BEHAVIORAL SLEEP MEDICINE 2018 UPDATE - DONNA ARAND, PHD, DABSM, FAASM SOCIETY OF BEHAVIORAL SLEEP MEDICINE SEPTEMBER 16-17, 2018 - SOCIETY OF ...

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BEHAVIORAL SLEEP MEDICINE 2018 UPDATE - DONNA ARAND, PHD, DABSM, FAASM SOCIETY OF BEHAVIORAL SLEEP MEDICINE SEPTEMBER 16-17, 2018 - SOCIETY OF ...
Behavioral Sleep Medicine
      2018 Update
      Donna Arand, PhD, DABSM, FAASM
     Society of Behavioral Sleep Medicine
            September 16-17, 2018
BEHAVIORAL SLEEP MEDICINE 2018 UPDATE - DONNA ARAND, PHD, DABSM, FAASM SOCIETY OF BEHAVIORAL SLEEP MEDICINE SEPTEMBER 16-17, 2018 - SOCIETY OF ...
Conflict of Interest Disclosures
Speaker:
   1. I do not have any potential conflicts of interest to disclose, OR
         2. I wish to disclose the following potential conflicts of interest

                                                                          Details of Potential Conflict

        Grant/Research Support

               Consultant
           Speakers’ Bureaus
            Financial support
                  Other

          3. The material presented in this lecture has no relationship with any of these potential conflicts, OR

          4. This talk presents material that is related to one or more of these potential conflicts, and the following objective
          references are provided as support for this lecture:

  1.
  2.
  3.
BEHAVIORAL SLEEP MEDICINE 2018 UPDATE - DONNA ARAND, PHD, DABSM, FAASM SOCIETY OF BEHAVIORAL SLEEP MEDICINE SEPTEMBER 16-17, 2018 - SOCIETY OF ...
Outline
I.     Guidelines, Recommendations and Legislation
II.    Infants, adolescents and college students
III.   Treatment of Insomnia
IV.    Understanding Insomnia
BEHAVIORAL SLEEP MEDICINE 2018 UPDATE - DONNA ARAND, PHD, DABSM, FAASM SOCIETY OF BEHAVIORAL SLEEP MEDICINE SEPTEMBER 16-17, 2018 - SOCIETY OF ...
Guidelines Recommendations and Legislation
BEHAVIORAL SLEEP MEDICINE 2018 UPDATE - DONNA ARAND, PHD, DABSM, FAASM SOCIETY OF BEHAVIORAL SLEEP MEDICINE SEPTEMBER 16-17, 2018 - SOCIETY OF ...
AASM Position Paper for
                        Treatment of Nightmare Disorder
• Recommended for PTSD-associated nightmares and nightmare disorder: image
  rehearsal therapy.

• May be used for PTSD-associated nightmares: cognitive behavioral therapy;
  cognitive behavioral therapy for insomnia; eye movement desensitization and
  reprocessing; exposure, relaxation, and rescripting therapy;
  the atypical antipsychotics olanzapine, risperidone and aripiprazole; clonidine;
  cyproheptadine; fluvoxamine; gabapentin; nabilone; phenelzine; prazosin;
  topiramate; trazodone; and tricyclic antidepressants.
• May be used for nightmare disorder: cognitive behavioral therapy; exposure,
  relaxation, and rescripting therapy; hypnosis; lucid dreaming therapy; progressive
  deep muscle relaxation; sleep dynamic therapy; self-exposure therapy; systematic
  desensitization; testimony method;                             nitrazepam;
  prazosin; and triazolam.
• Not recommended for treatment of nightmare disorder: clonazepam and
  venlafaxine.
Morgenthaler TI, Auerbach S, Casey KR, Kristo D, Maganti R, Ramar K, Zak R, Kartje R. Position paper for the treatment of nightmare disorder in
adults: an American Academy of Sleep Medicine position paper. J Clin Sleep Med. 2018;14(6):1041–1055.
BEHAVIORAL SLEEP MEDICINE 2018 UPDATE - DONNA ARAND, PHD, DABSM, FAASM SOCIETY OF BEHAVIORAL SLEEP MEDICINE SEPTEMBER 16-17, 2018 - SOCIETY OF ...
AASM Clinical Practice Guidelines for use of
             Actigraphy in Insomnia
No recommendations only Conditional suggestions for clinician use (lower degree of certainty)

• Use actigraphy to estimate sleep parameters in adult patients with insomnia disorder (Conditional)
    • Significant large mean differences between sleep logs and actigraphy in TST, SL and SE
    • Small differences between actigraphy and PSG in TST, SL
• Use actigraphy in the assessment of pediatric patients with insomnia disorder. (Conditional)
    • Significant large mean differences between sleep logs and actigraphy for TST and WASO
• Use actigraphy in assessment of adult patients with circadian rhythm sleep-wake disorder (Conditional)
    • Significant large mean differences between sleep logs and actigraphy for sleep onset and termination
• Use actigraphy in assessment of pediatric patients with circadian rhythm sleep-wake disorder (Conditional)
    • Significant large mean sleep difference between sleep logs and actigraphy in TST

Smith MT, McCrae CS, Cheung J, Martin JL, Harrod CG, Heald JL, Carden KA. Use of actigraphy for the evaluation of sleep disorders and
circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2018;14(7):1231–
1237.
BEHAVIORAL SLEEP MEDICINE 2018 UPDATE - DONNA ARAND, PHD, DABSM, FAASM SOCIETY OF BEHAVIORAL SLEEP MEDICINE SEPTEMBER 16-17, 2018 - SOCIETY OF ...
CDC reports insufficient sleep is common in
    middle school and high school students
Anonymous, voluntary, school-based paper and pencil questionnaire (Youth Risk Behavior Survey)
during regular class period
• Nationally about 58% of middle school students and 73% of high school students get insufficient
  sleep on school nights
• 50-64% of middle school students (n=52,000; 9 states) get < 9 hrs (KY -64%)
• 61-82% of high school students in grades 9-12 (n=14,000; 30 states) get
BEHAVIORAL SLEEP MEDICINE 2018 UPDATE - DONNA ARAND, PHD, DABSM, FAASM SOCIETY OF BEHAVIORAL SLEEP MEDICINE SEPTEMBER 16-17, 2018 - SOCIETY OF ...
California law would require middle school and
high school to start no earlier than 8:30 am
• Law was passed by legislature and waiting for Governor’s signature
• Start time law SB 328 would be effective July 1, 2021

    8:30

                                  8
BEHAVIORAL SLEEP MEDICINE 2018 UPDATE - DONNA ARAND, PHD, DABSM, FAASM SOCIETY OF BEHAVIORAL SLEEP MEDICINE SEPTEMBER 16-17, 2018 - SOCIETY OF ...
Economic Cost of Inadequate Sleep
• Estimated cost of inadequate sleep in Australia for 2016-17 and related
  to costs in similar economies using national surveys and databases.

