Sleep 2022.11.09 Miner

December 21, 2022

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00:00And so it is a particular pleasure
00:02for me today to introduce our Joint
00:05Sleep Conference speaker today,
00:07Doctor Brian Miner,
00:08who is my Yale colleague and
00:11happens to be a talented researcher.
00:13So Doctor Miner hails from McGill University.
00:17Where she received her
00:18undergraduate degree in Biology,
00:19followed by medical school at SUNY Downstate,
00:22and then she did her residency chief
00:25residency, her multiple fellowships,
00:27including geriatrics and
00:29Sleep Medicine at Yale.
00:30And she's been on faculty at Yale ever since.
00:34And so Brianna's work has been at the
00:37intersection of aging and sleep and.
00:40Given the state of the US
00:41population in respect to both,
00:42I think we're all likely to be in her
00:44office at some point in time or another.
00:47And her research has focused on
00:49redefining sleep disorders and
00:50sleep deficiency in the elderly,
00:52taking to the account the complexity
00:54of comorbidities from ecological,
00:56functional and psychosocial factors that
00:58impact quality of life and sleep quality.
01:01And so she is funded by multiple
01:03awards from the National Institute
01:06of Aging and the Pepper Center,
01:08as well as a prestigious beats
01:10and Career Development Award,
01:12which is geared towards growing
01:13leaders in the field of geriatrics.
01:14So Congrats to Brianne.
01:16She's been honored in multiple awards,
01:19including Best New Investigator
01:20Award from the American Geriatric
01:23Society and the Young Investigators
01:25Research Forum Award from the ASM.
01:27And on a personal note,
01:30Brian is a caring and thoughtful
01:32physician and an outstanding
01:33collaborator and teacher.
01:34And so I'm really excited to hear her talk
01:36today and sleep deficiency in the elderly,
01:38so please give a warm
01:40welcome to doctor minor.
01:43Thank you, Andre. Umm,
01:45that was a very gracious and warm
01:48introduction which can only be given
01:51by somebody who has done just as much
01:54post residency training as I have.
01:56And we also did our sleep
01:59fellowship at the same time.
02:00So Andre and I go back a ways.
02:03So I'm going to be talking about
02:06evaluation of sleep deficiency in older
02:08adults and so I can advance my slide.
02:12There we go.
02:14I'm going to start with acknowledgements.
02:16While I have everybody's attention.
02:18I'm going to get my thank
02:19yous out of the way.
02:20So as Andre mentioned,
02:22I sort of started this career through
02:24internal medicine and geriatrics.
02:27And so I'm very thankful to have
02:29had the opportunity to benefit
02:31from a T32IN geriatrics and from
02:33our pepper center here at Yale.
02:35That provided some of that early,
02:37very crucial funding.
02:38And I stand on the shoulders of these
02:41giants and geriatrics and aging.
02:44Research Mary Tinetti up here.
02:49Was she's our outgoing section chief,
02:52and she, frankly, you know,
02:54supported me when nobody else would.
02:56And then Terry freed our incoming
02:58section chief, who provided some really
03:00crucial and important advice for me
03:03at several junctures in my career,
03:05including when I was writing my K award.
03:07And then Tom Gill,
03:09who's my aging mentor now,
03:11and Tom is really a thought
03:13leader in aging research,
03:14and he's an incredible mentor and
03:17he's been very supportive and so I.
03:19Also want to highlight here,
03:21the American Academy of Sleep Medicine
03:23Foundation was sort of my first external
03:27funding and was really a lifeline
03:29for me at a very important time.
03:31Maybe things could have gone differently
03:33if I didn't get that first award.
03:34So I'm very thankful for that.
03:36And then as, as Andre mentioned,
03:38I'm funded by the NIH through the
03:41GEMSTORE and the Bison programs.
03:43So during my postdoctoral
03:47fellowship training and research,
03:49I was also working at our Adler Clinic,
03:52which is our geriatric assessment clinic.
03:55This picture you see is a statue
03:57that sits outside of the clinic.
03:59And in this clinic we really take care of a
04:04patient population with a lot of complexity,
04:07lot of medical problems.
04:08That or as we would say in geriatrics,
04:11multimorbidity.
04:12That's a term you'll hear me
04:14throw around a little bit today.
04:16Polypharmacy, many medications.
04:18They have cognitive and physical impairments.
04:22And our mission is to maintain the health.
04:27Quality and independence of this population.
04:31And really if at the other clinic we
04:33focus a lot on maintaining independence.
04:36It's the goal of our patients,
04:38it's the goal of the families
04:40that care for them.
04:41You know, we're really trying
04:42to keep them in the community.
04:44And this is really where my
04:46interest in sleep was born.
04:48And so,
04:48you know,
04:49I'm going to tell you guys some things
04:51that are probably not surprising to you,
04:53but sleep problems in this community,
04:55very common and very detrimental.
04:57That's what I'm showing.
04:58So as the number of chronic
05:00conditions increases,
05:02the prevalence of reporting a
05:04sleep problem also increases.
05:05So when people have more than
05:07three chronic conditions,
05:08we can see nearly 70% are
05:10reporting a sleep problem.
05:12And these sleep problems really
05:14run counter to the mission of
05:16geriatrics of maintaining that
05:18quality and health and independence.
05:20And I'm not going to talk so much
05:22today about cardiovascular and
05:24metabolic and immunologic outcomes.
05:27I'm really going to focus on
05:28those things that we care about,
05:30especially in an aging population.
05:33And so we know that sleep problems
05:36lead to falls and functional
05:39impairment hospitalization.
05:41Depression,
05:42cognitive impairment and dementia
05:45and institutionalization.
05:46And it's probably that last point
05:49that really got me to be very
05:51interested in sleep to see this is a
05:55problem that really was modifiable.
05:57But the issue was that I didn't
05:59really have the right tools.
06:00And, you know,
06:01I knew the things that we couldn't do.
06:04And so many of you may be familiar with this.
06:06This is the beers criteria that's published
06:08by the American Geriatric Society.
06:11And so these. The beers criteria really
06:14highlights potentially inappropriate
06:15medication use in older people.
06:17And So what you see here is all
06:19of the medications we might
06:21use to help people sleep.
06:22So we have your benzos,
06:24your Z drugs, you know any other
06:27medications we might use for sleep.
06:29And the the strength of the recommendation
06:31is strong that we don't use these
06:34medications and it tells you exactly
06:36why here with the rationale increase
06:38in risk of cognitive impairment,
06:40delirium falls, fractures.
06:42So in some ways,
06:45it almost seems like the cure
06:47is worse than the disease.
06:49And so this is what really led
06:51me to the Sleep Fellowship,
06:52because I felt like I needed better
06:55tools to serve this population and to.
06:59To really to treat these sleep problems.
