Clinical Sleep Disturbance Research Articles

The moderating role of circadian gene polymorphisms in the relationship between sleep disturbance and circulating lymphocyte subsets in colorectal cancer patients

AimWe investigated the impact of sleep disturbance on immune status in colorectal cancer (CRC) patients with consideration of the moderating role of circadian clock gene polymorphisms. MethodsA prospective longitudinal study design was used to collect information regarding sleep disturbance. Blood samples for immunologic assays were obtained the day before the first (baseline) and last cycles of 5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX) chemotherapy. Clinical sleep disturbance was compared between the two-time points using the Pittsburgh Sleep Quality Index (PSQI) global score. We analysed single-nucleotide polymorphisms in rs2278749, rs3749474, rs2291738, rs17031614, and rs2287161. The dependent variables included changes in the percentages of CD4+, CD8+, CD19+, and CD16/56+ lymphocytes between the two-time points. The results were analysed using moderated regression analysis; the p-values were adjusted using the false discovery rate. ResultsAmong the 104 patients, no significant dyadic associations were observed between changes in lymphocyte percentages and the PSQI global score. However, the moderated regression analysis revealed five significant associations (rs2287161 with CD8+, rs2278749 and rs2291738 with CD19+, and rs17031614 with CD4+ and CD16/56+ lymphocytes). The inclusion of each interaction resulted in a significant increase (5.7–10.7%) in the variance explained by changes in lymphocyte percentage. ConclusionPatients with specific circadian gene allele types may be more susceptible to immune dysregulation when experiencing sleep disturbances. Considering that sleep disturbance is a modifiable factor that can impact immune regulation, it is essential to prioritise the management of sleep disturbances in CRC patients receiving FOLFOX chemotherapy.

Sleep disturbance associated with temporal lobe degeneration in frontotemporal dementia

AbstractBackgroundSleep abnormalities are increasingly recognized as markers and potential drivers of neurodegenerative proteinopathies. However, the sleep phenotype of less common dementias remains poorly characterised. In particular, clinical experience suggests that patients with focal temporal lobe degeneration in the frontotemporal dementia spectrum can experience sometimes striking sleep disruption. We recently had the opportunity to corroborate this clinical impression in a small series of representative patients participating in a larger cohort study.MethodsTo date, we have studied seven patients and three healthy age‐matched controls. The patients’ diagnoses comprise behavioural variant frontotemporal dementia associated with focal right temporal lobe atrophy (n = 3), semantic dementia associated with focal left temporal lobe atrophy (n = 2), young onset Alzheimer’s disease and logopenic aphasia (each n = 1). No participant had a past history of a clinical sleep disorder. Detailed data on sleep patterns, adapted standard sleep questionnaires (Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale), overnight oximetry and neuropsychological test scores (covering domains of executive function, emotion processing, memory, and auditory perceptual learning) pre‐/post‐overnight sleep were collected with the assistance of patients’ caregivers.ResultsTwo patients with right temporal lobe atrophy and one with left temporal lobe atrophy had marked sleep fragmentation, in one right temporal case accompanied by frequent sleep attacks, with increased overall time in bed and/or attempting to sleep. Epworth and Pittsburgh indices in these patients indicated significant daytime sleepiness and reduced sleep quality; none had evidence of significant sleep apnoea on overnight oximetry. Comparatively mild clinical sleep disturbances were reported in patients with other dementia diagnoses. However, there was evidence for reduced auditory perceptual learning benefit from overnight sleep relative to healthy older controls, particularly in the patients with underlying Alzheimer pathology.ConclusionsThese preliminary findings suggest that focal temporal lobe degeneration may be associated with clinically relevant sleep disruption, as part of the more pervasive derangement of homeostasis in these syndromes. Further work is indicated to define the hypnic phenotype in detail, with sleep electrophysiology and correlative behavioural, neuroimaging and laboratory data in larger patient cohorts.

Decreased cerebrospinal fluid orexin levels not associated with clinical sleep disturbance in Parkinson's disease: A retrospective study.

