Sleep Continuity Research Articles

0273 Advanced assessment of sleep derived from hypnodensity

Abstract Introduction In a recent analysis of PSG studies with six, nine and twelve human scorers, we showed that sleep stage ambiguity is the rule rather than the exception, and that sleep stage probabilities (SSPs) calculated with artificial intelligence provide an excellent estimate of this ambiguity. Here we investigate clinical and demographic factors driving this ambiguity and evaluate potential benefits of using hypnodensity in addition to the traditional hypnogram for sleep assessment. Methods SSPs were determined in 195 healthy subjects aged 20–95 years and in 49 apnea patients aged 29–73 years (AHI: 5.8–105.5 events/hour). In addition to the recommended sleep parameters, we derived the percentage of ambiguous sleep stages (SSP ≤ 0.95), the mean amount of ambiguity per sleep stage (1-SSP), sleep stage continuity (absolute difference in SSP between two epochs) and sleep stage stability (two adjacent epochs belonging to the same sleep stage with SSP > 0.95 each) as well as NREM sleep depth (weighted average of NREM SSPs). Results The percentages of ambiguous NREM epochs (±SD) increased significantly with age (Pearson’s r=0.72; p< 0.01) from 40±9% in young healthy subjects (20-39 years, n=61) to 50±9% in middle-aged healthy subjects (40-59 years, n=59) and to 62±11% in older healthy subjects (≥ 60 years, n=75). The percentages of ambiguous REM epochs did not change significantly across age (r=0.1). Apnea patients showed an increased NREM ambiguity (77±15% compared to 53±10% in age- and sex-matched healthy controls; p< 0.01), while REM ambiguity was only slightly increased (p< 0.05). Furthermore, sleep stage continuity, stability, and NREM sleep depth decrease significantly with age and are significantly lower in apnea patients than in healthy controls (p< 0.01). Conclusion Artificial intelligence-based autoscoring shows ambiguity in 40% of NREM epochs in young healthy subjects, increasing to 77% in apnea patients. Assigning a single sleep stage to each epoch and presenting sleep architecture as a traditional hypnogram may be misleading, especially for older subjects and patients with sleep-disordered breathing. A hypnodensity chart representing sleep stage probabilities reflects this sleep staging ambiguity, provides all the information contained in a hypnogram, and offers insights into sleep ambiguity, continuity, stability, and sleep depth. Support (if any)

0310 Low light exposure during wake is associated with antepartum depressive symptoms

Abstract Introduction Antepartum depression affects 7-16% of pregnant women and occurs most frequently in the 3rd trimester. Previous studies have demonstrated a relationship between the level and timing of daytime light exposure and depression in non-pregnant populations. However, much less is known about the relationships between light exposure and depression during pregnancy. Thus, in this study, we tested the hypothesis that exposure to less daytime light will be associated with more antepartum depressive symptoms. Methods Data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b) and the nuMoM2b Sleep Duration and Continuity Substudy were used (N=708). Women enrolled in the substudy wore wrist actigraphy (Spectrum, Phillips Respironics) and completed a sleep log for seven days between 160-230 weeks of gestation. Daytime light exposure was defined as minutes spent at or above the threshold of 50 lux (TAT50) during the wake period, averaged over valid actigraphy recording days. Participants were divided into two groups by TAT50: >25th percentile and ≤25th percentile. The Edinburgh Postnatal Depression Scale (EPDS) was administered during the 1st and 3rd trimesters. A positive screening was defined as an EPDS composite score ≥10 or any endorsement of self-injurious thoughts. Wilcoxon rank sum tests were used to test differences between TAT50 groups. Results Low light exposure during the day was associated with antepartum depressive symptoms during the 1st and 3rd trimesters, after adjusting for age, season, race, poverty, sleep midpoint, and sleep duration (OR 1.7, p=0.047). Additionally, later sleep timing, greater day-to-day sleep variability, and increased time spent awake after sleep onset was seen in those exposed to less light (all p< 0.001). Conclusion Lower daytime light exposure is associated with poorer sleep quality and may increase risk for antepartum depressive symptoms. These data suggest that in addition to improving sleep quality, promoting daytime light exposure may be a modifiable risk factor for depression during pregnancy. Support (if any) Work supported by NHLBI grant R01 HL105549 and NICHD grant U10 HD063036. C.D.W. was funded, in part, by T32HL007909. K.J.R., and P.C.Z. are supported, in part, by R01 HL140580 and P01 AG011412. M.K. is supported, in part, by NIA P30AG059988.