07:01And so that's where I got to meet
07:04Andre and a lot of other people who are
07:07listening to this presentation today,
07:10this really great group of people,
07:12a lot of fun,
07:13but also incredible clinical
07:15and research mentors for me.
07:17And so in particular,
07:19I started to work with Clara
07:21Yaggi and Melissa Kanawat,
07:22their mentors on my K award and
07:25really helping me to bring that
07:28sleep expertise to the study of
07:30older adults with sleep problems.
07:35So with that sort of short introduction
07:38of how I got to where I am,
07:40I'm now going to tell you
07:42about the rest of the talk.
07:43So I'm going to talk about a case and
07:46then maybe sort of quickly go through
07:49some unique aspects of sleep in older
07:52adults because you know this is probably.
07:55Not due to a lot of you.
07:57This is this is probably stuff you know,
07:58but it it felt like we should at
08:00least touch upon it and highlight
08:01those things to make sure we're
08:03all on the same playing field.
08:04And then I'll talk about sleep deficiency,
08:06what it is,
08:07some of my earlier work looking at
08:08self reported sleep deficiency and
08:10some of the newer things I've been
08:12looking at that incorporate objective
08:14measures of sleep deficiency and
08:16then finally future directions.
08:20OK, so I realized I forgot to point this out,
08:23but this thing on the left here.
08:25So this is sort of, you know,
08:26This is why sleep is so great because,
08:28you know it's everywhere, right?
08:30So this picture was when I was
08:32in Disney World with my kids.
08:34I think we were waiting in
08:35line to meet Mickey Mouse.
08:36And you know, I snapped this picture of
08:38this poster and an informative lecture
08:40how to sleep presented by noted lecturer,
08:43educator, and somnambulist.
08:44Goofy. So I don't have to tell
08:46you guys what somnambulist means,
08:48but it says guaranteed.
08:49By the time this lecture is over,
08:51you'll be fast asleep.
08:53So hopefully not,
08:54hopefully I will engage you.
08:57We don't necessarily have this
08:59conference at the, you know,
09:01the best circadian time,
09:02but I I will try to keep you
09:06entertained as best I can. OK.
09:08So that starts with the next story,
09:11which is the case.
09:12OK.
09:12So we're going to tell this story
09:15of MC who's a real patient that I
09:18saw in my geriatrics clinic and.
09:21I would say, you know,
09:22she didn't come to see me about sleep,
09:25but her case is the sort of case
09:28that I experience commonly.
09:30So let me take you through this.
09:32So she's a 79 year old woman who
09:34presents for a medication review
09:35after relocating from Florida
09:37to live with her daughter in
09:39Connecticut and she's accompanied
09:41by her daughter at the visit.
09:43And that's the nice thing about
09:44seeing patients at our clinic is that
09:47we almost always have family there
09:49to provide some collateral report.
09:51So she was widowed three years prior,
09:53and since that time has had some decline.
09:56So recent episodes of confusion,
09:59poor appetite, delusional thoughts,
10:01and functional decline, decline.
10:03She's getting lost while driving.
10:05She's falling victim to financial scams.
10:07She's supposed to be responsible
10:10for giving herself her medications,
10:12but she's not refilling them,
10:13so probably not doing that appropriately.
10:16And she's depressed and socially
10:17isolated down in Florida,
10:19which is a big part of why she's
10:21moved to Connecticut.
10:23Other past medical history includes diabetes,
10:26hypertension,
10:26hypothyroidism and mild dementia.
10:29And this is her medication list.
10:31And as I told you, this is a real case.
10:33I'm not making this up.
10:34So you can see she's on some
10:37cardiovascular medications,
10:37but she's on a lot of psychoactive
10:40medications, aripiprazole and antipsychotic,
10:42bupropion and Buspirone.
10:44Donepezil, which is, you know,
10:46meant to increase the level of acetylcholine.
10:49But she's also on Solifenacin or VESA care,
10:52which blocks the sort of,
10:54you know,
10:55has has the opposite effect of the Donepezil.
10:57And she's on duloxetine and sertraline.
11:01And also,
11:01we don't know how she's taking
11:03these medications.
11:07So I asked her about sleep
11:09because I always ask about sleep,
11:11especially since doing my sleep fellowship,
11:13and she says she sleeps pretty well.
11:15She feels refreshed during the day.
11:17She wants to increase her solifenacin her
11:19VESA care due to frequent urination at night,
11:22and she sleeps in a recliner.
11:24Her daughter tells us that she snores.
11:27Her sleep schedule is 10:30 PM to 8:00 AM.
11:30Her latency is quote not long awakenings
11:333 to 4 * a night for nocturia.
11:36But she goes back to sleep easily
11:38and she says she naps probably about
11:41two days a week for 30 minutes.
11:43So again, because I'm a sleep doctor,
11:46I also collected this information,
11:48which is not common in her geriatrics clinic,
11:50which is something that I do when I when
11:53I'm concerned about a a sleep problem.
11:56So I got the insomnia severity
11:57index and the Epworth.
11:59We're going to come back to these,
12:00but suffice it to say, for now,
12:02her scores for both of these were
12:04very much in the normal range.
12:06So then this is where I get a
12:08little crowd participation.
12:09If possible I want to ask maybe
12:11if you all want to just like put a
12:14put a hand up in the on your video,
12:17would you get a sleep study for this patient?
12:26I see, yes. I see a head shake.
12:28Doctor Hilbert saying yes.
12:31Doctor Thomas saying yes, OK.
12:37All right, so. I did get a sleep
12:41study and I think, you know,
12:43when I'm presenting this sort of
12:46case to a primary care audience,
12:49they there's there's more sort of hesitance
12:52about whether to get a sleep study.
12:54But I did and I'm going to tell you why.
12:59So. First of all.
13:03The Solifenacin and also all
13:05the psychoactive medications,
13:06you know would make me concerned
13:09potentially about some sort of
13:11blunting of her awareness of of her,
13:14whether she might be sleepy and or you
13:16know how how she's actually sleeping.
13:22So the daughter reported the snoring,
13:24but the daughter also told us that
13:26probably she was sleeping more
13:27during the day than she let on.
13:29Again, it's where that collateral
13:31history becomes so important.
13:33And I think that's not news to, you know,
13:35to sleep audience like you guys.
13:37Before COVID, at least we would have,
13:39you know, the spouses coming in with
13:41the patients to tell us, Oh yeah,
13:43you know, he snores or whatever.
13:44So we're very used to getting collateral
13:47history and we do the same in geriatrics.
13:50Bedtime is long,
13:51so she's sleeping 9 1/2 hours.
13:54The Nocturia is probably,
13:56to a lot of you, a signal that she
13:59might have untreated sleep apnea.
14:01And so here's her home sleep study.
