Daytime Problems Research Articles

The effect of iron deficiency on quality of life outcomes after surgery for obstructive sleep apnoea.

This study aimed to assess the effect of iron deficiency on parent-reported changes in quality of life (QOL) among children receiving an adenotonsillectomy for paediatric obstructive sleep apnoea (OSA). This was a retrospective review study that recruited children under 16 years of age undergoing an adenotonsillectomy, adenoidectomy, or tonsillectomy for clinically diagnosed paediatric OSA between June 2020 and January 2021 inclusive, in Western Australia. The main outcome measures for this study were changes in QOL by age group and iron status, defined by an absolute change of more than 3 points on OSA-18 survey domains. About 249 participants had iron studies performed on perioperative blood samples drawn at operation and completed both pre-operative and post-operative OSA-18 QOL questionnaires at initial consultation and 8-12 weeks post-surgery, respectively. 41.8% were iron deficient, 53.8% were borderline iron deficient and 4.4% had normal iron levels. Following surgery, a decrease was observed for all OSA-18 score domains in post-operation scores compared to pre-operation scores in both iron-deficient and borderline iron-deficient cohorts. 'Daytime Problems' in the <2 years group, within the iron-deficient cohort, was the only domain that found to be non-superior (i.e. 'not better') following surgery. Following adenotonsillectomy, patients with paediatric OSA reported significant improvements in QOL regardless of their iron status. Those undergoing an adenotonsillectomy for paediatric OSA had a high prevalence of iron deficiency at operation, especially those under 6 years of age.

Sleep and daytime problems during the COVID-19 pandemic and effects of coronavirus infection, confinement and financial suffering: a multinational survey using a harmonised questionnaire

ObjectivesSleep is important for human health and well-being. No previous study has assessed whether the COVID-19 pandemic impacts sleep and daytime function across the globe.MethodsThis large-scale international survey used a...

Sleep Problems—Autism Toolkit

Sleep Problems—Autism Toolkit

Predicting the outcome after adenoidectomy-alone for adenoid hypertrophy causing sleep disordered breathing.

By using preoperative parameters age, body mass index, nasopharyngeal obstruction as assessed using flexible videonasopharyngoscopy, and quality of life scores in patients undergoing adenoidectomy-alone because of adenoid hypertrophy causing sleep disordered breathing, we aimed to examine the relationship between the change in quality of life scores, and preoperative parameters and to develop a tool to predict the change. Patients who were scheduled for adenoidectomy-alone in a 12-month period were included. Flexible videnonasopharyngoscopy of the nasopharynx was performed. Nasopharyngeal obstruction was measured by using Image J software. Preoperative quality of life was evaluated using OSA-18 quality of life survey. OSA-18 survey has 5 subcategories consisting of sleep disturbance (O1), physical suffering (O2), emotional distress (O3), daytime problems (O4), caregiver concerns (O5). A question about the overall quality of life(O6) was added. Postoperative OSA-18 domain scores were obtained at the 3-month-follow-up. Preoperative OSA-18 subscores were compared to postoperative subscores. Linear regression analysis to predict the proportional change in OSA-18 subscores was performed. Our study group consisted of 94 cases. Mean postoperative O1, O2,O3, O4 and O5 scores were significantly lower compared to the preoperative scores. Mean postoperative O6 score was significantly higher. Linear regression analysis was carried out for predicting change in O1(r2=0.686; p=0.006), O5(r2=0.711; p=0.003) and O6(r2=0.757; p=0.001). Change in quality of life scores for sleep disturbance, physical suffering and general quality of life may be predicted by using preoperative parameters.

