Association of sleep disturbances with geriatric age in atopic dermatitis patients

Abstract

To the Editor: Geriatric dermatology is an emerging field focused on the unique considerations of older adults with skin disease. Sleep disturbance (SD), polypharmacy, cognition, social support, and mobility should be considered while caring for all patients, especially geriatric patients. Atopic dermatitis (AD) is a chronic, pruritic skin disease associated with SD and fatigue in adults and children.1Li J.C. Fishbein A. Singam V. et al.Sleep disturbance and sleep-related impairment in adults with atopic dermatitis: a cross-sectional study.Dermatitis. 2018; 29: 270-277Crossref PubMed Scopus (56) Google Scholar The relationship of geriatric age with AD severity and SD remains poorly characterized. Therefore, we investigated the association of geriatric age with AD severity and SD. The study was approved by the institutional review board at Northwestern University. This was a cross-sectional, dermatology practice-based study of adults (aged ≥18 years) with AD diagnosed based on the Hanifin-Rajka criteria.2Hanifin J.M. Diagnostic features of atopic dermatitis.Acta Derm Venereol. 1980; 92: 44-47Google Scholar Patients seen at an eczema clinic at an academic medical center were serially recruited, and they completed self-administered electronic questionnaires prior to encounters between 2014 and 2019. AD severity was assessed using the patient-oriented eczema measure (POEM), eczema area and severity index, Scoring AD (SCORAD), SCORAD-itch, investigator global assessment, and patient global assessment. The frequency of SD due to eczema was assessed using POEM. The impact of itching on the activity of falling asleep was assessed using 5 dimensions (5D) of itch. Fatigue was assessed using the patient-reported outcome measurement information system (PROMIS)-global health. Difficulty sleeping, falling asleep, and staying asleep was assessed using PROMIS-SD. These tools were validated to assess AD severity and SD in AD patients.3Schwartzman G. Lei D. Yousaf M. et al.Validity and reliability of Patient-Reported Outcomes Measurement Information System Global Health scale in adults with atopic dermatitis.J Am Acad Dermatol. January 20, 2021; (https://doi.org/10.1016/j.jaad.2021.01.033)Abstract Full Text Full Text PDF Scopus (2) Google Scholar,4Lei D. Yousaf M. Janmohamed S.R. et al.Validation of four single-item patient-reported assessments of sleep in adult atopic dermatitis patients.Ann Allergy Asthma Immunol. 2020; 124: 261-266Abstract Full Text Full Text PDF PubMed Google Scholar Statistical analysis was performed using SAS 9.4.3 (SAS Institute). Multivariable logistic regression models assessed the associations of age (independent variable; ≥65 vs 18-64 years) with AD severity, SD, and fatigue (binary dependent variable), controlling for total POEM score, sex, and race. Adjusted odds ratio (aOR) and 95% CI were estimated. Geriatric age (≥65 years) was not associated with AD severity in the following assessments: eczema area and severity index: aOR, 1.47 (95% CI, 0.68-3.18); SCORAD: aOR, 1.10 (95% CI, 0.52-2.34); investigator global assessment: aOR, 1.87 (95% CI, 0.98-3.56); SCORAD-itch: aOR, 1.00 (95% CI, 0.55-1.81); patient global assessment: aOR, 0.80 (95% CI, 0.45-1.41); and POEM: aOR, 0.55 (95% CI, 0.29-1.06) (Table I). However, geriatric age was associated with increased number of nights of SD due to eczema (aOR, 2.14 [95% CI, 1.16-3.92]) as well as with delays in falling asleep and night-time awakenings due to itching (aOR, 1.88 [95% CI, 1.05-3.39]). Geriatric age was also associated with fatigue (aOR, 1.81 [95% CI, 1.05-3.09]), trouble sleeping (aOR, 1.98 [95% CI, 1.16-3.36]), and trouble staying asleep (aOR, 2.26 [95% CI, 1.32-3.89]) but not with difficulty falling asleep (aOR, 1.16 [95% CI, 0.66-2.03]) in AD patients (Table II).Table IAssociation between age and baseline AD severity in AD patients∗Multivariable logistic regression models were constructed using AD severity scales as the binary dependent variable. AD severity was defined as “Clear-Moderate” or “Severe.” Age (18-64 vs >65 years) was the independent variable. The covariables included sex and race (White/non-White).AD SeverityAge (y)Adjusted OR (95% CI)P18-64≥65EASI Clear-Moderate280 (86.7%)48 (82.8%)1.00 (ref) Severe43 (13.3%)10 (17.2%)1.47 (0.68-3.18).3269SCORAD Clear-Moderate271 (82.4%)49 (83.1%)1.00 (ref) Severe58 (17.6%)10 (16.9%)1.10 (0.52-2.34).7984IGA Clear-Moderate304 (82.8%)44 (73.3%)1.00 (ref) Severe63 (17.2%)16 (26.7%)1.87 (0.98-3.56).0576SCORAD-itch Clear-Moderate214 (64.7%)39 (66.1%)1.00 (ref) Severe117 (35.3%)20 (33.9%)1.00 (0.55-1.81).9938PtGA Clear-Moderate361 (71.1%)58 (76.3%)1.00 (ref) Severe147 (28.9%)18 (23.7%)0.80 (0.45-1.41).4378POEM Clear-Moderate386 (74.4%)58 (84.2%)1.00 (ref) Severe133 (25.6%)18 (15.8%)0.55 (0.29-1.06).0742AD, Atopic dermatitis; EASI, eczema area and severity index; IGA, investigator global assessment; OR; odds ratio; POEM, patient-oriented eczema measure; PtGA, patient global assessment; SCORAD, scoring AD.