14:04And lo and behold,
14:05she does have severe sleep apnea.
14:07So you can see a lot of apneas.
14:09You can see a lot of depth,
14:11two sort of dense periods of desaturation.
14:14Here's the close-up.
14:15So basically,
14:16this is, you know,
14:18pretty classic severe sleep apnea.
14:21So if we have these patients who come
14:24in and tell us their sleep is fine
14:26and then we find the sort of rippling
14:29sleep apnea on on a home sleep test,
14:31it really does sort of
14:33lead us to this question,
14:34how are we actually supposed to evaluate
14:37and screen people for sleep problems?
14:39So what is the best way to
14:40assess sleep in older adults?
14:42And so that's really been the focus
14:44of the research that I've been doing
14:47so far is thinking about those tools.
14:49And so before I get to that,
14:51I'm going to just run through and again,
14:53we won't spend a lot of time on
14:55this because I think this is
14:56not news to a lot of you,
14:57but let's talk about what's unique
14:59about sleep in older people.
15:02So these are the National Sleep
15:04Foundation recommendations.
15:05And so you can see that people 65 and older,
15:09the sort of sweet spot is 7 to 8 hours.
15:12Recognizing that five hours on one end of
15:14nine hours on the other might be appropriate.
15:17The seven to 8 hour recommendation
15:19really comes from the fact that
15:21people who sleep that duration tend
15:23to report better physical health,
15:25better mental health,
15:26and better quality of life.
15:28I used to use this as a way to say,
15:31to tell people,
15:31alright,
15:32you shouldn't come in and say, oh,
15:34I'm older so I don't need as much sleep.
15:36And so I think it's that helpful in that way.
15:39But I do think it is a problem
15:41to say anywhere between 5:00
15:43and 9:00 hours may be normal.
15:45And you know, I have,
15:46I had a patient recently who
15:49said I sleep six hours.
15:51I feel OK during the day.
15:53How do I know if that's enough?
15:55And I said,
15:56well,
15:56well isn't that the $1,000,000 question,
15:58but I am getting a bit ahead of myself.
15:59So for for for all intents and purposes,
16:03this is sort of the recommendation
16:05of a normal duration
16:06in older people.
16:10You all are also aware that sleep
16:13architecture changes as we age.
16:14And so whereas someone my daughter's
16:16age will spend a lot of time
16:18in R.E.M and slow wave sleep,
16:19older adults will spend less
16:21time in those stages of sleep,
16:23more time in lighter stages of sleep.
16:26And as a result, you know,
16:28a younger adult might have this
16:30sleep histogram that shows this
16:31nice sort of cycling through
16:33lighter and then deeper stages
16:34of sleep and these R.E.M cycles,
16:36whereas an older adult will
16:37look more like this.
16:39A shift towards lighter stages of
16:42sleep and more arousals from sleep.
16:45Some other things that change.
16:47So circadian rhythm changes with age.
16:50Phase advance becomes much more common,
16:52meaning that people may go to bed
16:54earlier and therefore get up earlier,
16:56and that's really a result of
16:57an earlier peak in melatonin.
17:03There's a decreased amplitude
17:04of the sleep wake rhythm,
17:06of body temperature,
17:07and of many different hormones.
17:08So it's a decrease in the
17:10difference between the peak and
17:12the through of those things,
17:13and also a loss of ability
17:16to phase shift as we age.
17:20And so, you know, obstructive sleep
17:23apnea isn't the only sleep disorder,
17:25but a very common one.
17:27And I think it's important
17:28just to highlight a couple ways
17:30in which this is different.
17:31In older people, it presents differently.
17:34So first of all, the prevalence
17:37of sleep apnea increases with age,
17:39and it's frequently undiagnosed,
17:41and that's because of this
17:43different presentation.
17:44So as opposed to a younger age group,
17:47there's an equal ratio of males to
17:49females when you start to diagnose
17:51sleep apnea in an older age.
17:53Obesity is a less important predictor
17:55of sleep apnea in this group and
17:57there's less reporting of snoring
17:59or pauses and breathing and more
18:01sort of sleep related complaints,
18:03insomnia,
18:04daytime sleepiness and then that that
18:06one that I alluded to before that I
18:08think is so important urination at night.
18:13And so this is another way that sleep
18:16is really different in this group.
18:18It's because there are all of these
18:21things impacting their sleeping.
18:23And so, as I like to say in a
18:25geriatric audience, sleep problems in
18:28this population are multifactorial.
18:30I've already mentioned the
18:32changes in sleep architecture.
18:34The other thing is that as we age,
18:36we collect conditions and those can
18:38affect sleep in a number of ways.
18:40They can be associated with sleep disorders.
18:43They could be associated with low
18:45levels of chronic inflammation.
18:46So, so they could have direct
18:49or indirect impacts on sleep.
18:51And then of course,
18:53with those conditions come the polypharmacy.
18:55And there are a lot of ways that
18:57medications can affect sleep.
18:59And I can tell you that as a geriatrician,
19:01when I have a patient with a sleep problem,
19:03one of the first things I'm doing
19:04is going to the medication. Yes.
19:06But there are also psychosocial
19:08behavioral factors.
19:09You know, maybe caregiving,
19:11substance use, bereavement that can,
19:13or social isolation,
19:15loneliness that could affect sleep,
19:17and then finally sleep disorders.
19:19Because nearly every one of these
19:21that we treat every day becomes
19:23more prevalent with age.
19:27So now that I've told you a little bit here,
19:29just sort of reminded you
19:31about these unique aspects,
19:32I want to talk about sleep deficiency,
19:35what it is, and some of the work that I've
19:37been doing to define this in older people.
19:40So this is a definition from the
19:43National Institutes of Health.
19:45Sleep deficiency is a condition that
19:47occurs due to poor sleep quality.
19:49For example, a sleep disorder like
19:53sleep apnea insufficient sleep.
19:55Or inappropriate sleep timing,
19:56which is to say sleep that is out of
19:59sync with the body is circadian rhythm,
20:01and that an impairment in one or
20:03more of these domains leads to an
20:06impairment in daytime function.
20:08So this I think is a really appealing
20:11way to study sleep and older people
20:13because it really is pointing to.
20:16These different domains in which
20:17the apparent impairments may arise,
20:19and it's looking at sleep from a
20:21more global perspective instead
20:23of focusing on one thing,
20:24it's really more comprehensive,
20:26which is important because these
20:29people tend to have multiple
20:31things going on simultaneously.
20:33And so I'll talk now a little
20:36bit of about some of the.
20:39The work using self reported
20:41measures and specifically looking at
20:44insomnia and hypersomnia or daytime
20:47sleepiness and in older adults and
20:50so this is work that I did using.
20:53Previously collected data from
20:54the precipitating events project.
