Sleep and daytime problems during the COVID-19 pandemic and effects of coronavirus infection, confinement and financial suffering: a multinational survey using a harmonised questionnaire

ObjectivesSleep is important for human health and well-being. No previous study has assessed whether the COVID-19 pandemic impacts sleep and daytime function across the globe.MethodsThis large-scale international survey used a harmonised questionnaire. Fourteen countries participated during the period of May–August 2020. Sleep and daytime problems (poor sleep quality, sleep onset and maintenance problems, nightmares, hypnotic use, fatigue and excessive sleepiness) occurring ‘before’ and ‘during’ the pandemic were investigated. In total, 25 484 people participated and 22 151 (86.9%) responded to the key parameters and were included. Effects of COVID-19, confinement and financial suffering were considered. In the fully adjusted logistic regression models, results (weighted and stratified by country) were adjusted for gender, age, marital status, educational level, ethnicity, presence of sleep problems before COVID-19 and severity of the COVID-19 pandemic in each country at the time of the survey.ResultsThe responders were mostly women (64%) with a mean age 41.8 (SD 15.9) years (median 39, range 18–95). Altogether, 3.0% reported having had COVID-19; 42.2% reported having been in confinement; and 55.9% had suffered financially. All sleep and daytime problems worsened during the pandemic by about 10% or more. Also, some participants reported improvements in sleep and daytime function. For example, sleep quality worsened in about 20% of subjects and improved in about 5%. COVID-19 was particularly associated with poor sleep quality, early morning awakening and daytime sleepiness. Confinement was associated with poor sleep quality, problems falling asleep and decreased use of hypnotics. Financial suffering was associated with all sleep and daytime problems, including nightmares and fatigue, even in the fully adjusted logistic regression models.ConclusionsSleep problems, fatigue and excessive sleepiness increased significantly worldwide during the first phase of the COVID-19 pandemic. Problems were associated with confinement and especially with financial suffering.

Racial Differences in Functional and Sleep Outcomes with Positive Airway Pressure Treatment

It is unclear if the response to positive airway pressure (PAP) treatment is different between African American (AA) and European Americans (EA). We examined whether race modifies the effects of PAP on sleep and daytime function. We assessed Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire, Psychomotor Vigilance Task and actigraphy in 185 participants with moderate-to-severe obstructive sleep apnea before and 3–4 months after PAP treatment. The participants were middle-aged (mean, 55.1 years), 83.8% men and 60.5% AA. Linear regression models were used to examine the effect of race on outcomes. The AA had smaller reductions in ESS (mean change (95% confidence interval, CI) AA, −2.30 [−3.35, −1.25] vs. EA, −4.16 [−5.48, −2.84] and frequency of awakenings (AA, −0.73 [−4.92, 3.47] vs. EA, −9.35 [−15.20, −3.51]). A race × PAP usage interaction term was added to the model to examine if the change in outcomes per 1 h increase in PAP usage differed by race. AA exhibited greater improvement in wake after sleep onset (β (95% CI) AA, −8.89[−16.40, −1.37] vs. EA, 2.49 [−4.15, 9.12]) and frequency of awakening (β (95% CI) AA, −2.59 [−4.44, −0.75] vs. EA, 1.71 [−1.08, 4.50]). The results indicate the importance of race in evaluating outcomes following PAP treatment.

Sleep, Function, Behaviour and Cognition in a Cohort of Children with Down Syndrome

