Disturbance of Sleep and Circadian Rhythm in Hospitalized Patients

Sleep and circadian disturbance are common in hospitalized patients. Problems related to sleep induction, frequent awakening, poor sleep quality, and disturbed circadian rhythm including daytime somnolence and nighttime arousal are frequently observed in the hospital. Disturbance of sleep and circadian rhythm could interfere recovery of the patients, prolong the length of stay, and contribute to patient dissatisfaction. Various factors affect sleep and circadian rhythm disturbance in the hospital. Intrinsic factors are related to patients, including medical and psychiatric conditions, uncontrolled pain, prescribed medications, and physical inactivity. External factors related to the hospital environment such as noisy environment, excessive exposure to artificial light, inappropriate humidity, and temperature are also known interrupters for sleep. Medical care provided by professionals, including nighttime vital sign monitoring, phlebotomy, and medication administration, can also contribute to sleep and circadian rhythm disturbances. This review aims to systematically address sleep and circadian rhythm disturbances in hospitalized patients, discuss factors that affect sleep in the hospital, and suggest non-pharmacological and pharmacological treatment options. Copyright © 2023 Korean Academy of Sleep Medicine.ope

Frailty and Insomnia in Older Adults

Frailty is a geriatric syndrome with increased risk for poor health outcomes, including falls, cognitive impairment, hospitalization, and mortality. In previous studies, associations between frailty and sleep-related factors or sleep disorders have been investigated. We examined the relationship between frailty and insomnia, which are both common condition in older adults. Hormonal changes with aging and/or lifestyle changes all affect sleep physiology, which are vulnerable to the risk of insomnia. As the severity of frailty decreases the quality of sleep, and the long/short sleep duration is related to the risk of frailty, it can be assumed that frailty and sleep are reciprocally related. The association between frailty and insomnia has been variously proven in epidemiological studies conducted around the world. A close evaluation of insomnia and frailty in older adults provides a basis for improving the health of people in the aged society. There are few related studies in Korea, and in the future, not only basic epidemiological studies but also studies explaining the psychoneuroendocrinological mechanism of the relationship between insomnia and frailty should be performed together.ope

The Effects of a Brief Intervention for Insomnia on Community Dwelling Older Adults

Objectives: Insomnia is one of the major concerns in the elderly population. Cognitive behavioral treatment for insomnia is the first line treatment option, but there are some limitations including time and cost burdens and the requirement for sufficient cognitive resources to obtain a proper treatment effect. The Brief intervention for insomnia (BII) is a treatment that focuses on behavioral aspects of insomnia in primary care practices. The purpose of this study was to evaluate the effects of BII in community-dwelling older adults. Methods: A total of 47 older adults with insomnia were enrolled from community centers between May 2016 and January 2018. They participated in the BII program for three weeks. We gathered sleep-related participant information with using the Pittsburgh sleep quality index (PSQI), the Sleep hygiene index, and a sleep diary. Clinical efficacy was evaluated by comparing total sleep time (TST), sleep latency (SL), waking after sleep onset (WASO), and sleep efficiency (SE) before and after the treatment. Results: There was significant improvement in sleep-related features after BII. Global score and sleep quality from the PSQI, freshness, and WASO from the sleep diary showed statistically significant improvement. Conclusion: We found BII showed positive clinical efficacy in community dwelling older adults, especially from the perspective of subjective sleep quality and WASO. This finding implies that BII can be effectively applied for the managment of elderly insomnia patients in a community setting.ope

