thresholds: PROMIS sleep disturbance ≥ 55, ISI ≥ 15, SAPS score ≥ 0.50, and sleep duration fewer than 6 or more than 9 hours. Sensitivity, specificity, and positive and negative predictive values of PROMIS sleep disturbance T-score ≥ 55 to identify patients with moderate-severe insomnia (ISI ≥ 15) were computed. RESULTS: In the cohort, 28.6% patients (624/2183) had PROMIS sleep disturbance score ≥ 55, 17.6% (142/808) had ISI ≥ 15, and 61.3% (761/1241) had a positive SAPS screen. The frequency of abnormal sleep scale scores was similar across time periods and stroke types. The sensitivity and specificity of PROMIS sleep disturbance T-score ≥ 55 to identify patients with ISI ≥ 15 were 0.89 (95% confidence interval 0.83-0.94) and 0.81 (95% confidence interval 0.78-0.84), respectively. CONCLUSIONS: The prevalence of sleep-related symptoms in patients with mild stroke are similar across stroke types and time periods after stroke. Potential approaches to screening for sleep disturbance in stroke patients are provided.

Effect of Positive Airway Pressure Therapy on Drowsy Driving in a Large Clinic-Based Obstructive Sleep Apnea Cohort.

STUDY OBJECTIVES: Drowsy driving related to obstructive sleep apnea (OSA) represents an important public health problem with limited data on the effect of positive airway pressure (PAP) therapy. We hypothesize that PAP therapy will reduce self-reported drowsy driving in a large clinic-based OSA cohort. METHODS: Drowsy driving (self-reported near-accidents/accidents) incidents from baseline to after PAP therapy (stratified by adherence) were compared in a cohort of 2,059 patients with OSA who initiated PAP therapy from January 1, 2010 to December 31, 2014. Multivariable logistic regression models evaluated the dependence of change in drowsy driving incidents on other factors, including change in Epworth Sleepiness Scale (ESS) and Patient Health Questionnaire-9 (PHQ9) scores. RESULTS: In the entire cohort (age 56.0 ± 13.1 years, 45.4% female, 76.0% white, average follow-up 124.4 ± 67.3 days), drowsy driving incidents reduced from 14.2 to 6.9% after PAP therapy (P < .001). In subgroups, drowsy driving incidents reduced from 14% to 5.3% (P < .001) in patients who self-reported adherence to PAP therapy and 14.1% to 5.3% (P < .001) in patients objectively adherent to PAP therapy. For each one-point improvement in Epworth Sleepiness Scale score, the odds of drowsy driving decreased by about 14% (odds ratio 0.86, 95% confidence interval 0.82 to 0.90). CONCLUSIONS: In this clinic-based cohort, drowsy driving improved after adherent PAP usage, with greater drowsy driving risk for those with greater sleep propensity. This highlights the importance of and need for routine drowsy driving assessments and careful clinical attention to PAP adherence and sleep propensity in this population. Our findings should be confirmed and may be used to provide support for initiatives to address the public health issue of drowsy driving.

The Epworth Sleepiness Scale: Validation of One-Dimensional Factor Structure in a Large Clinical Sample.

STUDY OBJECTIVES: The Epworth Sleepiness Scale (ESS) is used by clinicians and researchers to determine level of daytime sleepiness. The number of factors included in the scale has been debated. Our study objective was to clarify the dimensionality of the ESS using a large clinical sample. METHODS: A retrospective cohort study included all patients presenting for care in a tertiary care sleep disorders center who answered all items on the ESS from January 8, 2008 to September 28, 2012. Dimensionality was assessed using scree plot, eigenvalues, factor loadings, principal factor analysis, and confirmatory factor analysis. Multigroup confirmatory factor analysis (MGCFA) evaluated dimensionality within 10 subgroups of clinical interest. RESULTS: The mean age of the 10,785 study participants was 50 (± 15) years with 49% female, and 81% white. The one-factor solution explained 63% of the variability in responses with high factor loadings (> .67 for all 8 items). The scree plot identified one factor with eigenvalue > 1. Results of confirmatory factor analysis demonstrated a one-factor solution had acceptable goodness of fit as assessed by root mean square error of approximation of .094 (90% confidence interval: .089-.099). MGCFA confirmed measurement invariance within all 10 demographic and clinical subgroups. CONCLUSIONS: Our study confirmed the unidimensionality of the ESS in a large diverse clinical population. Results from this study can be used to justify the interpretation of the ESS within clinical populations, and supports valid comparisons between groups based on the ESS. Future studies are warranted to further understand the items comprising the ESS and potentially eliminate redundant items for increased efficiency in clinical settings.