0308 Impact of Customized Lighting on Sleep in Hospitalized Patients

Abstract Introduction Inpatient sleep may be disrupted for myriad reasons, including lighting exposure that is typically fixed at constant intensity and spectra. In this study we employed customized lighting that promotes circadian entrainment by exposing patients to blue-augmented lighting during the morning and blue-suppressed lighting evening to improve sleep timing and duration. Methods Two Mount Sinai hospital rooms (with 2 beds each) were outfitted with Eight Mattress sensors that use a combination of movement, breathing, heart rate, and temperature variables to estimate wake and sleep vigilance states in 30-second epochs. One room contained customized lighting between 7 am and 11 pm, while the other room contained standard hospital lighting. The current analysis includes 60 participants (30 in the control room and 30 in the custom lighting room), who were matched for time-of-year hospital admission date. We first analyzed the probability of sleep during any given 30-second epoch across each subject’s admission and compared the distributions of sleep probability across the 24-hour cycle for all subjects in the lighting vs control conditions. We additionally evaluated total nocturnal sleep duration(11 PM – 7 AM) by 1) summating all sleep epochs on nights containing at least 50% valid data and 2) normalizing all measured sleep epochs to all valid sleep/wake outputs (excluding indeterminate epochs). Results The distribution of sleep probability was significantly different in the lighting vs control condition (p < 0.001) with most apparent diversion of the distributions between 9 pm and 9 am. The average raw nocturnal sleep duration was significantly higher in lighting condition (270.0 ± 23 minutes vs 201 ± 23 min in control, p = 0.037), as was the average minutes of sleep per hour of valid recording (36.9 ± 15 minutes vs 28.4 ± 13 in control, p = 0.022). There were no significant differences in the number of nocturnal wake or indeterminate epochs between conditions. Conclusion Custom lighting appears to promote sleep in hospitalized patients, but the interpretation is tempered by absence of full validation of the mattress sensor against polysomnography. Future work will evaluate differences in sleep timing and continuity between conditions. Support (if any) McClung Foundation, R01 AG066870

0319 Evaluating Illness Severity from Acute to Chronic Insomnia: Is the First the Worst?

Abstract Introduction The Spielman 3P and Perlis 4P models represent illness severity over the course of insomnia disorder. The 3P model suggests that illness severity is worst when subjects experience acute illness (as compared to the subchronic and chronic phases of the disorder). The 4P model suggests that illness severity crescendos with chronicity. The present analysis uses an archival data set to assess illness severity with new onset illness (i.e.,from Good Sleep [GS] to Acute Insomnia [AI] and from AI to Chronic Insomnia [CI]). Illness severity is quantified in terms of Total Wake Time (TWT). Number of affected days/week is a tabulation of nights/week with clinical insomnia symptoms. Methods Subjects were recruited as GSs(N=911), followed up to 1-year with digital sleep diaries, and were classified as GS, AI, or CI based on standardized criteria. Data for CI subjects were anchored to the 1st of 14 days with insomnia so that day-to-day TWT, SL, WASO, and EMA were represented for ~100 days prior-to-and-following AI onset. A similar graphic (+/-Acute onset) was constructed for number of days per week with insomnia. GS data were matched to CI subjects dates (i.e., the data were temporally tethered). Segmented linear mixed regression models were applied to examine the change in slopes in the AI-to-CI period compared to GS and AI period. Results 883 subjects remained as GSs (Mage=53.1±10.8years;35.1%female;83.0%white), while 28 indi-viduals transitioned to AI and then CI (Mage=53.6±12.6years;39.3%female;89.3%white). Average TWT rose over the course of the first 2 weeks from the AI onset(b=1.6,SE=0.52minutes,p=0.002) and then was stable for 3 months(b=-0.004,SE=0.03,p=0.91). This worsening of sleep continuity was almost entirely related to increased WASO. Average number of affected days was found to be stable from AI to CI (b=0.002,SE=0.002,p=0.20). That is, while there was week-to-week variability in the number of days affected, no linear trend was evident. Conclusion These data suggest that, in our sample of CIs with primarily middle insomnia, the average severity and number of affected days was worst with the onset of AI (worst is first) and stable thereafter. Whether this temporal trend applies equally to new onset Initial and Late insomnia remains to be determined. Analyses ongoing. Support (if any) R01AG041783