∗ Multivariable logistic regression models were constructed using AD severity scales as the binary dependent variable. AD severity was defined as “Clear-Moderate” or “Severe.” Age (18-64 vs >65 years) was the independent variable. The covariables included sex and race (White/non-White). Open table in a new tab Table IIAssociation between age and baseline sleep disturbances in AD patients∗Multivariable logistic regression models were constructed using sleep disturbance scales as the binary dependent variable, with each threshold for sleep disturbance tailored to each scale. Age (18-65 vs >65 years) was the independent variable. The covariables included patient-oriented eczema measure score, sex, and race (White/non-White).Sleep DisturbanceAge (y)Adjusted OR (95% CI)P18-64≥65No. of nights of sleep disturbance due to eczema in the past week <3407 (78.6%)55 (72.4%)1.00 (ref) 3-7111 (21.4%)21 (27.6%)2.14 (1.16-3.92).0142Rating of the impact of itching on delay in falling asleep and night-time awakenings in the past 2 weeks 1-2640 (71.0%)98 (69.0%)1.00 (ref) >3262 (29.0%)44 (31.0%)1.88 (1.05-1.39).0348Rating of fatigue in the past 7 days None-Mild482 (58.1%)74 (55.2%)1.00 (ref) Moderate-Very Severe348 (41.9%)60 (44.8%)1.81 (1.05-3.09).0313Trouble sleeping in the past 7 days Never-Rarely278 (52.7%)32 (40.5%)1.00 (ref) Sometimes-Always250 (47.3%)47 (59.5%)1.98 (1.16-3.36).0118Trouble staying asleep in the past 7 days Never-Rarely278 (52.7%)29 (36.7%)1.00 (ref) Sometimes-Always250 (47.3%)50 (63.3%)2.26 (1.32-3.89).0030Difficulty falling asleep in the last 7 days Never-Rarely357 (67.7%)54 (68.4%)1.00 (ref) Sometimes-Always170 (32.3%)25 (31.6%)1.16 (0.66-2.03).5996Patient-oriented eczema measure sleep question: Over the last week, on how many nights has your sleep been disturbed because of the eczema? (No days, 1-2 days, 3-4 days, 5-6 days, or every day).5D-Itch sleep question: Rate the impact of your itching on sleep over the last 2 weeks: [Never affects sleep (1), occasionally delays falling asleep (2), frequently delays falling asleep (3), delays falling asleep and occasionally wakes me up at night (4), or delays falling asleep and frequently wakes me up at night (5)].Patient-reported outcome measurement information system (PROMIS)-global health fatigue question: How would you rate your fatigue on average? [None (1), mild (2), moderate (3), severe (4), or very severe (5)].PROMIS-sleep disturbance trouble sleeping question: In the past 7 days, he/she had trouble sleeping: [Never (1), rarely (2), sometimes (3), often (4), or always (5)].PROMIS-sleep disturbance trouble staying asleep question: In the past 7 days, he/she had trouble staying asleep: [Never (1), rarely (2), sometimes (3), often (4), or always (5)].PROMIS-sleep disturbance difficulty falling asleep question: In the past 7 days, he/she had difficulty falling asleep: [Never (1), rarely (2), sometimes (3), often (4), or always (5)].AD, Atopic dermatitis.∗ Multivariable logistic regression models were constructed using sleep disturbance scales as the binary dependent variable, with each threshold for sleep disturbance tailored to each scale. Age (18-65 vs >65 years) was the independent variable. The covariables included patient-oriented eczema measure score, sex, and race (White/non-White). Open table in a new tab AD, Atopic dermatitis; EASI, eczema area and severity index; IGA, investigator global assessment; OR; odds ratio; POEM, patient-oriented eczema measure; PtGA, patient global assessment; SCORAD, scoring AD. Patient-oriented eczema measure sleep question: Over the last week, on how many nights has your sleep been disturbed because of the eczema? (No days, 1-2 days, 3-4 days, 5-6 days, or every day). 5D-Itch sleep question: Rate the impact of your itching on sleep over the last 2 weeks: [Never affects sleep (1), occasionally delays falling asleep (2), frequently delays falling asleep (3), delays falling asleep and occasionally wakes me up at night (4), or delays falling asleep and frequently wakes me up at night (5)]. Patient-reported outcome measurement information system (PROMIS)-global health fatigue question: How would you rate your fatigue on average? [None (1), mild (2), moderate (3), severe (4), or very severe (5)]. PROMIS-sleep disturbance trouble sleeping question: In the past 7 days, he/she had trouble sleeping: [Never (1), rarely (2), sometimes (3), often (4), or always (5)]. PROMIS-sleep disturbance trouble staying asleep question: In the past 7 days, he/she had trouble staying asleep: [Never (1), rarely (2), sometimes (3), often (4), or always (5)]. PROMIS-sleep disturbance difficulty falling asleep question: In the past 7 days, he/she had difficulty falling asleep: [Never (1), rarely (2), sometimes (3), often (4), or always (5)]. AD, Atopic dermatitis. The geriatric AD patients had more profound SD, particularly staying asleep and fatigue despite having AD severity similar to younger adult AD patients. This is 1 of the first studies to examine AD severity and SD in geriatric AD patients. The limitations include its cross-sectional design and the lack of data on cognitive impairment, a potential confounding variable. In general, the mechanisms of SD in AD patients include pruritus, scratching, circadian melatonin rhythm, and various environmental factors.5Chang Y.S. Chiang B.L. Sleep disorders and atopic dermatitis: a 2-way street?.J Allergy Clin Immunol. 2018; 142: 1033-1040Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar However, increased SD in geriatric AD patients appears to be independent of AD and itch severity. Future studies are needed to determine why geriatric AD patients have increased SD due to itching and AD. None disclosed.