• Overall cost of inadequate sleep is $45.21 billion
      • Direct cost was $17.88B and indirect was $27.33B
      • $160 million for sleep disorders

• David Hillman, Scott Mitchell, Jared Streatfeild, Chloe Burns, Dorothy Bruck, Lynne Pezzullo; The economic cost of inadequate sleep, Sleep,
  Volume 41, Issue 8, 1 August 2018,
BEHAVIORAL SLEEP MEDICINE 2018 UPDATE - DONNA ARAND, PHD, DABSM, FAASM SOCIETY OF BEHAVIORAL SLEEP MEDICINE SEPTEMBER 16-17, 2018 - SOCIETY OF ...
Infants, adolescents and college students
Early Nighttime Parental Interventions and Infant
        Sleep Regulation Across the First Year
• Objective: To investigate how sleeping arrangement and 2 types of
  nighttime interventions(non distress and distress) at 1 and 3 months are
  associated with infants’ sleep development across the first 9 months.
• Method:
      • Participants: 107 families with solitary or cosleeping infants
      • Design: observation and survey at 1, 3, and 9 months
      • Measures:
             • Solitary and cosleeping infants
             • # distress-initiated wakings (DIW)
             • # non-distress initiated wakings (NDIW) (parents’ behaviors to non-distressed vocalizations or
               while infants were asleep)
Voltaire, ST, Teti, DM. Early Nighttime Parental Interventions and Infant Sleep Regulation Across the First Year. Sleep 2018, July13.
Parental Interventions and Infant Sleep
                         Regulation
• Results
      • Infant night wakings decreased over time
      • Non-distress initiated interventions moderated by sleep arrangement
             • Solitary sleeping infants with higher levels of NDIW showed less steep decline in wakings
               compared to solitary infants with low NDIW
      • Higher DIW at 1 and 3 months resulted in steeper decrease in night wakings for both
        solitary and cosleeping infants.
• Conclusion
      •   Responding to nighttime distress before 3 months predicts better infant sleep
      •   Not responding to non-distress before 3 months predicts better sleep
      •   Parental interventions after 3 month does not have similar impact
      •   Very early patterns of nighttime parenting may organize infant sleep          sleep
          regulation

Voltaire, ST, Teti, DM. Early Nighttime Parental Interventions and Infant Sleep Regulation Across the First Year.
Sleep 2018, July13
Midday Napping and Neurocognitive Function
           in Early Adolescents
• Participants: 363 chinese adolescents (12 + 0.38 years)
• Method: self-reported midday napping, nighttime sleep duration and sleep
  quality, computerized neurocognitive battery (accuracy and reaction time)

•   Xiaopeng Ji, Junxin Li & Jianghong Liu (Feb 2018) The Relationship Between Midday Napping And Neurocognitive Function in Early Adolescents,
    Behavioral Sleep Medicine
Napping and Neurocognitive in Early
                        Adolescents
• Results
     • 64% took >3 naps per week
     • 70% took naps over 30 minutes
     • Ss with frequent or longer naps reported significantly better night sleep quality
           • Frequent nappers (5-7d/week) had significantly better accuracy on sustained attention and
             nonverbal reasoning, faster reaction times on spatial memory
           • Naps of any length resulted in faster reaction time compared to non-nappers
           • Moderate duration nappers (31-60 min) had both faster speeds and greater accuracy

Conclusion: There is an association between habitual napping and
neurocognitive function in early adolescents. Naps 31-60 min seemed best
for speed and accuracy.
Xiaopeng Ji, Junxin Li & Jianghong Liu (Feb 2018) The Relationship Between Midday Napping And Neurocognitive Function in Early
Adolescents, Behavioral Sleep Medicine, DOI:
Sleep Hygiene Index as a Screening Tool in Nigerian
                     Students
• Purpose: To determine characteristics and usefulness of the sleep
  hygiene index in Nigerian undergraduate students
• Methods
      • Participants: 348 students randomly divided in two prior to factor analysis
      • Measures: SHI, PSQI, ESS, Morningness Eveningness Questionnaire (MEQ)

Seun-Fadipe CT, Aloba OO, Oginni OA, Mosaku KS. Sleep hygiene index: psychometric characteristics and usefulness as a screening tool in a
sample of nigerian undergraduate students. J Clin Sleep Med. 2018;14(8):1285–1292
Sleep Hygiene Index

• Results of SHI:
     •   SHI Internal consistency was .64
     •   Significant negative correlation with MEQ (r=-0.17)
     •   Significant positive correlation with PSQI (r=0.89)
     •   Significant positive correlation with ESS (r=0.29)
     •   Exploratory factor analysis in group 1 yielded 3 factors
     •   Corroborative factor analysis in group 2
     •   Cutoff score of 16 on SHI had sensitivity of .77 and specificity of 0.47 to identify
         students experiencing poor sleep quality
• Conclusion: SHI has satisfactory psychometric properties for evaluating
  sleep hygiene and as a screening instrument for poor sleep quality among
  Nigerian undergraduate students.
Seun-Fadipe CT, Aloba OO, Oginni OA, Mosaku KS. Sleep hygiene index: psychometric characteristics and usefulness as a screening
tool in a sample of nigerian undergraduate students. J Clin Sleep Med. 2018;14(8):1285–1292
Acceptability of Smartphone Applications for Improving Sleep
       Behavior in Low Income and Minority Adolescents
• Purpose: to determine acceptability and components to motivate
  engagement
• Participants: N=27 (age 14-18) low income and ethnically diverse group
• Method:
      • Three focus groups
      • Specific feedback on two commercial sleep promoting apps from 10 participants
        who had used one on their smart phone prior to interview, thematic analysis

