Exploring the Effect of Nightly Infusion Pump Alarms on Sleep in the Hospital

Purpose Optimal sleep helps parents and children cope with life-threatening disease. However, hospital-surroundings are noisy, negatively affecting sleep quality and quantity. We aimed to determine sleep quantity; sleep satisfaction; their relation to infusionpump alarms in pediatric cancer patients and parents; and sleep quality and daytime impairment in parents. Methods Patients (2–18 years), admitted for scheduled anti-cancer therapy were eligible, as were inrooming parents. Frequency and duration of nightly infusion pump alarms were recorded. Patients and parents wore an accelerometer to assess sleep quantity (sleep efficiency, wake after sleep onset, night awakenings), additionally daily sleep satisfaction was assessed. Parents filled out questionnaires on sleep quality (PROMIS Sleep Disturbance, Insomnia Severity Index) and daytime impairment (PROMIS Sleep-Related Impairment, PROMIS Fatigue). Sleep quality scores were compared to norms. In children and parents the relation between alarms and sleep was assessed using multilevel analyses. Results Nineteen children (age 8.8 ± 4.9 years, 40 nights) and 30 parents (age 41.1 ± 6.3, 46 nights) participated (response 78%). Nightly alarms sounded median 3 times / 6 minutes in parents and 5 times / 10 minutes in children. Parents scored worse than the norm on sleep disturbances (P .01), but not on daytime impairment, 16% experienced clinical insomnia. There was no relation between alarms and sleep quantity or satisfaction for children and parents. Conclusions This explorative study showed that alarms sound frequently at night and parents sleep poorly during admissions. However, sleep of children and parents and alarms were not significantly related here. Future research should identify and improve (other) disrupting factors in the hospital.

351 Informal Caregivers with Insomnia May Benefit From an Insomnia Treatment Using an Acceptance and Commitment Therapy Approach

Introduction Insomnia among informal caregivers (providing care to family/friends) is common and associated with worse mental and physical health outcomes. Traditional cognitive behavioral therapy for insomnia may be challenging for caregivers whose beliefs about sleep may relate to beliefs and behaviors that are intertwined with their unique situation of caregiving. We examined whether an insomnia treatment using an acceptance and commitment (ACT) approach (i.e. committing to values-based actions toward goals vs. experiential avoidance of distressing emotions/thoughts) plus sleep restriction, stimulus control and sleep hygiene improves sleep, mental health, and daytime symptoms among caregivers. Methods We analyzed data from women veterans with insomnia who were informal caregivers (mean age=44 years [range 25–57]; N=6) and were participating in a clinical trial of an ACT-focused treatment (termed ABC-I). We measured: Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Patient Health Questionnaire (PHQ-9), General Anxiety Disorder (GAD-7), 11 items assessing symptoms of daytime impairment due to poor sleep derived from the International Classification of Sleep Disorders-Third Edition, and the Acceptance and Action Questionnaire (AAQ). Student t-tests were used to compare outcomes between pre- and post-ABC-I. Results Caregivers showed significant improvements between pre- and post-ABC-I (all p-values<0.05) in the following outcomes: ISI (14.3±5.4 vs. 3.8±3.2), PHQ-9 (9.8±7.2 vs. 2.8±3.8), GAD-9 (9.0±6.6 vs. 2.0±1.8), and number of symptoms of sleep-related daytime impairment (6.8±4.0 vs. 3.8±3.5). Caregivers also showed improvement trends in PSQI (10.0±4.1 vs. 5.2±1.2, p=0.06) and AAQ score (24.0±12.7 vs. 16.2±8.0, p=0.05). Conclusion We found that caregivers with insomnia may benefit from ACT-based treatment in improving perceived sleep quality and insomnia, depression, anxiety, sleep-related daytime impairment and reduced experiential avoidance. This approach may increase motivation by linking the sleep program to core values, and acceptance and tolerance of emotions or thoughts may benefit caregivers with insomnia. Further studies using an ACT-based insomnia program are needed to test its effect in a larger sample of caregivers and evaluate benefits in terms of reduced stress and improved health. Support (if any) VA HSR&D (Martin IIR 13-058-2 and RCS-20–191), NIA (K23AG055668, Song), NHLBI (K23HL143055, Martin) of the NIH, VAGLAHS GRECC, and VA Office of Academic Affiliations (Kelly; Carlson).