Patients with Parkinson's disease (PD) often suffer from sleep disturbances, including excessive daytime sleepiness (EDS) and rapid eye movement sleep behavior disorder (RBD). These symptoms are also experienced by patients with narcolepsy, which is characterized by orexin neuronal loss. In PD, a decrease in orexin neurons is observed pathologically, but the association between sleep disturbance in PD and cerebrospinal fluid (CSF) orexin levels is still unclear. This study aimed to clarify the role of orexin as a biomarker in patients with PD. CSF samples were obtained from a previous cohort study conducted between 2015 and 2020. We cross-sectionally and longitudinally examined the association between CSF orexin levels, sleep, and clinical characteristics. We analyzed 78 CSF samples from 58 patients with PD and 21 samples from controls. CSF orexin levels in patients with PD (median = 272.0 [interquartile range = 221.7-334.5] pg/mL) were lower than those in controls (352.2 [296.2-399.5] pg/mL, p = 0.007). There were no significant differences in CSF orexin levels according to EDS, RBD, or the use of dopamine agonists. Moreover, no significant correlation was observed between CSF orexin levels and clinical characteristics by multiple linear regression analysis. Furthermore, the longitudinal changes in orexin levels were also not correlated with clinical characteristics. This study showed decreased CSF orexin levels in patients with PD, but these levels did not show any correlation with any clinical characteristics. Our results suggest the limited efficacy of CSF orexin levels as a biomarker for PD, and that sleep disturbances may also be affected by dysfunction of the nervous system other than orexin, or by dopaminergic treatments in PD. Understanding the reciprocal role of orexin among other neurotransmitters may provide a better treatment strategy for sleep disturbance in patients with PD.

JS09.5.A Is Radiation Dose to Sleep-relevant Brain Structures Associated with Lower Sleep Quality in Adults with Primary Brain Tumors?

Abstract Background Sleep plays a central role in optimal brain health and daily functioning, and poor sleep is associated with impaired cognitive functioning and reduced quality of life. Despite improved precision of modern radiotherapy (RT) for brain tumors, radiation to healthy tissue, including brain structures relevant for sleep/wake regulation, is often inevitable. In the present study, we investigate whether radiation dose to sleep/wake-relevant brain structures is associated with poorer patient-reported sleep quality in primary brain tumor patients. Material and Methods Patients who had received RT for non-glioblastoma primary brain tumors between 2006 and 2016 were included. They completed the Pittsburg Sleep Quality Index (PSQI) and mean radiation doses to sleep/wake-relevant structures (i.e., brainstem, thalamus, hypothalamus, and the pituitary and pineal glands) were calculated based on planning CTs and contrast-enhanced MR-images. Mean radiation dose (Dmean) to brain structures were compared between patients with and without impaired sleep outcomes using bootstrapped independent t-tests. Differences with effect sizes (ES, Cohen’s d) exceeding ± 0.3 are reported. Results A total of 78 patients (glioma, grade 1-3 = 28; meningioma = 22, pituitary = 16, other = 12) were included. Median time since RT was 4.6 years (range = 8.4 years). Mean global PSQI score was 5.13 (SD = 3.1). No differences were observed between tumor types, F (3,74) = 0.37, η 2= .02. Clinical sleep disturbance (PSQI > 5) was reported by 37.2% (n=29). Compared with patients without sleep disturbance, those with sleep disturbance had received a higher radiation dose to the pituitary gland, Dmean = 26.11 Gy, SE = 2.59, versus 34.57 Gy, SE = 3.43, ES(d) = - 0.46, 95% CI [-0.93, 0.003]. Furthermore, compared with patients reporting normal sleep latency (SL), those with poor SL had received a higher radiation dose to the pituitary gland, Dmean = 24.55 Gy, SE = 3.71, versus 32.60 Gy, SE = 2.48, ES(d) = - 0.44, 95% CI [-0.90, 0.03], and the brain stem, Dmean = 15.32 Gy, SE = 2.71, versus 20.20 Gy, SE = 2.01, ES(d) = -3.44, 95% CI [-0.80, 0.12]. Finally, compared with patients with a high sleep efficiency (>85%), those with a low sleep efficiency had received a higher radiation dose to the thalamus, Dmean = 18.11 Gy, SE = 2.36, versus 24.55 Gy, SE = 4.43, ES(d) = -0.35, 95% CI [-0.83, 0.15], and the pineal gland, Dmean = 16.20 Gy, SE = 2.48, versus 23.10 Gy, SE = 4.25, ES(d) = -0.36, 95% CI [-0.85, 0.13]. Conclusion The prevalence of clinical sleep disturbances in patients with primary brain tumors was high (37%). Our results indicated that higher radiation doses to the pituitary gland, brain stem, thalamus, and pineal gland may be risk factors for poor sleep quality in patients with a primary brain tumor.