0737 Age, menstrual phase, and circadian preference impact sleep in menstruating individuals

Abstract Introduction An eveningness chronotype is generally associated with reduced sleep continuity and quality, as well as social jetlag. Changes in hormones and menstrual phase similarly impact sleep, although research on the chronobiological effects of these changes are equivocal. This study aimed to examine the role of menstrual cycle in daily self-report and actigraphy-assessed sleep in two consecutive menstrual cycles. Methods Participants (n=51; 43% Caucasian), 18-35 years (23.67±4.68) completed actigraphy and daily sleep diaries over two menstrual cycles (m days=51.29). Four menstrual phases were identified via dates of menstrual bleeding and urinary ovulation testing: perimenstrual (±3 days of bleeding), mid-follicular, periovulatory, and mid-luteal. Relationships between menstrual phase and sleep parameters were estimated using multistep hierarchical linear modeling. Subjective and objective measures yielded the following sleep variables: Total Wake Time (TWTsub and TWTobj), Sleep Efficiency (SEsub and SEobj), and mid-sleep point (MSP). Participants completed the Morning-Eveningness Questionnaire (MEQ) at baseline. Results Mean cycle length was 28.61 days±2.69. Age was significantly associated with TWTobj (r=-.32, p <.001); SEobj (r=.34, p <.001), and MSP (r=-.42, p <.001) such that older participants had shorter TWT, higher SE, and earlier MSP. TWTobj was 4-7 minutes lower during the mid-follicular (61.54±3.37) and mid-luteal phases (63.11±3.29) compared to the perimenstrual phase (67.54±3.37; p <.001). SEobj was higher in the mid-luteal phase (82.50±0.79) vs. the perimenstrual phase (80.71±0.82, p =.006). Perimenstrual women reported 8-16 minutes longer awake (TWTsub=52.23±5.01, p <.001) and had 1-3% reduction in SEsub (89.70±0.10, p <.001). MEQ negatively predicted TWTobj (p=.004) and SEobj (p=.003), but did not vary across menstrual phase. In morning-type individuals, TST was significantly higher in the periovulatory (b =1.81, p=.01) and mid-luteal phases (b=2.03, p<.001) compared to the perimenstrual phase. Conclusion With increasing age, women experienced reduced time awake, higher sleep efficiency, and earlier sleep timing. Eveningness predicted greater total wake time and lower sleep efficiency. With menstrual phase considered, disturbed sleep was highest in the perimenstrual phase and women reporting a stronger preference for eveningness reported shorter TST during the perimenstrual phase. These findings highlight the importance of considering the menstrual cycle in the sleep health of menstruating individuals. Support (if any)

0822 Sleep and Nighttime Urine Production

Abstract Introduction Nocturia (waking from sleep to urinate) is the most common cause of sleep interruption among older adults and nocturnal polyuria (NP; increased sleep time urine production) is its most common cause. Conversely, poor sleep with repeated awakenings contributes to both nocturia and NP. However, whether a behavioral intervention to reduce repeated awakenings can improve nocturia and NP has not been examined in a clinical trial. The current study assesses the effect of Brief Behavioral Treatment for Insomnia (BBTI) on nocturia and NP in older adults. Methods Fifty-six community-dwelling older adults (mean age, 72±6 years; 64% women) with nocturia frequency ≥2 per night were randomized to receive BBTI vs information-only control (IC). All participants completed a 3-day voiding and sleep diary to assess nocturia, and sleep. Participants with a nocturnal polyuria index (NPi; percent of 24-hour urine volume excreted at night) ≥35% were considered to have NP. Results At baseline, nocturia frequency correlated with total sleep time (r=.54, p< 0.001) and duration of the first uninterrupted sleep period (FUSP, r=-.40, p=0.004) after adjusting for age and body mass index. BBTI significantly improved nocturia frequency compared to the IC group (-1.0±0.7 vs -0.3±0.9; p=.02). FUSP increased by 54±77 minutes in the BBTI group and NPi decreased by 7.1±13.2%, but these changes were not significantly different from the IC group. Change in NPi correlated with change in FUSP (r=-.36, p=.01; longer FUSP associated with lower NPi), but not with change in total sleep time (r=-.04, p=.7). Conclusion In older adults with nocturia, behavioral treatment directed solely at sleep also improves nocturia. Improving sleep continuity in the first half of the night and increasing FUSP, but not total sleep time, may also improve NP. Support (if any) NIA AG060292

0111 Wearable-based Measures of Sleep Across the Menstrual Cycle in Healthy Women in the Reproductive Stage and Early Menopause

Abstract Introduction Sleep is an essential part of women’s health and well-being. Hormonal fluctuations that occur across the menstrual cycle or when approaching menopause might affect sleep quality. Most studies rely on self-reported data, or laboratory measures in small samples, to examine changes in sleep across the menstrual cycle. Here, we investigated sleep quality, as measured continuously with a wearable device, across the menstrual cycle in different reproductive stages (reproductive, menopausal transition). Methods 56 women participated, with 31 in the reproductive stage (age: 24.65 +/- 6.09 years) and 25 in the early menopausal transition (47.36 +/- 2.78 years). Participants were healthy, without sleep disorders, and free of premenstrual and mood complaints, as well as not using hormonal contraceptives. Sleep was tracked with the Oura ring across an entire menstrual cycle – confirmed as ovulatory using ovulation tests. Participants also completed a sleep diary each morning, rating sleep quality and how refreshed they felt. Measures were averaged for four phases: menses, ovulation, mid-luteal, late-luteal. Participants were assessed for mood symptoms (DASS-21) once during each of these phases. Results Objective measures of sleep quality (Total Sleep Time, Efficiency, and Wake After Sleep Onset) did not change across the menstrual cycle in either group or differ between groups. Similarly, self-reported sleep and mood symptoms remained stable across the menstrual cycle, although women in the menopausal transition reported poorer sleep quality and felt less refreshed than reproductive stage women, overall. Physiological measures (Temperature, Heart Rate, and Heart Rate Variability) during sleep reflected the well-known fluctuations across the menstrual cycle (e.g., increased temperature in the luteal phase vs. menses) in both groups of women. Conclusion Objective, wearable-derived measures indicate sleep quality remains stable across the menstrual cycle during reproductive and early-menopausal transition stages, at least in healthy women without mood or premenstrual complaints. While women in the menopausal transition reported a poorer sleep quality, there was no difference in objective sleep continuity measures between groups. Future studies are needed to better understand sleep across the reproductive lifespan, considering cycle-related (e.g., premenstrual syndrome) and other factors that could make some women sensitive to menstrual cycle effects on sleep. Support (if any) NIH, RF1AG061355 (BAKER/MEDNICK)