Impact of Sleep-Disordered Breathing Treatment on Quality of Life Measures in a Large Clinic-Based Cohort.

STUDY OBJECTIVES: This study aims to report the effect of positive airway pressure (PAP) therapy on quality of life (QoL) measures in the clinical sleep-disordered breathing (SDB) population. METHODS: We examined general QoL measures assessed by European Quality of Life-5D (EQ-5D) and sleep-specific QoL by examining Functional Outcomes of Sleep Questionnaire (FOSQ) scores before and after PAP therapy retrospectively in a clinical SDB population using paired and two-sample t tests. Age and socioeconomic status (SES) effect modification on pre-PAP QoL measures were investigated utilizing the interaction terms. RESULTS: A total of 2,027 patients with SDB initiated PAP therapy between January 1, 2010 and December 31, 2014. The mean age of the cohort was 56.2 years (standard deviation = 13.2), with 45.8% female and 76.9% Caucasians. EQ-5D change after exclusion of those with normal QoL was 0.042 (0.152) in all patients, 0.051 (0.150) in patients who were PAP adherent by self-report, and 0.050 (0.132) in patients who were objectively PAP adherent (n = 704 of 1,011 with available objective adherence data, 69.6%). Change in FOSQ after excluding those with normal FOSQ was 1.9 (2.9) in all patients, 2.2 (2.9) in patients who were PAP adherent by self-report, and 2.3 (2.9) in patients who were objectively PAP adherent. Those with (1) worse QoL at baseline and younger age and (2) worse QoL at baseline and residing in lower SES strata had worse outcomes after PAP therapy (P < .05). CONCLUSIONS: We found consistent improvement in global and sleep-specific QoL measures after PAP therapy, hence providing evidence of PAP benefit in the clinical population and rationale for targeted efforts to optimize QoL in younger and lower SES subgroups.

Impact of Sleep-Disordered Breathing Treatment on Patient Reported Outcomes in a Clinic-Based Cohort of Hypertensive Patients.

STUDY OBJECTIVES: We hypothesized that patient reported outcomes (PROs) improve with positive airway pressure (PAP) in patients with sleep-disordered breathing (SDB) and hypertension (HTN). METHODS: Questionnaire-based PROs (sleepiness [Epworth Sleepiness Scale, (ESS)], depression [Patient Health Questionnaire-9 (PHQ-9)], and fatigue [Fatigue Severity Scale (FSS)]) were retrospectively examined in patients with SDB and HTN at baseline and within a year following PAP initiation. PRO changes were estimated using multivariable linear mixed-effect models adjusted for baseline age, sex, race, body mass index, resistant hypertension (RHTN) status, cardiac and diabetes history, and correlation between repeated measurements. Age and race by PAP interaction terms (mean change, 95% CI) were examined. RESULTS: 894 patients with HTN and SDB were examined. 130 (15%) had baseline RHTN (age 58 ± 12 y, 52.9 % male, BMI 36.2 ± 9.1 kg/m2). In multivariable models, a significant improvement in sleepiness ESS (-2.09, 95% CI: -2.37, -1.82), PHQ-9 (-1.91, 95% CI: -2.25, -1.56), and FSS scores (-4.06 95% CI: -4.89, -3.22) was observed. A significant race by PAP effect interaction was observed (p < 0.0001 for all PROs); Caucasians had greater improvements than non-Caucasians. The interaction term of effect of PAP and age was significant for ESS (p = 0.04) and PHQ-9 (p = 0.0003), indicating greater improvement in younger patients. CONCLUSIONS: Consistent improvement of broad PRO domains in response to PAP in SDB was observed in this clinic-based hypertensive cohort; Caucasians and younger patients derived greater benefit.

Neck Circumference-Height Ratio as a Predictor of Sleep Related Breathing Disorder in Children and Adults.