0993 Impact Of Changing School Start Times On Parent Sleep

Abstract Introduction No studies have previously considered how healthy school start times impact parents. Since parent and child sleep schedules, in particular wake time, are associated, we examined whether changing school start times would impact parent sleep (elementary school [ES] 9:00am to 8:00am, middle school [MS] 8:00am to 8:50am, high school [HS] 7:10am to 8:20am). Methods Parents of students (grades K-12) completed online surveys pre-change, one-year, and two-years post-change (2017 n=11,579; 2018 n=8,884; 2019 n=8,796), reporting weekday bedtime and wake time (sleep duration calculated bedtime to wake time). Four PROMIS sleep questions asked about sleep “quality”, feeling “alert” upon waking, feeling “tired” during the day, and “daytime problems” because of sleep. Finally, parents were asked one-year post-change how happy they were about the new school start times. Results Parents with only ES students reported earlier bedtimes and wake times (10 and 13 minutes). Parents with &amp;gt;1 HS student woke later (HS only: 22 minutes; MS and HS: 25 minutes; ES and HS: 10 minutes; all 3 levels: 14 minutes) and slept longer (HS only: 19 minutes; MS and HS: 21 minutes; ES and HS: 12 minutes; all 3 levels: 18 minutes), with changes maintained two years. Similarly, parents of only ES students reported no change in sleep quality/impairment. Post-change, more parents with &amp;gt;1 MS or HS student reported good sleep quality (average increase=6.9%), feeling alert (average increase=5.8%), not feeling tired (average increase=5.0%), and having few daytime problems (average increase=4.2%), with benefits maintained two-years post-change. Across levels, parents who were “very happy” about start time changes slept longer than “very unhappy” parents (12-30 minutes); however, across levels, child sleep did not differ between happy and unhappy parents. Conclusion This is the first study to examine the impact of changing start times on parents of students in grades K-12. Study results show no significant impact on parents of elementary students. However, similar to students, parents of middle/high school students reported later wake times and increased sleep duration. Notably, parents’ happiness with start time changes was related to parent, but not student, sleep duration. Support Robert Wood Johnson Foundation’s Evidence for Action Grant

Waking to use technology at night, and associations with driving and work outcomes: a screenshot of Australian adults.

The use of smartphones/electronic devices and their relationship with outcomes are understudied in adult populations. We determined daytime functional correlates of using technology during the night in a population sample of Australian adults. A cross-sectional, national online survey of sleep health was conducted in 2019 (n = 1984, 18-90 years). Nocturnal technology use was assessed with: "In the past seven days, how often did you wake or were woken to send or receive text messages, emails or other electronic communications?" Waking to use technology during all/most nights was reported by 4.9%, with 13.8% reporting two to three nights per week, and 12.7% reporting just one night per week. Technology users were more likely to be younger, employed, experience financial stress, and speak English as a second language. In adjusted analyses, compared to no use, technology use at least two to three nights per week was significantly associated with daytime problems (sleepiness, fatigue and impaired mood, motivation, and attention) and was more evident in participants not reporting/perceiving a sleep problem. Technology use was independently associated with at least one drowsy driving-related motor vehicle accidents/near miss per month (odds ratio [OR] = 6.4, 95% CI = 3.8 to 10.7) and with missing work (OR = 4.8, 95% CI: 3.2 to 7.2) and making errors at work (OR = 2.2, 95% CI = 1.5 to 3.3) at least 1 day in the past 3 months due to sleepiness/sleep problem. These associations were not significantly modified by age. Public health implications of waking to engage with electronic devices at night may be significant in terms of safety, productivity, and well-being. Limiting sleep-disrupting technology use will require innovative language-diverse strategies targeted broadly across age groups.

DOZ047.107: Increased quality of life burden related to obstructive sleep apnea in children with aerodigestive disease

Abstract Objective The aim of this study was to determine the impact of sleep-disordered breathing on quality of life (QOL) in children with aerodigestive disease compared to children without aerodigestive disease. Methods Retrospective, IRB-approved, single-institution review of OSA-18 survey results administered to an unselected population of pediatric otolaryngology patients, some of whom had also been seen in the multidisciplinary aerodigestive clinic, was carried out. Results 476 non-aerodigestive patients and 43 aerodigestive patients were compared using total OSA-18 score and the summed scores from the 5 domains that comprise the OSA-18: (1) sleep disturbance, (2) physical suffering, (3) emotional distress, (4) daytime problems, and (5) caregiver concern. Sleep-related QOL was significantly worse for children with aerodigestive disease compared to those without aerodigestive disease across domains of sleep disturbance (P = 0.011), physical suffering (P = 0.028), and caregiver concern (P = 0.016). Total OSA-18 scores were in the mild impact range, and they did not differ significantly between the two populations. Conclusion While the focus of many aerodigestive programs is on the pathophysiological relationship between the upper digestive tract, the laryngotracheal airway, and the lungs, the present study elucidates a significant impact of upper airway obstruction during sleep on the QOL of children with aerodigestive disease. In recognition of this impact, certain airway centers have added a multidisciplinary approach to upper airway obstruction to their aerodigestive treatment armamentarium. At the minimum, airway treatment centers should consider systematic screening of all children with aerodigestive disease for QOL burden related to OSA.