Clinical Characteristics of HIV-Infected Patients With Sleep Disturbance

Objective This study aims to examine clinical characteristics and to identify possible risk factors of sleep disturbances in people living with HIV (PLWH). Methods All research data of patients who were first diagnosed with HIV/AIDS from January 1, 2012 to December 31, 2021 and complained of sleep disturbance at least once were retrospectively reviewed by the Severance Clinical Research Analysis Portal (SCRAP) service of Severance hospital. The presence of sleep disturbance was evaluated based on whether insomnia disorder diagnosis code was included or whether insomnia medication was prescribed. The patients were divided into either the group with sleep disturbance within 3 months (SDW3) and the group with after 3 months (SDA3). All data were reported using descriptive statistics. Results Of the 674 patients diagnosed with HIV during the period, 56 patients experienced sleep disturbances at least once and approximately 50% of patients have experienced sleep disturbance in the first 3 months after HIV diagnosis. CD4+ cell count at the time of first onset of sleep disturbance was significantly lower (p=0.03) and HIV viral load at the time of first onset of sleep disturbance was significantly higher (p<0.001) in SDW3 group. SDW3 patients showed higher rates of opportunistic infections compared to SDA3 patients. Conclusion The current study suggests that further investigation of the underlying pathophysiology of sleep disturbance and association with immunological changes for early diagnosis and treatment of sleep disturbance in PLWH.ope

Digital cognitive behavioral therapy for insomnia on depression and anxiety: a systematic review and meta-analysis

Despite research into the development of digital cognitive behavioral therapy for insomnia (dCBT-I), research into the outcomes of dCBT-I on insomnia and the associated clinical conditions of depression and anxiety have been limited. The PubMed, PsycINFO (Ovid), Embase, and Cochrane databases were searched for randomized controlled trials (RCTs) on adult patients with insomnia also having reported measures of depressive or anxiety symptoms. In total, 2504 articles were identified after duplicate removal, and 22 RCTs were included in the final meta-analysis. At the post-treatment assessment, the dCBT-I group had a small to moderate effect in alleviating depressive (standardized mean difference (SMD) = -0.42; 95% CI: -0.56, -0.28; p < 0.001; k = 21) and anxiety symptoms (SMD = -0.29; 95% CI: -0.40, -0.19; p < 0.001; k = 18), but had a large effect on sleep outcome measures (SMD = -0.76; 95% CI: -0.95, -0.57; p < 0.001; k = 22). When considering treatment adherence, the treatment effects of those in the high adherent groups identified a more robust outcome, showing greater effect sizes than those in the low adherent groups for depression, anxiety, and sleep outcomes. Furthermore, additional subgroup analysis on studies that have used the fully automated dCBT-I treatment without the support of human therapists reported significant treatment effects for depression, anxiety, and sleep outcomes. The results demonstrated that digital intervention for insomnia yielded significant effects on alleviating depressive and anxiety symptoms as well as insomnia symptoms. Specifically, the study demonstrated significant effects on the above symptoms when considering treatment adherence and implementing fully automated dCBT-I.ope

Associations of Self-Consciousness with Insomnia Symptoms

Objective Insomnia is a very common health problem that are getting more attention. Self-consciousness is one of the factors related to anxiety or rumination that affect insomnia symptoms. However, the number of studies regarding self-consciousness and insomnia is scarce. The objective of study is to evaluate effects of self-consciousness on insomnia symptoms. Methods A total of 90 healthy adults (mean age 28 years, 58% female) were enrolled to the study. Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI) were used to define poor sleepers (PSQI score 8 or higher, or ISI score 8 or higher). Objective sleep parameters were obtained through actigraphy device, and subjective sleep parameters were obtained through sleep diaries concordantly. Self-consciousness scale was used to evaluate three domains of self-consciousness including public self-consciousness, private self-consciousness, and social anxiety. Binary regression analysis and multiple logistic regression analysis were conducted to find correlation between self-consciousness and insomnia symptoms. Results Among three self-consciousness domains, only social anxiety showed significant correlation to poor sleepers [odds ratio (OR)=1.091, p=0.046]. Social anxiety was also significantly correlated with both PSQI score 8 or higher (B=0.091, p=0.002) and ISI score 8 or higher (B=0.087, p=0.047). Private self-consciousness was negatively associated with ISI score 8 or higher (B=-0.202, p=0.043). Conclusion High social anxiety had a significant correlation to poor sleep. The result of this study implies high self-consciousness with emotional distress could affect insomnia symptoms.ope