0612 Understanding Narcolepsy Treatments From the Patient’s Perspective: A Survey of People Living With Narcolepsy

Abstract Introduction Individuals with narcolepsy were surveyed to better understand desired treatment outcomes and how those outcomes map to commonly experienced symptoms, treatment awareness, and medication usage. Methods In February 2022, an email invitation to a 27-question online survey was sent to US members of MyNarcolepsyTeam, a social network of >9,800 members. Results In total, 110 members completed the survey. The most frequently mentioned desired treatment goals aligned with the most commonly reported symptoms: being able to stop sleeping during the day (77%); increased energy (62%); improved memory (36%); improved productivity (29%); improved sleep continuity (22%); and for patients with narcolepsy type 1, reducing cataplexy (28%). A common theme was desire for a medication that would treat the underlying cause and not just improve specific symptoms. In one patient’s own words: “I want to see treatments that target the root problem of poor nighttime sleep rather than just being a band-aid for [excessive daytime sleepiness] EDS, like stimulants are.” Only a small percentage of respondents (13%) were not currently taking any type of medication to address narcolepsy symptoms. 64% were currently taking ≥2 medications to address both the daytime and nighttime symptoms. Most commonly mentioned current treatments were dextroamphetamine-amphetamine (30%), modafinil (22%), melatonin (16%), armodafinil (15%), venlafaxine (14%), and oxybate (14%). Notably, 33% of patients taking sodium oxybate chose sleeping through the night as a desired outcome. Most common sources for learning about treatments were narcolepsy-specific websites (53%), MyNarcolepsyTeam specifically (45%), the patient’s doctor (42%), scientific articles (42%), and advocacy groups (37%). Conclusion Patients experience a wide range of both daytime and nighttime symptoms and seek relief from both sets of symptoms including EDS (93%), fatigue (79%), cognitive challenges (74%), as well as sleep disruptions (63%). As a result, the majority need multiple medications. Understanding the experiences and needs of people with narcolepsy provides significant opportunities for clinicians to support, educate, and treat their patients holistically. Additionally, content readily available on the internet, whether it is narcolepsy-specific content or social networks, helps patients proactively discuss options with their clinician. Support (if any) Avadel Pharmaceuticals

0931 App-Supported Sleep Coaching: Implications for Sleep Duration and Sleep Quality

Abstract Introduction Sleep coaching programs have emerged to address sleep health needs for subclinical populations. Yet, few such programs have been formally evaluated. Methods Data were obtained from N=51 consecutive users who completed the 12-week Sleep Reset program. Sleep Reset (Simple Habit, Inc.) includes ongoing text-based communication with trained coaches and a mobile app that includes a sleep diary, educational modules, mindfulness exercises, and progress-tracking. Potential users with a contraindicated medical/psychiatric problem or a likely sleep disorder (including Insomnia Disorder) are referred for additional care/support. The coaching included information about sleep and circadian principles (e.g., sleep hygiene, behavioral scheduling, light exposure, relaxation) and techniques based on CBTI (e.g., stimulus control). T-tests examined change scores for diary-derived sleep latency (SL), wake after sleep onset (WASO), total sleep time (TST), number of awakenings (NWAK), and sleep efficiency (SE). N=3 had uninterpretable baseline TST. Post-hoc analyses examined those who reported at least one sleep continuity disturbance (SL>=30, WASO>=30, SE< 0.85; N=44) vs none (N=7) and short sleepers (TST< 360 min; N=19) vs 6+ hours (N=32). Results Those who participated in the program saw a mean increase in SE of 6.4% (95%CI [2.7%,10.2%], t(50)=3.4, p=0.001) and TST of 57.8 mins (95%CI [33.8,81.8], t(47)=4.9, p< 0.0005), and a mean decrease in SL of 12.2 mins (95%CI [-20.0,-4.4], t(50)=-3.1, p=0.003), WASO of 32.4 mins (95%CI [-52.7,-12.0]. t(50)=-3.2, p=0.002), and NWAK of 0.3 awakenings (95%CI [-0.7,-0.01], t(50)=-2.1, p=0.046). Those who reported a problem were more likely to show an improvement in SE (+7.9% vs -0.3%, p=0.001), SL (-14.8 vs +4.0 mins, p=0.0008), and WASO (-40.5 vs +15.8 mins, p=0.0001), but groups did not differ in terms of change in NWAK and TST. Short sleepers saw a relative improvement in SE (+12.2% vs +3.0%, p=0.037) and TST (+109.8 vs +23.7 mins, p=0.0001), but no differences in change to SL, WASO, and NWAK. Conclusion The sleep coaching program improved sleep quality and duration for participants without sleep disorders. Those with baseline sleep continuity problems received the most benefit to SL and WASO, and short sleepers saw a nearly 2-hour average increase in TST. Future studies need to extend this work with control groups. Support (if any)