20:56This is a community dwelling
20:59cohort in New Haven.
21:01People were at least 70 at the
21:03time that they entered the study.
21:05And every 18 months they have these
21:07very detailed home assessments.
21:09We get things like medical conditions,
21:12medication use,
21:13cognitive function, depression,
21:16so very detailed measures
21:18in these older people.
21:21And about six or seven years into the study,
21:24they started to collect
21:26different sleep measures,
21:26including the Epworth and the ISIL.
21:29And so that's some of the data.
21:31What I'm going to present to you.
21:33And so our hypothesis was that when we
21:36looked at these measures and we looked
21:38at these symptoms of hypersomnia,
21:40insomnia that they would
21:42be prevalent and severe.
21:44And the reason is because of all of
21:45the things that I previously told you,
21:47right.
21:47They have they have more medical conditions,
21:50more medications and and and all
21:52of these things sort of convening
21:55to potentially impact their sleep.
21:58So here is the cohort,
22:00just to get give you a sense
22:02of what they looked like.
22:03So you can see on average the
22:05age was 84 at the time that
22:07we were studying their sleep.
22:09They have a lot of medical problems,
22:11they have obesity,
22:12cardiovascular disease, lung disease.
22:14They have.
22:15They use a lot of medications, on average 9.
22:18And there's a lot of depression,
22:21cognitive impairment and low
22:22physical activity in this,
22:24in this cohort.
22:28So here's the Epworth,
22:29which probably doesn't need a lot
22:31of description in this group,
22:32but I just want to remind you all this,
22:34the range is zero to four and really
22:36we think clinically significant
22:38hypersomnia is 10 and above and that
22:4110 to 15 is sort of more moderate,
22:43whereas 16 and above is severe.
22:46And so here's what we found
22:48in the pep cohort.
22:49So the median Epworth score
22:51in this cohort was six,
22:53so very much in the normal range and
22:56those people that cut off of 10 and
22:58above it was about 23% of the cohort.
23:01So you know very common, but also.
23:04Pretty mild overall,
23:06most of those people are falling
23:09into that mild category.
23:11And when we looked at insomnia,
23:12so just remind you that I, I how it works.
23:15So we have the insomnia symptoms and then
23:18the sort of DSM criteria about whether,
23:21you know people are worried
23:22about their sleep,
23:23about whether they think it
23:25interferes with activities.
23:26So this range is 0 to 28.
23:28The threshold is really 8 and above and
23:31then mild is 8 to 14 moderate insomnia,
23:3415 to 21 in severe is 22 to 28.
23:38So here's what we saw in this cohort with
23:41respect to the Insomnia Severity index.
23:44So if we use that sort of cut off of
23:47eight and above to to establish insomnia,
23:50that was in 43% of the cohort.
23:53But again they they the severity
23:55was pretty mild.
23:56So among those people with
23:58an abnormal ISIS score,
24:00the mean ISIS score was 12,
24:02so in that mild range.
24:05And we also looked at what
24:06happened to the ISI over time.
24:08And so here I'm comparing the three
24:10different age groups we have in black,
24:12our youngest olds,
24:13in red the oldest old or the
24:15middle old and blue the oldest old.
24:18And you can see these ISIL,
24:19the mean ISIS scores over time
24:22are really overlapping and they're
24:24falling below that threshold.
24:26And so I would say that, you know,
24:30this was a surprising result.
24:32You know, we have this cohort,
24:34older people, a lot of medical problems,
24:36a lot of medications, they're depressed,
24:39they're cognitively impaired.
24:40And yet we have this kind
24:42of discordance between.
24:44I mean,
24:45we do see these symptoms are common,
24:47but they're not severe.
24:49And so it really did cause us to think well.
24:53Is there,
24:54is there discordance between
24:55how they perceive their sleep or
24:58how they report their sleep and
25:00how they're actually sleeping?
25:01And and to think maybe the existing
25:04self reported sleep measures are
25:06not appropriate in this age group
25:08and so if if not, why might that be?
25:11What are some potential mechanisms
25:13here that might sort of explain the
25:15discordance between what people
25:17are reporting and what we're seeing
25:19on objective measures?
25:20So first,
25:21it could be that symptoms are better
25:23tolerated in this group, right?
25:25They've been living with these
25:26symptoms for a long time,
25:27so maybe because of that they're
25:29less likely to report
25:31them. Could be lifestyle mediated.
25:33They might not have the same caregiving
25:35responsibilities, they may not have
25:37the same work responsibilities,
25:38and so they can sort of adjust their
25:41lifestyle to deal with those sleep problems,
25:44whether it's trouble sleeping
25:46at night or daytime sleepiness.
25:48There is this phenomenon which
25:50is the paradox of well-being.
25:51And really what that is is that,
25:53you know, older people may be less likely
25:56to report dispatch dissatisfaction or
25:59distress because their actual state
26:01of health exceeds what they expected.
26:04And I do hear this in clinic all the time.
26:06It's sort of like well,
26:07what do you expect?
26:08I'm 85, you know, so I think that they're,
26:10it's possible that there are you know.
26:14Perhaps they they're doing better
26:16than they thought, and so they might
26:18not report symptoms because of that.
26:21And then, you know,
26:22there's this question about
26:23validity of existing measures.
26:25I'm really studying a population in
26:27their in their 80s and these were not
26:29people who were studied in some of these.
26:31Of these sort of, you know,
26:33original validation studies.
26:35And so, you know,
26:36if I were to point out just a
26:38couple things like let's look at a
26:40couple of questions from the ISIS.
26:41How worried or distressed are
26:43you about your sleep problem?
26:45How much does it interfere with
26:47your daily function?
26:49Perhaps that's not particularly
26:51meaningful to this population.
26:53And then if we look at the Epworth,
26:55the, you know, and are they,
26:57many of my patients have low vision,
26:59so they might not be reading, they might.
27:01Not be watching TV and they
27:03may no longer be driving,
27:05and so it's possible that certain questions
27:07in the airports don't apply either.
27:11And so then the the other potential
27:14mechanism is could there be a
27:16blunted awareness of symptoms.
27:18So we have seen this in
27:20other domains of health.
27:21So for example, older adults have
27:24milder respiratory symptoms in
27:26response to bronchoconstriction.
27:28They have less severe symptoms
27:30in response to hypoglycemia
27:32and they have higher rates of
27:35silent myocardial ischemia.
27:36And then actually specifically
27:38in the world of sleep,
27:40one of my prior mentors published
27:43this work where he was comparing
27:46middle-aged and older adults.
27:47And what he found in this work
27:49is that the older adults had
27:51more severe sleep disorders,
27:52but were reporting milder insomnia,
27:55mild hypersomnia and less fatigue.
28:00So why does it matter?
28:04This is the shrug emoji.
