Showing papers by "Cathy A. Alessi published in 2003"

The role of actigraphy in the study of sleep and circadian rhythms.

Abstract: In summary, although actigraphy is not as accurate as PSG for determining some sleep measurements, studies are in general agreement that actigraphy, with its ability to record continuously for long time periods, is more reliable than sleep logs which rely on the patients' recall of how many times they woke up or how long they slept during the night and is more reliable than observations which only capture short time periods Actigraphy can provide information obtainable in no other practical way It can also have a role in the medical care of patients with sleep disorders However, it should not be held to the same expectations as polysomnography Actigraphy is one-dimensional, whereas polysomnography comprises at least 3 distinct types of data (EEG, EOG, EMG), which jointly determine whether a person is asleep or awake It is therefore doubtful whether actigraphic data will ever be informationally equivalent to the PSG, although progress on hardware and data processing software is continuously being made Although the 1995 practice parameters paper determined that actigraphy was not appropriate for the diagnosis of sleep disorders, more recent studies suggest that for some disorders, actigraphy may be more practical than PSG While actigraphy is still not appropriate for the diagnosis of sleep disordered breathing or of periodic limb movements in sleep, it is highly appropriate for examining the sleep variability (ie, night-to-night variability) in patients with insomnia Actigraphy is also appropriate for the assessment of and stability of treatment effects of anything from hypnotic drugs to light treatment to CPAP, particularly if assessments are done before and after the start of treatment A recent independent review of the actigraphy literature by Sadeh and Acebo reached many of these same conclusions Some of the research studies failed to find relationships between sleep measures and health-related symptoms The interpretation of these data is also not clear-cut Is it that the actigraph is not reliable enough to the access the relationship between sleep changes and quality of life measures, or, is it that, in fact, there is no relationship between sleep in that population and quality of life measures? Other studies of sleep disordered breathing, where actigraphy was not used and was not an outcome measure also failed to find any relationship with quality of life Is it then the actigraph that is not reliable or that the associations just do not exist? The one area where actigraphy can be used for clinical diagnosis is in the evaluation of circadian rhythm disorders Actigraphy has been shown to be very good for identifying rhythms Results of actigraphic recordings correlate well with measurements of melatonin and of core body temperature rhythms Activity records also show sleep disturbance when sleep is attempted at an unfavorable phase of the circadian cycle Actigraphy therefore would be particularly good for aiding in the diagnosis of delayed or advanced sleep phase syndrome, non-24-hour-sleep syndrome and in the evaluation of sleep disturbances in shift workers It must be remembered, however, that overt rest-activity rhythms are susceptible to various masking effects, so they may not always show the underlying rhythm of the endogenous circadian pacemaker In conclusion, the latest set of research articles suggest that in the clinical setting, actigraphy is reliable for evaluating sleep patterns in patients with insomnia, for studying the effect of treatments designed to improve sleep, in the diagnosis of circadian rhythm disorders (including shift work), and in evaluating sleep in individuals who are less likely to tolerate PSG, such as infants and demented elderly While actigraphy has been used in research studies for many years, up to now, methodological issues had not been systematically addressed in clinical research and practice Those issues have now been addressed and actigraphy may now be reaching the maturity needed for application in the clinical arena

The Role of Actigraphy in the Study of Sleep and Circadian Rhythms AMERICAN ACADEMY OF SLEEP MEDICINE REVIEW PAPER

Abstract: 1.0 BACKGROUND ACTIGRAPHY HAS BEEN USED TO STUDY SLEEP/WAKE PATTERNS FOR OVER 20 YEARS. The advantage of actigraphy over traditional polysomnography (PSG) is that actigraphy can conveniently record continuously for 24-hours a day for days, weeks or even longer. In 1995, Sadeh et al.,1 under the auspices of the American Sleep Disorders Association (now called the American Academy of Sleep Medicine, AASM), reviewed the current knowledge about the role of actigraphy in the evaluation of sleep disorders. They concluded that actigraphy does provide useful information and that it may be a “cost-effective method for assessing specific sleep disorders...[but that] methodological issues have not been systematically addressed in clinical research and practice.” Based on that task force’s report, the AASM Standards of Practice Committee concluded that actigraphy was not indicated for routine diagnosis or for assessment of severity or management of sleep disorders, but might be a useful adjunct for diagnosing insomnia, circadian rhythm disorders or excessive sleepiness.2 Since that time, actigraph technology has improved, and many more studies have been conducted. Several review papers have concluded that wrist actigraphy can usefully approximate sleep versus wake state during 24 hours and have noted that actigraphy has been used for monitoring insomnia, circadian sleep/wake disturbances, and periodic limb movement disorder.3,4 This paper begins where the 1995 paper left off. Under the auspices of the AASM, a new task force was established to review the current state of the art of this technology.