The moderating role of gender in the association between quality of social relationships and sleep

To determine whether the association between perceived social support or strain in close relationships and sleep outcomes varies by gender. Participants were selected from the Biomarker projects of either the MIDUS II or MIDUS Refresher study if they were in a married-or married-like relationship and shared a bed with their partner (N = 989). A subsample also participated in a seven-day sleep study (n = 282). Perceived social support and strain from partner, family, and friends were examined by self-report questionnaires. We used the Pittsburgh Sleep Quality Index, sleep daily diary, and actigraphy to measure both subjective and objective sleep. Social support and strain were both associated with sleep outcomes. Specifically, higher social support was associated with fewer daily reports of light sleep and feeling more rested in the morning, while higher social strain was associated with higher clinical sleep disturbance. For women, but not men, social support was significantly associated with lower daily sleep disturbance while perceived social strain was significantly associated with higher daily sleep disturbance, lighter sleep, feeling less rested in the morning, lower sleep efficiency, and longer sleep onset latency. Mainly among women, social support and strain are associated with an important transdiagnostic health outcome–sleep–which may have implications for a wide range of health disparities. Interpersonal stressors may increase health risks differently for women compared to men and one mechanism that may link social relationships to long-term health outcomes is sleep.

Dysregulated arousal as a pathway linking childhood neglect and clinical sleep disturbances in adulthood

BackgroundA history of childhood maltreatment has a well-established association with clinical sleep disturbances in adulthood, which is a transdiagnostic contributor to many chronic diseases. ObjectiveDetermine whether actigraphy-measured indices of dysregulated arousal during sleep explain associations between abuse or neglect in childhood and clinical sleep disturbances in adulthood. Participants and settingParticipants were 646 individuals, ages 25–83 (59.3% female) from the MIDUS II Biomarker, Refresher studies. MethodsParticipants completed the Childhood Trauma Questionnaire, wore an actigraph for seven days, and rated sleep quality using the Pittsburgh Sleep Quality Index (PSQI). ResultsBoth neglect (b = 0.66, SE = 0.33, p = .04) and abuse (b = 1.09, SE = 0.32, p < .001) were associated with clinical sleep disturbance. Actigraphy-measured sleep efficiency mediated the link between neglect and clinical sleep disturbances (ab = 0.33, SE = 0.12, 95%CI [0.12, 0.57]). However, no such link between abuse and clinical sleep disturbances was mediated by actigraphy-measured indices. Sleep onset latency did not mediate the link between neglect or abuse and sleep disturbance. Models covaried for other maltreatment, gender, and age. ConclusionsWhile the unique associations between abuse or neglect and clinical sleep disturbances were robust in this sample, only sleep efficiency emerged as a mediator linking maltreatment and clinical sleep disturbances. Critically, this mediation was specific to neglect. Abuse and neglect may lead to disease through distinct pathways. Moreover, potential dysregulation in arousal that leads to sleep inefficiency may be a specific pathway through which experiences of neglect in childhood contribute to chronic disease.