28:05This is my daughter's doing their
28:07best impression of the shrug emoji.
28:09This is something that I really had
28:13to bring to the geriatrician audience
28:15because they said if it ain't broke,
28:18don't fix it, right?
28:19If they're not reporting the sleep problems,
28:21then what are you doing here?
28:22They, they they didn't
28:23really love this idea of the,
28:25the road that I was going down.
28:27And so, you know what I say to them is this
28:30is potentially a missed opportunity, right?
28:33If we're not.
28:35Hearing the symptoms,
28:37if we're not detecting these sleep problems,
28:41then we're not intervening upon them
28:43and we're not preventing the adverse
28:45outcomes that could come about
28:47because of these sleep problems.
28:48And I would also say we're not
28:51appropriately evaluating our interventions.
28:53And so the example like I'd like
28:55to give is the LIFE study which
28:58was this large national multi site
29:00study of older adults to look at a
29:03physical activity and intervention
29:05to prevent disability and as a
29:09secondary outcome they looked at the.
29:11Effect of this physical activity
29:14intervention on the Epworth and
29:16the ISIL and there was no change.
29:18And so is that because physical
29:21activity doesn't do anything to
29:23help sleep or is it because we don't
29:25have the right tools to evaluate the
29:27change in sleep that might happen from
29:30a physical activity intervention?
29:34So this really sort of took me to the
29:37next part of my research was to to
29:41start incorporating some objective
29:43measures of sleep deficiency and so.
29:48I'm going to tell you a bit about
29:50this project that I did where I was
29:51looking at really if you think about
29:53it in terms of sleep deficiency,
29:54insufficient sleep duration,
29:56so comparing self reported
29:58and objective short sleep.
30:00And so, you know, I wanted to look
30:02at the prevalence of short sleep,
30:04but again because I was thinking about
30:07this potential discordance between
30:08what older adults were reporting and
30:10how they may actually be sleeping,
30:12I wanted to look at the diagnostic accuracy
30:15of self report versus an objective measure.
30:18And so you know,
30:19we define short sleep is less
30:21than or equal to six hours.
30:23I'm showing you this U-shaped curve,
30:25which probably many of you have seen before,
30:27but we know that sleep duration.
30:30Has this huge shaped curve whether
30:32we're talking about mortality and many
30:34other cardiovascular and metabolic
30:36outcomes and it's really you know,
30:38so, so long sleep is associated
30:40with worsening outcomes,
30:41but then short sleep really at 6
30:43hours and below is also associated
30:46with these adverse outcomes.
30:48So that's how we define short sleep
30:51and I use data from the study of
30:55osteoporotic fractures and the
30:57osteoporotic fractures in men study,
30:59the ancillary study that's based on sleep.
31:03A lot of you are probably familiar
31:04with this and if you're interested
31:06in aging at all and sleep,
31:07you know this is this is really
31:10a really wonderful resource.
31:12And so I'm going to spend a little
31:14time talking about it because
31:15a couple of the projects that I
31:17did have been using data from.
31:19These two cohorts so soft is women
31:21and at the time I'm studying them,
31:25the mean age was 84.
31:26You can see over 3000 women and then men.
31:29Mr Oss about 3000 men with a mean age of 76.
31:34And so these studies were designed
31:37to evaluate many determinants
31:39of successful aging.
31:40And so because of that,
31:41they incorporated comprehensive sleep
31:43visits at a couple different time points.
31:46And as part of that comprehensive visit,
31:51we had actigraphy.
31:52So that's the objective measure
31:54that I use for the study that
31:56I'm going to tell you about.
31:58And then I just want to highlight
32:00a couple things because I'm going
32:02to refer to them here and also
32:03in some of the other studies.
32:05But this is a big reason why this
32:07is such a wonderful cohort to study
32:09because we get to study all of these
32:11things that are so important in older people.
32:14Multimorbidity,
32:14which I'm going to be defining
32:16as having at least chronic 3
32:19chronic medical conditions,
32:20they have measures of depression and anxiety.
32:24They have great information about
32:26medication use, so antidepressants.
32:28Activating medications which is a
32:31stimulant or an oral steroid and
32:34then CNS active medications, so.
32:36Benzodiazepines,
32:37anticonvulsants,
32:37narcotics and antipsychotics
32:39and then they have
32:42information on these geriatric
32:44conditions or geriatric syndromes.
32:47So cognitive impairment,
32:48physical impairment which is really
32:51a gate speed is a well validated
32:54measure of physical impairment.
32:56They have frailty and a previously
32:58validated soft frailty index
33:00and then information on falls,
33:02another really important geriatric syndrome.
33:06OK. So again, because I'm going to be
33:08talking about this cohort for a bit,
33:10I figured I should just tell
33:12you a little bit about them.
33:13So you can see men were a
33:16little bit younger than women,
33:18average age was 76 versus 84.
33:20And that's just because the men's cohort,
33:23that study started later.
33:24So by the time the sleep
33:26visit was done in the women,
33:27they were actually significantly older.
33:31You can see the minority race.
33:32Ethnicity is about 10% of these cohorts.
33:35And you can also see the women probably as
33:37a function of the fact that they're older,
33:39they're less educated,
33:40they're more likely to live
33:42alone or be widowed,
33:43and they have more medical conditions,
33:45more multimorbidity,
33:46more depression,
33:47anxiety and more physical impairment.
33:53And so here is the study where we really
33:55looked at the agreement between a self
33:57report of short sleep and the objective,
33:59in this case actor graphic short sleep.
34:02And so this is here's some very fancy
34:05statistics where I'm doing a two by
34:08two table and calculating sensitivity
34:10specificity using actigraphy as the
34:12sort of reference standard here.
34:14And so I want to just focus
34:16on these blue quadrants,
34:18which is where things don't match.
34:20OK, so you have someone who's.
34:23Saying they don't have short sleep
34:25but Actigraphy is showing it.
34:26Or they say they do and actigraphy
34:29is showing they have normal sleep.
34:31So you can see this about 30% of
34:33men in the women also very common
34:36to have these discordant numbers and
34:39so if you look at the sensitivity.
34:43It's pretty poor.
34:44So there's a high false negative rate.
34:46Specificity is a little bit better,
34:49but also still pretty poor with
34:51a high false positive rate.
34:53So what this means is that, you know,
34:56we have missed opportunities.
34:57We have, you know,
34:59short sleep that we're potentially
35:01missing and we're not intervening upon.
35:04But we also have the potential for overtree,
35:07right?
35:07Perhaps we're identifying people with
35:09short sleep and maybe using a benzodiazepine.
35:13And that's inappropriate and setting
35:15them up for risk of adverse outcomes.
35:20So you know, this is I think really
35:23pointing to the need to go beyond just
35:26self reported measures and older people.
