Sleep Assessment & Intervention in Hospital and Community-Based Settings Sara Nowakowski, PhD, CBSM University of Texas Medical Branch
Who am I? Clinical Psychologist, Board certified in Behavioral Sleep Medicine See patients in Women s Health Care Clinic (409) 772-9507 Thursday mornings 8:00am-12:00pm at University Health Clinic 3 rd Floor, Galveston Thursday afternoons 1:00-5:00pm at League City Campus Suite 2.100 Mothers & Babies Group starting August 13 Mondays 6:00-8:00pm, Bay Colony Pedi Clinic Sleep Research 1. Hospital Recovery 2. Surgical Recovery 3. Menopause
Objective Sleep Assessments Polysomnography (PSG) Actigraphy
Comparison of Fitness Monitors vs Actigraphy Multi PIs: Nowakowski & Lyons Participants: Healthy Adults (N=40) Mean age = 42 ± 14 50% female Devices: Actiwatch-2 Fitbit Flex Jawbone UP Misfit Shine Study Duration = 1 week Outcomes: Total Sleep Time Wake After Sleep Onset Sleep Efficiency (TST/TIB*100) Day 1 Lab Free range walk Treadmill walk Survey 7 days Home Devices worn on same wrist for 7 consecutive days at home
Total Sleep Time Bland Altman Plots Solid line= mean Dashed line = 60 mins above/below mean
Subjective Sleep Assessments Pittsburgh Sleep Quality Index (PSQI) Retrospective measure of sleep quality over the past month Insomnia Severity Index 7-item measure of insomnia severity to detect clinical level of insomnia and measure treatment response PROMIS Sleep Disturbance and Sleep-Related Impairment Sleep Diary Prospective measure of sleep. Consensus sleep diary* has 9 core items: -Napping -Bedtime -Time attempt to sleep -Number of awakenings -Duration of awakenings -Final wake-up time -Rise time -Rating of sleep quality *Carney CE, Buysse DJ, Ancoli-Israel S, et al. The consensus sleep diary: standardizing prospective sleep self-monitoring. Sleep. 2012;35(2):287-302.
Sleep Terminology Sleep Efficiency Ratio of total time spent asleep (total sleep time) in an evening to the total amount of time spent in bed. A measure of sleep continuity. Sleep Efficiency = Total Sleep Time x 100 Time in Bed E.g., if an individual spends 8 hours in bed in a given evening, but only actually sleeps for 4 of those hours, his/her sleep efficiency for that evening would be 50% Wake After Sleep Onset Amount of time individual is awake during the night after sleep onset A measure of sleep disturbance
Sleep and Hospital Recovery
Sleep and Physical Function During Acute Hospitalization and Recovery* Participants: Older Adult Patients (N=27) Mean age = 74 ± 8 years Average Length of Stay = 3.9 days Admission Diagnosis - Cardiovascular 56% - Pulmonary 22% - Metabolic 13% Outcomes: Short Physical Performance Battery (SPPB) Pittsburgh Sleep Quality Index (PSQI) Actigraphy - Wake After Sleep Onset - Sleep Efficiency Hospital SPPB PSQI Actigraphy 30 days Home SPPB PSQI Actigraphy *Ancillary study to PACE study (Volpi, Deer)
Poorer Sleep Predicts Poorer Physical Function Recovery following Hospitalization
Sleep and Surgical Recovery
Participants: Women (N=16) Mean age = 41 ± 7.3 years Sleep and Pain Around Hysterectomy: Concurrent Oophorectomy = 65% no Hysterectomy Route - Total Laparoscopic 56% A Prospective Cohort Study - Robotic-Assisted Laparoscopic 25% - Vaginal 13 % - Robotic-Assisted Vaginal 6% Outcomes: PROMIS - Pain Intensity Pittsburgh Sleep Quality Index (PSQI) Actigraphy & Sleep Diary - Total Sleep Time - Wake After Sleep Onset Baseline 7 Days Pre-Surgery PROMIS - PI Sleep Diary Actigraphy Post-Surgery 7 days PROMIS - PI Sleep Diary Actigraphy
Preoperative Sleep Predicts Postoperative Pain Greater sleep duration following surgery across 24h (~+60 min nap) Greater nighttime sleep disturbance following surgery Pre-operative sleep duration predicts post-operative pain intensity Pre-operative sleep disturbance predicts post-operative pain intensity
Sleep and Menopause
Sleep and Inflammation R01HL105647, PI: Thurston Screening 304 peri/post women Age 40-60 nonsmoking Free of clinical CVD Sleep actigraphy (3 days) Physiologic hot flash monitoring (24 hrs) Blood draw
Sleep and Inflammation Lower Sleep Efficiency associated with Higher Interlekin-6 (IL-6) β =.13, p =.026 Lower Sleep Efficiency associated with Higher von Willebrand Factor (VWF) β =.19, p =.003 Higher WASO associated with Higher von Willebrand Factor β =.15, p =.012 Nowakowski S, Matthews KA, von Kanel R, Hall MM, Thurston RC Sleep. 2018;41(5):287-302. PMCID: PMC5946814
Cognitive Behavioral Therapy for Menopausal Insomnia (K23NR014008, PI: Nowakowski) Participants: Peri or Postmenopausal Women (N=40) Mean age = 55 ± 6.2 Insomnia Disorder (DSM-IV) 1 Nocturnal Hot Flash/Night Study Duration = 20 weeks Outcomes: Insomnia Severity Actigraphy & Sleep Diary - Wake After Sleep Onset - Sleep Efficiency Depression Week 1-2 Screen Survey PSG Week 3-10 S1 S2 S3 S4 Week Survey 11-12 PSG Follow- Up Month 1 Online Survey Follow- Up Month 3 Online Survey