0867 Lower Bedtime HRV is Associated with Higher WASO in Middle-Aged Adults with Chronic Insomnia

Abstract Introduction Short sleepers (< 6 hours per night) represent a unique phenotype of insomnia associated with more severe biological implications compared to insomnia with normal sleep duration. A primary contributor to shorter sleep duration is more time spent awake after sleep onset (i.e., WASO), which has deleterious effects on long-term cardiac physiology. For instance, short sleepers with higher WASO have lower parasympathetic activity at sleep onset compared to those with lower WASO or greater sleep duration. Methods Results presented here are derived from baseline assessments collected as a part of a clinical trial comparing three modalities of cognitive behavioral therapy for insomnia in middle-aged adults (50-65yrs) with chronic insomnia (N = 23). During their baseline assessment, individuals first completed one night of in-home polysomnography. Total sleep time was PSG derived. The following night, they wore an Equivital Harness equipped with an electrocardiogram (ECG) for 24 hours. In this investigation, inter-beat intervals were derived from ECG in 10-minute segments just before and just after bedtime (i.e., when the individual tried to sleep). WASO was calculated using sleep diaries during the night they wore the Harness and the following week. Results Preliminary data N = 23) show that high frequency (0.15-0.4Hz) heart rate variability (HRV; i.e., parasympathetic activity) at bedtime is not associated with WASO that night or WASO averaged across the following week. However, when the sample was narrowed to short sleepers only (□6hours; n = 7), lower levels of bedtime HRV (B = -.81, p = .028) is associated with greater WASO during the following week. In short sleepers, mean score of both before and after bedtime HRV predicted 65% of variance in WASO averaged across the next seven nights (R2 = .653, F (1, 5) = 9.41, B = -0.81, p = .28). These effects were not significant in individuals with sleep durations longer than 6 hours. Conclusion In this small sample, short sleepers display a unique, inverse relationship between cardiac vagal activity and sleep continuity, replicating similar findings regarding parasympathetic activity at sleep onset and subsequent WASO. Support (if any) This project is supported by the Psychology Department at the University of Arizona.

0783 Sleep Continuity and Quality in Adolescents with Functional Abdominal Pain

Abstract Introduction Functional Abdominal Pain Disorders (FAPD), in which chronic abdominal pain occurs independently of organic pathology, are common in adolescents. FAPD can lead to significant impairment in daytime function and may overlap with sleep disorders. Though several studies have explored the nature of sleep disturbances experienced by adolescents with FAPD, none have characterized differences in sleep architecture in this population. Methods Adolescents (age 11-18 years) with FAPD and age/gender-matched controls were prospectively recruited to undergo polysomnography (PSG). PSG was performed according to AASM guidelines, scored by a registered sleep technologist, and interpreted by a board-certified sleep physician. The first four hours of artifact-free NREM sleep were analyzed using fast Fourier transformation with Welch tapered windows of 1024 samples (and 50% overlap) averaged over 30-second epochs. Total power was calculated for very low (0.3 – 1 Hz), delta (1 – 4 Hz), theta (4 – 8 Hz), and alpha (8-12 Hz) frequencies. Comparisons between groups were made using Wilcoxon rank sum tests or t-tests for non-normal and normal data, respectively. Results A total of 41 subjects were recruited (FAPD n=21, control n=20). The FAPD group had a greater arousal index and a lower percentage of NREM 3 sleep when compared to the control group (FAPD arousals: mean=10.08/min ± 4.89 min, control arousals mean=7.31/min ± 3.61/min, p = 0.046), FAPD NREM 3: mean=20.13% ± 5.47%, control NREM 3: mean=24.77% ± 6.94%, p =0.023). Delta power was significantly lower in the FAPD group compared to controls (FAPD Delta mean=488.67 µV2 ± 282.82 µV2, control Delta mean=1193.14 µV2 ± 663.89 µV2, p < 0.001). Conclusion This study demonstrates significant differences in sleep architecture of adolescents with FAPD compared to their peers. In particular, decreased proportions of NREM 3 sleep and lower Delta power are indicative of diminished slow wave sleep (SWS). Reductions in SWS may be indicative of common neurotransmitter pathways shared between sleep and chronic pain syndromes, or secondary to sleep disruption associated with pain. Further research is indicated. Support (if any) This research is supported by the Cincinnati Children’s Research Foundation and the Summer Medical Student Respiratory Research Fellowship program at Cincinnati Children’s.

Associations of actigraphy measures of sleep duration and continuity with executive function, vigilance, and fine motor control in children with snoring and mild sleep-disordered breathing.