35:30But I also want to show you that this is not
35:33just when we're talking about sleep duration.
35:35And so this next project that I'm going to
35:38present with the Mr Ross and soft cohorts
35:41looks at positive sleep discrepancy.
35:43So first let me tell you what that is.
35:45I didn't make it up to sort of a
35:47known entity in Sleep Medicine.
35:49This is when self reported sleep is
35:51in the direction of less impairment
35:53and corresponding objective measures.
35:55And so it really is now we're
35:58focusing on that sort of false.
36:00Negative quadrant, OK.
36:04And again,
36:04I think it's important because this is
36:06a missed opportunity and potentially
36:08this is a common thing to find an
36:10older people for all of those things
36:12that I mentioned before because of
36:14because we're not asking the right
36:16questions or maybe they're you know
36:18have a blunted awareness of symptoms.
36:21And so we wanted to look at the prevalence
36:23of positive sleep discrepancy and also
36:26what are the characteristics associated
36:28with positive sleep discrepancy.
36:30So again we're looking in the Mr Ross
36:33and soft cohort and so when I now I want
36:35to tell you this is how we sort of.
36:38You know,
36:38started to look at this analytical sample.
36:41So we started with people who had
36:43no self reported sleep deficiency.
36:45And here I'm defining that as
36:47people with a normal score on the
36:49Epworth and a normal score on the
36:52Pittsburgh Sleep Quality index.
36:53OK,
36:53so these are people really
36:55if we had administered these
36:56questionnaires when they said OK,
36:58these people don't have a problem.
37:02So in men we had about 3000 with Actigraphy.
37:06And on the next slide, I'll be clear why.
37:08I was sort of focusing on
37:10people with actigraphy.
37:11And so it was about 1500 men.
37:15Of that group who had normal,
37:18Epworth and PSQI scores so in women.
37:23We were looking at visit 9 and
37:26830 of them had actigraphy data
37:30and of those 333 women had normal
37:34scores on the Epworth and the PSQI.
37:37And so now I'm going to tell you how
37:39I defined objective sleep deficiency.
37:43That was having a deficit and
37:44at least one of these domains.
37:47So duration or saying now a
37:49deficit and duration which was an
37:52active average activity,
37:53raphy duration less than 320 minutes
37:56or it's it's a little over 5 hours.
38:00Quality was also from Actigraphy wake
38:03after sleep onset of at least 88 minutes.
38:06Regularity was the standard deviation
38:08of the actigraphy derived sleep
38:10midpoint being greater than 65 minutes.
38:13And I base these on previously
38:15published work from Mr Oss looking
38:18at these different domains and
38:20how they predicted mortality.
38:23So that's sort of where these
38:24cut offs are derived from.
38:26And then I looked at daytime alertness
38:29using the psychomotor vigilance task.
38:31And so basically we defined an
38:33impairment in daytime alertness based
38:35on falling in the worst quartile.
38:37For the cohort,
38:39for the psychomotor vigilance task.
38:41And why use the Pvt?
38:43It's because we think that that sort
38:45of quality of sustained attention or
38:48daytime alertness that you measured,
38:50the Pvt is particularly sensitive
38:54to deficits in.
38:57Sleep in homeostatic sleep
38:59or in circadian sleep.
39:04OK. So again. We're defining positive
39:08sleep discrepancy as having normal
39:10self reported scores but having a
39:12deficit in one of those domains.
39:14And So what we did is we did
39:16logistic regression basically to
39:18find the characteristics that are
39:20associated with falling in this group.
39:22And so we're really not considering
39:25these groups here where you know,
39:27yes, they have both self reported
39:29and objective sleep deficiency.
39:31We're not considering people who
39:33have self reported sleep deficiency,
39:35but you know, normal. Objective measures.
39:38We're really comparing them
39:39to the reference group here,
39:41which is people who are, you know,
39:44who really have normal sleep.
39:47And so first of all,
39:48I'll show you the prevalence.
39:49So here we'll start with the men
39:52and you can see you know what what
39:55were the the prevalence of having
39:57an abnormality in each domain.
39:59And so overall,
40:00of all those men who had normal
40:03Epworth and PSQI scores,
40:05about almost 50% of them had a deficit
40:09in an objective sleep deficiency.
40:13In women, fairly similar.
40:16So 46% of those women with
40:19normal Epworth and PSQI scores
40:21actually had an objective deficit.
40:24Or objective sleep deficiency.
40:28So we then looked at, you know,
40:31by comparing them to that normal sleep group,
40:35we found those clinical characteristics
40:37that were significantly associated with
40:39having positive sleep discrepancy.
40:41So you can see age, obesity,
40:44napping, you can see those.
40:48Those geriatric impairments that we
40:51think are so important in aging.
40:53And in women,
40:55we found very fairly similar results.
40:57So older age was associated with
41:00having positive sleep discrepancy,
41:02obesity and napping.
41:04Multimorbidity.
41:07And then having those geriatric syndromes
41:09and that was similar in men and women.
41:14So positive sleep discrepancy.
41:17Very common.
41:19We see it again with increasing age,
41:21with obesity, with medical comorbidity,
41:24with geriatric syndromes.
41:24And I I think this is important
41:27because I think this is a missed
41:29opportunity and we're potentially
41:30not detecting these sleep problems.
41:33And so you know that's why the
41:34focus of my work going forward
41:36is to really say we need better
41:38instruments to improve detection of
41:40sleep deficiency in this population.
41:43And so I'm just gonna finish with
41:45one more project that I'll tell you
41:48about and that's looking at insomnia
41:50with objective short sleep duration,
41:53which is, you know,
41:54sort of interesting.
41:54I don't think I imagined it this way,
41:58but it really is measuring sleep in a more
42:01comprehensive way because it's looking
42:03across domains of sleep deficiency.
42:06And so probably many of you know
42:08this is being recognized more and
42:10more as a high risk phenotype.
42:12And so I'm pointing to really I
42:15think sort of seminal papers that
42:17have looked at this in younger,
42:19more middle age groups and shown
42:21that this phenotype is associated
42:24with worsening with mortality,
42:26cardiovascular disease,
42:28diabetes and even cognitive
42:30performance impairments.
42:31There's some this is somewhat controversial,
42:33but there's some evidence to suggest
42:36that this group is actually that CBT.
42:39I may be less effective in this group.
42:42And so we wanted to study this.
42:44It had previously been studied
42:45in middle age groups.
42:46We wanted to study this in older people.
42:49And so here's how we did it in Mr
42:51Ross and soft. And it was really.
42:54Sort of replicating the way that insomnia
42:58was identified in previous work in sleep,
43:02heart health in middle-aged
43:04people to look at this phenotype.