The persistence of sleep disturbance and its correlates in children with moderate to severe traumatic brain injury: A longitudinal study

ObjectivesThe primary aim was to examine whether sleep disturbances persist in children in the chronic stage of recovery from moderate or severe traumatic brain injury (TBI). The secondary aim was to examine whether memory difficulties and/or other previously identified factors relate to sleep disturbances in children with moderate to severe TBI. MethodsThis longitudinal study included 21 children with moderate to severe TBI, 8–18 years old, recruited from an urban tertiary paediatric specialised brain injury rehabilitation unit. Participants were seen 5 years and again 7 years post-injury, on average. Sleep disturbances were assessed with Sleep Disturbance Scale for Children (SDSC). Correlates that were considered included indicators of TBI severity, and questionnaires assessing everyday memory, fatigue, internalizing and externalizing behaviors and pain intensity. ResultsThe SDSC scores of children with moderate to severe TBI indicated greater disturbances in initiating and maintaining sleep, arousal, sleep-wake transition, and excessive somnolence relative to the norms, at follow-up. The mean SDSC scores and the number of participants with subclinical to clinical sleep disturbances on the SDSC remained unchanged from baseline to follow-up. At follow-up, the SDSC initiating and maintaining sleep, and excessive somnolence scales were associated with poorer everyday memory and greater fatigue. ConclusionsChildren with moderate to severe TBI experience ongoing sleep disturbances for years post-injury. Greater sleep disturbances are associated with worse functional outcomes. Further research into sleep disturbances and development of treatments is important, as it could improve the outcomes of children with TBI.

0926 Examining Sleep In Parents And Children With Behavioral Or Clinical Sleep Disturbances

Abstract Introduction Sleep problems, such as insomnia are frequently reported in children. These sleep disturbances have either a behavioral (e.g. difficulties initiating or maintaining sleep) or clinical etiology (e.g. autism, asthma and T1 diabetes). Unlike clinical populations, outcomes in parents of children with behavioral sleep problems are underexamined. This study aimed to examine sleep in parents and children with behavioral or clinical sleep disturbances. Methods 290 parents (parents Mage = 35.9±5.2y, children Mage = 4.1± 2.3y) were recruited. Child’s sleep was reported using Child’s sleep habits questionnaire (CSHQ). Parent sleep was assessed using Pittsburgh sleep quality index (PSQI), Pre-sleep arousal scale (PSAS), and Glasgow sleep effort scale (GSES). A demographic question on the nature of child’s sleep disturbance was used to categorize parents into a) behavioral (n=206) or b) clinical group (n=84). Results Overall, 71% of parents and 67% of children had clinically significant sleep disturbance (PSQI ≥ 5 and CSHQ ≥ 41 respectively). Significant associations were observed between CSHQ and a) PSQI (r=0.47, p&amp;lt;.001), b) GSES (r=0.21, p&amp;lt;.001), and c) PSAS (r=0.46, p&amp;lt;.001). Step-wise regression reported that CSHQ was the strongest predictor of PSQI, accounting for 22% variance in scores (p&amp;lt;.001), followed by PSAS (7%). Independent groups t-tests found no differences in parents’ sleep quality (p=.06) and pre-sleep arousal (p=.38) between clinical and behavioral groups. However, 47% of parents in the clinical group took longer than 30 minutes to fall asleep, as opposed to 30% of parents in behavioral group (t(289)=-2.39, p=.01). Conclusion Parents report having poor sleep irrespective of the nature of child’s sleep difficulties. It is possible that parents in the clinical group may underreport their sleep problems due to increased attention towards child’s symptoms and diagnosis. Nevertheless, if any sleep related issues occur in children, the impact on parental sleep should be considered during assessment. Support N/A

Walk to a better night of sleep: testing the relationship between physical activity and sleep