Using Parental Report to Identify Children at Risk for Poor Sleep and Daytime Problems

ABSTRACT Objective To examine objective sleep patterns and the daytime behavioral, emotional and academic functioning of school-age children above and below the clinical cutoff score for the Child Sleep Habits Questionnaire (CSHQ), which is a parental-report-based measure of sleep disturbances. Participants 48 boys and 74 girls aged 7–11 years. Methods Participants’ sleep was assessed in their home environment using a miniature actigraph (AW-64 series; Mini-Mitter, Sunriver, OR, USA) for five consecutive weeknights. The parents provided their child’s report card and completed a battery of questionnaires that included the CSHQ, the Child Behavior Checklist, a demographic questionnaire and a health questionnaire. Results Children that were above the cutoff score of the CSHQ had later objectively measured sleep schedule, were less likely to obtain the recommended amount of sleep for their age, had higher levels of internalizing and externalizing symptoms and a higher prevalence of clinical levels of externalizing and internalizing problems, had lower grades in English and French as a Second Language, and were more likely to fail these subjects. Discriminant analysis revealed that information from the objective sleep and emotional/behavioral and academic measures could significantly discriminate between those with or without parent-reported sleep disturbance. Conclusion Parental reports of sleep disturbances can be used to identify children at increased risk for sleep, emotional, behavioral and academic problems. Such questionnaires should be incorporated into clinical practice and school-based evaluations with the goal of identifying undiagnosed children who might be at risk for poor adjustment related to night- and daytime difficulties.

Variations in Genes Related to Sleep Patterns in Children With Autism Spectrum Disorder.

Sleep disturbance is a frequent comorbidity in children with autism spectrum disorder (ASD), affecting an estimated 40-80% of cases. Previous reports have shown relationships between several circadian rhythm-related genes and sleep problems in ASD. The purpose of the present study was to relate variation in and around melatonin synthesis and suprachiasmatic nucleus genes to sleep problems in a large sample of children with ASD. This secondary analysis used existing genotypic and phenotypic data for 2,065 children, aged 4-18 years, from the Simons Simplex Collection (SSC). Sleep problems were measured with the SSC Sleep Interview. Expression quantitative trait loci and single nucleotide polymorphisms in 25 circadian genes were chosen primarily for their impact on expression levels of target genes in the brain. Associations between variants and composite sleep problems, nighttime problems, daytime problems, and sleep duration problems were calculated using logistic regression analysis. Age, sex, nonverbal IQ, ASD severity, gastrointestinal distress, seizures, and ancestry were included as covariates. Transmission disequilibrium tests were performed to test for overtransmission of alleles in the same variants. No significant associations or transmission disequilibrium were found between gene variants and sleep problems in this sample of children with ASD. Variation in expression of investigated genes in the melatonin synthesis and suprachiasmatic nucleus pathways did not have notable impacts on sleep problems in this large sample of children with ASD. Future research could explore translational and posttranslational effects of these genes or the effects of genes in other sleep-homeostasis pathways on sleep patterns.

Toxoplasma gondii IgG associations with sleep-wake problems, sleep duration and timing.

Background:Evidence links Toxoplasmagondii (T. gondii), a neurotropic parasite, with schizophrenia, mood disorders and suicidal behavior, all of which are associated and exacerbated by disrupted sleep. Moreover, low-grade immune activation and dopaminergic overstimulation, which are consequences of T. gondii infection, could alter sleep patterns and duration.Methods:Sleep data on 833 Amish participants [mean age (SD) = 44.28 (16.99) years; 59.06% women] were obtained via self-reported questionnaires that assessed sleep problems, duration and timing. T. gondii IgG was measured with ELISA. Data were analyzed using multivariable logistic regressions and linear mixed models, with adjustment for age, sex and family structure.Results:T. gondii seropositives reported less sleep problems (p < 0.005) and less daytime problems due to poor sleep (p < 0.005). Higher T. gondii titers were associated with longer sleep duration (p < 0.05), earlier bedtime (p< 0.005) earlier mid-sleep time (p < 0.05).Conclusions:It seems unlikely that sleep mediates the previously reported associations between T. gondii and mental illness. Future longitudinal studies with objective measures are necessary to replicate our findings.