Mirja Quante, Neha Khandpur, Emily Z. Kontos, Jessie P. Bakker, Judith A. Owens & Susan Redline (2018) A Qualitative Assessment of the
Acceptability of Smartphone Applications for Improving Sleep Behaviors in Low-Income and Minority Adolescents, Behavioral Sleep Medicine,
DOI: 10.1080/15402002.2018.1432483
Acceptability of Smartphone Sleep Apps

• Results:
      • Barriers identified
            • reluctance to follow schedule on weekends
            • concern about parting with electronics at bedtime
      • Intrigued by idea but skeptically they could adopt sleep hygiene practices
      • More interested in making changes on weekdays than on weekends
      • Feedback on 2 sleep apps not targeting adolescents was positive with good
        adherence and engagement and perceived health benefits
• Conclusion
      • Need to adapt sleep hygiene apps to targeted populations and consider social and
        cultural factors
      • Importance of platform, setting and messenger to deliver info to adolescents

Mirja Quante, Neha Khandpur, Emily Z. Kontos, Jessie P. Bakker, Judith A. Owens & Susan Redline (2018) A Qualitative Assessment of the
Acceptability of Smartphone Applications for Improving Sleep Behaviors in Low-Income and Minority Adolescents, Behavioral Sleep Medicine,
DOI: 10.1080/15402002.2018.1432483
Insomnia Treatment
Exposure, Relaxation and Rescripting Therapy
(ERRT) for trauma-related nightmares
• Objective: To conduct a dismantling study of exposure, relaxation and
  rescripting therapy for nightmares
• Method
       • Participants (n=70) reported mean of 6 traumatic events,
         mean 30 nightmares/mos, mean nights with nightmares was 4
       • Design:
              • Randomized to 2 conditions
                     • ERRT with nightmare exposure and rescripting (EX) n=37, Exposure 30 min in 1 session
                     • ERRT without nightmare exposure and rescripting (NEX) n=33
              • follow-up at 1 week, 3 months and 6 months post treatment
       • Measures: nights with nightmares, nightmares per week and nightmare severity
              • Secondary measures: insomnia, depression, fear of sleep, PTSD, sleep quality
•   Pruiksman KE,Cranston CC, Rhudy JL, Micol RL, Davis JL. Randomized controlled trial to dismantle exposure, relaxation and rescripting therapy for
    trauma-related nightmares. Psychological Truama: Theory, Research, Practice and Policy, 2018, Jan; 10(1), 67-75.
ERRT for Trauma for Nightmares
                                                                                     Insomnia                                                       Nightmare Severity
                                           18
                                                                                                                                  4.5
                                           16
                                                                                                                                   4
                 Insomnia Severity Scale

                                           14
                                                                                                                                  3.5

                                                                                                              Nigtmare Severity
                                           12
                                                                                                                                   3
                                           10
                                                                                                                                  2.5
                                                   8
                                                                                                                                   2
                                                   6
                                                                                                                                  1.5
                                                   4               No exposure                                                               No exposure
                                                                                                                                   1
                                                   2
                                                                   Exposure                                                       0.5        Exposure
                                                   0
                                                                                                                                   0
                                                              baseline     1-month      3-month    6-month
                                                                                                                                        baseline    1-month   3-month   6-month
                                                                         # Nights with Nightmares                                                  Nightmare Frequency
                                                         4                                                                        4.5
                                                        3.5                                                                        4
                                                         3                                                                        3.5

                                                                                                              Nightmares/week
                                     Number of nights

                                                                                                                                   3
                                                        2.5
                                                                                                                                  2.5
                                                         2
                                                                                                                                   2
                                                        1.5
                                                                                                                                  1.5
                                                         1           No exposure                                                   1         No exposure
                                                        0.5                                                                       0.5
                                                                     Exposure                                                                Exposure
                                                         0                                                                         0
                                                                baseline      1-month    3-month    6-month                             baseline    1-month   3-month   6-month
ruiksman KE,Cranston CC, Rhudy JL, Micol RL, Davis JL. Randomized controlled trial to dismantle exposure, relaxation and rescripting therapy for trauma-related nightmares. Psychological Truama:
Theory, Research, Practice and Policy, 2018, Jan; 10(1), 67-75.
ERRT for Trauma Related Nightmares
                                        PTSD Severity                                                                                        Depression
                  60                                                                                     30

                  50                                                                                     25

                                                                                     Depression Scale
                  40                                                                                     20
           PTSD

                  30                                                                                     15

                  20                                                                                     10
                                                    No exposure                                                                                          No exposure
                  10                                                                                             5
                                                    Exposure                                                                                             Exposure
                   0                                                                                             0
                         baseline   1-month   3-month      6-month                                                         baseline     1-month    3-month     6-month

                                          Fear of Sleep                                                                                      Sleep Quality
            40                                                                                                        16
            35                                                                                                        14
            30                                                                                                        12

                                                                                                   Quality of Sleep
            25                                                                                                        10
            20                                                                                                         8
            15                                                                                                         6
            10                                          No exposure                                                    4                                     No exposure
             5                                                                                                         2                                     Exposure
                                                        Exposure
             0                                                                                                         0
                       baseline     1-month   3-month        6-month                                                         baseline    1-month    3-month      6-month
Pruiksman KE,Cranston CC, Rhudy JL, Micol RL, Davis JL. Randomized controlled trial to dismantle exposure, relaxation and rescripting therapy for trauma-related
nightmares. Psychological Truama: Theory, Research, Practice and Policy, 2018, Jan; 10(1), 67-75.
ERRT for Trauma Related Nightmares
• Results:
     • ERRT with and without nightmare exposure significantly improved outcomes (nights
       with nightmares, nightmares per week, nightmare severity)
     • Both conditions significantly improved on fear of sleep, sleep quality, insomnia
       severity, daytime sleepiness, PTSD symptom severity and depression severity.
     • Significant main effect for time for all variables
     • No difference between groups at any point