ObjectivesMany do not sleep well, particularly middle-aged and older adults. Physical activity (PA) shows promise for improving sleep; however, populations with clinical sleep disturbances have been a research focus. It remains unclear whether low-impact daily PA, like walking, can affect sleep in healthy adults. DesignThe current study was embedded within a 4-week randomized controlled trial to increase PA. SettingParticipants from the greater Boston area were recruited to participate in a 4-week walking intervention on a rolling basis between October 2015 and August 2016. ParticipantsFifty-nine participants (72% female) were enrolled in the study, with an average age of 49.43 (±8.40) years. InterventionThe 4-week intervention was aimed at increasing participants’ daily steps as the primary outcome. The current, supplementary study examined relationships between monthly and daily PA and sleep. MeasurementsSteps and active minutes were measured daily using a Fitbit Zip. Self-reports of sleep quality and duration were assessed daily, along with before and after the intervention. Results and conclusionsAveraged across the month, daily active minutes were positively related to sleep quality but not duration. Sex moderated this relationship; women who took more steps and were more active reported sleeping better than those less active. Within persons, on days that participants were more active than average, they reported better sleep quality and duration in both sexes. Results suggest that low-impact PA is positively related to sleep, more so in women than men. Findings also showed that PA plays a greater role in predicting sleep quality than duration.

Pediatric Obesity Education Educational Components

Pediatric Obesity Education Educational Components

The contribution of sleep quality and quantity to public health and work ability

We all need sleep, and appreciate the importance of good, sufficient sleep for our daily well-being and functioning at work and during leisure time. People with no sleep problems take good sleep for granted, but sleep deprivation and different sleep disturbances are prevalent, and continue to increase across populations. Despite the notable burden of poor sleep on health,1 studies published on sleep remain relatively scarce in general epidemiological and public health journals. Although clinical sleep disturbances have been actively examined in sleep medicine and experimental researchers have figured out the basic mechanisms underlying control of sleep and wakefulness, epidemiological research integrating sleep with social and public health is still quite young. We are increasingly more and more aware that sleep is also a social behaviour closely related to our social environment. The first study that reported a U-shaped association between sleep duration and mortality was published in 1964.2 It …

The role of beliefs and attitudes about sleep in seasonal and nonseasonal mood disorder, and nondepressed controls

BackgroundUnhelpful sleep-related cognitions play an important role in insomnia and major depressive disorder, but their role in seasonal affective disorder has not yet been explored. Therefore, the purpose of this study was to determine if individuals with seasonal affective disorder (SAD) have sleep-related cognitions similar to those with primary insomnia, and those with insomnia related to comorbid nonseasonal depression. MethodsParticipants (n=147) completed the Dysfunctional Beliefs and Attitudes about Sleep 16-item scale (DBAS-16) and the Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorder Version (SIGH-SAD), which assesses self reported sleep problems including early, middle, or late insomnia, and hypersomnia in the previous week. All participants were assessed in winter, and during an episode for those with a depressive disorder. ResultsIndividuals with SAD were more likely to report hypersomnia on the SIGH-SAD, as well as a combined presentation of hypersomnia and insomnia on the Pittsburgh Sleep Quality Index (PSQI). The SAD group reported DBAS-16 scores in the range associated with clinical sleep disturbance, and DBAS-16 scores were most strongly associated with reports of early insomnia, suggesting circadian misalignment. LimitationsLimitations include the self-report nature of the SIGH-SAD instrument on which insomnia and hypersomnia reports were based. ConclusionsFuture work could employ sleep- or chronobiological-focused interventions to improve clinical response in SAD.

Pediatric Periodic Limb Movement Disorder: Sleep Symptom and Polysomnographic Correlates Compared to Obstructive Sleep Apnea