Objective: To describe the sleep problems experienced by children with Down syndrome attending a tertiary sleep clinic and relationship with behaviour, function and cognition. Methods: Data were collected from children with Down syndrome aged 3–18 years old. Carers completed the Abbreviated Child Sleep Habits Questionnaire, Child Behaviour Checklist and Life-Habits Questionnaire at enrolment. Cognitive assessment (Stanford-Binet 5) was undertaken by a trained psychologist. Children received management for their sleep problem as clinically indicated. Results: Forty-two subjects with a median age of 6.8 years (Interquartile Range-IQR 4.5, 9.8) were enrolled. A total of 92% were referred with snoring or symptoms of Obstructive Sleep Apnoea (OSA), with 79% of those referred having had previous ENT surgery. Thus, 85% of all participants underwent a sleep study and 61% were diagnosed with OSA (OAHI ≥ 1/h). Based on questionnaires, 86% of respondents indicated that their child had a significant sleep disorder and non-respiratory sleep problems were common. Non-respiratory problems included: trouble going to sleep independently (45%), restless sleep (76%), night-time waking (24%) and bedtime resistance (22%). No significant correlations were found between sleep measures (behavioural and medical sleep problems) and the behavioural, functional or cognitive parameters. Conclusion: Sleep disorders were very common, especially non-respiratory sleep problems. OSA was common despite previous surgery. No association was found between sleep-related problems (snoring, sleep-study-confirmed OSA or non-respiratory sleep problem) and parent-reported behavioural problems, functional impairments or intellectual performance. This may reflect limitations of the measures used in this study, that in this population ongoing problems with daytime function are not sleep related or that a cross-sectional assessment does not adequately take into account the impacts of past disease/treatments. Further research is required to further evaluate the tools used to evaluate sleep disorders, the impact of those disorder on children with Down syndrome and interventions which improve both sleep and daytime function.

P128 Sleep Need is more Strongly Associated with Self-rated Health and Daytime Function than Sleep Duration

Introduction Most studies examining associations between sleep and health outcomes focus on sleep duration or efficiency, ignoring individual differences in sleep need. We investigated whether sleep need is a more influential correlate of self-rated daytime function and health than sleep duration. Methods This study is a secondary analysis of the 2019 Sleep Health Foundation online survey of adult Australians (N=2,044, aged 18–90 years). Hierarchical multiple linear regressions assessed variance explained by demographics (Model 1: age, sex, BMI), self-reported sleep duration (Model 2: Model 1 + weighted variable of weekday/weekend sleep duration), and individual sleep need (Model 3: Model 2+ how often they get enough sleep to feel their best the next day, on a 5-point scale) on daytime function items for fatigue, concentration, motivation, and overall self-rated health (EQ-5D, VAS 0–100). Results Sleep need explained an additional 17.5–18.7% of the variance in fatigue, concentration, motivation, and health rating (all p < 0.001 for R² change) in Model 3. Model 2 showed that sleep duration alone only explained 2.0–4.1% of the variance in these outcomes. Findings were similar when stratified by sex. Sleep need also explained greater variance for older adults than for younger and middle-aged adults, especially on health rating (Model 3: R² change = 0.11 for ages 18-24y, 0.14 for 45-54y, 0.27 for 75y+). Conclusions Sleep need explains more variance in daytime function and self-rated health than sleep duration. The role of sleep need on other daytime consequences, and in clinical populations, needs further exploration.

Effect of Raising Family Cognition on Improving Adherence and Quality of Life of 8-12-Year-Old Children Wearing Orthokeratology Lenses

Objective: To investigate the effect of raising family cognition on improving adherence and quality of life of 8-12-year-old children wearing orthokeratology lenses. Methods: From July 2019 to July 2020,120 children with orthokeratology lenses of our hospital were selected and randomly divided into two groups. The control group (n = 60) was given routine nursing, while the observation group (n = 60) was given home nursing intervention on the basis of the control group. To observe the treatment compliance, family cognition degree, sleep quality and quality of life in the two groups. Results: Compared with the control group, the patients in the observation group had higher treatment compliance and family cognition degree, lower scores of times to fall asleep, sleep duration, sleep disturbance and daytime function, and higher scores of physiological function, mental health, social function and emotional function (P<0.05). Conclusion: Strengthening home nursing intervention for patients wearing orthokeratology lenses can improve the cognition level of family members on the one hand, improve the compliance of children on the other hand, and improve the sleep quality and quality of life at the same time.

