The Impact of Trauma on Sleep Quality: Examining the Role of Nightmares in Cognitive Impairment

Sleep and allergic disease: A summary of the literature and future directions for research

The impact of chronic hepatitis C infection on the circadian clock and sleep

Poor sleep quality, often resulting from poor sleep hygiene, is common among medical students. Educational interventions aimed at improving sleep knowledge are beneficial for sleep quality in healthy populations. However, sleep education is often given minimal attention in medical school curriculums. The aim of the study was to explore whether a short educational intervention could improve sleep knowledge, and consequently sleep quality, among medical students. We recruited preclinical- and clinical-stage medical students during the 2017-2018 academic year. Students completed a demographic survey, the Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale (ESS), and the Assessment of Sleep Knowledge in Medical Education (ASKME) questionnaire. Students then attended a lecture on the physiology and importance of sleep. To assess the efficacy of the intervention, questionnaires were repeated 4 months thereafter. A total of 87 students (31 preclinical) with a mean age of 25.86 years (standard deviation [SD], 3.33), 51 of whom were women, participated in the study. At baseline, students had poor sleep quality with a PSQI mean score of 5.9 (SD, 2.37), without significant sleepiness, and a mean ESS score of 8.86 (SD, 4.32). The mean ASKME scores were consistent with poor sleep knowledge at 11.87 (SD, 4.32). After the intervention, the mean ASKME results improved to 14.15 (SD, 4.5; P < .001), whereas sleep quality did not. The effect was similar in preclinical and clinical medical students. Sleep knowledge was inadequate among medical students, who also experienced poor sleep quality. A short educational intervention improved sleep knowledge but was insufficient at improving sleep quality. Further studies are needed to determine which interventions may provide benefit in both sleep knowledge and sleep quality.

The purpose of this study was to determine sleep quality and presence of sleep disorders in participants with spinal cord injury (SCI). A web-based survey, available online from February 2011 to July 2013, using validated sleep questionnaires, advertised via the internet and locally through SCI consumer organizations in the United States, Australia, New Zealand, and Canada, was designed to evaluate sleep in adults with self-reported SCI. Demographic characteristics and medical history were obtained from participant self-report. In our study population, 70% of the 304 participants were male with a mean age of 45 ± 13 years. The mean duration of injury was 16 ± 12 years. Cervical injuries were reported by 49% and thoracic injuries noted in 40% of participants. Increased sleep apnea risk was noted in 31% of participants, with 66% reporting snoring. Insomnia symptoms were reported by 54% of the respondents. Almost 40% of participants ranked their sleep quality as "fairly bad" to "very bad" in the previous month, 29% reported "often" or "almost always" waking up because of pain, and 22% had difficulty falling asleep because of leg cramps. In the past year, 27% of the respondents reported daily uncomfortable leg sensations and 28% found these leg symptoms to be "moderately to extremely distressing." This study increases the awareness that insomnia, sleep apnea, and poor sleep quality are common in individuals with chronic SCI; often coexisting. There is a need for increased screening for sleep problems by healthcare providers taking care of individuals living with SCI.