Although periodic limb movements in sleep (PLMS) have been described in multiple pediatric publications, periodic limb movement disorder (PLMD) has not. The aims of this study were to describe the prevalence, sleep-related correlates, and polysomnographic correlates of PLMD in a large pediatric case series, and compare these to pediatric obstructive sleep apnea (OSA). All PLMD cases (defined by International Classification of Sleep Disorders, 2nd edition criteria + respiratory disturbance index [RDI] < 3) and OSA cases (defined by RDI ≥ 3 + PLMS < 5), from a single pediatric sleep practice, over a 2-year time span, were included. Chart, questionnaire, and polysomnographic data were compiled. Of 468 referred children, 66 PLMD cases were identified (14%). The PLMD cases, mean age 8.1 years (range 1-17), were clinically characterized by frequent sleep onset and maintenance problems, difficulty awakening, restless sleep, leg pain/discomfort at night, and parasomnias. Compared to 90 OSA children, those with PLMD had a history of significantly more sleep onset and maintenance problems, leg pain/discomfort at night, parasomnias, getting out of bed at night, and family history of restless legs syndrome. Polysomnographically, PLMD cases had more awakenings, stage 1 sleep, stage shifts, and spontaneous arousals. These data indicate that pediatric PLMD has important clinical and polysomnographic correlates. In addition, PLMD has many characteristics that are different from pediatric OSA, suggesting that PLMD is a distinct pediatric sleep disorder, of which clinicians should be aware.

Sleep Disruptions Among Returning Combat Veterans From Iraq and Afghanistan

Post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) are common injuries among returning combat veterans from the wars in Iraq and Afghanistan. Although these combat injuries have been associated with increased sleep disruption, little is known about the nature and specificity of sleep problems within these common injury categories. A retrospective chart review of 69 consecutive referrals to the Waiter Reed Army Medical Center sleep clinic was conducted. All cases were active duty soldiers who had recently returned from combat deployment in Iraq or Afghanistan. Data from polysomnographically (PSG) recorded sleep stages, sleepiness scales, and documented medical diagnoses were extracted from medical records. Sleep data were compared across diagnoses of PTSD, TBI, and other clinical conditions. As expected, clinical sleep disturbances, including rates of obstructive sleep apnea, excessive awakenings, daytime sleepiness, and hypoxia, were high for the sample as a whole. However, no differences across diagnostic groups were found. Differences were observed, however, on PSG measures of sleep quality, suggesting more frequent arousals from sleep among patients with PTSD and greater slow wave sleep among those with TBI. Except for REM latency, medication status had virtually no effect on sleep variables. Among recently redeployed combat veterans, clinically significant sleep disturbances and problems with sleep-disordered breathing are common but nonspecific findings across primary diagnoses of PTSD, TBI, major depression, and anxiety disorder, whereas more subtle differences in sleep architecture and arousals as measured by overnight PSG recordings were modestly, but significantly, effective at distinguishing among the diagnostic groups.

Sleep Disturbances In Hospitalized Hematopoietic Stem Cell Transplant (HSCT) Patients

Sleep disturbances are patient outcomes that are sensitive to oncology nursing care. These may lead to a variety of physical and psychological dysfunctions, such as insomnia, chronic pain, respiratory distress, obesity, and anxiety. While sleep disturbances have been studied previously in HSCT patients, these studies have not examined the acute phase of transplantation. Motivated by the ONS Putting Evidence into Practice (ONS-PEP) initiative, this study was designed to quantify the sleep disturbances present in the hospitalized stem cell transplant population, correlate disturbances with patient characteristics, and ascertain the patient's perceptions of the reasons behind the disturbances. We designed a prospective descriptive study of all adult HSCT patients admitted to the inpatient BMT unit for at least 14 days, with a planned accrual of 100 patients. Patients were approached on day 14 of hospitalization and asked to complete a questionnaire that included the widely-used and validated Insomnia Severity Index (ISI), demographics, and patient-perceived contributors to sleep disturbances. We calculated descriptive statistics for the ISI, and then used chi-square and Fisher's exact tests to examine the association between patient demographics and the severity of insomnia. We tabulated the frequency of patient perceived contributors to sleep disturbance. In this interim analysis, we report results for 33 patients. Seven patients were excluded because of a history of a sleep disorder. The mean score on the ISI was 11.27 (SD 5.46, range 0-21). 27.3% of patients reported no significant disturbance, 42.2% met criteria for threshold disturbance (scores of 8 -14) and 30.3% met criteria for clinical sleep disturbance (scores of 15-21). All women (100%) reported some degree of sleep disturbance, compared with only 60 percent of men (Fisher's exact p=.02). The most frequent reasons for sleep disturbance were frequent bathroom use (87.5%), staff interruptions for care (87.5%), and uncontrolled physical symptoms (50%). Sleep disturbances were common in the HSCT population, with a significant relationship to gender. We plan to use our findings to develop and test interventions to improve the quality of sleep in HSCT patients, with a goal to strengthen the evidence for sleep disturbance interventions recommended by the ONS-PEP initiative. Final analyses on accrued patients will be reported at the time of presentation.