Conclusions: ERRT with and without nightmare exposure and rescripting can
significantly alleviate nightmare and related distress.
Pruiksman KE,Cranston CC, Rhudy JL, Micol RL, Davis JL. Randomized controlled trial to dismantle exposure, relaxation and rescripting
therapy for trauma-related nightmares. Psychological Truama: Theory, Research, Practice and Policy, 2018, Jan; 10(1), 67-75
Aerobic Exercise vs CBT-I in Cancer Patients
• Objective: Access the efficacy of 6-week home based aerobic exercise program
  (EX) compared to 6-week self-administered CBT-I
• Method:
      • Participants: 41 patients (78% F, mean age 57) with various types of Cancer and insomnia
        (ISI>8)
      • Design: randomized controlled trial, repeated measures
            • Groups: Exercise (EX) (n-20) and CBT (n=21)
            • Testing: pre- and post-treatment, 3 and 6 month follow-up
      • Measures:
            • ISI
            • PSQI
            • sleep diaries (SOL, WASO, TWT and SE)

Mercier J, Ivers H, Savard J. A non-inferiority randomized controlled trial comparing a home-based aerobic exercise program to a self
administered CBT-I in cancer patients. Sleep 2018, Jul 25
Exercise vs CBT-I in Cancer Patients
                                                      Insomnia Severity Index Score
                                                                                                                                                            PSQI
                                             18
                                                                                                                 14
                                             16
             Insomnia Severity Index Score

                                             14                                                                  12
                                             12                                                                  10
                                             10

                                                                                                PSQI Score
                                                                                                                       8
                                              8
                                              6                                                                        6

                                              4                                    CBT-I                               4
                                                                                                                                                                         CBT-I
                                              2                                    Exercise                            2                                                 Exercise
                                              0
                                                      Pre     Post    3-month FU 6-month FU                            0
                                                                                                                                  Pre              Post     3 month FF   6 month FU

                                                             Sleep Onset Latency                                                                            WASO
                                              45                                                                             70
                                              40                                                                             60
                                              35
                                                                                                                             50

                                                                                                             Minutes Awake
                                              30
                                 Minutes

                                              25                                                                             40
                                              20                                                                             30
                                              15
                                                                                                                             20
                                              10                                                                                        CBT-I
                                                                                     CBT-I
                                                  5                                                                          10
                                                                                                                                        Exercise
                                                                                     Exercise
                                                  0                                                                           0
                                                       Pre     Post    3-month FU 6-month FU                                        Pre              Post    3-month FU 6-month FU
Mercier J, Ivers H, Savard J. A non-inferiority randomized controlled trial comparing a home-based aerobic exercise program to a self administered CBT-I in cancer patients. Sleep 2018, Jul 25
Exercise vs CBT-I in Cancer Patients

                                 Total Sleep Time                                                       Sleep Efficiency
                    460                                                                      90

                    440                                                                      85

                                                                       % Sleep Efficiencyy
                    420                                                                      80
 Minutes of Sleep

                    400                                                                      75

                    380                                                                      70
                                                     CBT-I
                                                                                                                            CBT-I
                    360                                                                      65
                                                     Exercise
                                                                                                                            Exercise
                    340                                                                      60
                          Pre    Post   3-month FU      6-month FU                                Pre   Post   3-month FU    6-month FU

Mercier J, Ivers H, Savard J. A non-inferiority randomized controlled trial comparing a home-based aerobic exercise program to a self
administered CBT-I in cancer patients. Sleep 2018, Jul 25
Exercise vs CBT-I in Cancer Patients by Patient
                                    Preference
                                        ISI                                                   Sleep Efficiency                                           PSQI
            18
                                                                                   90                                              16

            16                                                                     80                                              14
            14                                                                     70
                                                                                                                                   12

                                                              % Sleep Efficiency
            12                                                                     60
                                                                                                                                   10

                                                                                                                      PSQI score
ISI Score

            10                                                                     50
                                                                                                                                   8
             8                                                                     40
                                                                                                     CBT-I matched                 6
             6         CBT-I matched                                               30                                                   CBT-I matched
                                                                                                     EX-matched                    4    EX-matched
             4         EX-matched                                                  20
                       CBT-I mismatch                                                                CBT-I mismatch                     CBT-I mismatch
             2                                                                     10                                              2
                       EX mismatch                                                                   EX mismatch                        EX mismatch
             0                                                                      0                                              0
                          Pre                 Post                                      Pre             Post                               Pre              Post

                 Mercier J, Ivers H, Savard J. A non-inferiority randomized controlled trial comparing a home-based aerobic exercise program to a self
                 administered CBT-I in cancer patients. Sleep 2018, Jul 25
Exercise vs CBT-I in Cancer Patients

• Results
      • Exercise and CBT-I significantly improved ISI, PSQI and most sleep diary parameters at FU
        (significant main effect of time)
      • Exercise was statistically inferior to CBT-I at post treatment based on ISI
      • Exercise was non-inferior at follow-up
      • Objective actigraphy data did not significantly differ between groups
      • General persistence of sleep difficulties in CBT-I and EX with remission rates of 30% and 35%
        respectively post treatment and at follow-up

• Conclusions:
      • Exercise and CBT-I significantly improved sleep
      • CBT-I remains treatment of choice in CA-related insomnia, although exercise has some
        beneficial effects

Mercier J, Ivers H, Savard J. A non-inferiority randomized controlled trial comparing a home-based aerobic exercise program to a self
administered CBT-I in cancer patients. Sleep 2018, Jul 25
Zero-time exercise on inactive adults with
             Insomnia Disorder: pilot RCT
• Objective: To evaluate the effects of lifestyle-integrated zero-time
  exercise on insomnia in inactive adults with insomnia disorder
• Method:
      • Participants- 37 physically inactive adults (49.9 +13.6 years, 91.9%F)
        with insomnia disorder from community
      • Design: Random controlled trial
            • ZTEx (n-18) attended two 2-hr training lesson on ZTEx & practiced daily for 8 weeks
            • Sleep hygiene education (SHE) (n=19) attended two 2-hr lessons on same schedule
      • Measures: ISI, actigraphy, sleep dairy
• Wing-Fai Yeung, Agnes Yuen-Kwan Lai,Fiona Yan-Yee Ho, Lorna Kwai-Ping Suen,Ka-Fai Chung, Janice Yuen-Shan Ho, Lai-Ming Ho, Branda Yee-
  Man Yu,Lily Ying-Tung Chan, Tai-Hing Lam. Effects of Zero-time Exercise on inactive adults with insomnia disorder: A pilot randomized
  controlled trial. SleepMedicine, 2018.
Zero-time Exercise in Insomnia