A large body of evidence has accumulated over the last five decades regarding the consequences of insufficient sleep duration and/or inadequate sleep quality (including sleep breathing disorders such as obstructive and central sleep apnea). It has been shown that insufficient sleep duration, sleep apnea, and insomnia are associated with a variety of adverse health outcomes.1 The negative effects of sleep disturbances may affect many aspects of human health by inducing metabolic, cardiovascular, immunological, and mental alterations. Furthermore, sleep duration has been found to be an independent risk factor for total mortality. A pioneering population-based study including 1 064 004 individuals, published more than 50 years ago, suggested that an increased mortality risk in men was associated with either short (6 hours or less) or long (9 hours or more) sleep duration.2 In particular, individuals who slept less than five hours per night had very high death rates, and this was also the case for who slept ten or more hours per night. A recent meta-analysis of 60 studies representing over 3 million participants showed a possible increase in cardiovascular mortality associated with either longer or shorter duration of sleep than 7 or 8 hours, thus providing an updated evidence in favor of a J-shaped relationship between sleep duration and mortality.3 It is also worth of mention that subjective poor sleep quality, assessed in 17 out of 60 studies, was independently associated with coronary heart disease but not with cardiovascular mortality and non-fatal stroke. A scientific statement released in 2016 by the American Heart Association, based on a comprehensive review of individual studies and their meta-analyses, highlighted the fact that sleep duration, mostly short sleep, and sleep disorders (insomnia symptoms, sleep-disordered breathing, periodic limb movement disorder, restless leg syndrome) are related to adverse cardiometabolic risk factors, such as obesity, metabolic syndrome, hypertension, type 2 diabetes mellitus, as well as to cardiovascular disease.4 The mechanisms underlying the association between sleep disturbances and unfavorable health consequences remain a topic of debate. Poor sleep quality has been shown to increase circulating levels of leptin and ghrelin, which in turn may promote insulin resistance and development of obesity. Increased plasma adrenaline, norepinephrine, and cortisol concentrations as well as low-grade inflammation and endothelial dysfunction have been associated with abnormal sleep patterns. A putative link between sleep disorders with heightened sympathetic nervous activity and/or reduced parasympathetic activity leading to sympathovagal imbalance and, ultimately, to cardiac autonomic dysfunction has been reported in different clinical settings.5, 6 Several epidemiological studies have shown significant associations between chronic insomnia, short sleep duration, poor sleep quality, and the risk of hypertension resulting from chronic sympathetic overactivity and/or arterial baroreflex dysfunction.7 A meta-analysis from 13 studies (6 cross-sectional studies and 7 prospective cohort studies) including a total of 347,759 participants (115,007 with hypertension) showed a U-shaped relationship between sleep duration and hypertension.8 In particular, the excess of hypertension risk associated with a short sleep period (ie, ≤5 hours) was 81% greater compared to the reference sleep time (ie, 7 hours) in cross-sectional studies and 31% greater in prospective cohort studies. Notably, the association between short sleep duration and hypertension was stronger in women than men. A more recent meta-analysis (comprising 54 studies and 1 074 207 subjects) targeted the relationship between six sleep parameters (ie, obstructive sleep apnea, oxygen desaturation index, sleep quality, short or long sleep duration, and snoring) and revealed that poor sleep quality but not sleep duration was a key risk factor for hypertension (OR = 1.38, 95% CI :1.082–1.760).9 In this issue of the Journal Oliveira-Silva and coworkers10 report the results of a cross-sectional study aimed at investigating the association between sleep quality with cardiac autonomic dysfunction, as assessed by the spectral analysis of heart rate (HR) and blood pressure (BP) variability, in a group of forty-seven treated essential hypertensive men. The study sample did not include patients with overt cardiovascular disease, subclinical target organ damage, grade II and III obesity, elderly, patients on treatment with insulin, beta-blockers, and non-dihydropyridine calcium channel antagonists. Sleep quality was investigated by the Pittsburgh Sleep Quality Index (PSQI). PSQI is a questionnaire examining seven sleep items: subjective sleep quality (a subjective feeling of satisfaction in daily sleep), sleep latency (time for transition from full wakefulness to sleep), habitual sleep efficiency (ratio of hours slept to total hours in bed), daytime dysfunction (trouble staying awake during social activities), sleep duration and use of sleep medication, and sleep disturbance (interruption of sleep). The global PSQI score ranges from 0 to 21, higher numbers reflecting worse sleep quality. A total of 24 out of 47 patients included in the study were identified as "poor sleepers" (PQSI score> 5); their demographic and clinical characteristics were not different from those of patients with preserved or good sleep quality.10 Furthermore, no differences were found in the number antihypertensive drugs (2/3 of patients in both groups were on monotherapy) as well as in the various classes of BP-lowering drugs, in particular diuretics. Cardiovascular parameters were assessed with the patients in sitting position by ten minutes recording of HR and beat-to-beat BP using photo-plethysmography. Autonomic modulation was then evaluated by the spectral analysis of HR and BP variability. Patients with poor sleep quality exhibited an impaired cardiac parasympathetic modulation (ie, lower HR high-frequency band) and reduced cardiac baroreflex sensitivity. In addition, correlation analyses showed that PSQI score was directly related to average HR and inversely related to HR high-frequency band, HR total variance, and cardiac baroreflex sensitivity. Some previous studies evaluating the effect of global sleep status on cardiac autonomic function, as assessed by HR variability and catecholamine levels, have been carried out in patients with cardiovascular disease (ie, acute myocardial infarction). In this critical setting, higher levels of adrenaline and norepinephrine, a significant increase in low-frequency power as well as low-frequency/high-frequency power ratio and reduced high-frequency power were found in 147 patients (61% men) with poor sleep quality as compared to their counterparts with good sleep quality (n = 156, 67% men).11 In clinical terms, sympathetic hyperactivity, associated with short-lasting poor sleep quality, resulted in increased prevalence of ventricular tachycardia in the following week after acute myocardial infarction. The findings provided by Oliveira-Silva et al. extend to the uncomplicated hypertension setting the view that poor sleep quality may adversely affect the sympathovagal balance and worsen the risk of cardiovascular complications in poor sleeper hypertensive patients. Some aspects and limits of this interesting study deserve to be commented on. Subjective and objective estimates of sleep (ie, actigraphy) are often discordant among subjects with sleep disorders who generally tend to under-report sleep time and over-report wake time at night. The PSQI is widely used by clinicians and researchers in order to assess several aspects of sleep as it has been validated in general population-based samples as well as in many different clinical settings. It cannot be ignored, however, that several studies have reported rather limited correlations between subjective evaluation of quality and duration of sleep and more-objective measures. For instance, an analysis of 669 participants in the CARDIA (Coronary Artery Risk Development in Young Adults) Sleep Study documented a moderate correlation (r = 0.45) between self-reported and objectively measured sleep duration based on wrist actigraphy, providing evidence of systematic errors and bias of subjective evaluations.12 Similar conclusions were reported in a large study aimed at comparing self-report sleep quality and actigraphy results in a cohort of 2,086 Hispanic Americans.13 Overall, the PSQI can be regarded as a good screening tool, but not a substitute for sleep disorder diagnoses based on a comprehensive clinical interview performed by skilled clinicians with the support of objective measurements; therefore, data obtained by this questionnaire should be considered with caution.14 The high prevalence of patients with poor sleep quality (ie, 51%) in the Oliveira-Sousa study was similar to that reported by Wang et al. in acute myocardial infarction 11 and raises the question of whether this sample reflects the real burden of sleep disturbances in the community. Data from the 2007 to 2008 National Health Nutrition Examination Survey (NHANES) targeting the prevalence of sleep symptoms have shown that long sleep latency, self-reported difficulty in falling asleep, sleep maintenance difficulties, and early morning awakenings were reported by more than 50% of the participants.15 This supports the concept that sleep disturbances involve a very large fraction of the general population and, consequently, conditions such as hypertension, obesity, diabetes could be even more exposed to the risk of poor quality sleep. Finally, differences in sleep between men and women have been reported in the literature in the last decades; unfortunately, the present study did not address the intriguing aspect of gender-based differences in the association between sleep disorders and cardiac autonomic dysfunction. In community-based studies, women have been shown to report shorter sleep duration, more frequently sleep symptoms, and higher rates of insomnia.16 Furthermore, the strength of association between short sleep duration/poor quality sleep and hypertension has been reported to be stronger in women than in men. In conclusion, the study by Oliveira-Souza and coworkers has the merit of raising the question about the relationship between sleep quality and cardiac autonomic function in the hypertension setting, suggesting that poor sleep quality is accompanied by substantial alterations of the sympathovagal modulation. Assessment of sleep quality, a point so far neglected, should be included in clinical practice and research, as it may contribute to a more comprehensive cardiovascular risk stratification of hypertensive patients as well as to the analysis of factors responsible for cardiac damage. It is evident that further larger studies, based on more accurate evaluation of sleep, are needed in order to more deeply explore the role of alterations of sleep quality on cardiovascular outcomes, as in the recent past it has been performed for the sleep apnea syndrome.17, 18 The authors report no conflicts of interest.