Neurocognitive consequences of sleep deprivation.

Sleep deprivation is associated with considerable social, financial, and health-related costs, in large measure because it produces impaired cognitive performance due to increasing sleep propensity and instability of waking neurobehavioral functions. Cognitive functions particularly affected by sleep loss include psychomotor and cognitive speed, vigilant and executive attention, working memory, and higher cognitive abilities. Chronic sleep-restriction experiments--which model the kind of sleep loss experienced by many individuals with sleep fragmentation and premature sleep curtailment due to disorders and lifestyle--demonstrate that cognitive deficits accumulate to severe levels over time without full awareness by the affected individual. Functional neuroimaging has revealed that frequent and progressively longer cognitive lapses, which are a hallmark of sleep deprivation, involve distributed changes in brain regions including frontal and parietal control areas, secondary sensory processing areas, and thalamic areas. There are robust differences among individuals in the degree of their cognitive vulnerability to sleep loss that may involve differences in prefrontal and parietal cortices, and that may have a basis in genes regulating sleep homeostasis and circadian rhythms. Thus, cognitive deficits believed to be a function of the severity of clinical sleep disturbance may be a product of genetic alleles associated with differential cognitive vulnerability to sleep loss.

Diagnosis and management of restless legs syndrome in children

Recent published evidence suggests that restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) are common condition in children and adolescents. It is likely that if left untreated, RLS and PLMD may lead to adverse cardiovascular and neurocognitive consequences. However, the diagnosis of RLS and PLMD in children is challenging, particularly because children are relatively unable to describe typical RLS symptoms. The International Restless Legs Study Group has recently published consensus criteria for the diagnosis of RLS and PLMD in children. In addition to clinical description of RLS symptoms, supportive evidence including the presence of clinical sleep disturbances, documented periodic limb movements in sleep from overnight sleep study and family history of restless legs syndrome may be required. Few if any controlled studies have addressed the management of RLS and PLMD, which may involve both non-pharmacologic and pharmacologic approaches. In this context, the importance of avoidance of aggravating factors and good sleep hygiene cannot be overemphasized. Children with evidence of low-iron storage, i.e., low-serum ferritin and/or iron levels may likely benefit from iron therapy. While there is overall limited experience regarding the use of dopaminergic agents in children with RLS and PLMD, published reports suggesting efficacy of compounds such as levodopa, ropinirole, pramipexole and pergolide have emerged. Other medications including benzodiazepine, anti-convulsants, alpha-adrenergic and opioid medications have not been adequately studied in children. Children with RLS and PLMD should have regular follow-up visits to evaluate clinical improvement and to monitor adverse effects from the selected therapy. Based on aforementioned findings, it is clear that a substantial research effort is needed to evaluate the pathophysiology, clinical presentation, treatment modalities, and overall long-term outcome of children with RLS and PLMD.