Quality of Life and Behavioural Assessment in Post-adenotonsillectomy Cases of Paediatric Age Group.

Adenotonsillectomy is a widely practiced surgical intervention to manage obstructive sleep apnoea syndrome (OSAS) in the paediatric age group. We conducted a prospective, non randomised, interventional study among 40 patients in paediatric age group (2-18years) suffering from adenotonsillar hypertrophy with an indication of adenotonsillectomy based on American Academy of Otolaryngology-Head and Neck Surgery criteria. Care givers completed the obstructive sleep apnoea 18 (OSA 18) quality of life (QoL) survey and Rutter Children's Behaviour Questionnaire (RCBQ) before adenotonsillectomy as well as 6months after surgery. We found that mean score of OSA 18 and total RCBQ decreased significantly 6months after surgery. The mean score of OSA 18 (4.12 ± 1.4) and total RCBQ score (20.5 ± 2) significantly reduced to 1.19 ± 0.12 and 7.4 ± 2.55 (p < 0.0001), respectively, after surgery. There was significant improvement in all the domains of OSA 18 score after intervention including sleep disturbance (mean score change 2.56, p < 0.0001), physical suffering (2.99, p < 0.0001), emotional distress (2.71, p < 0.0001), daytime problems (2.56, p < 0.0001), caregiver concerns (3.76, p < 0.0001). We also observed that QoL as well as behaviour was independent of age and gender of patients. This study demonstrates significant score changes across all questionnaire domains, comparing pre and post operative data indicating an improvement in their quality of life and behaviour. Hence, we advocate that adenotonsillectomy may be considered as an effective treatment in properly selected patients with OSAS.

Psychometric Properties of the Simons Simplex Collection Sleep Interview.

An estimated 40%-80% of children with autism spectrum disorders (ASD) have sleep problems. The Simons Simplex Collection Sleep Interview (SSCSI) is a parent-report questionnaire assessing bedtime and nighttime sleep problems and daytime function. The present study evaluated the factorial model of the SSCSI that best characterizes children aged 4-18 years with ASD. Exploratory factor analysis was performed using principal component analysis and promax rotation, beginning with 16 items and ending with 10 items. Exploratory factor analysis concluded with ten dichotomous items, plus ageand regular sleep duration, in three factors: nighttime problems, daytime problems, andsleep duration problems. The analysis was performed on the full sample, and onprepubertal (4-8-years), pubertal (9-13-years), and postpubertal (14-18-years) subgroups. Further refinement, including confirmatory factor analysis, test-retest reliability, and convergent validity testing, is needed.

Sleep Dysfunction and Behavioral Daytime Problems in Children with Autism Spectrum Disorders: A Comparative Study.

To compare parent reported sleep behaviors of children with Autism Spectrum Disorders (ASD) and normal healthy controls and to examine the association of sleep disturbances with daytime behavioral difficulties in children with ASD. Sixty ASD children (85% boys) (Mean age=6.1 y, SD=2.4) were recruited from the Psychology unit of the Department of Pediatrics of a tertiary care hospital. An age and socio-economic status matched group of typically developing (TD) children (N=60) were also recruited. The Children's Sleep Habits Questionnaire (CSHQ) was used to measure sleep problems. The Childhood Psychopathology Measurement Schedule was used to measure day time behavioral difficulties. Sleep problems were nearly two times more prevalent among children with ASD (88.3%) as compared to the TD group (46.7%) (χ2=23.74, P=0.0001). The total CSHQ and 6 out of the 8 subscales scores of the ASD group were also significantly higher than the TD group. Overall, children with ASD displayed significant more bedtime resistance than controls (t= 3.95, P=0.001). The sleep duration subscale showed that children with ASD, relative to the TD group, slept too little (χ2=23.08, P=0.0001), did not sleep the right amount of time (χ2= 11.86, P=0.003), and displayed significant variation in the duration of time slept (χ2=11.96, P=0.003). In addition, parent reported sleep dysfunction had a significant relationship with daytime reported behavior difficulties (r=0.53, P=0.01) in children with ASD. Stepwise multiple regression analysis revealed that 30% of the variance in number of daytime behavioral problems was explained by only two variables: total CSHQ scores and duration of night awake time (F=11.18, P=0.001). Children with ASD are at a high risk for sleep problems and this is associated with daytime behavior disturbances. Pediatricians should routinely screen ASD children for sleep problems and initiate timely and appropriate interventions.

