Who meets national early childhood sleep guidelines in Aotearoa New Zealand? A cross-sectional and longitudinal analysis

Study Objectives To investigate the proportion of children in Aotearoa New Zealand (NZ) who do or do not meet sleep duration and sleep quality guidelines at 24 and 45 months of age and associated sociodemographic factors. Methods Participants were children (n=6,490) from the Growing Up in New Zealand longitudinal study of child development with sleep data available at 24 and/or 45 months of age (48.2% girls, 51.8% boys; 22.4% Māori [the Indigenous people of NZ], 12.9% Pacific, 13.4% Asian, 45.2% European/Other). Relationships between sociodemographic factors and maternally-reported child sleep duration (across 24 hours) and night wakings were investigated cross-sectionally and longitudinally. Estimates of children in NZ meeting sleep guidelines were calculated using a range of analytical techniques including Bayesian linear regression, negative binomial multiple regression, and growth curve models. Results In NZ, 29.8% and 19.5% of children were estimated to have a high probability of not meeting sleep duration guidelines and 15.4% and 8.3% were estimated to have a high probability of not meeting night waking guidelines at 24 and 45 months respectively, after controlling for multiple sociodemographic variables. Factors associated cross-sectionally with children’s sleep included ethnicity, socioeconomic deprivation, material standard of living, rurality and heavy traffic, and longitudinal sleep trajectories differed by gender, ethnicity and socioeconomic deprivation. Conclusions A considerable proportion of young children in NZ have a high probability of not meeting sleep guidelines but this declines across the ages of 24 and 45 months. Sleep health inequities exist as early as 24 months of age in NZ.

Validation of Somno-Art Software, a novel approach of sleep staging, compared with polysomnography in disturbed sleep profiles

Integrated analysis of heart rate (electrocardiogram [ECG]) and body movements (actimetry) during sleep in healthy subjects has previously been shown to generate similar evaluation of sleep architecture and continuity with Somno-Art Software compared to polysomnography (PSG), the gold standard. However, the performance of this new approach of sleep staging has not yet been evaluated on patients with disturbed sleep. Sleep staging from 458 sleep recordings from multiple studies comprising healthy and patient population (obstructive sleep apnea [OSA], insomnia, major depressive disorder [MDD]) was obtained from PSG visual scoring using the American Academy of Sleep Medicine (AASM) rules and from Somno-Art Software analysis on synchronized ECG and actimetry. Inter-rater reliability, evaluated with 95% absolute agreement intra-class correlation coefficient, was rated as "excellent" (ICCAAAvg95% ≥0.75) or "good" (ICCAAAvg95% ≥0.60) for all sleep parameters assessed, except NREM and N3 sleep in healthy participants (ICCAAAvg95% =0.43, ICCAAAvg95% =0.56) and N3 sleep in OSA patients (ICCAAAvg95% =0.59) rated as "fair" inter-rater reliability. Overall sensitivity, specificity, accuracy and Cohen's kappa coefficient of agreement (κ)on the entire sample were respectively of 93.3%, 69.5%, 87.8% and 0.65 for wake/sleep classification and accuracy and κ were of 68.5% and 0.55 for W/N1+N2/N3/REM classification. These performances were similar in healthy and patient population. The present results suggest that Somno-Art can be a valid sleep-staging tool in both healthy subjects and patients with OSA, insomnia or MDD. It could complement existing non-attended techniques measuring sleep-related breathing pattern or be a useful alternative to laboratory-based PSG when this latter is not available.