• Results:
      • ZTEx had lower ISI scores than SHE with large between group effect size of 0.94-
        1.10 at weeks 2,4,6,8 but difference was non-significant at 8 weeks.
      • No difference in sleep diary or actigraphy
      • 83% finished ZTEx training and
      • 78% did ZTEx >5 days per week for 8 weeks

Conclusion: Simple and brief ZTEx training has high acceptability and
compliance and effectively reduced ISI in inactive adults with Insomnia.
Wing-Fai Yeung, Agnes Yuen-Kwan Lai,Fiona Yan-Yee Ho, Lorna Kwai-Ping Suen,Ka-Fai Chung, Janice Yuen-Shan Ho, Lai-Ming Ho, Branda Yee-Man
Yu,Lily Ying-Tung Chan, Tai-Hing Lam. Effects of Zero-time Exercise on inactive adults with insomnia disorder: A pilot randomized controlled trial.
SleepMedicine, 2018.
Comparative Treatments for Insomnia and
           Sleep Quality in Hot Flashes
• Purpose: Assess interventions for insomnia in women with
  vasomotor symptoms (VMS)
• Method:
      • Design: Pooled data from 4 RCT n=546 peri and
        postmenopausal F with ISI >12, >14 VMS/week.
      • Interventions: escitalopram 10-20 mg/d, yoga, aerobic exercise, 1.8g/d
        omega 3 fatty acids, 17-beta estradiol 0.5mg.d, venlafaxine XR 75mg.d, and
        CBT-I
      • Outcomes: ISI, PSQI at baseline, 4 weeks, 8 weeks and some at 12 weeks

Katherine A Guthrie et al. Sleep, Volume 41, Issue 1, 1 January 2018, zsx190. Effects of Pharmacologic and Nonpharmacologic Interventions on
Insomnia Symptoms and Self-reported Sleep Quality in Women With Hot Flashes: A Pooled Analysis of Individual Participant Data From Four
MsFLASH Trials
Treatments for Insomnia and Sleep Quality in Hot Flashes

                                          ISI changes compared to control                                                                             PSQI
                               1
                                                                                                                                      0

                               0
                                                                                                                                    -0.5

                               -1

                                                                                                    PSQI Difference form Baseline
ISI Difference from Baseline

                                                                                     Escitalopram
                                                                                                                                     -1
                                                                                     Exercise
                               -2
                                                                                     Yoga
                                                                                     Omega-3                                        -1.5
                               -3
                                                                                     Estradiol
                                                                                     Venlafaxine                                     -2
                               -4                                                    CBT-i

                                                                                                                                    -2.5
                               -5

                                      0                4                  8
                               -6                                                                                                    -3    0   4             8
                                                       Weeks                                                                                       Weeks

                               Katherine A Guthrie et al. Sleep, Volume 41, Issue 1, 1 January 2018, zsx190. Effects of Pharmacologic and Nonpharmacologic
                               Interventions on Insomnia Symptoms and Self-reported Sleep Quality in Women With Hot Flashes: A Pooled Analysis of Individual
                               Participant Data From Four MsFLASH Trials
Treatments for Insomnia and Sleep Quality in
                  Hot Flashes
• Results:
     • CBT-I produced the greatest reduction in ISI from baseline compared to controls -5.2 points
       (95% CI -7.0 to -3.4)
     • Exercise and venlafaxine were similar (-2.1 and -2.3)
     • CBT-I produced largest reduction in PSQI of -2.7 points (-3.9 to -1.5)
     • Yoga, exercise, estradiol, venlafaxine and escitalopram produced significant decrease of 1.2-
       1.6 points
     • Omega-3 supplements did not improve insomnia symptoms

Conclusion: Results support the recommendation for CBT-I as a first line treatment
in healthy midlife women with insomnia symptoms and moderately bothersome
VMS.

Katherine A Guthrie et al. Sleep, Volume 41, Issue 1, 1 January 2018, zsx190. Effects of Pharmacologic and Nonpharmacologic
Interventions on Insomnia Symptoms and Self-reported Sleep Quality in Women With Hot Flashes: A Pooled Analysis of Individual
Participant Data From Four MsFLASH Trials
CBT-I and Neuropsychological Functioning in Older Adults
            with Mild Cognitive Impairment
• Purpose: Determine if CBT-I improves sleep and cognitive function in
  older adults with mild cognitive impairment
• Methods:
     • 6 session CBT-I
     • 2 groups –
           • CBT-I (n=14)
           • Active control (n=14)
     • Neuropsychological battery at baseline, post-treatment and 4 month FU

Cassidy-Eagel E, Siebern A, Unti L, Glassman J, O’Hara R. Neuropsychological Functioning in Older Adults with Mild Cognitive
  Impairment and Insomnia Randomized to CBT-I or Control Group Clin Gerontol, 2018 Mar-Apr;41(2):136-144.
CBT-I and Neuropsychological Functioning
• Results:
      • significant improvement in sleep
      • a significant change on a key measure of executive functioning sub task of inhibition
        (Condition 3 of D-KEF Color-Word Interference Test),
      • a positive trend on the inhibition-switching task (p < .10;) Condition 4 of D-KEF Color-
        Word Interference Test),
      • no change in a measure of verbal memory (HVLT-R Delayed Recall) compared with
        the active control
• Conclusion: CBT-I has potential to improve sleep and cognitive function in
  older adults with MCI