Characteristics of sleep in children with autism spectrum disorders from the Simons Simplex Collection

BackgroundAn estimated 40–80% of children with ASD have sleep problems, including bedtime behavior problems, difficulty falling asleep and staying asleep, decreased sleep time, and daytime sleepiness. This study aimed to examine the relationship between sleep problems and characteristics of children with ASD in a large, nationwide sample. MethodsThis secondary analysis of children 4- to 18-years explored 11 sleep problems using the Simons Simplex Collection Sleep Interview (SSCSI). The SSCSI includes nighttime problems, daytime problems, and sleep duration problems subscales. Chi square, Kruskal-Wallis and Mann- Whitney U tests were performed to detect differences between age groups, sexes, and sleep problem groups (none/minimal, mild, moderate/severe). Odds ratios for variables associated with sleep problems were assessed using baseline and adjacent category logistic regression. Two-way interaction effects were included in regression models, and stratified analyses were performed for age groups. ResultsApproximately 41% of children were categorized as having mild or moderate/severe sleep problems. The most commonly reported SSCSI items were in the nighttime problems subscale; difficulty falling asleep was the most frequently reported item. Mean sleep duration was approximately 9 h, although more than one-quarter slept less than the hours recommended for their age. Increased odds of sleep problems were most frequently associated with gastrointestinal distress (GID) and non-verbal IQ (NVIQ), followed by male sex and age. ADOS severity score is likely not associated with sleep problems in this sample. ConclusionsThis study advances our understanding of sleep in ASD by showing that GID, NVIQ, sex, and age increased the odds of sleep problems in children with ASD. These results reinforce that healthcare professionals should screen for sleep problems in children with ASD and suggest future lines of inquiry.

Multimodal brain imaging investigation of self-reported sleep quality and daytime sleepiness in older adults with heart failure

ABSTRACTPurpose of the study: Individuals with heart failure (HF) have a high frequency of sleep problems. Patients with HF present with structural brain changes different from normal aging including reductions in brain volume, increases in white matter hyperintensity (WMH) and reduced cerebral blood flow. These structural changes in the brain may explain the pathophysiology of sleep and daytime problems. The objective of this study was to determine whether multimodal imaging data are related to self-reported sleep problems and daytime sleepiness in older adults with HF.Methods: Participants in this study underwent magnetic resonance imaging scans on the General Electric 3.0 T Discovery MR750 to acquire WMH, cerebral blood flow and brain volume. Data on 37 stable HF patients (mean age = 68; SD = 5.75) were included.Results: In this sample, WMH was associated with daytime sleepiness (p = 0.025). However, gray and white matter volume and cerebral blood flow were not associated with daytime sleepiness, sleep quality or insomnia.Conclusion: Although further studies are needed to determine the relationship between WMH and sleep and daytime problems, the findings preliminarily support that increases in WMH from ischemic changes could explain increases in daytime sleepiness among people with HF.

Nocturia is more bothersome than daytime LUTS: Results from an Observational, Real-life Practice Database including 8659 European and American LUTS patients.

Lower urinary tract symptoms (LUTS) encompass several diagnoses, including overactive bladder (OAB) and benign prostatic hyperplasia (BPH). Nocturia is a standalone symptom, but also included in OAB and BPH. Current discussion addresses whether the overlap of the diagnoses is too broad, leading to misdiagnosis. This study explored the differences in level, causes and consequences for patients with a diagnosis of daytime LUTS compared with a diagnosis of nocturia, and discussed whether people are being treated for the symptoms that truly bother them the most. Data were drawn from a survey of physicians and patients in France, Germany, Spain, UK and USA. Physicians filled out patient record forms (PRFs) for patients with LUTS diagnosis. The patients completed the patient self-completion form (PSC). Three PRO questionnaires were included; the OAB-q SF, NI-Diary and WPAI. Patients were grouped based on the diagnoses assigned to them by their physicians in a real-life setting. Eight thousand seven hundred and thirty eight patients had a LUTS diagnosis and 5335 completed a PSC. Patients diagnosed with night-time symptoms were significantly more bothered by their LUTS than only daytime LUTS patients (all questionnaires P<.0001). Patients with nocturia reported being tired "always" or "usually" more often than patients with daytime problems only (P<.0001). Only 13% of patients with nocturia had an initial sleep period of more than 2-3hours. In this population of real-life patients, those with a diagnosis of nocturia reported significantly higher impact on their quality of life than patients with a diagnosis of daytime LUTS only. The underlying causes of bother were related to sleep problems. It is essential that nocturia is understood, treated and monitored as a distinct problem from OAB and BPH, to ensure that patients are treated for their main symptom.