Background: Sleep disturbance is associated with multiple adverse cardiovascular-related health outcomes. Little is known about the relationship between psychological well-being, an independent modifiable risk factor for cardiovascular disease, and sleep disruptions. This study examines cross-sectional and longitudinal associations of optimism with sleep duration and quality. Methods: Data were collected from 3,549 Black and White adults aged 33-45 years who participated in the Coronary Artery Risk Development in Young Adults (CARDIA) study during follow-up years 15 (2000-2001) and 20 (2005-2006). Optimism was assessed in 2000-2001 using the Life-Orientation Test—Revised, with possible scores ranging from 6 (least optimistic) to 30 (most optimistic). Single-item questions on sleep quality and duration in the past month were assessed during 2000-2001 and 2005-2006. Cross-sectional analyses considered optimism and sleep measures at follow-up year 15. Longitudinal analyses considered 5-year incidence of poor sleep quality (fairly/very bad) and duration (short/long sleep) in 2005-2006 by optimism in 2000-2001 (participants with poor sleep quality and duration in 2000-2001 were excluded). Results: Among 3,549 participants (56% female, 46% Black) with complete data on optimism in 2000-2001, 15.9% reported fairly/very bad sleep quality. Sleep duration was distributed as follows: short-sleep (47.9%), sufficient sleep (31.6%), and long-sleep (20.5%). In unadjusted and fully adjusted models, a 1-unit higher optimism score was cross-sectionally associated with 11% lower odds of having fairly/very bad sleep quality and 3-5% lower odds of having short-sleep duration (Table 1). Cross-sectional associations were attenuated after adjustment for depressive symptoms (not shown). Incidence of poor sleep quality in 2005-2006 was 7% lower with each unit higher optimism score, after full adjustment. Conclusion: Optimism is associated with lower incidence of poor self-reported sleep quality over a 5-year period.

The impact of hospitalization on sleep in late-life is underexplored. The current study examined patterns of sleep quality before, during, and following hospitalization, investigated predictors of sleep quality patterns, and examined predictors of classification discordance between two suggested clinical cutoffs used to demarcate poor/good sleep. This study included older adults (n = 163; mean age 79.7 ± 6.9 years, 31% female) undergoing inpatient post-acute rehabilitation. Upon admission to inpatient post-acute rehabilitation, patients completed the Pittsburgh Sleep Quality Index (PSQI) retrospectively regarding their sleep prior to hospitalization. They subsequently completed the PSQI at discharge, and 3 months, 6 months, 9 months, and 1 year post discharge. Patient demographic and clinical characteristics (pain, depression, cognition, comorbidity) were collected upon admission. Using latent class analysis methods, older adults could be classified into (1) Consistently Good Sleepers and (2) Chronically Poor Sleepers based on patterns of self-reported sleep quality pre-illness, during, and up to 1 year following inpatient rehabilitation. This pattern was maintained regardless of the clinical cutoff employed (> 5 or > 8). Logistic regression analyses indicated that higher pain and depressive symptoms were consistently associated with an increased likelihood of being classified as a chronic poor sleeper. While there was substantial classification discordance based on clinical cutoff employed, no significant predictors of this discordance emerged. Clinicians should exercise caution in assessing sleep quality in inpatient settings. Alterations in the cutoffs employed may result in discordant clinical classifications of older adults. Pain and depression warrant detailed considerations when working with older adults on inpatient units when poor sleep is a concern.