197 Refining the Subjective Assessment of Sleep: An SEM Approach

Introduction Given that sleep is multidimensional, the assessment of sleep requires an examination of a number of different domains. Accordingly, there is an abundance of self-report sleep questionnaires that are widely used for both research and clinical use. The surplus of available measures can be problematic, as it often leads to difficulties in selecting the best measure for a given purpose/context. In addition, the use of multiple measures to assess sleep may be an inefficient use of time and resources if they are not measuring unique constructs. The purpose of the current study is to evaluate the factor structure of five sleep measures. A confirmatory factor analysis (CFA) was initially used to evaluate whether each of these scales are measuring different factors of sleep, with follow-up exploratory factor analysis (EFA) as needed. Methods An archival analysis was performed using data from an online study, Investigating Sleep Across Normal Development (ISLAND Study). The sample consisted of 3,284 adults aged 18+. The following measures were utilized: RU SATED, PROMIS Sleep-Related Impairment, Sleep Self-Efficacy, Insomnia Severity Index, and the Sleep Regularity Questionnaire. Results As expected, the CFA model fit was determined to be poor and an EFA was then conducted to assess the factor structure of these scales. The EFA revealed a four-factor structure comprised of 25 items: Sleep-Related Daytime Impairment, Sleep Regularity, Sleep Disturbance, and Sleep-Related Daytime Enhancement. Conclusion The findings from the current study add to the literature supporting the multidimensionality of sleep, as well as the continued need to assess the various facets that comprise this construct. Although the literature supports the utility of these five measures, the present study found that within a community sample, these measures are not entirely unique. Further, the present study extends our knowledge and the literature by revealing a novel factor of sleep – Sleep-Related Daytime Enhancement. It may be worthwhile for researchers and clinicians to consider latent sleep factors that contribute to sleep disturbance and sleep health. Future work is needed to further confirm the observed factor structure and assess the psychometrics of this new scale. Support (if any) National Institute on Aging (K23AG049955, PI: Dzierzewski).

225 Sleep Timing and Chronotype in Mothers: Longitudinal Changes and Associations with Wellbeing from Pregnancy to 2 Years Postpartum

Introduction Women experience significant changes to sleep during perinatal periods. Existing research focuses on sleep duration and quality, but not sleep timing or chronotype (i.e., preferred timing for activity and sleep). This study investigated change trajectories of sleep timing and chronotype from late pregnancy to two years postpartum, and examined longitudinal associations between chronotype and insomnia, sleep-related daytime impairment, and mood. Methods Data were from a 2-arm randomized controlled trial testing behavioral sleep and diet interventions. A community sample of nulliparous women without severe sleep/mental health conditions participated. Women self-reported bedtime, risetime, chronotype (reduced Morningness-Eveningness Questionnaire), Insomnia Severity Index, and PROMIS Depression, Anxiety, and Sleep-Related Impairment over 7 time points: 30 and 35 weeks’ gestation, and postpartum months 1.5, 3, 6, 12 and 24. Results 163 women (mean age 33.35 ± 3.42 years) took part. Mixed effects models controlling for age and group allocation showed that both bed- and risetimes became progressively earlier over time by approximately 20-30 minutes on average (p < .001); chronotype also shifted progressively towards morningness (p < .01). After controlling for covariates (sleep duration and efficiency, mental health history, social support, age, group allocation), greater morningness was significantly associated with lower symptoms of insomnia and sleep-related impairment over time (p-values < .001); longitudinal associations between chronotype and symptoms of depression and anxiety were non-significant (p-values > .65). Conclusion This is one of the first studies to examine longitudinal changes in sleep timing and chronotype from pregnancy to two years postpartum. Sleep timing and chronotype became progressively earlier over the first two postpartum years. The magnitude of changes is beyond what is expected with increasing age. Greater morningness was associated with lower sleep complaints and sleep-related daytime impairment during the postpartum period. The mechanisms underlying these associations require further research. Support (if any) Australasian Sleep Association, Monash University, Australian Government RTP Scholarship and National Health and Medical Research Council.