Sleep problems among adolescents: is there a relation with deliberate self-harm and aggression?

Background Adequate sleep during adolescence is important for healthy development and proper daytime functioning. Sleep problems are commonly reported in adolescents, with an estimated prevalence between 17 and 45%. Besides, adolescence period is usually associated with various behavioral problems such as aggression and self-harm. Aims The aim of this study was to evaluate sleep habits and the presence of sleep problems in an Egyptian adolescent sample. Moreover, this study aimed to examine the presence of a relationship between sleep problems and the development of aggression and self-harm among those adolescents. Patients and methods A total of 117 adolescents in the preparatory stage participated in this study. Three self-report questionnaires were used, Child and Adolescent Sleep Checklist, the Deliberate Self-Harm Inventory, and the Aggression Scale, for students for assessment of sleep problems, deliberate self-harm (DSH), and aggression, respectively, among those adolescents. Results A total of 117 adolescents, 51 (43.6%) male and 66 (56.4%) female, participated in this study; their mean age was 13.85±0.81 years. Bedtime problems and daytime problems are more common among adolescents, with higher scores (8.10±3.99 and 6.56±3.61, respectively). Of those, 36 (30.8%) adolescents had a score of 18 or more, and so they were considered to have sleep problems. The participated adolescents had score ranging from 3 to 38 in the Aggression Scale, with a mean±SD of 12.36±8.32. A total of 24 (20.5%) adolescents had engaged in self-harm according to the Deliberate Self-Harm Inventory. Moreover, a significant positive correlation (P Conclusion Bedtime problems and daytime problems were common among the participated adolescents. Moreover, DSH and aggressive behaviors were reported. This study provides evidence that there is a strong relationship between sleep problems and both DSH and aggressive behaviors among those adolescents. Early detection, diagnosis, and treatment of sleep problems and promoting sleep hygiene will, undoubtedly, improve adolescents’ daily functioning and will have good impact on controlling these annoying behavioral problems.

Restless legs syndrome and impact on work performance

Restless legs syndrome (RLS) is a neurological sensorimotor disorder characterized by unpleasant sensations in the legs and an uncontrollable urge to move them for relief. The RSL prevalence in the general population is 0.1% - 11.5%, and increases with age, with the highest effect of producing a primary sleep disorder (70%-80%). Women appear to be at increased risk, as do individuals with certain chronic conditions, including renal failure and anemia. The pathophysiology of RLS is incompletely understood, but it probably results from derangements in dopamine and iron metabolism, and has a genetic component. RSL could be idiopathic or secondary (usually related with iron deficiency, terminal renal failure, pregnancy, and spinal cord lesions). RLS patients usually have sleep disorders, so the disease can cause difficulties and problems in occupational and social life. Subjects with RLS symptoms appear to experience significantly more daytime problems, including being late for work, making errors at work, or missing work because of sleepiness. The diagnosis of RLS is made by following the criteria of the International Restless Legs Syndrome Study Group (IRLSSG). Pharmacologic RLS therapy, in which dopaminergic drugs constitute the first line, is effective and may have a dramatic effect on symptoms and quality of life. Identifying and treating RLS may improve sleep quality, daytime function and work performance.

Nocturnal manifestations of Parkinson's disease and atypical Parkinsonism.