Children with snoring and mild sleep-disordered breathing may be at increased risk for neurocognitive deficits despite few obstructive events. We hypothesized that actigraphy-based sleep duration and continuity associate with neurobehavioral functioning and explored whether these associations vary by demographic and socioeconomic factors. 298 children enrolled in the Pediatric Adenotonsillectomy Trial, ages 3 to 12.9 years, 47.3% from racial or ethnic minority groups, with habitual snoring and an apnea-hypopnea index < 3 were studied with actigraphy (mean 7.5 ± 1.4 days) and completed a computerized vigilance task (Go-No-Go) and a test of fine motor control (9-Hole Pegboard). Caregivers completed the Behavior Rating Inventory of Executive Function. Regression analyses evaluated associations between sleep exposures (24-hour and nocturnal sleep duration, sleep fragmentation index, sleep efficiency) with the Behavior Rating Inventory of Executive Function Global Executive Composite index, pegboard completion time (fine motor control), and vigilance (d prime on the Go-No-Go), adjusting for demographic factors and study design measures. Longer sleep duration, higher sleep efficiency, and lower sleep fragmentation were associated with better executive function; each additional hour of sleep over 24 hours associated with more than a 3-point improvement in executive function (P = .002). Longer nocturnal sleep (P = .02) and less sleep fragmentation (P = .001) were associated with better fine motor control. Stronger associations were observed for boys and children less than 6 years old. Sleep quantity and continuity are associated with neurocognitive functioning in children with mild sleep-disordered breathing, supporting efforts to target these sleep health parameters as part of interventions for reducing neurobehavioral morbidity. Registry: ClinicalTrials.gov; Name: Pediatric Adenotonsillectomy for Snoring (PATS); URL: https://clinicaltrials.gov/ct2/show/NCT02562040; Identifier: NCT02562040. Robinson KA, Wei Z, Radcliffe J, etal. Associations of actigraphy measures of sleep duration and continuity with executive function, vigilance, and fine motor control in children with snoring and mild sleep-disordered breathing. J Clin Sleep Med. 2023;19(9):1595-1603.

The impact of alertness vs. fatigue on interrogators in an actigraphic study of field investigations

Investigative interviews (e.g., interrogations) are a critical component of criminal, military, and civil investigations. However, how levels of alertness (vs. sleepiness) of the interviewer impact outcomes of actual interviews is unknown. To this end, the current study tracked daily fluctuations in alertness among professional criminal investigators to predict their daily experiences with actual field interviews. Fifty law-enforcement investigators wore a sleep-activity tracker for two weeks while keeping a daily-diary of investigative interviews conducted in the field. For each interview, the investigators indicated how well they established rapport with the subject, how much resistance they encountered, how well they maintained their own focus and composure, and the overall utility of intelligence obtained. Daily alertness was biomathematically modeled from actigraphic sleep duration and continuity estimates and used to predict interview characteristics. Investigators consistently reported more difficulties maintaining their focus and composure as well as encountering more subject resistance during interviews on days with lower alertness. Better interview outcomes were also reported on days with subjectively better sleep, while findings were generally robust to inclusion of covariates. The findings implicate adequate sleep as a modifiable fitness factor for collectors of human intelligence.

Developmental changes in obstructive sleep apnea and sleep architecture in Down syndrome.

Down syndrome (DS, also known as Trisomy 21) is a condition associated with abnormal neurodevelopment and a higher risk for sleep apnea. Our study sought to better understand and characterize the age-related developmental differences in sleep architecture and obstructive sleep apnea (OSA) severity in children with DS compared to euploid individuals. Retrospective review of polysomnograms in over 4151 infants, children, and adolescents in the pediatric sleep center at Children's National Hospital in Washington D.C. (0-18 years) including 218 individuals with DS. The primary findings of our study are that: (1) severe OSA (obstructive apnea-hypopnea index ≥ 10/h) was more prevalent in the DS group (euploid 18% vs. DS 34%, p < 0.001) with the highest OSA severity being present in young children (<3 years old) and adolescents (>10 years old), (2) abnormalities in sleep architecture in children with DS were characterized by a prolonged rapid-eye movement (REM) sleep onset latency (SOL) (euploid 119 min vs. DS 144 min, p < 0.001) and greater arousal indexes (euploid 10.7/h vs. DS 12.2/h, p < 0.001), (3) developmental changes in the amount of REM sleep or slow wave sleep were not different in DS individuals relative to euploid children, (4) multivariate analyses showed that OSA and REM sleep latency differences between DS and euploid individuals were still present after adjusting by age, biological sex, and body mass index. Severe OSA is highly prevalent in children with DS and follows an age-dependent "U" distribution with peaks in newborns/infants and children >10 years of age. Children with DS also have disturbances in sleep architecture characterized by a longer REM SOL and elevated arousal indexes. As sleep cycle generation and continuity play crucial roles in neuroplasticity and cognitive development, these findings offer clinically relevant insights to guide anticipatory guidance for infants, children, and adolescents with DS.

Effects of emerging alcohol use on developmental trajectories of functional sleep measures in adolescents.