Cassidy-Eagel E, Siebern A, Unti L, Glassman J, O’Hara R. Neuropsychological Functioning in Older Adults with Mild Cognitive Impairment and
Insomnia Randomized to CBT-I or Control Group Clin Gerontol, 2018 Mar-Apr;41(2):136-144.
CBT for Older Adults with Insomnia and
                       Depression
• Purpose: To determine if CBT-I is effective for older adults with comorbid insomnia and
  depression and compare CBT- I to CBT-I plus mood strategies (CBT-I+)
• Methods:
     • Participants: n=72 (56% F, age 75 +7) with comorbid insomnia & depression DX
       based on DSM-5, clinical interviews; ISI and GDS >10)
           • Exclusions: cognitive impairment, changes in psychotropic meds in 4 wks, high risk, in ECT or
             psychotherapy
     • Design:
           • 8-week RCT within community mental health services
           • 3 conditions in group therapy, 60-90min (CBT-I, CBT-I+, Psychoeducation control group)
           • No demographic or sleep and mental health characteristics differences between groups
     • Measures:
           • ISI, Geriatric Depression Scale at pre, post, FU (weeks 0, 8, 30 respectively)

• Paul Sadler, Suzanne McLaren, Britt Klein, Jack Harvey, Megan Jenkins; Cognitive behavior therapy for older adults with
  insomnia and depression: a randomized controlled trial in community mental health services, Sleep, Volume 41, Issue 8, 1
  August 2018
CBT-I in Insomnia and Depression

                             Insomnia Severity Index                                                                        Depression Severity
                                                                                                                       20
            20
                                                                                                                       18
            18
                                                                                                                       16
            16

                                                                                          Geriatric Depression Scale
                                                                                                                       14
            14

            12                                                                 CBT-I                                   12
ISI Score

            10                                                                 CBT-I+                                  10

             8                                                                 Control                                  8

             6                                                                                                          6

             4                                                                                                          4

             2                                                                                                          2

             0                                                                                                          0
                       Pre           Post         Follow-up                                                                      Pre        Post   Follow-up

                 Paul Sadler, Suzanne McLaren, Britt Klein, Jack Harvey, Megan Jenkins; Cognitive behavior therapy for older adults with
                 insomnia and depression: a randomized controlled trial in community mental health services, Sleep, Volume 41, Issue 8, 1
                 August 2018
CBT in Insomnia & Depression
• Results:
     • CBT-I and CBT-I+ both showed significantly greater reduction in insomnia and
       depression severity compared to PCG control
     • Large effects sizes, high retention and strong remission rates
     • Results were maintained at follow-up

• Conclusion: CBT-I, and CBTI+ were both effective in reducing
  insomnia and depression severity in older adults.

Paul Sadler, Suzanne McLaren, Britt Klein, Jack Harvey, Megan Jenkins; Cognitive behavior therapy for older adults with
insomnia and depression: a randomized controlled trial in community mental health services, Sleep, Volume 41, Issue 8, 1
August 2018
Music and Sleep Quality in Primary Insomnia-
               a Meta-analysis
• Purpose: To determine if music improves sleep quality in adults with
  primary insomnia
• Method: Network meta-analysis
      • Databases: PubMed, Embase, Cochrane Library,
        China National Knowledge Infrastructure Library
      • Publications from 1998 to May 2017
      • Music interventions for primary insomnia
      • Outcome was sleep quality (PSQI and overall sleep quality)
      • Secondary outcomes were sleep latency and sleep efficiency

Feng F, Zhang Y, Hou J, Cai J, Jiang Q, Li X, Zhao Q, Li BA. Can music improve sleep quality in adults with primary insomnia? A systematic review
   and network meta-analysis. Int J Nurs Stud. 2018 Jan;77:189-196.
Music and Sleep Quality
• Results:
      • 20 trials, N=1339 insomnia patients; 684 music intervention groups; 655 no music control
      • 12 treatment groups: acupuncture, music & language induction, listening to music, music and
        acupuncture, music assisted relaxation, music assisted relaxation and stimulus control, music
        with exercise, stimulus control, usual care (health info and hypnosis), western medicine,
        placebo music
      • All interventions significantly better than usual care for improving PSQI
      • Only music-associated relaxation was significantly better than usual care for improving
        overall sleep quality
      • Only music-assisted relaxation and listening to music had significant advantages for sleep
        latency
      • Listening to music top rated intervention by patients and ranked best for improving SE
• Conclusions:
      • Music intervention offers clear advantages for adults with primary insomnia.
      • Listening to music and music-associated relaxation are probably the best options to consider
        in the application of music intervention.

Feng F, Zhang Y, Hou J, Cai J, Jiang Q, Li X, Zhao Q, Li BA. Can music improve sleep quality in adults with primary insomnia? A systematic review
and network meta-analysis. Int J Nurs Stud. 2018 Jan;77:189-196.
Blocking Nocturnal Blue Light for Insomnia
• Purpose: To determine if wearing amber-tinted blue light-blocking lenses before bed improves
  sleep in individuals with insomnia
• Method:
     • Participants: n=14 (8 F; age 46.6 + 11.5) with insomnia >3 months (ISQ)
           • Exclusion: OSA, sleep disorders, >5 on STOP-Bang, shift work, smoker, beta blockers,
             psychiatric disorder, antidepressives or anti anxiety meds, pregnant, breastfeeding of caffeine >400mg/day
     • Design:
           • Randomized placebo controlled crossover design
           • Amber or clear lens glasses worn for 2 hrs before bedtime for 1 week with 4 wk washout
           • Told to put on glasses during night awakening if light turned on, electronic device used or got out of bed
     • Measures:
           • Pittsburgh Insomnia Rating Scale and Quality of Life, Distress and Sleep Parameter subscales completed at 1800
             after 7-d of intervention
           • Post sleep questionnaire completed every day (SOL, TST, WASO, overall evaluation of sleep and soundness)
           • Log of when used the glasses
           • Actigraphy