Recent progress in understanding the lifelong effects of early childhood adversities has clarified the need for an organized strategy to identify and intervene with children, adolescents, and families who may be at risk for maladaptive responses. Trauma-informed care (TIC) in child health care operationalizes the biological evidence of toxic stress with the insights of attachment and resilience to enhance health care delivery to mitigate the effects of trauma. The resulting pediatric health care delivery strategy promotes and restores resilience in children and adolescents, partners with families to support relational health, and reduces secondary trauma among pediatric health care clinicians. This policy statement summarizes what policy makers, legislators, and health care organizations need to consider in terms of infrastructure, resources, and financial support to facilitate the integration of TIC principles into all pediatric points of care. The accompanying clinical report describes the elements of TIC in the direct care of children, adolescents, and families and covers the spectrum from prevention to treatment. The recommendations in this statement and the clinical report build on other American Academy of Pediatrics policies that address the needs of special populations (such as children and adolescents in foster or kinship care, in immigrant and refugee families, or in poor or homeless families) and are congruent with American Academy of Pediatrics policies and technical reports concerning the role of pediatric clinicians in the promotion of lifelong health.Over the past 2 decades, basic science has explained how cumulative adverse childhood experiences in the relative absence of safe, stable, nurturing relationships (SSNRs)1 alter neurohormonal stress responses, gene expression, telomere length, brain development, and immunity, enabling researchers to elucidate how the body biologically embeds childhood trauma. Recent studies of toxic stress support assertions that the origins of lifelong health are in early childhood and that chronic stress in childhood strongly predicts adult health status.2,3 In the context of expanding evidence, pediatricians and others involved in community-based early childhood systems need strategies to mitigate the damaging effects of early childhood trauma and to promote resilience in children and families. Trauma-informed care (TIC) offers an organizing principle for pediatric practice that improves awareness of the spectrum of trauma-related symptoms, promotes an emotionally safe environment of care, and provides specific interventions to mitigate the effects of trauma exposure.4,5 This policy statement presents recommendations for policy makers, legislators, and health care organizations for implementation of TIC into pediatric health systems. The accompanying clinical report6 presents best-practice guidance for TIC in the direct care of children and adolescents.TIC is defined by the National Child Traumatic Stress Network as medical care in which all parties involved assess, recognize, and respond to the effects of traumatic stress on children, caregivers, and health care providers. TIC also includes attention to secondary traumatic stress (STS), the emotional strain that results when an individual, whether a health care worker or parent, hears about or witnesses the traumatic experiences, past or present, of children.Every pediatric encounter presents opportunities to promote family resilience and relational health.7 Informed by research in infant mental health and neurodevelopment, early relational health refers to the establishment of foundational relationships during the first 3 years of life that are central to successful physiologic, emotional, and moral development of the young child.8 Relational health, in a more general sense, is applicable to all age groups, is dyadic, and includes the capacity of both the child and caregiver to enter into a safe, secure, nurturing relationship allowing both to thrive.1,9,10 Strong foundational relationships support resilience and buffer stress in children, so they can be considered primary prevention of stress-related disturbance. Trauma-informed practices also support relational health and family resilience as important protective factors for those who have been exposed to persistent adversity or potentially traumatic events (see Fig 1).Human neuroendocrine–immune networks respond to internal and external sensors that identify danger and safety by activating in dangerous circumstances and deactivating when danger has subsided.11 Toxic stress responses occur with prolonged activation of the neuroendocrine–immune system and dysregulation of homeostasis (or allostasis if multiple systems are involved)12 in the absence of buffering by SSNRs. Toxic stress responses can result in lifelong impairments in physical, mental, and relational health.13The concept of toxic stress adds an important physiologic basis to the study of attachment and our understanding of trauma. Trauma is defined as an event, series of events, or circumstances experienced by a person as physically or emotionally harmful that can have long-lasting adverse effects on the person’s functioning and well-being (emotional, physical, or spiritual).14 Attachment theory describes the deep and enduring relationship between a child and adult caregiver that ideally provides a secure base from which the child can develop and explore the world.15Resilience is the dynamic process of adaptation to or despite significant adversity by using protective factors and learned skills to manage stressful circumstances.16 Resilience may allow a person to experience tolerable rather than toxic stress in response to adversity. Some characteristics of resilient children include strong executive functions (self-control of attention and impulses) and a strong personal identity, often related to a cultural or faith tradition.17 However, most important to both resilience and relational health is the capacity for young children to form at least one stable, caring, and supportive relationship.9,18Almost half of American children, or 34 million younger than 18 years, have faced at least one potentially traumatic early childhood experience.19 More than 1 in 7 adults report exposure during childhood to 4 or more adverse childhood experiences such as abuse, neglect, or other household adversity,20 including intimate partner violence or parental incarceration. Certain populations are at higher risk for trauma exposure, both physical and emotional. In surveys, poverty or financial stress is the most commonly reported childhood adversity, second only to loss of a parent.21,22 Exposure to divorce, child maltreatment, sexual abuse, intimate partner violence, bullying, parental mental illness, parental substance use problems, and community violence are also common.21 Specific populations at high risk for trauma include children and adolescents who identify as LGBTQ, have developmental or behavioral problems,23–25 are in foster or kinship care, are incarcerated, are living in deep poverty, or are immigrants. Potentially traumatic environmental and community-level conditions include economic stress, school or community violence, adverse experiences during and after immigration, natural disasters, pandemics, and mass-casualty events such as shootings or bombings.Racism is a common cross-cutting risk factor. Racial, ethnic, or religious bigotry magnifies the risk inherent to other special populations.26 Experiences ranging from hate crimes, police profiling, bullying, or microaggressions to covert discrimination are traumatic events and may be internalized as trauma by those who are victims, indirectly or directly, of the events.27,28 Historical trauma refers to the collective, transgenerational emotional and psychological injury of specific ethnic, racial, or cultural groups and their descendants who have experienced major events of oppression such as genocide, forced displacement, or slavery.29,30 Originally applied to children of the Holocaust, the concept is now applied to American Indian and Alaskan native people, African American people, Mexican American people, Japanese American people, and other groups of people who have experienced mass trauma.30 Investigators link historical “soul wounding” to current health and behavioral disorders including substance use disorder, domestic violence, and suicide, particularly in Indigenous communities.29,31 Children separated from families during immigration and/or detained in group facilities overseen by the Office of Refugee Resettlement are a recent special population at severe risk for long-term sequelae resulting from forced family separation.32,33In November 2019, the Centers for Disease Control and Prevention reviewed the emerging literature linking early childhood adversity with adult illnesses20,34 and analyzed survey data from 25 states over 2 years.3,35 Researchers concluded that reducing exposure to early childhood trauma and mitigating posttrauma effects would generally and significantly reduce adult morbidity and mortality. Using logistic regression modeling, they estimated potential reductions in incidence from low for obesity (1.7%) to high for heavy drinking, chronic obstructive pulmonary disease, and depression (23.9%, 27.0%, and 44.1%, respectively). Recommendations included creating healthy communities, supporting SSNRs, and developing programs that apply primary (reducing exposure to childhood adversity) and secondary prevention (mitigating the effects of exposure) on the basis of principles of TIC.The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) presents a list of trauma-related disorders ranging from mild (adjustment disorder) to severe (posttraumatic stress disorder [PTSD]).36 Two additional categories, reactive attachment disorder and disinhibited social engagement disorder, are specific to young children (please see the DSM-5 for complete diagnostic criteria). This nosology can be expanded to describe other presentations common in pediatric health care settings: developmental trauma disorder (DTD), pediatric medical traumatic stress (PMTS), and STS, the last being most relevant for health care workers, family members, and caregivers.The diagnosis of PTSD, as outlined in the current DSM-5, does not adequately describe the variable presentations of trauma manifestations in children across developmental stages.37 Children with complex trauma histories often exhibit heterogeneous developmental symptoms as well as difficulties with intimate relationships and with regulation of attention and impulse control.38 DTD is a proposed new diagnostic category that incorporates these differences and attempts to better describe the disturbances that occur in multiple developmental domains.39 The omission of DTD in the DSM-5 has been controversial,40 and the search for a better nosology of trauma, including DTD, is ongoing.41PMTS refers to the distress that patients and family members experience during hospitalization for a perceived life-threatening diagnosis or while living with or caring for individuals with life-altering chronic conditions.42 PMTS is underrecognized and rarely addressed despite its high prevalence.43,44 Up to 80% of ill or injured children and their families may have traumatic stress reactions after a life-threatening illness, injury, or procedure.45 In some surveys, up to 20% of parents of children admitted to a PICU develop PTSD within a few months.45 The suffering of family members and caregivers is often not addressed because of existing structural and reimbursement obstacles for multigenerational care.Although research on PMTS (and on pediatric postintensive care syndrome)46,47 is ongoing, researchers in 1 study found that approximately 10% of children developed PTSD 3 to 5 months after major surgery, and 28% developed posttraumatic stress symptoms (PTSS) resulting in functional disability by parent report.48 PTSS can also occur after a severe injury or diagnosis of an illness such as cancer. In another family study, more than 10% of children had persistent functional impairment from PTSS at 6 weeks and 1 year after a potentially life-threatening injury or diagnosis, and 15% of mothers and 8% of fathers met criteria for PTSD at 1 year.49As described earlier, STS may occur in parents, other family members, and health care workers such as physicians, nurses, other hospital staff, first responders, and therapists. STS may have many of the same long-term effects on health that affect children exposed to trauma.50 Some health care workers may also develop disabling posttrauma symptoms that can interfere with quality of life both at work and home. Health care workers may have their own trauma histories that contribute to their reactions when exposed to the suffering of others. Nonclinical staff may also experience STS triggered by their own trauma histories, especially if the health care facility is located in an area with high adversity and nonclinical staff live in the vicinity.Preliminary evidence exists of a synergistic effect among STS, depression, and burnout in affected health care workers.51 STS in combination with burnout has been associated with a significant increase in the frequency of medical errors.52,53 Depression, anxiety, and suicide are greater risks for physicians than for the general population. In the United States, the rate of suicide among female physicians is 130% higher than among women who are not physicians; the rate for male physicians is 40% higher than for men who are not physicians.51 Burnout includes a spectrum of pathologic conditions that develop in the context of occupational stress and is almost twice as prevalent among physicians. The risk among nurses for burnout, depression, and STS is even higher. More than half of nurses reported suboptimal mental or physical health,54 approximately 35% reported a high degree of emotional exhaustion,55 and 18% reported depression in national surveys. Reports of posttraumatic stress among health care workers related to the coronavirus disease 2019 pandemic prompted worldwide concern for increased awareness and trauma-informed support for the mental health of all involved.56Core principles that can be helpful for policy development, outlined by the National Council on Behavioral Health (2019)57 are outlined in the following sections. Implementation of TIC at a practice level is described in detail in the accompanying clinical report.6The health care organization, workspace, and every encounter should be characterized by compassion, cultural humility, equity, collaboration, and safety for families and employees. An emotionally safe workplace includes acknowledgment of and particular attention to racial and gender discrimination, including implicit bias both in rendering care and workplace human relations. A review of health care settings from the viewpoints of patients, families, and staff can uncover practices, processes, or details in the environment that are potentially traumatizing.Hospital and health system leadership can annually review policies and procedures to ensure a safe work environment and setting to provide TIC, to reduce STS and burnout, and to promote sensitivity to the needs of trauma survivors.58 The alignment of financial and human capital resources to support an optimal health environment in all levels and locations of care is extremely important. Surveys designed to assess system readiness for implementation are available and can be adapted for pediatric health care settings.Surveillance and standardized screening to assess staff and patients for trauma exposure, symptoms, and strengths are important components of trauma-informed pediatric care. Universal screening, when implemented within the larger context of trauma-informed approaches and endorsed and supported by administrative leadership, reduces stigma and allows standardized responses such as time off or referral to an employee assistance program. Families and youth may be queried at the point of care, such as at the time of hospital admission. Formal screening should always be for the benefit of children and adolescents, avoid retraumatization, and identify protective as well as risk factors.59 More specific information about screening is included in the accompanying clinical report.6Involvement of families and youth in the development of TIC policies and practices, particularly regarding cultural, historical, and gender issues, is essential to building an environment of support and mutuality.14 Both formal and informal structures, such as Family Advisory Councils and family-centered rounds,60 create a cultural expectation of collaboration and enable the health care team to understand the strengths and vulnerabilities of individual families and of the populations served. When appropriate, tribal elders, traditional healers, and other faith community leaders can be included in developing individual care plans or institutional quality-improvement efforts. A whole-person, whole-family, whole-community perspective promotes improved awareness of how cultural backgrounds affect the perception of trauma, safety, and privacy.61,62TIC, from a public health perspective, includes primary, secondary, and tertiary prevention strategies. Primary prevention is a comprehensive approach that addresses social determinants of health (such as structural racism, poverty, and violence) that are often root causes of community trauma.63 Promotion of relational health and other resilience factors (such as strong executive function and self-efficacy) may be considered primary prevention.64 Following the fourth edition of Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, promotion of early childhood relational health is a core purpose of both pediatric primary care and early childhood education.65The National Child Traumatic Stress Network includes the promotion of child and family resilience, enhancement of protective factors, awareness of parent or caregiver trauma, and involvement of families in program development and evaluation as secondary prevention.66 Trauma-informed therapies (eg, trauma-focused cognitive behavioral therapy) for symptomatic children and youth are considered tertiary prevention. These therapies are especially important for high-risk populations as identified earlier.67–70 Attachment-based dyadic therapies, such as parent–child interaction therapy, may serve to prevent development of persistent traumatic stress symptoms in high-risk families71 and may be considered both secondary and tertiary prevention.Recruitment and pre-employment practices may help discern the capacity for empathy among prospective employees.72 Training and education of all administrators, clinicians, and staff, both clinical and nonclinical, can promote the appreciation of the lifelong effects of trauma on child and adolescent development and family resilience and the implementation of trauma-aware practices. Continuous quality-improvement programs translate new knowledge and skills about childhood trauma into supervision, training, and patient care.Prevention of STS requires specific training of all staff to raise awareness, promote resilience, and explore the interaction among STS, burnout, depression, substance use, and professional quality of life. Supportive supervision and peer mentoring offer opportunities for all employees to reflect on their own trauma histories and to promote compassion, nonjudgmental attitudes and collaboration.73Trauma-informed health care systems establish and support collaborative, interdisciplinary relationships among community and public health agencies that serve children and adolescents to coordinate care for children, adolescents, and families exposed to trauma. Schools,74 juvenile justice programs,75 mental health professionals,76 home visiting services, child welfare systems,76 and foster care agencies77 are natural partners for pediatric health organizations in promoting community resilience. Many have established TIC programs. Community early intervention programs can help prevent and mitigate adversity and often have the advantage of caring for young children in their natural environment as home visitors.78–80Federal agencies such as the Centers for Disease Control and Prevention can continue and expand research to improve understanding of the developmental effects of trauma and the efficacy of specific interventions for historically resilient populations. Urgently needed are successful strategies to interrupt the intergenerational transfer of family violence. Strategies are also crucial to blunt the impact of historical trauma in communities of color and in American Indian and Alaskan native populations in the United States.30 It is particularly important to identify the origins of and successfully mitigate community violence, including racism, misogyny, and religious, ethnic, and cultural bias.State-level resources can be directed to implementation, dissemination, and evaluation of trauma-informed community programs, such as interagency and multigenerational strategies for opioid dependency. One example of a state interagency, multigenerational treatment program is Ohio START (Sobriety, Treatment and Reducing Trauma).81 States could develop a communication infrastructure to facilitate data sharing, improve interdisciplinary/interagency cooperation, and engage community partners including foundations and academic institutions.Federal guidelines can require that state Medicaid programs ensure comprehensive coverage for all children and adolescents and pregnant mothers without regard for legal or immigration status and mandate that coverage include mental health and substance use disorder services. Financing that increases access to high-quality, comprehensive, coordinated, culturally competent health care for high-risk populations is a high priority. Federal and state regulations can require all insurers, including Medicaid and private health insurers, to include coverage for TIC elements, including surveillance, screening, diagnosis, counseling, case management, follow-up, community collaboration, mental health care, and home visiting.In large health systems, leadership can align its mission and financing with the core elements of trauma-informed systems.82 Supporting TIC includes payment for trauma-informed, integrated mental health services, care coordination, rigorous case management, and seamless referral networks for intensive treatment. Prevention of secondary trauma, including care of affected health care workers, should be built into the mission of the health system.Academic health centers train and educate the next generation of physicians, nurses, and ancillary health personnel and can promote the transformation to TIC in all health settings through education, research, and advocacy. Children’s hospitals and health systems can model mental health integration83 and trauma-informed practices throughout all service lines.84 Because children’s hospitals embrace population health management and community advocacy, they may serve as the anchor institution collaborating with community agencies to address social adversity at the neighborhood level while promoting TIC services.85 Together with community pediatric care systems, academic health centers and children’s hospitals can integrate core elements of education into workforce training for health care workers and community partners such as first responders, child welfare workers, teachers, and juvenile justice personnel.86,87Deborah L. Shropshire, MD, FAAP