374 Cognitive Behavioral Therapy with Exercise in Adults with Insomnia and Short Sleep: Daytime Function Outcomes from a Pilot Study

Introduction Cognitive behavioral therapy for insomnia (CBT-I) is efficacious, but there is mixed evidence as to whether improvement is blunted in adults with insomnia and short sleep duration. Exercise training can reduce physiologic hyperarousal and may increase homeostatic sleep drive, which could potentiate CBT-I treatment effects. This pilot study explored changes in self-reported outcomes from a CBT-I intervention augmented by exercise training in a sample of adults with insomnia and objective short sleep duration. Methods Eight adults (50% female, 62.5% white) with insomnia disorder and short sleep duration (mean actigraphic TST &lt;6.5 hr) completed a 12-week single-arm trial. Participants self-administered the online “Sleep Healthy Using the Internet” (SHUT-I) CBT-I program with additional staff guidance while completing a supervised exercise program (EX; 150 min/wk of moderate-intensity aerobic exercise and 2 days/wk of strength training). Participants completed assessments of self-reported sleep and daytime function pre- and post-intervention, including the Insomnia Severity Index (ISI), Flinders Fatigue Scale (FFS), Ford Insomnia Response to Stress Test (FIRST), Perceived Stress Scale (PSS), and Epworth Sleepiness Scale (ESS). Differences between timepoints were analyzed using paired t-tests and Cohen’s d effect size calculations. Results Insomnia severity significantly decreased after the intervention (ISI: p&lt;0.001, d=2.99), with 75% reporting post-intervention ISI ≤ 7. Likewise, fatigue significantly decreased after the intervention (FFS: p=0.032, d=0.95). Symptoms of stress-related sleep reactivity and stress were also reduced (FIRST: p=0.012, d=1.19; PSS: p=0.014, d=1.14). Though nonsignificant, large reductions in sleepiness were additionally observed (ESS: p=0.058, d=0.80). Conclusion In this pilot trial among patients with insomnia and short sleep duration, online CBT-I plus a supervised exercise program resulted in a significant reduction in insomnia severity. The intervention also produced large and meaningful reductions in fatigue and stress, which are common daytime impairments in patients with insomnia. Future research should attempt to disentangle the independent contributions of CBT-I and exercise on outcomes in this population. Support (if any) NIH: K23HL118318

544 Burden of Sleep Disturbance in Black Pregnant Women

Introduction Black women disproportionately experience poor perinatal outcomes compared to other racial/ethnic groups. Poor sleep has emerged as a strong contributor to adverse pregnancy outcomes and, in the non-pregnant population, sleep-wake disturbances have a high prevalence with often greater severity among Blacks. Nonetheless, the majority of studies have included largely White populations which has restricted our understanding of race-specific burdens and morbidities of sleep disturbance. The goal was to describe the burden of sleep-wake disturbance in Black pregnant women and associations with pregnancy outcomes. Methods Black women at least 18years and &gt;28 weeks pregnant were recruited from prenatal clinics. All women completed questionnaires about their sleep including the presence and timing of habitual-snoring (pre-pregnancy or pregnancy-onset), the Epworth Sleepiness Scale (ESS), and the General Sleep Disturbances Scale (GSDS) to determine poor sleep quality and poor daytime function as well as symptoms of insomnia. We also analyzed three commonly-reported sleep problems as individual question items (difficulty getting to sleep, wake up during sleep period, and wake up too early at the end of a sleep period). Demographic information and diagnoses were abstracted from medical records. Results Overall, 235 women enrolled; mean age was 27.6 + 6.2 years, mean BMI 31.7 + 9.8kg/m2, and 64% were in receipt of Medicaid. Eighty-percent of women reported &gt;three sleep-wake disturbances, and almost half experienced a burden of &gt;five disturbances. Women with pregnancy-onset habitual-snoring (but not those with pre-pregnancy habitual-snoring) had increased odds of poor sleep quality aOR 8.2 (95% CI 1.9, 35.9), trouble staying asleep aOR 3.6 (95% CI 1.0, 12.5), waking up too early aOR 2.7 (95% CI 1.1, 6.2), excessive daytime sleepiness aOR 2.3 (95% CI 1.1, 4.7), and poor daytime function aOR 8.7 (95% CI 2.5, 29.9). In contrast, women with pre-pregnancy habitual-snoring had increased odds for chronic hypertension, preterm delivery and fetal growth restriction; aOR 2.6 (95% CI 1.1, 6.3), aOR 2.8 (95% CI 1.1, 6.9), and aOR 5.1 (95% CI 1.7, 15.2), respectively. Conclusion Black women have a significant burden of sleep-wake disturbances. These findings highlight the excess risk that habitual-snoring confers to sleep-wake disturbances and perinatal outcomes in an infrequently studied yet highly vulnerable population. Support (if any) NIH NHLB-IHL089918