Genetic and Environmental Influences on Sleep-Wake Behaviours in Adolescence

Study Objectives To investigate the influence of genetic and environmental factors on sleep-wake behaviours across adolescence. Methods Four hundred and ninety-five participants (aged 9 to 17; 55% females), including 93 monozygotic (MZ) and 117 dizygotic (DZ) twin pairs, and 75 unmatched twins, wore an accelerometry device and completed a sleep diary for two weeks. Results Individual differences in sleep onset, wake time, and sleep midpoint were influenced by both additive genetic (44-50% of total variance) and shared environmental (31-42%) factors, with a predominant genetic influence for sleep duration (62%) and restorative sleep (43%). When stratified into younger (aged 9-14) and older (aged 16-17) subsamples, genetic sources were more prominent in older adolescents. The moderate correlation between sleep duration and midpoint (rP = -.43, rG = .54) was attributable to a common genetic source. Sleep-wake behaviours on school and non-school nights were correlated (rP = .44-.72) and influenced by the same genetic and shared environmental factors. Genetic sources specific to night-type were also identified, for all behaviours except restorative sleep. Conclusions There were strong genetic influences on sleep-wake phenotypes, particularly on sleep timing, in adolescence. Moreover, there may be common genetic influences underlying both sleep and circadian rhythms. The differences in sleep-wake behaviours on school and non-school nights could be attributable to genetic factors involved in reactivity to environmental context.

Chronotype as self-regulation: morning preference is associated with better working memory strategy independent of sleep

Study objectives We set out to examine how chronotype (diurnal preference) is connected to ability to function in natural conditions where individuals cannot choose their sleep schedule. We conducted a cross-sectional study in military conscript service to test the hypothesis that sleep deprivation mediates the adverse effects of chronotype on cognitive functioning. We also examined the effects of time of day. Methods 140 participants (ages 18-24 years) completed an online survey, including the Morningness-Eveningness Questionnaire (MEQ) and a Cambridge Neuropsychological Test Automated Battery (CANTAB). Most (n=106) underwent an actigraphy recording. After bivariate analyses, we created a mediation model (self-reported sleepiness and sleep deprivation mediating effect of chronotype on cognition) and a moderation model (synchrony between most alert time and testing time). Results Reaction times in inhibition task correlated negatively with sleep efficiency and positively with sleep latency in actigraphy. There was no relation to ability to inhibit responses. More significantly, spatial working memory performance (especially strategicness of performance) correlated positively with morning preference and negatively with sleep deprivation before service. Synchrony with most alert time of the day did not moderate these connections. No other cognitive task correlated with morningness or sleep variables. Conclusions In line with previous research, inhibitory control is maintained after insufficient sleep but with a tradeoff of slower performance. The connection between morning preference and working memory strategy is a novel finding. We suggest that diurnal preference could be seen as an adaptive strategy, as morningness has consistently been associated with better academic and health outcomes.

Diagnosed or prescribed only? A national analysis of initial evaluation and management of insomnia among older adult Medicare beneficiaries

Study Objectives To describe initial insomnia-related encounters among a national sample of Medicare beneficiaries, and to identify older adults at risk for potentially inappropriate prescription insomnia medication usage. Methods Our data source was a random 5% sample of Medicare administrative claims data (2006-2013). Insomnia was operationalized as International Classification of Disease, Ninth Revision, Clinical Modification diagnostic codes. Insomnia medications included FDA-approved insomnia-related medication classes and drugs. Logistic regression was employed to identify predictors of being “prescribed only” (i.e., being prescribed an insomnia medication without a corresponding insomnia diagnosis). Results A total of N=60,362 beneficiaries received either an insomnia diagnosis or a prescription for an insomnia medication as their first sleep-related encounter during the study period. Of these, 55.1% (n=33,245) were prescribed only, whereas 44.9% (n=27,117) received a concurrent insomnia diagnosis. In a fully adjusted regression model, younger age (odds ratio (OR) 0.98; 95% confidence interval (CI) 0.98, 0.99), male sex (OR 1.15; 95% CI 1.11, 1.20), and several comorbid conditions (i.e., dementia [OR 1.21; 95% CI 1.15, 1.27] and anemia [OR 1.17; 95% CI 1.13, 1.22]) were positively associated with being prescribed only. Conversely, black individuals (OR 0.83; 95% CI 0.78, 0.89) and those of “other” race (OR 0.89; 95% CI 0.84, 0.94) were less likely to be prescribed only. Individuals who received care from a board-certified sleep medicine provider (BCSMP) were less likely to be prescribed only (OR 0.27; 95% CI 0.16, 0.46). Conclusions Fewer than half of Medicare beneficiaries prescribed insomnia medications ever received a formal sleep-related diagnosis.