Shechter, A, Kim EW, St-Onge, MP, Westwood, AJ. Blocking nocturnal blue light or insomnia: A randomized controlled trial. J Psychi
Res, Jan 2018, 96, 196-202
Blocking Nocturnal Blue Light
• Results: Compared to clear lenses, amber lenses significantly
  improved:
   •   PIRS total score (88 vs 72)
   •   QOL (18 vs 14)
   •   Distress (56 vs 46)and Sleep Parameter subscales (13 vs 11)
   •   Overall quality & soundness of sleep significantly higher (3.3 vs 4; 3.3 vs 4.3)
   •   Reported wake up time significantly delayed (6h:47m vs 7h:15m)
   •   Subjective TST increased (347 vs 399 min)
   •   No difference in actigraphy sleep parameters between groups
Conclusion: Amber lenses are a safe, affordable and an easily
implemented therapeutic intervention for insomnia symptoms.
Understanding Insomnia
Explanations Given for Going to Bed Late
• Participants: N=17 (7F) ages 20-62 who were frequent bedtime
  procrastinators and without a Dx of sleep disorders or shift work
• Method: in-depth structured interview and thematic analysis
• Results: Three emerging themes
       • Deliberate procrastination- willful delay because they deserved time for themselves
       • Mindless procrastination- lost track of time
       • Strategy delay- need delay in order to fall asleep quickly

• Conclusion: Different causes can direct interventions
•   Sanne Nauts, Bart A. Kamphorst, Wim Stut, Denise T. D. De Ridder & Joel H. Anderson (2018) The Explanations People Give for Going to Bed Late: A
    Qualitative Study of the Varieties of Bedtime Procrastination, Behavioral Sleep Medicine
Insomnia as a Path to Alcoholism
• Objective: To assess the risks of Alcohol as a sleep aid by evaluating tolerance
  development to sedative–hypnotic effects and subsequent dose escalation
• Method:
     • Participants: volunteers 21-55 (50% F) with insomnia (DSM-4: SE
Insomnia a Path to Alcoholism
• Exp 1 - comparison between night 2 (N2) of alcohol vs night 6 (N6)
   •   0.6g/kg dose had higher SE and TST on N2 compared to 0 and 0.3g/kg (p
Insomnia and Alcohol

                                % Nights Alcohol Chosen                                                     Number of Refills
                           60                                                                  8
                                   54                                                                                          Placebo
                                                                                               7
                           50                                                                                                  Alcohol

                                                                                               6
 % Nights Alcohol Chosen

                           40                                      37

                                                                           Number of Refills
                                                                                               5

                           30                                                                  4

                                                                                               3
                           20

                                                                                               2
                           10
                                                                                               1

                            0                                                                  0
                                 Alcohol                         Placebo                           Alcohol pre Tx      Placebo preTX
                                           Pre Treatment Group

Timothy Roehrs, Thomas Roth; Insomnia as a path to alcoholism: tolerance development and dose escalation, Sleep,
Volume 41, Issue 8, 1 August 2018
Insomnia a Pathway to Alcohol

Results:
• 0.6 g/kg ethanol increased TSE and stage 3 on night 2, effects lost by night 6
• After 6 nights of pretreatment, choice nights had more self-administered ethanol
  refills than placebo

Conclusion:
• Alcohol is a risk as a sleep aid among individuals with insomnia.
• Initially a moderate dose of ethanol improved NPSG sleep but was lost by night 6.
• Tolerance was associated with enhanced self-administration
Timothy Roehrs, Thomas Roth; Insomnia as a path to alcoholism: tolerance development and dose escalation, Sleep, Volume 41, Issue 8, 1 August 2018
Insomnia Patients With Objective Short Sleep Duration
       Have a Blunted Response to CBT for Insomnia1
• Purpose: Do insomnia patients with 6 hrs objective sleep time (normal sleep time)
• Participants: n=60, ages 40-75 (51% F)without co-morbid mental health or sleep interfering
  conditions. Complaint of SMI, DX insomnia based on DSM-4, WASO>60 on diary, insomnia >6
  months with onset after 10 years old, reporting >1 poor sleep hygiene practice. Exclusions:
  pregnant, medical condition affecting sleep, major psychiatric disorder, 15 or PLMSA>15, other sleep disorders, PSG TST
  >2 hours different from subjective estimate.
• Design: participants randomly assigned waitlist or 1,2,4 or 8 treatment sessions. Initially blind to
  number of sessions until after first session to encourage maximum use of first session. Baseline
  actigraphy and some actigraphy during treatment, first session 45-60 min and subsequent session
  15-30 min)
• Measures: baseline PSG, actigraphy, sleep diary, ISQ, Therapy evaluation questionnaire all done
  for 2 weeks baseline, through 8 week treatment period and for 2 weeks at 3 and 6 month follow-
  up

  Christina J. Bathgate PhD1, Jack D. Edinger PhD1,2, Andrew D. Krystal MD2. Insomnia Patients with Objective Short Sleep Duration have a blunted response to CBT
  for insomnia. SLEEP, Vol. 40, (1), 2017.
Insomnia Patients with Short Sleep Duration
          have Blunted Response to CBT-I
                           Insomnia Sleep Questionnaire                                          % WASO < 31 min
                     100                                                                    90
                      90                                                                    80
                      80                                                                    70
                      70

                                                                              % MWASO
Insomnia Patients with Short Sleep Duration
       have Blunted Response to CBT-I
                      Sleep Efficiency >80%                                                  % Total Wake Decline
                 60                                                                                              90
                                                                                                                 80
                 50
                                                                                                                 70
                 40
% with SE >80%

                                                                                                                 60

                                                                                                % participants
                                                                        short sleeper 6h
                                                                                                                 40
                 20                                                                                              30
                                                                                                                 20
                 10
                                                                                                                 10
                  0                                                                                               0
                        baseline        6-month FU                                                                    33%
                                                                                                                             % of Wake Decline

Christina J. Bathgate PhD1, Jack D. Edinger PhD1,2, Andrew D. Krystal MD2. Insomnia Patients with Objective Short Sleep Duration
have a blunted response to CBT for insomnia. SLEEP, Vol. 40, (1), 2017.
Total Sleep Time Measured by Actigraphy and
                 Diaries in Each Group
                                           TST 6 h
                         400                                                                                                420

                         350                                                                                                400

                                                                                                   Total Sleep Time (min)
                         300
Total Sleep Time )min)