Sleep and cognitive functioning are linked. Yet, how sleep hours and sleep quality shape day-to-day subjective cognition, including cognitive interference and memory lapses, remains unclear. This study examined the unique and joint associations of sleep hours and quality with daily cognitive interference and memory lapses, investigating age-related variations. Participants were 915 adults (aged 43-83) from the Midlife in the United States Study who completed 8 days' diaries. Multilevel models evaluated the unique and joint associations of sleep hours and sleep quality with cognitive interference and memory lapses focusing at the within-person level, beyond between-person associations. Age-stratified models explored potential differences across age groups. Poorer sleep quality was associated with increased next-day cognitive interference, controlling for sleep hours. Individuals with poorer sleep quality across the study period also experienced greater cognitive interference and more frequent memory lapses. The association between poorer sleep quality and heightened cognitive interference was mitigated both on days when sleep hours were longer than usual and among individuals with longer sleep hours than others in the sample. Age-stratified analyses demonstrated that longer daily and habitual sleep hours mitigated the adverse effects of poorer sleep quality on cognitive interference only in adults aged 60-67. Poor sleep hours and quality may impair daily cognition, yet extra sleep hours can mitigate the negative association of poor sleep quality on daily cognitive interference, especially among young-old adults. These findings highlight the nuanced interplay of sleep hours, sleep quality, and age in shaping daily cognition.