P163 Slow wave transcranial electrical stimulation during wake to investigate the consolidation of new learning

Introduction Slow, oscillatory, transcranial electrical stimulation (so-tES) applies a current over the scalp that oscillates in intensity at a frequency associated with slow wave sleep (SWS; 0.75Hz). When applied during SWS, so-tES can enhance SWS EEG power compared to sham stimulation, as well as overnight declarative memory consolidation. When applied during wake, so-tES can enhance local EEG power in the slow wave frequency range (0.5–4.5Hz) compared to sham. Therefore, this study will investigate whether so-tES can enhance the early consolidation of new learning compared to sham, when applied during wake. A preliminary analysis of data will be presented. Methods Healthy, young, right-handed adults (18–35 years) practiced a motor sequence learning task for 30 minutes, before receiving 15 minutes of active or sham so-tES (0.75Hz) during quiet wakefulness. Task performance was assessed by recording the total number of correct sequences performed in 30 seconds before practice, after practice, and after stimulation. Performance improvements will be compared between stimulation conditions. Non-invasive, electrophysiological corticospinal excitability measurements (i.e., motor-evoked potentials) were also recorded at six timepoints throughout each session, to investigate whether active so-tES can modulate corticospinal excitability differently to sham. Progress to date Data collection is ongoing, and completion is expected by late 2021. Intended outcome and impact We expect so-tES to enhance early skill consolidation during wake, and that enhanced consolidation will be associated with less variable measurements of corticospinal excitability, when compared with sham stimulation.

O018 Changes in sleep parameters in children with Down Syndrome following treatment

Introduction There is limited evidence about how sleep changes in children with Down syndrome (DS) following sleep interventions. This study evaluated changes in sleep over time in children receiving treatment comparing to a control group who did not. Methods Children with DS, 3-16yrs, attending the sleep clinic were followed for 24-months. Sleep parameters including parent completed child sleep habits questionnaire (CSHQ), PSG and home sleep diary were obtained pre and post sleep interventions for children undergoing treatment. Data was obtained at similar intervals for the control group who were followed over the same time period. Results Data was obtained for 41 participants, 16 children received an intervention and 25 did not. Interventions included ENT surgery (7), CPAP (4), melatonin (3) or a combination (2). The intervention group had a significantly higher average total CSHQ score overall than those in the control group (0.01). Scores decreased over time but remained higher than in controls throughout, and were clinically significant in both groups (>41). Sleep diary estimated average total sleep duration did not differ between groups and was 10hrs/night. PSG showed improvement in OAHI in those children undergoing pre and post intervention studies. Discussion Evaluation of sleep parameters in this referred cohort of children with Down syndrome demonstrates total sleep duration in keeping with national recommendations and improvement in obstruction with treatment. However, CSHQ results indicate ongoing sleep difficulties reported by parents, despite standard sleep interventions. This may reflect persisting non-respiratory sleep disorders, which are not being adequately addressed at present.