                                                                                                                            380
                         250

                         200                                                                                                360

                         150
                                                                       Diary                                                340
                         100
                                                                       Actigraphy                                                            Diary >6h
                                                                                                                            320
                          50
                                                                                                                                             Actigraphy >6h
                           0                                                                                                300

                               Christina J. Bathgate PhD1, Jack D. Edinger PhD1,2, Andrew D. Krystal MD2. Insomnia Patients with Objective Short Sleep Duration have a
                               blunted response to CBT for insomnia. SLEEP, Vol. 40, (1), 2017.
Total Sleep Time Measured by Actigraphy and
             Diaries in Each Group
Conclusions
• Varying insomnia phenotypes show differential response to CBT
• Insomnia patients with objective short sleep time 6 hours TST
• Suggested that insomnia patients with short objective sleep time may
  benefit more from CBT combined with pharmacological treatment

• Christina J. Bathgate PhD1, Jack D. Edinger PhD1,2, Andrew D. Krystal MD2. Insomnia Patients with Objective Short Sleep Duration
  have a blunted response to CBT for insomnia. SLEEP, Vol. 40, (1), 2017
PTSD is Associated with Reduced
                 Parasympathetic Activity in NREM
• Purpose: Examine high frequency HR variability (HF-HRV)in sleep in
  PTSD
• Methods:
     • Participants: 62 veterans, with PTSD (n=29, age 33+7) and without PTSD
       (n=33, age31+8))
     • Measures:
           •   self-reported sleep quality
           •    insomnia severity index
           •   Self-reported disruptive nocturnal behaviors
           •   in-lab PSG
Christi S Ulmer, Martica H Hall, Paul A Dennis, Jean C Beckham, Anne Germain, Posttraumatic Stress Disorder Diagnosis is Associated
  with Reduced Parasympathetic Activity during Sleep in United States Veterans and Military Service Members of the Iraq and
  Afghanistan Wars, Sleep 2018, August 29
HF HRV in PTSD
Results:
       • PTSD vets had significantly lower HF HRV in NREM compared to those
         without PTSD. This was significant in 1st and 4th NREM cycles.
       • Groups did not differ in REM
                                                                                                          HF HRV
                                                                                  900
                                                                                  800
                                                                                  700
                                                                                  600

                                                                         HF HRV
                                                                                  500
                                                                                                                                                 Control
                                                                                  400
                                                                                                                                                 PTSD
                                                                                  300
                                                                                  200
                                                                                  100
                                                                                    0
                                                                                             NREM                          REM

Conclusion: There is blunted parasympathetic modulation during NREM in young
veterans with PTSD
Christi S Ulmer, Martica H Hall, Paul A Dennis, Jean C Beckham, Anne Germain, Posttraumatic Stress Disorder Diagnosis is Associated with Reduced Parasympathetic
Activity during Sleep in United States Veterans and Military Service Members of the Iraq and Afghanistan Wars, Sleep 2018, August 29
Influence of Exercise Time of Day on Salivary
                     Melatonin Responses
• Purpose: Evaluate the influence of exercise time of day on melatonin
• Methods:
      • 12 regularly exercising males (age 20.8+0.6)
      • randomized crossover design
      • All completed 3 protocols separated by > 5 days:
             • morning exercise (AMEX; 09:00)
             • afternoon exercise (PMEX, 1400)
             • no exercise
      • Exercise was 30 min of running at 75% of VO2max
      • Saliva collected at 20:00h, 22:00h and 03:00 h following each session

Carlson LA, Pobocik KM, Lawrence MA, Brazeau DA, Koch AJ. Influence of Exercise Time of Day on Salivary Melatonin Responses Int J Sports Physiol
Perform. 2018 Aug 30:1-13
Influence of time of Exercise on Melatonin
• Results: Significant time and condition effects
   • s-melatonin significantly increased 03:00 compared to 20h and 22h for all
     conditions.
   • s-melatonin at 22:00 significantly higher after AMEX (16.5 ± 7.5 pg·mL-1)
     compared to PMEX (13.7 ± 6.1 pg·mL-1) . Neither differed from control

• Conclusion: Exercising in the afternoon may blunt melatonin
  secretion as compared to morning exercise. If sleep is an issue
  morning exercise may be preferable to afternoon exercise.
Reproducibility of the Epworth Sleepiness Scale
 • Objective- to measure reproducibility of ESS in suspected
   OSA pts 1

 • Method- retrospective comparison of ESS score at referral
   and after 1st sleep clinic visit
    • Demo: 154 pts (68% M), mean age 51 +13, AHI = 43 + 40

 Campbell AJ, Neill AM, Scott DA. Clinical reproducibility of the Epworth Sleepiness Scale for patients with suspected sleep
 apnea. J Clin Sleep Med. 2018;14(5):791-5.
Changes in ESS Score
• Results –
   • No statistically significant difference between mean ESS score at referral and first
     visit (13.7 ± 4.9 vs 13.5 ± 4.6) (P = .61)
   • Ave ESS change was -0.2 + 3.9
   • 7% dropped from above ESS=10 and 7.8% increased over ESS=10
                                                                                                                                          8%
       • 8% had an ESS change of 7 or more
       • 21% had an ESS change of 5 points or more                                                                                                                   7 or more
       • 46% had an ESS change of 3 points or more                                                                                               21%                 5 or more
                                                                                                                           46%
                                                                                                                                                                     3 or more
• Conclusion: ESS is variable and should not be used as the
  sole tool to prioritize patients for OSA assessment
Campbell AJ, Neill AM, Scott DA. Clinical reproducibility of the Epworth Sleepiness Scale for patients with suspected sleep apnea. J Clin Sleep Med. 2018;14(5):791-5.
Requiem for Clinical Use of the ESS

Commentary on the ESS reproducibility study
     • ESS performed worst with 39% sensitivity compared to STOP
       BANG at 87% for identifying OSA risk
     • Need to abandon this subjective measure in evaluation of OSA

1Omobomi O, Quan SF. A requiem for the clinical use of the Epworth Sleepiness Scale. J Clin Sleep Med. 2018;14(5):711–712.
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