A Validation Study of PROMIS Sleep Disturbance (PROMIS-SD) and Sleep Related Impairment (PROMIS-SRI) Item Banks in Individuals with Idiopathic Parkinson’s Disease and Matched Controls

Background: Parkinson’s disease (PD) is associated with sleep disturbance (SD) and sleep-related impairment (SRI). Validation of self-report measures of these problems is needed in PD. The Patient-Reported Outcomes Measurement Information System (PROMIS) includes tools that assess these problems (PROMIS-SD and PROMIS-SRI, respectively). Objective: This study aimed to further validate these measures in individuals with PD and matched controls. Methods: Individuals with early-stage PD (n=50) and matched controls (n=48) completed measures of SD including the PROMIS-SD, Pittsburgh Sleep Quality Index (PSQI), and Insomnia Severity Index (ISI). They also completed measures of daytime impairment including the PROMIS-SRI, Epworth Sleepiness Scale, State-Trait Anxiety Inventory, Beck Depression Inventory 2nd edition, and Parkinson’s Disease Questionnaire-39. Internal consistency for the PROMIS measures were assessed using Cronbach’s α coefficient and item-total correlations in the total sample. Convergent and divergent validity of the PROMIS item banks were assessed using Spearman correlations. Results: The PROMIS item banks had excellent internal consistency (α>0.94). Supporting convergent validity, the PROMIS-SD had strong correlations with other measures of SD (ρ>0.68, for PSQI and ISI) and the PROMIS-SRI had moderate to strong correlations with all measures of daytime impairment (ρ=0.41–0.72). Supporting divergent validity within the PD group, the PROMIS-SD correlated more strongly with SRI than with the Parkinson’s Disease Questionnaire total score, a metric of PD related impairment. Conclusion: In middle-aged and older adults, with and without early-stage PD, the PROMIS-SD and PROMIS-SRI are reliable and valid measures of SD and SRI, respectively.

Insomnia Disorder—Pathophysiology

Insomnia disorder is defined as persistent difficulty with initiating or maintaining sleep, or early morning awakening accompanied by daytime impairment. Although insomnia disorder is a highly prevalent disorder and a major public health burden, the pathophysiology of the disorder is still not fully understood. Neurobiological as well as psychological models have been suggested highlighting genetic, behavioral, cognitive, emotional, and neurobiological factors. While psychological perspectives emphasize the role of dysfunctional sleep-related cognitions and a selective attention toward sleep-related stimuli, neurobiological perspectives particularly look at physiological alterations such as brain circuits that may be involved in the pathophysiology of insomnia. Relevant models explaining how insomnia develops and how it becomes chronic are described, and the evidence is summarized. Thus, this chapter provides an overview of important etiological models and further approaches dealing with the pathophysiology of insomnia disorder.

Cognitive-Behavioral and Pharmacological Treatments for Insomnia: A Combined Approach

Insomnia is the most prevalent sleep disorder (10-40%). It is defined as the subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep and that results in some form of daytime impairment. Among the typical symptoms, there are fatigue, decreased mood or irritability, general malaise, and cognitive impairment. According to the International Classification of Sleep Disorders 3rd edition, ICSD-3, it has been defined as chronic (lasting more than three months) or short-term insomnia (less than three months).In clinical practice, the usual therapeutic approach is pharmacological (benzodiazepines, z drugs, slow wave sleep enhancers), even if the American Academy of Sleep Medicine (AASM), the American College of Physicians (ACP), and the European Sleep Research Society (ESRS) guidelines suggest that the first clinical choice should be non-pharmacological (cognitive behavioral therapy). A combined (non-pharmacological and pharmacological)approach could be considered in poor responders to manage drug dependence and to increase compliance to treatment and patients’ quality of life.

0373 Blacks with Obstructive Sleep Apnea Report Greater Nighttime Insomnia Symptoms than Whites, but Don’t Endorse Daytime Impairment

Introduction Few studies have assessed insomnia severity in racial/ethnic minority patients with OSA. In recognition of the burden of OSA in blacks compared to whites, the current study sought to examine insomnia symptoms in a sample of black and white patients newly diagnosed with OSA, prior to treatment, at 3 and 6 months. Methods 94 patients newly diagnosed with OSA provided demographics (age, sex, race/ethnicity), socioeconomic status, and completed the well-known and validated Insomnia Severity Index (ISI). To assess insomnia complaints, we ascertained total ISI score, nighttime sleep complaints, and daytime impairment. Linear regression and repeated measures analysis were conducted. Results Mean age was 57.43 years ±13.55; 63.8% were men and 35% were black. Mean BMI was 32.35±7.04and 35% were diagnosed with hypertension. The mean ISI score for the total sample was 13.06±7.06. The total ISI was significantly higher in blacks than whites, respectively (M=15.00±7.17; M=12.02±6.83, p<0.05) indicating moderate clinical insomnia in blacks, but not whites. In covariate-adjusted linear regression, nighttime complaints were statistically more pronounced in blacks (b=1.71, SE=0.82, p<0.05) and women (b=2.05, SE=0.72, p<0.01). There were no significant racial/ethnic differences with daytime impairment, but gender differences in daytime impairment remained (b=2.93, SE=1.04 p<0.01). Results from repeated measures effects of race over time revealed that blacks had higher nighttime complaints across all time-points (b=2.51, SE=1.10, p<0.05), but we did not observe a race-by-time interaction effect (b=-0.89, SE=0.50). Conclusion For the first time, we observed that overall ISI score and nighttime complaints are more pronounced in blacks than whites. Notably, only women endorsed complaints of daytime impairment. Findings from the study may contribute to understanding who will need treatment for relief of insomnia complaints. Support K23HL125939