What is Cognitive Behavioral Therapy (CBT) for Insomnia? Behaviors: A set of instructions for changing behaviors that are incongruent with good sleep or ability to cope with hot flashes Cognitions: Address thoughts related to sleep and hot flashes that interfere with good sleep increase hot flash bother Reduce suffering (hope, realistic expectation, acceptance)
CBTMI Components Technique Sleep restriction Stimulus control Cognitive therapy Sleep hygiene & Hot flash coping Relaxation training Aim Restrict time in bed to improve sleep depth & consolidation In bed only when asleep to strengthen bed/bedroom as sleep stimulus Address maladaptive beliefs about sleep & hot flashes Promote habits that help sleep & hot flashes eliminate bad habits & hot flash triggers Reduce physical/psychological arousal
Menopause Education Control (MEC) A single 50-minute session Introduced as self-help intervention Educational handouts Discuss menopausal symptoms & sleep hygiene
CBTMI - Results P <.001 Time x Treatment Arm Interaction P <.001 Time x Treatment Arm Interaction P =.019 P =.014 P =.003 * * * * Insomnia Severity Sleep Disturbance Depression
Improving Sleep Habits to Optimize Medical Rehabilitation
Theoretical Model Sleep & Health Injury/ Illness Hospitalization Genetic Predisposition Arousal/ Insomnia Injury/ Illness Hospitalization CBTI Poorer Rehabilitation New / Worsening Sleep Disturbances Enhanced Rehabilitation Treatment of Insomnia Impaired Functioning Sleep Fragmentation Improved Functioning SWS / REM Increase Daytime Sleepiness Hyperarousal Reduced Daytime Sleep Autonomic & Arousal Control SNS Activation & Inflammatory Response Reduced Inflammation Vicious Cycle of Poor Sleep & Poor Health Improved Sleep Promotes Health
Objective To examine the effects of cognitive behavioral therapy (CBT) for insomnia on sleep and functional outcomes in a randomized, placebo-controlled trial in orthopedic patients with insomnia undergoing rehab. CBT vs Control
SleepHab Research Strategy Screening Ineligible Eligible Participants: Older patients admitted for hip or knee arthroplasty (N=124) Age = 55+ Insomnia Disorder (DSM-5) Referral & attendance of medical rehabilitation Refuse Consent to participate Hospital Bedside assessment & treatment Discharge & Rehabilitation Home assessment & randomization CBTI (4 home sessions) Control (4 home sessions) Post-treatment assessment Randomization: 1:1 Randomization Stratified by initial rehab setting - Inpatient - Skilled Nursing - Home Health - Outpatient 6-month assessment
Procedures CBT-I Assessment Hospital session Control 2 6 Blood draw
CBT-I Adapted for Physical Challenges Standard Practice Sleep restriction Stimulus control Napping/Daytime sleep Sleep hygiene education Cognitive therapy Modification Gradually restrict time in by 15-30 minutes each week until sleep efficiency 85% is reached Sit in bed or chair near bed doing sleeppromoting activity if unable to sleep during night Gradually reduce amount of time spent napping by 15-30 minutes each week Promote habits that help sleep and encourage physical and social activities Relaxation and mindfulness meditation
Health Education Control (HEC) Four 60-minute home sessions Educational handouts and discussion on health topics (NIH Age Page) Sleep Hygiene Education Credible & acceptable control for interventionist contact, homework assignments, and passage of time Both interventions described as health strategies to improve rehab to mask intervention To order free NIA Publications: https://order.nia.nih.gov
Sleep Outcomes Insomnia Severity Index (ISI) 7 item validated self-report scale to assess insomnia 10 = detect insomnia -8.4 point change score = moderate improvement Actigraphy (Actiwatch-2) Wake After Sleep Onset Sleep Efficiency Worn 1 week each assessment: hospital through post-discharge post-treatment 6-month follow up
Functional Outcomes Motor Function PROMIS Physical Function & Mobility NIH Toolbox Motor Tests StepWatch-4 Cognitive Function PROMIS Applied Cognitive Abilities NIH Toolbox Cognition Tests Functional Status Physical Self-Maintenance Scale ADLs Instrumental ADL Scale - IADLs
PROMIS Health Outcomes Pain Intensity Fatigue Depression Psychological Well-Being Social Satisfaction Ability to Participate Other Outcomes Rehabilitation Attendance Self-report via weekly text message or phone call Proinflammatory Cytokines Interleukin-6 (IL-6) C-reactive protein (CRP) von Willebrand factor antigen (VWF)
Questions? Feedback?
Collaborators: Acknowledgements Rachel Deer & Elena Volpi (PACE Study) Mostafa Borahay (Hysterectomy Study) Rachel Manber & Rebecca Thurston (Menopause Studies, K23 Co-Mentors) Timothy Reistetter, Rachel Deer, Zbigniew Gugala (SleepHab Study) NIH Grants: K23NR0140089 Nowakowski R01NR018342 Nowakowski UL1TR001439 UTMB Institute of Translational Science P30 AG024832 Claude D. Pepper OAIC