In this Supplement of the Journal of Neural Transmission, we address an important feature of Parkinson’s syndrome, i.e. nocturnal problems. We feel very honoured that so many eminent experts in this field have contributed to a supplement which should be of interest to everyone who deals with Parkinson’s disease (PD). It is accepted by neuroscientists that PD is a progressive disease with an accumulation of a-synuclein (Spillantini et al. 1997). Since these accumulations are also found in the mesencephalon where sleep regulation is located, it follows that impairment of sleep is a natural consequence of this progressive disease (Braak et al. 2003). Even James Parkinson addressed sleep problems in his essay on the shaking palsy when he writes ‘‘...as the malady proceeds, the sleep becomes much disturbed...’’ (Parkinson 1817). REM sleep behaviour disorder (RBD) is associated with hyposmia, constipation and depression as among the most frequent and important pre-motor symptoms in PD (Bhidayasiri and Reichmann 2013; Reichmann 2010). Patients with RBD lack physiological atonia during REM sleep and frequently scream and move violently, often injuring their sleeping partners. More than 60 % of these patients will later develop a second neurodegenerative disorder, very often PD or atypical parkinsonism (Claassen et al. 2010). But there are many more nocturnal disturbances in patients with PD such as nocturia, pollakisuria, problems falling asleep, problems staying asleep, restless legs syndrome, pain during nighttime, early morning akinesia and many more (Grandas and Iranzo 2004). Patients rate nighttime problems rather high when they are asked what impairs their quality of life the most (Barone et al. 2009). Thus, it is obvious that we need scales to quantify these features. Fortunately, such scales have been developed which give a good estimate of sleep problems in PD (Hogl et al. 2010). For others we can use the Parkinson’s disease sleep scale (PDSS) or the scales for outcomes in PD sleep (SCOPA-S) (Chaudhuri et al. 2002; Marinus et al. 2003). Of all nonmotor symptoms in PD, sleep problems belong to the most serious ones since they do not only impair quality of sleep and rest but also impair motor performance in the early morning and give rise to fatigue and somnolence during daytime (Comella 2006). Both nighttime and daytime problems also impair the quality of life of the patients’ caregivers since they do not find enough rest to take care of the patients during the daytime (Martinez-Martin et al. 2007). Thus, treatment of nocturnal problems in PD is extremely important. Most PD specialists use a long-acting dopamine replacement therapy to address a dopaminergic trough during the nighttime (Ray Chaudhuri et al. 2012; Trenkwalder et al. 2011). It is helpful to use extendedrelease preparations of levodopa since there would not be any interference with food at nighttime (Chouza et al. 1990). Long-acting dopamine agonists are extremely helpful to overcome nighttime problems and to increase the possibility of a good start of the next day. In addition, the H. Reichmann Klinik und Poliklinik fur Neurologie, Universitatsklinikum Carl Gustav Carus, Dresden, Germany

Association of Eveningness With Problem Behavior in Children: A Mediating Role of Impaired Sleep

Eveningness, the preference of being active during the evening in contrast to the morning, has been associated with markedly increased problem behavior in adolescents; however, the underlying mechanisms are still not understood. This study investigates the association of eveningness with behavior and cognition in children aged 7–12 yrs, and explores the potential mediating role of a variety of sleep factors. Parents of 333 school-aged children (mean age = 9.97 yrs; 55% girls) completed a sleep log and several questionnaires regarding eveningness, sleep habits, and behavioral problems. Intellectual abilities, working memory, and attention were assessed using the short-form of the Wechsler Intelligence Scale for Children (WISC) and subtasks of the Amsterdam Neuropsychological Tasks. Results showed that eveningness predicted behavioral problems over and above the effects of demographic variables (age, sex, and familial socioeconomic status) (p = 0.003). Significant partial correlation was found for eveningness and sleep duration during weekdays (p = 0.005), and not during weekends. Furthermore, evening orientation was associated with a reduced rested feeling on weekday mornings (p < 0.001), but not on weekends. The most important sleep characteristic showing association with many cognitive and behavioral measures was the subjective feeling upon awakening—particularly during weekdays. Bootstrap mediation analyses demonstrated that sleep significantly mediated the effects of eveningness on behavioral problems, working memory, and sustained attention. Interestingly, mediation was only significant through the subjective feeling upon awakening on weekdays. The current findings indicate that the subjective feeling upon awakening is a much better predictor of daytime problems than subjective sleep quantity. Furthermore, the data suggest that negative outcomes in evening types are due to the fact that they wake up before their circadian drive for arousal and prior to complete dissipation of sleep pressure during weekdays. Interventions that target the misalignment of endogenous circadian rhythms and imposed rhythms are discussed. (Author correspondence: kbheijden@fsw.leidenuniv.nl)