STUDY OBJECTIVES: While neck circumference (NC) is a useful predictor of obstructive sleep apnea (OSA) in adults, childhood OSA is difficult to predict clinically. We utilized the neck circumference-height ratio (NHR) to normalize NC in growing children. Our study aimed to determine if (1) NC is a reproducible clinical measurement; (2) NHR predicts OSA in children; (3) this metric translates to adults. METHODS: For this retrospective study, paired NC measurements (from clinic and sleep laboratory) in 100 consecutive adult subjects were used to confirm inter-observer reproducibility. Polysomnographic (PSG) and anthropometric data from children aged 5-18 years presenting consecutively between July 2007 and February 2012 was obtained. Children with genetic syndromes, severe neurological disorders, craniofacial abnormalities, tracheostomy, past adenotonsillectomy, in-hospital PSG or sleep efficiency < 80% were excluded. Data were analyzed using χ(2) test and logistic and linear regression models. These analyses were also applied to 99 adult patients with similar exclusion criteria. RESULTS: Adult NC measurement had inter-observer correlation of 0.85 (N = 100). Among children, after correcting for BMI-Z scores, NHR conferred additional predictive value, in both logistic regression and linear models, for both apnea-hypopnea index (AHI) > 2 and > 5 (N = 507). In children, for NHR > 0.25, the odds ratio of AHI > 2 was 3.47. In adults, for NHR > 0.25, the odds ratio of AHI > 5 was 18. CONCLUSIONS: NHR can be included as a simple screening tool for OSA in children and adults, which along with other predictors, may improve the ability of clinicians to triage children and adults at risk for OSA for further evaluation with PSG.

Longitudinal Effect of CPAP on BP in Resistant and Nonresistant Hypertension in a Large Clinic-Based Cohort.

BACKGROUND: Clinic-based effectiveness studies of sleep-disordered breathing (SDB) treatment in reducing BP in resistant hypertension (RHTN) vs non-RHTN are sparse. We hypothesize that CPAP use in SDB reduces BP significantly in RHTN and non-RHTN in a large clinic-based cohort. METHODS: Electronic medical records were reviewed in patients with SDB and comorbid RHTN and non-RHTN for CPAP therapy initiation (baseline) and subsequent visits. We estimated generalizable BP changes from multivariable mixed-effects linear models for systolic BP (SBP), diastolic BP, and mean arterial pressure, adjusting for RHTN status, age, sex, race, BMI, cardiac history, and diabetes and repeated measure correlation. RESULTS: Of 894 patients, 130 (15%) had RHTN at baseline (age, 58 ± 12 years; 52% men; BMI, 36 ± 9 kg/m(2)). Patients with RHTN had significantly higher BP overall (P < .001), most notably for SBP (6.9 mm Hg; 95% CI, 3.84, 9.94). In the year following CPAP initiation, improvements in BP indexes did not generally differ based on RHTN status in which RHTN status was a fixed effect. However, there was a significant decrease in SBP (3.08 mm Hg; 95% CI, 1.79, 4.37), diastolic BP (2.28; 95% CI, 1.56, 3.00), and mean arterial pressure (2.54 mm Hg; 95% CI, 1.73, 3.36) in both groups. CONCLUSIONS: In this clinic-based effectiveness study involving patients closely followed for BP control, a significant reduction of BP measures (strongest for SBP) was observed in response to CPAP which was similar in RHTN and non-RHTN groups thus informing expected clinical CPAP treatment response.

A pilot study: portable out-of-center sleep testing as an early sleep apnea screening tool in acute ischemic stroke.

INTRODUCTION: Prompt diagnosis of obstructive sleep apnea (OSA) after acute ischemic stroke (AIS) is critical for optimal clinical outcomes, but in-laboratory conventional polysomnograms (PSG) are not routinely practical. Though portable out-of-center type III cardiopulmonary sleep studies (out-of-center cardiopulmonary sleep testing [OCST]) are widely available, these studies have not been validated in patients who have recently suffered from AIS. We hypothesized that OCST in patients with AIS would yield similar results when compared to conventional PSG. METHODS: Patients with AIS had simultaneous type III OCST and PSG studies performed within 72 hours from symptom onset. The accuracy of OCST was compared to PSG using: chi-square tests, receiver operatory characteristic curves, Bland-Altman plot, paired Student's t-test/Wilcoxon signed-rank test, and calculation of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS: Twenty-one out of 23 subjects with AIS (age 61±9.4 years; 52% male; 58% African-American) successfully completed both studies (9% technical failure). Nearly all (95%) had Mallampati IV posterior oropharynx; the mean neck circumference was 16.8±1.6 in. and the mean body mass index (BMI) was 30±7 kg/m(2). The apnea hypopnea index (AHI) provided by OCST was similar to that provided by PSG (19.8±18.0 vs 22.0±22.7, respectively; P=0.49). On identifying subjects by OCST with an AHI ≥5 on PSG, OCST had the following parameters: sensitivity 100%, specificity 85.7%, PPV 93%, and NPV 100%. On identifying subjects with an AHI ≥15 on PSG, OCST parameters were as follows: sensitivity 100%, specificity 83.3%, PPV 81.8%, and NPV 100%. Bland-Altman plotting showed an overall diagnostic agreement between OCST and PSG modalities for an AHI cutoff >5, despite fine-grained differences in estimated AHIs. CONCLUSION: Compared with PSG, OCST provides similar diagnostic information when run simultaneously in AIS patients. OCST is a reliable screening tool for early diagnosis of OSA in AIS patients.