Cognitive Behavioral Therapy for Insomnia Reduces Hypnotic Prescriptions

Objective: This study determined whether cognitive behavioral therapy for insomnia (CBT-i) decreased the need for sleep medications and produced better treatment outcomes than pharmacotherapy alone. Methods: We reviewed data from patients with insomnia in the outpatient clinic of a general hospital between 2009 and 2015. We compared 41 patients who received five sessions of CBT-i with 100 age- and sex-matched patients who received pharmacotherapy only. We evaluated the change in prescription for sleep (i.e., antidepressants, hypnotics, and others) between the first and last visits using repeated measures analysis of variance (ANOVA). Clinical global impressions and completion status at the last visit were assessed using the chisquare test. Results: We found a significant decrease in the prescription rate and the dosage of hypnotics among patients who received CBT-i when compared with control patients. There was no significant change in the dosage of antidepressants between the two groups. Achievement of case closure was better in the CBT-i group at the trend level. Clinical global impression at the last visit was not significantly different. Conclusion: These results show that CBT-i reduces the need for hypnotics among insomnia patients. Our results indicate that CBT-i offers additional benefits beyond improving sleep characteristics and thus provides another reason for recommending CBT-i as a first-line treatment for insomnia.ope

The Associations between Anger Expression and Insomnia among Community-Dwelling Older Adults in Korea

Objective : Sleep disturbance is one of the most common health problems in older adults. Anger expression tendency has been studied on many aspects of health. Some studies have reported that individuals with poor anger regulation were more likely to have insomnia. Considering emotional arousal affects insomnia, anger expression tendency could be associated with inaomnia in older adults. The objective of this study is to investigate correlation between anger expressions and insomnia symptoms among community-dwelling older adults in Korea. Methods : A total of 235 older adults (mean age 75 years, 67.2% female) were enrolled to this study. We interviewed the participants to gather demographic information, medical history, stress level using the Perceived Stress Scale, sleep quality using the Pittsburgh Sleep Quality Index and anger expression using Korean adaptation of the State-Trait Anger Scale. Simple and logistic regression analyses were used to find correlations between anger expression and insomnia symptoms. Results : Forty percent of the participants had sleep initiation difficulty (sleep latency >30 min). Higher anger expression tendency (odds ratio=1.122, p=0.009) was significantly related to sleep initiation difficulty after controlling age, sex, education, socioeconomic status, perceived stress, depression, and total sleep time. Meanwhile, anger expression tendency was not associated with total sleep time after controlling covariates. Conclusion : Older adults with higher anger expressions showed a tendency to have sleep initiation difficulty. Further studies are needed to determine whether modifying of anger expression can control physiological and cognitive arousal and improve sleep disturbance.ope

Prediction of sleep disturbances in korean rural elderly through longitudinal follow up

Objectives: Sleep disturbance is a very rapidly growing disease with aging. The purpose of this study was to investigate the prevalence of sleep disturbances and its predictive factors in a three-year cohort study of people aged 60 years and over in Korea. Methods: In 2012 and 2014, we obtained data from a survey of the Korean Social Life, Health, and Aging Project. We asked participants if they had been diagnosed with stroke, myocardial infarction, angina pectoris, arthritis, pulmonary tuberculosis, asthma, cataract, glaucoma, hepatitis B, urinary incontinence, prostate hypertrophy, cancer, osteoporosis, hypertension, diabetes, hyperlipidemia, or metabolic syndrome. Cognitive function was assessed using the Mini-Mental State Examination for dementia screening in 2012, and depression was assessed using the Center for Epidemiologic Studies Depression Scale in 2012 and 2014. In 2015, a structured clinical interview for Axis I psychiatric disorders was administered to 235 people, and sleep disturbance was assessed using the Pittsburgh Sleep Quality Index. The perceived stress scale and the State-trait Anger Expression Inventory were also administered. Logistic regression analysis was used to predict sleep disturbance by gender, age, education, depression score, number of coexisting diseases in 2012 and 2014, current anger score, and perceived stress score. Results: Twenty-seven percent of the participants had sleep disturbances. Logistic regression analysis showed that the number of medical diseases three years ago, the depression score one year ago, and the current perceived stress significantly predicted sleep disturbances. Conclusion: Comorbid medical disease three years previous and depressive symptoms evaluated one year previous were predictive of current sleep disturbances. Further studies are needed to determine whether treatment of medical disease and depressive symptoms can improve sleep disturbances.ope