Adolescence is characterized by significant brain development, accompanied by changes in sleep timing and architecture. It also is a period of profound psychosocial changes, including the initiation of alcohol use; however, it is unknown how alcohol use affects sleep architecture in the context of adolescent development. We tracked developmental changes in polysomnographic (PSG) and electroencephalographic (EEG) sleep measures and their relationship with emergent alcohol use in adolescents considering confounding effects (e.g. cannabis use). Adolescents (n = 94, 43% female, age: 12-21 years) in the National Consortium on Alcohol and Neurodevelopment in Adolescence (NCANDA) study had annual laboratory PSG recordings across 4-years. Participants were no/low drinkers at baseline. Linear mixed effect models showed developmental changes in sleep macrostructure and EEG, including a decrease in slow wave sleep and slow wave (delta) EEG activity with advancing age. Emergent moderate/heavy alcohol use across three follow-up years was associated with a decline in percentage rapid eye movement (REM) sleep over time, a longer sleep onset latency (SOL) and shorter total sleep time (TST) in older adolescents, and lower non-REM delta and theta power in males. These longitudinal data show substantial developmental changes in sleep architecture. Emergent alcohol use during this period was associated with altered sleep continuity, architecture, and EEG measures, with some effects dependent on age and sex. These effects, in part, could be attributed to the effects of alcohol on underlying brain maturation processes involved in sleep-wake regulation.

Well-being therapy and sleep hygiene in a non-clinical population of adults reporting poor sleep quality and distress: A remote pilot randomized controlled study

ABSTRACT Objectives This pilot randomized controlled study evaluates the feasibility and preliminary efficacy of a 7-week remote intervention combining well-being therapy and sleep hygiene to improve sleep and psychological outcomes among adults reporting poor sleep and distress. Methods Thirty-one participants (81% women, 40.2 ± 13.0 y, 48% racial/ethnic minority) were recruited from the community during the COVID-19 pandemic through online and local advertisement, and randomized to well-being therapy+sleep hygiene or sleep hygiene-only. Study outcomes were evaluated by self-reported questionnaires administered at baseline and post-intervention and a daily sleep diary. Results Compared to sleep hygiene-only, well-being therapy+sleep hygiene led to greater improvements in wake after sleep onset (time-by-group interaction: 3.6 ± 1.5 min, p = .017), personal growth (β −3.0, 95%CI −5.2, −0.8, p = .01), and purpose in life (β −3.5, 95%CI −6.1, −0.9, p = .009). Anxiety, perceived stress, sleep quality, and insomnia symptoms improved similarly in both groups (between-group differences, p > .05). Improvements in sleep quality, insomnia, and sleep duration were associated with reductions in multiple measures of psychological distress (all p < .05). Conclusions These findings suggest that, in a non-clinical setting of individuals suffering from combined poor sleep and psychological distress, the addition of well-being therapy to sleep hygiene may provide additional benefits for sleep by promoting sleep continuity and well-being.

Abstract P561: Reallocation of Sedentary Time With Light Physical Activity is Associated With Higher Sleep Efficiency in African Caribbeans

Introduction: Sleep efficiency (or sleep continuity, i.e., a ratio of time spent sleeping to time spent in bed), is inversely associated with hypertension, impaired glucose metabolism, CVD risk, and mortality risk. Prolonged sedentary behavior and physical activity are independently associated with sleep efficiency. However, it is not well documented how substituting time in sedentary behavior with physical activity affects sleep efficiency, especially among African-ancestry populations, who are at high risk for CVD. Aim: To determine if displacement of sedentary time with activity was cross-sectionally associated with higher sleep efficiency among African Caribbean men (n=231) and women (n=668) from the Tobago Health Study. Methods: Sleep efficiency, sedentary behavior (SB), light physical activity (LPA), and moderate to vigorous physical activity (MVPA) were collected using a SenseWear Pro Armband. Participants wore the armband at all times, except in water, for 4-7 days. We used the Isotemporal Substitution Framework paired with linear regression to examine associations of SB, LPA and MVPA with sleep efficiency adjusting for age, education, BMI, hypertension, diabetes, smoking, alcohol consumption, caffeine intake, and sleep medication. Results: Men (mean age ± Standard deviation: 63.2 ± 8.2 years; mean BMI 28.2 ± 4.8 kg/m 2 ) spent on average less time in SB (12.4 ± 2.9 hours/day) and more time in LPA (4.7 ± 2.1 hours /day) and MVPA (0.92 ± 0.88 hours/day) than women (mean age 55.6 ± 8.7 years; mean BMI 31.8 ± 6.4 kg/m 2 ) (all p-vales &lt;0.001). Men had lower sleep efficiency (74.6% ± 10.4) than women (81.2% ± 0.96; p-value &lt;0.001). Cross-sectionally reallocating 1 hour of SB with LPA was associated with a 1% higher sleep efficiency (p-value=0.016) in men and with a 0.37% higher sleep efficiency in women (p-value=0.074). In men, reallocating 1 hour of SB with MVPA and 1 hour of LPA with MVPA were significantly associated with lower sleep efficiency [-1.9% (p-value=0.014) and -2.8% (p-value=0.017), respectively]; in women these associations were not statistically significant. Interaction term for sex and sleep efficiency was statistically significant (p-value &lt;0.0001). Conclusions: In this population with short sleep duration, reallocating 1 hour of SB with LPA was associated with higher sleep efficiency in both genders. In contrast, among men only, reallocating 1 hour of SB to MVPA and 1 hour of LPA to MVPA were unexpectedly associated with lower sleep efficiency. Further research is warranted to understand these relationships longitudinally to determine how truly replacing SB for activities of different intensities impacts sleep health, which could then potentially inform lifestyle guidelines in older Caribbeans. In this highly sedentary population, interventions aimed at increasing LPA may be easier to implement and maintain and provide greater sleep and overall health benefit.