0340 Regional Changes in Sleep Electroencephalography Power in Youth with Sleep-Disordered Breathing: A High-Density EEG Study

Introduction Daytime neurobehavioral impairments are commonly associated with sleep disordered breathing (SDB) in children. However, a large number of studies have shown only minimal differences in sleep between children with SDB relative to control children, suggesting that sleep dysfunction is not responsible for daytime impairment. Importantly, however, previous studies have measured sleep EEG using only frontal scalp electrodes, failing to capture the regional features of sleep that are prominent during development. Here we measure sleep using hdEEG in SDB and healthy children to determine if regional sleep impairment is related to daytime neurobehavioral performance. Methods Overnight high-density electroencephalography (hdEEG, 256 channels) was recorded in 17 children with sleep disordered breathing (SDB) (age: M = 8.46, SD = 1.82, AHI: M = 11.3, SD = 8.6, 53% female) and 17 age and sex matched controls (age: M = 8.47, SD = 1.66, AHI: M = 1.5, SD = .64). Attentional capacity was assessed using the Test of Variables of Attention (TOVA) before and after sleep. Group differences in sleep macrostructure variables were assessed using unpaired t-tests. All-night spectral analysis was performed for NREM sleep and averaged across groups. Topographic differences between groups were assessed using statistical non-parametric mapping. Pearson correlations were used to determine associations between sleep and TOVA variables. Results Sleep macrostructure did not differ between groups. All-night spectral density analysis revealed a global increase in high-frequency activity in N2N3 and N3, in the alpha band (8-12 Hz, p<0.05). Global alpha power was higher in SDB youth, although this effect reached significance during N3 in a large cluster of posterior channels (N=55, p=.02). Conclusion Elevated alpha during NREM is frequently considered a correlate of nonrestorative sleep. In this sample of youth with SDB, posterior alpha is robustly increased during the deepest stage of NREM sleep. In this small sample, however, alpha power did not predict performance on an attentional task sensitive to the effects of impaired sleep. Support R21 HD092986-02 to SJ

0213 The Association Between Work-Related Job Demands and Daytime Impairment in Professional Firefighters

Introduction Sleep is an important predictor of daytime functioning and is impaired in first responders. The present study investigated whether job demands were associated with daytime impairment in professional firefighters. We hypothesized that the frequency of emergency calls would predict daytime impairment above and beyond years of service, sleep apnea risk, and sleep duration. Methods Participants were 267 (251 males; mean age=41.94) firefighters from the Richmond, Virginia Fire Department who completed pen-and-paper surveys in small groups assessing sleep duration (Pittsburgh Sleep Quality Index; PSQI), sleep apnea risk (STOP-BANG), job demands (number of emergency calls received per day), and sleep-related impairment (Patient Reported Outcomes Measurement Information System 8-item short-form; PROMIS). A three block hierarchical regression was used to assess the contribution of job demands to daytime impairment. Results The final model significantly predicted sleep-related daytime impairment, F(4,260)=11.51, p<.001, R2=.15. Each block in the model accounted for significant change in variance, years of service and sleep apnea risk (R2=.05), sleep duration (∆R2=.08), number of calls (∆R2=.01). Number of emergency calls significantly predicted daytime impairment (β=.14) above and beyond number of years of service (β= -.24), sleep duration (β= -.29), and sleep apnea risk (β=.03). Conclusion With 2–18 emergency calls per 24-hour period, the results suggest that job-related demands are a unique contributor to daytime functioning in professional firefighters. As such, it will be important for interventions aimed at improving sleep in professional firefighters to incorporate information unique to the profession (i.e., job specific demands and intensity of work) as specific treatment factors. Support This work was supported by the National Institute on Aging (K23AG049955, PI: Dzierzewski).