Introduction The association between sleep and cognitive functioning is well documented. However, less is known about the distinct roles of sleep duration and sleep quality in shaping day-to-day subjective cognitive experiences, such as rumination and memory lapses. Additionally, it remains unclear whether these two sleep dimensions interact—either compensating for one another or amplifying adverse effects. Understanding age-related variations in such interactions warrants attention, given age-linked shifts in sleep patterns and cognitive resilience. Methods Data were drawn from 964 adults (Mage=60.59, SDage=9.20) who took part in the MIDUS III main survey and an 8-day diary study. Each day, participants reported the previous night’s sleep duration and quality, followed by measures of rumination and memory lapses. Multilevel models examined both between-person (habitual) and within-person (daily fluctuation) effects of sleep duration and quality, as well as their interaction, on next-day cognition, adjusting for socio-demographics, physical health, and daily covariates. Results Independent of sleep duration, poorer sleep quality was linked to more frequent rumination, both at the between-person (B=-0.14, SE=0.02, p &amp;lt;.001) and within-person (B=-0.05, SE=0.01, p &amp;lt;.001) levels. In this model, shorter sleep duration predicted greater rumination only at the within-person level (B=-0.01, SE=0.004, p=.045). For memory lapses, poorer sleep quality was associated with more lapses at the between-person level (B=-0.37, IRR=0.69, SE=0.09, p &amp;lt;.001), while sleep duration had no independent relation. Longer sleep duration attenuated the negative association of poorer sleep quality with rumination both at the between-person (B=0.02, SE=0.01, p=.018) and within-person (B=0.02, SE=0.01, p=.007) levels. No significant interaction emerged for memory lapses. The compensatory effect of sleep duration on the sleep quality—rumination link was evident only among adults aged 60–67, but for adults aged 43-59, or 67-83. Conclusion Findings highlight the independent and joint roles of sleep duration and quality in daily subjective cognition. Longer sleep may help offset poor sleep quality’s detrimental cognitive effects, particularly in early old adulthood, offering insights for tailored interventions. Support (if any)