792 Sleep and Daytime Function in Patients with Multiple Sclerosis

Introduction Fatigue is a core symptom of Multiple Sclerosis (MS) and impairs function and quality of life. Studies show that sleep-disordered breathing (SDB) is also common in persons with MS and may exacerbate fatigue. Within a larger study of patients with spinal cord injuries and disorders, we evaluated the relationships among sleep-disordered breathing severity, sleep quality, and functional outcomes in patients with MS. Our objective was to examine the impact of SDB severity and sleep quality on the severity of fatigue and functional impairment in this population. Methods Twenty-five subjects (average age=57(11), min=35, max=79; 80% male; average AHI=27(20) min=3, max=70; and 67% with AHI &gt; 15) 24 completed in-laboratory polysomnography (PSG) to measure apnea-hypopnea index (AHI) and sleep efficiency (SE) and questionnaires about sleep and function: Insomnia Severity Index (ISI), Pittsburg Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Flinders Fatigue Scale (FFS), PHQ-9 depression scale (excluding sleep item), Brief Pain Inventory (BPI) and World Health Organization Quality of Life (WHOQOL). Relationships between sleep measures (AHI and SE from PSG, ISI and PSQI) and daytime function (ESS, FFS, PHQ-9, BPI and WHOQOL) were assessed by bivariate correlation. Results At the baseline visit, we assessed participant’s daytime sleepiness, fatigue, sleep quality, and depression. The mean scores on questionnaires: ESS was 8.0(5.6), ISI was 11.5(6.7), PSQI was 9.3(4.4), FFS was 17.3(8.7), BPI severity was 3.4 (3.13), BPI interference was 3.5 (3.5), PHQ-9 was 7.3(5.8). There were significant relationships between ISI and FFS (r=0.78, p&lt;0.001), PSQI and FFS (r=0.68, p=0.001), ISI and WHOQOL Physical Domain (r=-0.64 p=0.001), as well as SE and FFS (r=-0.45, p=0.041). There was no significant correlation between AHI and FFS (p=0.395). Conclusion In veterans with MS, insomnia symptom severity was associated with daytime fatigue and decreased quality of life (QOL). Insomnia may represent a modifiable cause of daytime fatigue in patients with MS. Recognition and management of insomnia may improve outcomes in this population. Further research should evaluate whether insomnia interventions may benefit daytime fatigue and improve QOL. Support (if any) VA Rehabilitation Research and Development Service, (RX002116; PI Badr); VA HSR&D RCS20-191 and NIH/NHLBI K24 HL143055 (PI Martin).

Effects of sleep restriction on the sleep electroencephalogram of adolescents

Study Objectives This report describes findings from an ongoing longitudinal study of the effects of varied sleep durations on wake and sleep electroencephalogram (EEG) and daytime function in adolescents. Here, we focus on the effects of age and time in bed (TIB) on total sleep time (TST) and nonrapid eye movement (NREM) and rapid eye movement (REM) EEG. Methods We studied 77 participants (41 male) ranging in age from 9.9 to 16.2 years over the 3 years of this study. Each year, participants adhered to each of three different sleep schedules: four consecutive nights of 7, 8.5, or 10 h TIB. Results Altering TIB successfully modified TST, which averaged 406, 472 and 530 min on the fourth night of 7, 8.5, and 10 h TIB, respectively. As predicted by homeostatic models, shorter sleep durations produced higher delta power in both NREM and REM although these effects were small. Restricted sleep more substantially reduced alpha power in both NREM and REM sleep. In NREM but not REM sleep, sleep restriction strongly reduced both the all-night accumulation of sigma EEG activity (11–15 Hz energy) and the rate of sigma production (11–15 Hz power). Conclusions The EEG changes in response to TIB reduction are evidence of insufficient sleep recovery. The decrease in sigma activity presumably reflects depressed sleep spindle activity and suggests a manner by which sleep restriction reduces waking cognitive function in adolescents. Our results thus far demonstrate that relatively modest TIB manipulations provide a useful tool for investigating adolescent sleep biology.