Sleep apnea and epilepsy: who's at risk?

Obstructive sleep apnea (OSA) is highly prevalent, affecting 25% of men and 10% of women. Treatment reduces seizures in some patients. Awareness of the comorbidity of sleep disturbances in epilepsy has been increasing. No study has explored OSA predictors in patients unselected for epilepsy severity and sleep disorder symptoms. We assessed cross-sectional OSA prevalence and predictors (apnea-hypopnea index [AHI] ≥10) in 130 consecutive adults using structured interview, subjective assessments, and polysomnography. Obstructive sleep apnea prevalence was 30%, 16% having moderate-severe disease, rates that markedly exceed general population estimates. Obstructive sleep apnea predictors in multivariate modeling included age, dental problems, and standardized AED dose. Male gender, older age, higher BMI, hypertension, and dental problems were associated with higher AHI. Adults with epilepsy appear at increased risk for OSA, increasing with age and AED load, regardless of gender, BMI, and seizure frequency. These findings support the implementation of routine OSA screening in adult epilepsy clinics.

Placebo-controlled comparison of prazosin and cognitive-behavioral treatments for sleep disturbances in US Military Veterans.

OBJECTIVE: Pharmacological and cognitive-behavioral treatments targeting insomnia and nightmares have been shown to be effective in the treatment of military veterans with sleep complaints comorbid with symptoms of stress-related disorders, including Post-Traumatic Stress Disorder (PTSD), but the two approaches have not been directly compared. This randomized controlled trial compared the effects of prazosin vs. a behavioral sleep intervention (BSI), targeting nightmares and insomnia against a placebo pill control condition on sleep and daytime symptoms. METHODS: Fifty United States military veterans (mean age 40.9years, SD=13.2years) with chronic sleep disturbances were randomized to prazosin (n=18), BSI (n=17), or placebo (n=15). Each intervention lasted 8weeks. Participants completed self-report measures of insomnia severity, sleep quality, and sleep disturbances. All kept a sleep diary throughout the intervention period. Polysomnographic studies were conducted pre- and post-intervention. RESULTS: Both active treatment groups showed greater reductions in insomnia severity and daytime PTSD symptom severity. Sleep improvements were found in 61.9% of those who completed the active treatments and 25% of those randomized to placebo. CONCLUSION: BSI and prazosin were both associated with significant sleep improvements and reductions in daytime PTSD symptoms in this sample of military veterans. Sleep-focused treatments may enhance the benefits of first-line PTSD treatments.

Efficacy of brief behavioral treatment for chronic insomnia in older adults.

BACKGROUND: Chronic insomnia is a common health problem with substantial consequences in older adults. Cognitive behavioral treatments are efficacious but not widely available. The aim of this study was to test the efficacy of brief behavioral treatment for insomnia (BBTI) vs an information control (IC) condition. METHODS: A total of 79 older adults (mean age, 71.7 years; 54 women [70%]) with chronic insomnia and common comorbidities were recruited from the community and 1 primary care clinic. Participants were randomly assigned to either BBTI, consisting of individualized behavioral instructions delivered in 2 intervention sessions and 2 telephone calls, or IC, consisting of printed educational material. Both interventions were delivered by a nurse clinician. The primary outcome was categorically defined treatment response at 4 weeks, based on sleep questionnaires and diaries. Secondary outcomes included self-report symptom and health measures, sleep diaries, actigraphy, and polysomnography. RESULTS: Categorically defined response (67% [n = 26] vs 25% [n = 10]; χ(2) = 13.8) (P < .001) and the proportion of participants without insomnia (55% [n = 21] vs 13% [n = 5]; χ(2) = 15.5) (P < .001) were significantly higher for BBTI than for IC. The number needed to treat was 2.4 for each outcome. No differential effects were found for subgroups according to hypnotic or antidepressant use, sleep apnea, or recruitment source. The BBTI produced significantly better outcomes in self-reported sleep and health (group × time interaction, F(5,73) = 5.99, P < .001), sleep diary (F(8,70) = 4.32, P < .001), and actigraphy (F(4,74) = 17.72, P < .001), but not polysomnography. Improvements were maintained at 6 months. CONCLUSION: We found that BBTI is a simple, efficacious, and durable intervention for chronic insomnia in older adults that has potential for dissemination across medical settings. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00177203.