Creating Trauma-Informed Long-Term Care Organizations

Although food insecurity has been associated with poor sleep outcomes in young and middle-aged adults, few studies have examined this relationship in older adults. This study aimed to examine the relationship between food insecurity and sleep duration, quality, and disturbance among older adults in six low-income countries (LMICs). We analyzed nationally representative cross-sectional data from 33,460 adults (≥50 years) from the Study on global AGEing and adult health (SAGE). Food insecurity (FI) was assessed using two questions regarding the frequency of eating less and hunger caused by a lack of food. Sleep outcomes included self-reported sleep duration, sleep quality, and sleep disturbances (difficulty falling asleep, frequent sleep interruptions, and early awakening) assessed based on self-reports over two nights. Multivariable logistic regression was used to assess country-specific relationships between food insecurity and sleep outcomes, and random-effects models were used to estimate pooled associations. The prevalence of FI among older adults in the overall population was 16.2%. In pooled analyses, FI was significantly associated with long sleep duration ≥ 9 h (OR=1.58, 95% CI: 1.30 to 1.93; P=0.001). There were also significant pooled associations between FI and poor sleep quality (OR=1.34, 95% CI: 1.14 to 1.56; P < 0.001) and sleep disturbances (OR=1.44, 95% CI: 1.08 to 1.91; P = 0.014). In conclusion, the current study found that FI is adversely associated with sleep duration, quality and disturbances in older adults, with some heterogeneity by country. The findings suggest food policies and intervention programs are needed for vulnerable households.

목 적: 노인성 우울증에서의 수면장애와 인지기능 저하의 동반은 흔히 나타나는 증상이다. 본 연구의 목적은 지역 사회에 살고 있는 노인 우울증 환자에서 나타나는 수면장애와 인지기능 저하의 양상을 파악하고 수면장애가 인지기능 저하와의 상관관계를 살펴보는 것이다. 방 법: 본 연구의 대상자들은 지역사회에 거주하고 치매 등의 인지기능 장애를 가지고 있지 않으며 수면 및 기분, 인지기능에 영향을 주는 정신과 약물을 복용하고 있지 않은 282명의 65세 이상 노인으로 하였다. 우울증의 평가를 위해 노인성 우울척도(Geriatric depression Scale, GDS)를 평가하였으며 GDS 점수에 따라 10점 미만을 대조군으로 하였고 10점 이상 17점 미만을 경도 우울증군, 17점 이상을 중증도 우울증군으로 분류하였다. 모든 대상자들에게 1회의 야간수면다원검사를 시행하여 객관적인 수면지표를 얻었고 피츠버그 수면의 질 지수(PSQI)를 평가하여 주관적인 수면의 질을 평가하였으며 CERAD-K 신경심리검사를 통하여 인지기능을 평가하였다. 결 과: 연구 대상자들의 평균연령, 성별, 내과적 질환 여부는 세 군 간에 유의한 차이가 없었으나 교육 연한은 대조군에 비해 중증도 우울증군에서 유의하게 낮은 결과를 보였다(p=0.015). 수면다원검사와 피츠버그 수면의 질 지수를 통하여 얻어진 수면지표들 중 REM수면시간, 무호흡-저호흡 지수, 산소 탈포화 지수, PSQI 점수는 세 군 간에 유의한 차이가 있었다(모든 p<0.05). 신경인지기능검사 결과에서는 단어목록재인검사, 스트룹 색깔 및 단어검사, 벤톤 시각 기억 검사-A, 길 만들기 검사-B에서 세 군 간에 통계적으로 유의한 차이가 나타났다(모든 p<0.05). 우울증군에서의 수면장애와 인지기능 저하 간에 상호 인과 관계를 알아보기 위한 Pearson 상관분석과 단계적 다중선형회귀분석 결과 수면장애와 인지기능 저하 간에 상호 관련성은 없는 것으로 나타났다. 결 론: 본 연구에서 노인성 우울증 환자에서 나타나는 수면무호흡증을 제외한 수면장애는 인지기능 저하에 직접적인 영향을 미치지는 않는 것으로 나타났다. 이러한 결과는 노령화에 따른 수면장애 및 수면구조의 변화와 연령, 교육 수준 등의 영향으로 인한 것으로 보인다. 그러나 노인 인구에서의 수면장애의 높은 유병률과 잠재적으로 인지기능에 미칠 수 있는 부정적인 영향력을 고려할 때 후속 연구를 통한 노인성 우울증 환자에서의 수면장애와 인지기능 저하의 상호 관련성에 대한 논의가 요구된다. Objectives: Depression, sleep complaints and cognitive impairments are commonly observed in the elderly. Elderly subjects with depressive symptoms have been found to show both poor cognitive performances and sleep disturbances. However, the relationship between sleep complaints and cognitive dysfunction in elderly depression is not clear. The aim of this study is to identify the association between sleep disturbances and cognitive decline in late-life depression. Methods: A total of 282 elderly people who underwent nocturnal polysomnography in a sleep laboratory were enrolled in the study. The Korean version of the Neuropsychological Assessment Battery developed by the Consortium to Establish a Registry for Alzheimer's Disease (CERAD-K) was applied to evaluate cognitive function. Depressive symptoms were assessed with the geriatric depression scale (GDS) and subjective sleep quality was measured using the Pittsburg sleep quality index (PSQI). Results: The control group (<TEX>$GDS{\leq}9$</TEX>) when compared with mild (<TEX>$10{\leq}GDS{\leq}16$</TEX>) and severe (<TEX>$17{\leq}GDS$</TEX>) depression groups, had significantly different scores in the Trail making test part B (TMT-B), Benton visual retention test part A (BVRT-A), and Stroop color and word test (SCWT)(all tests p<0.05). The PSQI score, REM sleep duration, apnea-hypopnea index and oxygen desaturation index were significantly different across the three groups (all indices, p<0.05). A stepwise multiple regression model showed that educational level, age and GDS score were predictive for both TMT-B time (adjusted <TEX>$R^2$</TEX>=35.6%, p<0.001) and BVRT-A score (adjusted <TEX>$R^2$</TEX>=28.3%, p<0.001). SCWT score was predicted by educational level, age, apnea-hypopnea index (AHI) and GDS score (adjusted <TEX>$R^2$</TEX>=20.6%, p<0.001). Poor sleep quality and sleep structure alterations observed in depression did not have any significant effects on cognitive deterioration. Conclusion: Older adults with depressive symptoms showed mild sleep alterations and poor cognitive performances. However, we found no association between sleep disturbances (except sleep apnea) and cognitive difficulties in elderly subjects with depressive symptoms. It is possible that the impact of sleep disruptions on cognitive abilities was hindered by the confounding effect of age, education and depressive symptoms.