A Multi-institutional Study of Interlaboratory Variance in the Estrogen and Progesterone Receptor Assays

Purpose The expression of hormone receptors is the most reliable factor for predicting the responsiveness to hormonal therapy At present, immunohistochemistry (IHC) is considered as a practically reliable method. This study was designed to examine the interlaboratory variance in immunohistochemical assays for estrogen receptor (ER) and progesterone receptor (PR) in Korea Methods The Korean Study Group for Breast Pathology (KSGBP) made a questionnaire to know the current situation in HR assay in Korea. The questionnaire was sent to the members of KSGBP by e-mail, which were included eight questions relating to tissue handling, ER/PR IHC procedure and interpretation method. Forty laboratories replied with the completed questionnaire Results All 40 laboratories were using formalin as a fixative. Pretreatment was performed using six different methods including autoclave (25%), microwave (30%) and full autostainer (15%). Primary antibodies for ER were SP1 in 40%, 6F11 in 27.5% and 1D5 in 32.5%. Primary antibodies for PR were more variable (seven clones) than those for ER Interpretation method used was Allred system in 20%, modified Allred system in 15%, report the % of positive tumor cells in 45%, positive/negative in 15% and others in 5% The expression rate of ER was ranged from 45.6% to 93% (mean 635%) and the expression rate of PR was ranged from 27% to 90% (mean 59 1%) The differences according to the numbers of breast cancer in each institute, primary antibodies, detection systems and interpretation methods did not influence to the expression rate of ER/PR, statistically (p>0 05) Conclusion In Korea, the interlaboratory variance in ER/PR IHC procedure was too huge to make a standardized method We suggest the proper quality control program such as ER/PR staining with positive internal and external controls and negative control might be better to aim at getting similar results among the different laboratones rather than trying to standardize the procedure.Yun YH, 2007, BREAST CANCER RES TR, V106, P245, DOI 10.1007/s10549-006-9490-7UMEMURA S, 2006, BREAST CANC, V13, P232JOO HJ, 2006, MANUAL QUALITY CONTR, P139Goldhirsch A, 2005, ANN ONCOL, V16, P1569, DOI 10.1093/annonc/mdi326Mann GB, 2005, J CLIN ONCOL, V23, P5148, DOI 10.1200/JCO.2005.02.076Rudiger T, 2002, AM J SURG PATHOL, V26, P873Rhodes A, 2001, AM J CLIN PATHOL, V115, P44Fitzgibbons PL, 2000, ARCH PATHOL LAB MED, V124, P966Rhodes A, 2000, J CLIN PATHOL, V53, P292Rhodes A, 2000, J CLIN PATHOL, V53, P125Harvey JM, 1999, J CLIN ONCOL, V17, P1474Taylor CR, 1999, AM J CLIN PATHOL, V111, P443Barnes DM, 1998, EUR J CANCER, V34, P1677Barnes DM, 1996, BRIT J CANCER, V74, P1445Alberts SR, 1996, CANCER, V78, P764GREENE GL, 1982, J STEROID BIOCHEM, V16, P353GREENE GL, 1980, P NATL ACAD SCI-BIOL, V77, P5115