O017 Parents’ experiences of having a child with Down Syndrome and sleep difficulties

Introduction This qualitative study that investigates parents’ experiences of having a child with Down Syndrome (DS) and sleep difficulties is a part of a broader mixed-method study entitled Sleep Difficulties in Children with Down Syndrome: An Evaluation of Parent/Carer and Family Quality of Life. Methods We conducted semi-structured interviews with 26 parents (fathers n = 4 and mothers n = 22), and reflexive Thematic Analysis (TA) was operationalised for data analysis. The interviews covered the following key topics: DS diagnosis; timeline of their child’s sleep patterns and difficulties; implications for parental sleep, day-time function, and well-being; family dynamics; and access to supports. Results Most participants described negative experiences at time of diagnosis, including not feeling listened to, and receiving inconsistent, insensitive and inadequate information and/or treatment. Most strikingly, no parents recall receiving sleep specific information. Most participants described their child’s sleep difficulties affecting their own sleep, day-time function and family dynamics, yet they commonly normalised these experiences. Such normalisation was a recurring theme across their experiences of having a child with DS and is contextualised by their accounts of resisting prejudiced attitudes towards their child since diagnosis. Discussion This is the first qualitative study to investigate parents’ experiences of having a child with DS and sleep difficulties. Implications include professional development for health care workers focusing on sleep as a significant comorbidity for these children, and awareness of families’ tendencies to normalise their experiences when delivering care.

O021 Preferred attributes of care pathways for obstructive sleep apnoea from the perspective of diagnosed patients and high-risk individuals: a discrete choice experiment

Background The current health care system is challenged with a large and rising demand for obstructive sleep apnoea (OSA) services. A paradigm shift in OSA management is required to incorporate the preferences of diagnosed patients and individuals at high-risk of OSA. This study aimed to provide empirical evidence of the values and preferences of individuals diagnosed with OSA and high-risk populations regarding distinct OSA care pathway features. Methods A discrete choice experiment (DCE) was undertaken in two groups: those with a formal diagnosis of OSA (n=421) and those undiagnosed but at high-risk of having OSA (n=1033). The DCE approach used mixed logit regression models to determine preferences relating to eight salient features of OSA management pathway, i.e. initial assessment, setting and diagnosis costs, waiting times, results interpretation, treatment options, provider of ongoing care and frequency of follow up visits. Results The findings indicate that all eight attributes investigated were statistically significant factors for respondents. Generally, both groups preferred low diagnostic costs, fewer follow-up visits, minimum waiting time for sleep study results, and sleep specialists to recommend treatment and as ongoing care providers. Management of OSA in primary care was acceptable to both groups and was the most preferred option by the high-risk group for sleep study testing and ongoing care provision. Discussion The DCE results offer a promising approach for systematic incorporation of patient and high-risk groups preferences into the future design and delivery of care pathways for OSA management.

P061 The effect of anxiety on symptom burden in patients with obstructive sleep apnoea

Background There is a high prevalence of anxiety in patients with obstructive sleep apnoea and such patients often describe fatigue in addition to sleepiness. We currently use the Epworth Sleepiness Scale (ESS) to quantify sleepiness in our patients, but we do not have useful tools for assessing fatigue. Fatigue is a common symptom in patients with many medical conditions but has not been well studied in patients presenting to sleep services. Our hypothesis is that patients with obstructive sleep apnoea who have a comorbid anxiety disorder, as measured by the Hospital Anxiety and Depression Scale (HADS) are likely to have increased symptom burden such as fatigue or poorer functional outcomes of sleep. Methods Analysis of prospectively collected data from 128 adult patients referred for suspected obstructive sleep apnea to Monash University Health Sleep Clinic. All patients have completed a comprehensive questionnaire prior to their first clinical review assessing their symptom burden at baseline. Questionnaires completed include extensive symptom and medical history assessment, the Fatigue Severity Scale (FSS), ESS, HADS, Functional Outcomes of Sleep Questionnaire (FOSQ), Insomnia Severity Index (ISI) and Global Fatigue Score. All patients were subsequently reviewed by a clinician and have overnight polysomnography data available. Progress to date; Data collected for all 128 participants. Preliminary analysis currently underway. Intended outcome & impact; We intend to examine whether the comorbidity of anxiety results in an increased or different symptom burden in patients referred for suspected obstructive sleep apnoea when compared to patients without a history of anxiety.