BackgroundQuality of life (QOL) is reduced in patients with atrial fibrillation (AF). However, data regarding the association between sleep quality, one of the major components of QOL, and AF are insufficient. This cross‐sectional study aimed to elucidate whether sleep quality is reduced in patients with AF.MethodsWe recruited 2054 consecutive outpatients (64 ± 10 years, 1089 men) who had regularly presented to 26 clinics affiliated with the Tamagawa Medical Association, Tokyo, Japan. The patients were divided into paroxysmal AF (PaAF), persistent or permanent AF (PeAF), and non‐AF groups. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). The global PSQI score was calculated according to the answer to each question, and poor sleep quality was defined as a global PSQI score ≥6 points. Logistic regression analysis was used to obtain odds ratio for poor sleep quality in the PaAF and PeAF groups, relative to the non‐AF group.ResultsThe PaAF group showed significantly increased odds ratio for poor sleep quality (1.49, 95% confidence interval 1.02–2.17), after adjusting for multiple potential confounders. In contrast, no significant odds ratio for poor sleep quality was observed in the PeAF group (1.09, 95% confidence interval 0.70–1.71). Among the PSQI components, poor subjective sleep quality and sleep disturbances were the main determinants of poor sleep quality in the PaAF group.ConclusionSleep quality was found to be reduced in patients with PaAF, and this may be attributed to poor subjective sleep quality and sleep disturbances.

Background: Research indicates that parental caregivers of children with chronic illnesses have reported sleep disturbance and poor sleep quality, possibly due to nighttime caregiving, frequent monitoring, disturbance of the child's sleep, and emotional distress. Among chronic illnesses, Acute Lymphoblastic Leukemia (ALL) is the most common pediatric cancer and the maintenance phase is the third and longest phase of treatment, often requiring caregivers to be vigilant advocates and care providers. However, despite the high prevalence of ALL and the attending demands of caregiving, knowledge of the impact of worry and child sleep disturbance on sleep quality among this specific population of caregivers is limited. Therefore, the aim of this informative pilot study was to describe overall subjective sleep quality and disturbance among caregivers of children in the maintenance phase of ALL, as well as to examine the relationship between subjective sleep quality, child sleep disturbance, and worry of caregivers in order to inform the literature and the development of future quantitative studies. The current study was part of a larger study which aimed to prospectively describe the impact of corticosteroids on sleep patterns and health-related quality of life of 128 children with ALL over a 28-day period in maintenance treatment. Method: At a single time point, 32 caregivers of children with ALL ages 3 to 12 receiving care at The Children's Hospital of Philadelphia (CHOP) and St. Christopher's Hospital for Children completed measures of demographic information, caregiver worry, and subjective sleep quality of the past month, as well as measures regarding the child's developmental history and sleep habits and disturbance of the past week. Results: Participants were 28 mothers and 4 fathers (75% married, 81.3% Caucasian, 12.5% Hispanic) ranging in age from 21 to 67 years old. No significant relationship was found between higher levels of caregiver subjective sleep quality, child sleep disturbance and caregiver worry. However, caregivers were nearly evenly divided between good and poor sleepers, as 43.8% were found to be poor sleepers and scored &gt;5 on the PSQI. Conclusions: Though limited, the findings provide a description of the subjective sleep quality and disturbance of this distinct caregiver population and highlight the need for further research and support of caregivers of children with pediatric illnesses, particularly sleep patterns, quality, and sources of sleep disturbance over time.