Abstract MP76: The Association Between Sleep Health and Gestational Weight Gain

Background: Poor sleep health is associated with weight gain and obesity outside of pregnancy. Still, there is little research regarding the impact of sleep health on weight among pregnant populations, particularly using a multidimensional sleep-health framework. This study examined associations between mid-pregnancy sleep health indicators, multidimensional sleep health, and gestational weight gain (GWG). Methods: This was a secondary data analysis of the Nulliparous Pregnancy Outcome Study: Monitoring Mothers-to-be Sleep Duration and Continuity Study (n=745). Indicators of individual sleep health domains (i.e., regularity, nap duration, timing, efficiency, and duration) were assessed via actigraphy between 16 and 21 weeks of gestation. We defined “good” sleep health in each domain based on empirical thresholds. Multidimensional sleep health was based on sleep profiles derived from latent class analysis. Total GWG, the difference between self-reported pre-pregnancy weight and the last measured weight before delivery, was converted to z-scores using gestational age- and BMI-specific charts. GWG was defined as low (&lt;-1 SD), moderate (-1 or +1 SD), and high (&gt;+1 SD). Results: We identified four distinct sleep profiles (Figure 1). While indicators of individual sleep domains were not associated with GWG, multidimensional sleep health was associated with higher risk of low GWG. Compared to people with a good sleep profile (Class 1), people with a low efficiency and long sleep duration profile (Class 4) had a 1.88 (95% CI 1.04 to 3.39) higher risk of low GWG (vs. moderate GWG) in models adjusting for education, depressive symptoms, race, smoking status. Discussion: Multidimensional sleep health was more strongly associated with GWG than were individual sleep domains. Future research should determine whether sleep health is a useful intervention target for optimizing GWG. Figure 1- Probabilities of each sleep characteristic by sleep profile, derived from latent class analysis

Animal models of human insomnia.

Insomnia disorder (chronic sleep continuity disturbance) is a debilitating condition affecting 5%-10% of the adult population worldwide. To date, researchers have attempted to model insomnia in animals through breeding strategies that create pathologically short-sleeping individuals or with drugs and environmental contexts that directly impose sleeplessness. While these approaches have been invaluable for identifying insomnia susceptibility genes and mapping the neural networks that underpin sleep-wake regulation, they fail to capture concurrently several of the core clinical diagnostic features of insomnia disorder in humans, where sleep continuity disturbance is self-perpetuating, occurs despite adequate sleep opportunity, and is often not accompanied by significant changes in sleep duration or architecture. In the present review, we discuss these issues and then outline ways animal models can be used to develop approaches that are more ecologically valid in their recapitulation of chronic insomnia's natural aetiology and pathophysiology. Conditioning of self-generated sleep loss with these methods promises to create a better understanding of the neuroadaptations that maintain insomnia, including potentially within the infralimbic cortex, a substrate at the crossroads of threat habituation and sleep.

Brain-derived neurotrophic factor (BDNF) variants and promoter I methylation are associated with prolonged nocturnal awakenings in older adults.

Brain-derived neurotrophic factor (BDNF) is important for sleep physiology. This study investigates whether BDNF variants and promoter I methylation may be implicated in sleep disturbances in older adults. Genotyping was performed for seven BDNF single nucleotide polymorphisms (SNPs) in 355 community-dwelling older adults (aged ≥65 years) and BDNF exon 1 promoter methylation was measured in blood samples at baseline (n=153). Self-reported daytime sleepiness and insomnia, ambulatory polysomnography measures of sleep continuity and architecture, and psychotropic drug intake were assayed during follow-up. Logistic regression adjusted for age, sex, comorbidities, body mass index, and psychotropic drug intake. Associations were found specifically between wake time after sleep onset (WASO) and four SNPs in the participants not taking psychotropic drugs, whereas in those taking drugs, the associations were either not significant (rs6265 and rs7103411) or in the reverse direction (rs11030101 and rs28722151). Higher BDNF methylation levels were found at most CpG units in those with long WASO and this varied according to psychotropic drug use. The reference group with short WASO not taking drugs showed the lowest methylation levels and the group with long WASO taking treatment, the highest levels. Some SNPs also modified the associations, the participants carrying the low-risk genotype having the lower methylation levels. This genetic and epigenetic study demonstrated blood BDNF promoter methylation to be a potential biomarker of prolonged nocturnal awakenings in older people. Our results suggest the modifying effect of psychotropic drugs and BDNF genetic variants in the associations between methylation and WASO.