Development of short forms from the PROMIS™ sleep disturbance and Sleep-Related Impairment item banks.

This article reports on the development of short forms from the Patient-Reported Outcomes Measurement Information System (PROMIS™) Sleep Disturbance (SD) and Sleep-Related Impairment (SRI) item banks. Results from post-hoc computerized adaptive testing (CAT) simulations, item discrimination parameters, item means, and clinical judgments were used to select the best-performing 8 items for SD and SRI. The final 8-item short forms provided less test information than the corresponding full banks, but correlated strongly with the longer forms. The short forms had greater measurement precision than the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS), as indicated by larger test information values across the continuum of severity, despite having fewer total items--a major advantage for both research and clinical settings.

Pathologies of awakenings: the clinical problem of insomnia considered from multiple theory levels.

Limit cycle-based mid-level theories that rationalize effective clinical treatments for chronic insomnia have empirical support from whole-organism studies of sleep physiology, but their relation to network-level and cellular neurobiologies remains obscure. The neurobiology of pharmacological treatments for insomnia has been increasingly understood, but has not been fully integrated with psychological theories or electroencephalographic descriptions of sleep. Better clinical diagnostic and treatment frameworks will require both greater conceptual clarity as to what an "awakening" is descriptively and detailed investigations to relate fundamental neuroscience to clinical technologies can be both accessible and diagnostically useful to clinicians.

Development and validation of patient-reported outcome measures for sleep disturbance and sleep-related impairments.

STUDY OBJECTIVES: To develop an archive of self-report questions assessing sleep disturbance and sleep-related impairments (SRI), to develop item banks from this archive, and to validate and calibrate the item banks using classic validation techniques and item response theory analyses in a sample of clinical and community participants. DESIGN: Cross-sectional self-report study. SETTING: Academic medical center and participant homes. PARTICIPANTS: One thousand nine hundred ninety-three adults recruited from an Internet polling sample and 259 adults recruited from medical, psychiatric, and sleep clinics. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: This study was part of PROMIS (Patient-Reported Outcomes Information System), a National Institutes of Health Roadmap initiative. Self-report item banks were developed through an iterative process of literature searches, collecting and sorting items, expert content review, qualitative patient research, and pilot testing. Internal consistency, convergent validity, and exploratory and confirmatory factor analysis were examined in the resulting item banks. Factor analyses identified 2 preliminary item banks, sleep disturbance and SRI. Item response theory analyses and expert content review narrowed the item banks to 27 and 16 items, respectively. Validity of the item banks was supported by moderate to high correlations with existing scales and by significant differences in sleep disturbance and SRI scores between participants with and without sleep disorders. CONCLUSIONS: The PROMIS sleep disturbance and SRI item banks have excellent measurement properties and may prove to be useful for assessing general aspects of sleep and SRI with various groups of patients and interventions.

Night-to-night sleep variability in older adults with and without chronic insomnia.

OBJECTIVES: (1) To quantify night-to-night variability in sleep behaviors and sleep measures among older chronic insomnia (CI) subjects and non-insomnia (NI) controls; (2) to investigate systematic temporal patterns of sleep behaviors and sleep measures across nights; and (3) to examine clinical correlates of sleep variability. METHODS: Sixty-one older adults with CI (71.4years old, 67% F) and 31 older adults with NI (70.7years old, 65% F) completed questionnaires, kept sleep diaries and wore wrist actigraphs for 2 weeks. Mixed models were used to estimate within-subject mean and standard deviation values; these were then compared across groups. Mixed models were also used to determine associations across nights of sleep measures. RESULTS: CI and NI differed on mean values for clinical ratings and sleep diary measures, but not for actigraphy measures. CI also showed significantly greater variability than NI on most sleep diary measures and on actigraphically measured wakefulness after sleep onset (WASO) and sleep efficiency. Among CI, neither diary nor actigraphy measures from one night correlated with values from the previous night. Diary WASO, sleep time, actigraphy sleep latency and sleep time, however, positively correlated with values from the previous two nights. Variability measures were not correlated with other global clinical measures among CI. CONCLUSIONS: Compared to NI, older adults with CI report worse sleep and greater night-to-night variability, which was confirmed with actigraphy. There was little evidence for positive or negative correlation of sleep measures across nights. Variability of sleep may be an important target for insomnia treatments.