43:06And so insomnia was based on having any of
43:09the following at least three times a week,
43:12trouble getting to sleep within 30 minutes,
43:14waking up in the middle of
43:15the night or early morning,
43:16or taking a medication to help with sleep.
43:19And then a sort of departure from
43:20what had been done previously,
43:22if you know this work from the Penn State
43:24cohort is sleep Heart health study,
43:25then you probably know they
43:27use polysomnography,
43:27polysomnography to define a sleep
43:30duration of less than six hours.
43:33We used actigraphy for a number of reasons,
43:36but I would say if we really want to be
43:39able to study this phenotype going forward,
43:42then doing it with polysomnography
43:44just isn't feasible.
43:46So we are using actigraphy and I think,
43:49you know,
43:50we don't have a whole lot of time to talk
43:52about the benefits and the limitations.
43:53But let's just say the benefit
43:55is that any of you who use it
43:58know man actigraphy is so easy,
44:00especially compared to polysomnography.
44:03OK, so here's what we found in the men.
44:07So if we are starting with.
44:11That sort of the 3000 people from
44:14that first sleep visit of Mr OSS,
44:16we then take out these other phenotypes.
44:19OK, so your long sleep duration,
44:23asymptomatic short sleep and your
44:25insomnia with normal sleep duration,
44:27OK. So I'm showing you
44:29the prevalence of those.
44:30But really what we're focusing down
44:32here on is those people who had insomnia
44:35with short sleeve and those people
44:38who had normal sleep and so of that,
44:40you know, 3000. Plus. Population.
44:44About 20% of the men had insomnia
44:46with short sleep duration,
44:47so you can see fairly common,
44:49you know, a fifth of the cohort.
44:52So then in women,
44:54when we sort of separated out those groups,
44:57we can see that insomnia with short
45:00sleep duration was about 13% of women.
45:05And so now I'm going to show you what
45:07happens when we compare insomnia with short
45:10sleep duration to people with normal sleep.
45:12And this is a busy slide,
45:14but I'm going to sort of break it down
45:16for you to make it more digestible.
45:18We have our men here, our normal
45:20sleepers versus insomnia with short sleep,
45:22and our women here are normal sleep
45:24versus insomnia with short sleep.
45:25And what you'll see is across the board,
45:28people with insomnia and short
45:30sleeve have more health conditions,
45:32more depression, anxiety,
45:35more sleep disorders.
45:37They have more medication,
45:39so they're more likely to
45:41use antidepressants.
45:42Activating medications, CNS,
45:44CNS, active medications.
45:46They're more likely to have
45:48those psychosocial and behavioral
45:50factors that can impact sleep.
45:52Like living alone and and napping
45:55and they're more likely to
45:57have geriatric conditions.
45:58And again,
45:59here's another slide with a lot of numbers,
46:01but the,
46:02what I'm really just trying to show you
46:05here is that when we adjust for age,
46:08race, ethnicity, education,
46:11obesity and multimorbidity,
46:13those relationships are maintained.
46:15So they are robust to adjusting
46:18for all of those things.
46:21So we see in both men and women that
46:23those with insomnia and short sleep
46:25are much more likely to have obesity.
46:28Multimorbidity.
46:29Cognitive problems,
46:31depressive issues and geriatric impairments,
46:35and so I think you know.
46:39This really.
46:40This is a group with high medical burden.
46:44I'm probably at risk for adverse outcomes.
46:47That's some work that needs to be done,
46:49but I think it also shows the
46:51benefit of taking the sort of
46:53multifaceted approach of defining
46:55sleep in a more comprehensive way.
47:00And so I'll I'll end them
47:02with future directions,
47:03which is the focus of my K award in
47:06trying to define sleep deficiency by
47:09measuring each of these different domains.
47:13And so I am doing home based polysomnography.
47:17That's the gold standard,
47:19but I'm also trying to see whether an EEG
47:22measuring headband might be sufficient to
47:25define sleep quality in this population.
47:28I'm using Actigraphy to try to get at that
47:31domain of inappropriate sleep timing.
47:34And so right now I'm really in the the
47:37first couple phases of the work which are,
47:41you know, quantitative phase,
47:42where I'm really comparing self
47:44reported and objective measures of
47:45sleep deficiency in this age group.
47:47And then I'm also starting to
47:50do qualitative interviews where
47:51I'm exploring how these people.
47:54Describe their sleep and their
47:55impairments during the day to to try
47:58and determine whether there might
47:59be better ways to assess that with.
48:03With with self reported measures
48:06and hopefully ultimately to define
48:08or develop a new sleep deficiency
48:11instrument to detect this and older
48:13people that's really sort of specifically
48:16designed for use in older people.
48:19So that's the focus of my OK,
48:22that's what I'm in the thick of right now
48:24and so I'll just end with some key points.
48:28Sleep deficiency is a global
48:30construct capturing deficits
48:31arising due to poor sleep quality,
48:33insufficient duration and
48:36or inappropriate timing.
48:38This sleep deficiency in older
48:40adults is multi factorial.
48:42Self reporting instruments alone
48:44may not be sufficient to describe
48:46this entity in older adults.
48:48Future work should incorporate measures
48:51to that evaluate sleep comprehensively.
48:53So that is all I have and then I'll
48:56end with the thank yous again and sort
48:59of point to all of these wonderful
49:01people that I get to work with and
49:04sleep in geriatrics here at Yale.
49:13Great. Uh, thank you.
49:16Brianne was a great talk, a
49:19lot of interesting information,
49:20a lot of broke information.
49:21So I think we have a couple of
49:24comments and questions in the chat
49:27and we'll start with John Winkleman.
49:30And so it John mentions that you've
49:32shown us cross-sectional associations,
49:34Mr Oz has longitudinal data.
49:36Have you examined your group of
49:38interest for long term outcomes?
49:40Yeah, so that's what we're working on now.
49:44Great, great. And then Robert Thomas
49:48has a question and a statement.
49:51Intervention plea is exclamation point.
49:54So the description is good.
49:56But there's no mystery that elderly
49:58have multifaceted sleep loss.
49:59And So what is the pragmatic approach
50:01to change the sleep in the elderly?
50:04So yeah, I mean. First,
50:08there's no easy answer here,
50:09and I'm probably.
50:12Not telling you something you don't
50:14know already, but I think what I,
50:17what I commonly experience is
50:20that when these people come to me,
50:23you know, they've just been on benzos
50:25or see drugs forever and they've
50:27never had their sleep evaluated.
50:28And so I think definitely having
50:31a very good history and work up
50:34is important in these people.
50:36And I would say I think there's,
50:39you know, because there are so many
50:41different things that can affect their sleep.
50:43But there's a lot of.
50:44Different things so we can intervene on.
50:46You know, I mentioned medications, right?
50:48So that's definitely something we
50:50can change to make sleep better.