Early manifestations of restless legs syndrome in childhood and adolescence

Objective To describe the symptomatology reported by a series of children and adolescents who at initial consultation did not meet full diagnostic criteria for pediatric restless legs syndrome (RLS) but subsequently did so over the course of clinical follow-up. Methods Retrospective assessment of all patients with pediatric RLS receiving ongoing care in a pediatric sleep/neurology practice at a large multispecialty clinic ( n = 50). Eighteen children and adolescents who met inclusion and exclusion criteria were identified by chart review. All but one had undergone polysomnography. Results Detailed sleep histories were available for 10 girls and 8 boys, all of whom presented initially with clinical sleep disturbance. Mean age at the initial sleep evaluation was 10.3 years and mean age at RLS diagnosis was 14.7 years. Detailed descriptions of the sensory RLS symptoms were recorded. Retrospective age of onset for chronic clinical sleep disturbance was a mean of 3.1 years, with 10 families reporting onset in infancy. Of the 18, 16 reported chronic sleep-onset problems and eight sleep-maintenance problems at the time of initial evaluation. Ten had a history of growing pains. Thirteen were found to have a family history of RLS. Eleven of 17 had periodic leg movements in sleep (PLMS) ⩾5 per hour. Comorbidities included parasomnias (7), attention-deficit/hyperactivity disorder (ADHD) (13), oppositional defiant disorder (ODD) (4), anxiety disorders (6), and depression (5). Serum ferritin levels of <50 ng/mL were found in 16 of 18. Conclusions In this group of 18 children and adolescents, clinical sleep disturbance preceded a diagnosis of definite RLS by an average of 11.6 years. Many had a diagnosis of periodic limb movement disorder (PLMD) or met research criteria for probable or possible RLS prior to meeting criteria for definite RLS. These findings suggest that some aspects of RLS can occur long before full diagnostic criteria are present. Comorbidities were common, with parasomnias, ADHD, ODD, anxiety, and depression each found in more than 20% of these cases. The 2003 National Institutes of Health (NIH) diagnostic criteria for pediatric RLS are supported by this work.

P.1.117 Morning light therapy as an augmenting strategy of antidepressant treatment

Unhelpful sleep-related cognitions play an important role in insomnia and major depressive disorder, but their role in seasonal affective disorder has not yet been explored. Therefore, the purpose of this study was to determine if individuals with seasonal affective disorder (SAD) have sleep-related cognitions similar to those with primary insomnia, and those with insomnia related to comorbid nonseasonal depression.Participants (n=147) completed the Dysfunctional Beliefs and Attitudes about Sleep 16-item scale (DBAS-16) and the Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorder Version (SIGH-SAD), which assesses self reported sleep problems including early, middle, or late insomnia, and hypersomnia in the previous week. All participants were assessed in winter, and during an episode for those with a depressive disorder.Individuals with SAD were more likely to report hypersomnia on the SIGH-SAD, as well as a combined presentation of hypersomnia and insomnia on the Pittsburgh Sleep Quality Index (PSQI). The SAD group reported DBAS-16 scores in the range associated with clinical sleep disturbance, and DBAS-16 scores were most strongly associated with reports of early insomnia, suggesting circadian misalignment.Limitations include the self-report nature of the SIGH-SAD instrument on which insomnia and hypersomnia reports were based.Future work could employ sleep- or chronobiological-focused interventions to improve clinical response in SAD.

Are periodic leg movements associated with clinical sleep disturbance?

We examined 67 patients with periodic leg movement (PLM) disorder who were seen in a university-based sleep center. The most common reasons for coming to the sleep center were insomnia, sleepiness and a request for an evaluation for possible sleep apnea. There was a significant positive correlation between PLM arousal index and age but no association with gender. Approximately one-quarter of patients were under age 30. The multiple sleep latency test (MSLT) revealed borderline normal wakefulness in the group as a whole (sleep latency of 10.2 +/- 0.9 minutes), and there was no significant correlation between the PLM arousal index and either the MSLT mean sleep latency or a measure of subjective sleepiness. Similarly, the PLM arousal index did not differentiate those who entered with chief complaints of insomnia or sleepiness. There was no significant difference in the PLM arousal index in those who reported that they did or did not awaken refreshed in the morning. In summary, in this clinical population we found no significant association between the PLM arousal index and the subjective complaint of disturbed sleep, an objective measure of daytime sleepiness or a sense of awakening refreshed in the morning. Other interesting observations included the relatively high frequency of a PLM index > 5 in patients under 30 years old and a relatively high rate of past treatment for depression.