Does an exercise and incontinence intervention save healthcare costs in a nursing home population

Abstract: OBJECTIVES: To determine whether an intervention that combines low-intensity exercise and incontinence care offsets some of its costs by reducing the incidence of selected health conditions in nursing home residents. DESIGN: Randomized, controlled trial with the incidence and costs of selected, acute conditions compared between a 6-month baseline and an 8-month intervention phase. SETTING: Four nursing homes. PARTICIPANTS: One hundred ninety incontinent, long-stay nursing home residents. INTERVENTION: Low-intensity, functionally oriented exercise and incontinence care were provided every 2 hours from 8:00 a.m. to 4:00 p.m. for 5 days a week for 8 months. MEASUREMENTS: Predefined acute conditions hypothesized to be related to physical inactivity, incontinence, or immobility were abstracted from residents' medical records by blinded observers during a 6-month baseline period and throughout the 8-month intervention. Conditions included those in the dermatological, genitourinary, gastrointestinal, respiratory and cardiovascular systems; falls; pain; and psychiatric and nutritional disturbances. Costs were determined using Current Procedural Terminology Center and Medicare allowable cost reimbursement at a rate of 80%. RESULTS: The intervention group had significantly better functional outcomes than the control group (strength, mobility endurance, urinary and fecal incontinence) and a reduction of 10% in the incidence of the acute conditions, which was not significant. There were no significant differences between groups in the cost of assessing and treating these acute conditions between baseline and intervention. CONCLUSION: The intervention, which is consistent with federal and clinical practice guidelines, significantly improved functional outcomes but did not reduce the incidence and costs of selected acute health conditions. The cost of implementing these labor-intensive interventions for frail nursing home residents will have to be justified based on functional and quality-of-life outcomes and are unlikely to be offset by savings in medical care costs in this population.

The Effects of an Exercise and Incontinence Intervention on Skin Health Outcomes in Nursing Home Residents

Abstract: OBJECTIVES: To examine skin health outcomes of an exercise and incontinence intervention. DESIGN: Randomized controlled trial with blinded assessments of outcomes at three points over 8 months. SETTING: Four nursing homes (NHs). PARTICIPANTS: One hundred ninety incontinent NH residents. INTERVENTION: In the intervention group, research staff provided exercise and incontinence care every 2 hours from 8:00 a.m. to 4:30 p.m. (total of four daily care episodes) 5 days a week for 32 weeks. The control group received usual care from NH staff. MEASUREMENTS: Perineal skin wetness and skin health outcomes (primarily blanchable erythema and pressure ulcers) as measured by direct assessments by research staff, urinary and fecal incontinence frequency, and percentage of behavioral observations with resident engaged in standing or walking. RESULTS: Intervention subjects were significantly better in urinary and fecal incontinence, physical activity, and skin wetness outcome measures than the control group. However, despite these improvements, differences in skin health measures were limited to the back distal perineal area, which included the sacral and trochanter regions. There was no difference between groups in the incidence rate of pressure ulcers as measured by research staff, even though those residents who improved the most on fecal incontinence showed improvement in pressure ulcers in one area. CONCLUSION: A multifaceted intervention improved four risk factors related to skin health but did not translate into significant improvements in most measures of skin health. Even if they had adequate staffing resources, NHs might not be able to improve skin health quality indicators significantly if they attempt to implement preventive interventions on all residents who are judged at risk because of their incontinence status.

The yield, reliability, and validity of a postal survey for screening community-dwelling older people.

Abstract: OBJECTIVES: To assess the yield, reliability, and validity of a postal survey developed to identify older persons in need of outpatient geriatric assessment and follow-up services. DESIGN: A longitudinal cohort study. SETTING: Outpatient primary care clinic at a Department of Veterans Affairs teaching ambulatory care center. PARTICIPANTS: Patients (N = 2,382) aged 65 and older who returned a Geriatric Postal Screening Survey (GPSS) that screened for common geriatric conditions (depression, cognitive impairment, urinary incontinence, falls, and functional status impairment). Validity and reliability testing was performed with subsamples of patients classified as high or lower risk based on responses to the GPSS. MEASUREMENTS: Test-retest reliability was measured by percentage agreement and kappa statistic. The diagnostic validity of the 10-item GPSS was tested by comparing single GPSS items to standardized geriatric assessment instruments for depression, mental status and functional status, as well as direct questions regarding falls, urinary incontinence, and use of medications. Validity was also tested against clinician evaluation of the specific geriatric conditions. Predictive validity was tested by comparing GPSS score with 1-year follow-up data on functional status, survival, and healthcare use. RESULTS: Respondents identified as high risk by the GPSS had scores that indicated significantly greater impairment on structured assessment instruments than those identified as lower risk by GPSS. The overall mean percentage agreement between the test and retest surveys was 88.3%, with a mean weighted kappa of 0.70. In comparison with a structured telephone interview and with a clinical assessment, individual items of the GPSS showed good accuracy (range 0.71–0.78) for identifying symptoms of depression, falls, and urinary incontinence. Over a 1-year follow-up period, the GPSS-identified high-risk group had significantly (P < .05) more hospital admissions, hospital days and nursing home admissions than the lower-risk group. CONCLUSION: A brief postal screening survey can successfully target patients for geriatric assessment services. In screening for symptoms of common geriatric conditions, the GPSS identified a subgroup of older outpatients with multiple geriatric syndromes who were at increased risk for hospital use and nursing home admission and who could potentially benefit from geriatric intervention.