50:52I think we could probably do a better
50:54job of identifying and treating
50:56sleep disorders in these people.
50:59So, you know,
50:59I I think we have to start there.
51:01I mean I'm very the reason.
51:05Would I have wanted jump to interventions?
51:07Yes.
51:07But I I do think that we need better
51:09tools before we jump to interventions.
51:12And So what I hope is,
51:13you know,
51:14maybe the future is like a
51:16deprescribing intervention to see
51:18how that helps sleep or to really
51:20think about what are we doing to
51:22these people when in their sleep,
51:24when we give them things like
51:26antipsychotics or, you know,
51:28because I think that's something
51:29in geriatrics,
51:30they are used very frequently
51:32off labeled to help with sleep.
51:34But what are we actually doing
51:36to these people?
51:37And so I think we need better
51:38tools to figure that out.
51:43Great. Thank you, Brianne.
51:45So I I'll ask a oh,
51:47here's another question from John.
51:50How did your patient do when
51:51treated for their sleep apnea?
51:53Great question.
51:53Actually did great. She was one of
51:55those people who just took to it.
51:56There's no problem. So, I mean,
52:01maybe you could maybe you sort of look
52:03at her home sleep test and say, oh,
52:05she's just got apneas and, you know,
52:07maybe she just needs to open up her airway.
52:10I don't know. She she did very well.
52:13But I don't think that I'm
52:15particularly good at figuring out
52:17who those people are going to be.
52:18I I just think that in my population
52:22they all deserve a chance because,
52:24you know, for a lot of them,
52:27cognition is a priority. Right.
52:29And there's not a lot else
52:30we can do to help cognition.
52:32So if we can find a sleep disorder
52:35like sleep apnea and treat it,
52:37even though we know the treatment
52:39can be hard,
52:40I think a lot of them are willing to,
52:42you know,
52:43to do the work because that is a that is
52:46an important patient centered outcome.
52:50So Brian, I wanted to ask you a question
52:52about defining adequate sleep duration.
52:55I think one of the papers you had.
52:58Mentioned was a paper from Wallace and
53:02Sleep noting the situation was defined based
53:05on cardiovascular outcomes or et cetera.
53:07Yeah. And so. You know,
53:10it seems like based on your
53:11description for geriatric approach,
53:12you know we got to be looking
53:13at things other than mortality,
53:15we got to be looking at function
53:17and institutionalization and so on.
53:18And so do we have data on
53:20well functioning older adults,
53:22men and women and conversely
53:23you know those who are poor,
53:25poorly functional to anchor this
53:27definition of short sleep duration
53:28versus long sleep duration rather
53:30than looking at things like
53:32mortality or incidence of diabetes.
53:34I mean you know again it's I sort of
53:37I'm not particularly interested in.
53:39Those outcomes when I'm trying to think
53:41about what I want to do to help my patients,
53:44but I'm sort of using it as
53:45a benchmark to say, alright,
53:47can we all agree that if sleep duration,
53:49this sleep duration is associated
53:51with mortality in older people
53:53that this is a good way to define?
53:55You know, poor sleep duration.
53:59So. So I I see your point. I'm,
54:03I'm kind of just using it as a benchmark,
54:06but you know, I do think.
54:10I mean and you probably know this just
54:12as well as I do that there are if you
54:15think about you know treatment of OSA,
54:18you know maybe there are certain
54:20outcomes where we're,
54:21we're not meeting the metric,
54:22but there are other things that
54:24are more patient centered and
54:26more having to do with symptoms
54:28where where CPAP does help people.
54:30Just wondering if there is a cohort
54:32of people that is like really well
54:35off and healthy aging Agers and
54:37you look at their sleep to define.
54:40There are people studying like the,
54:42you know, sent to gennario ANS
54:45and people who are just just,
54:47you know, genetically they come for
54:48this stuff from the stock where
54:50everybody lives to like past 100.
54:52So there are people studying those groups,
54:54but I don't know that anybody
54:56is studying their sleep.
54:57It's an interesting idea.
55:00So there's another question in
55:02the chat and from John Cronin.
55:03Do you have any experience using
55:05promise fatigue or promise
55:06sleep disturbance in your work?
55:08And any thoughts on their
55:10value compared to ESS or I I,
55:13for example, yeah. I have not.
55:19I, you know, I'm familiar with those and
55:22I have certainly looked at them. Umm.
55:26I don't have a sense that they're better
55:29or worse than what we have already.
55:32I mean, I I think.
55:35You, you you just have to be sort
55:37of judicious in what you're asking
55:39people in your study to do which is
55:41why I'm not also collecting those
55:43measures currently because I think
55:45you know you probably want to do,
55:47you have to do fatigue and then promise
55:50has two different in addition to fatigue,
55:52it's the sleep disturbance and I can't
55:54remember the other one and so it just
55:56ends up being a lot of questions.
55:58And so you know,
55:59I think if you really wanted to focus
56:01on promise you'd probably do those and
56:03you wouldn't collect anything else.
56:05Or you'd be very limited in what
56:06else you could collect.
56:10Sounds good maybe one last question
56:12from Robert Thomas you've you've you're
56:15using things like Knox Self applied
56:18system and the and the band and so
56:21Doctor Thomas wondering what about
56:23other wearable track to track sleep
56:25such as the aura ring or circle ring
56:28or whatever whatever other ring or or.
56:32Watch the people use.
56:33Yeah. So, um, I think, you know,
56:37I'm not particularly wedded
56:38to one kind of technology.
56:40I just want to use technology
56:42that's sort of more feasible.
56:47I can't say off the top of my head,
56:49you know, the reason I went with the
56:51headband is because you can get EG with it.
56:53So I'm not as familiar with the
56:55ring and what it does, you know,
56:57as opposed to actigraphy
56:58or as opposed to doesn't.
57:00I mean, it doesn't.
57:01How how good is the the sleep
57:03architecture that you get from the rain?
57:10I don't know, robertino.
57:14Well, depends on what technology.
57:18It is clear that you don't get the EEG, but.
57:22You can get a fair amount of,
57:24you can get activity monitoring.
57:25Yes, you can get kind of you know,
57:27finger activity,
57:29finger movements, hand movements.
57:32You can get oximetry, of course.
57:34You can get heart rate,
57:36so you can get do a heart
57:38rate variability assessment.
57:39You can measure sleep
57:41quality in different ways.
57:43And of course you can track it infinitely.
57:45Hmm, so that's a.
57:47So you can do the more direct measurements,
57:51which you do infrequently,
57:53and fill the gaps with.
57:58The variables, the Fitbit is pretty good.
58:01The new, the latest Fitbit Apple
58:04Watch Sleep assessment is decent.
58:06Now, the problem is that they
58:08are not tuned to elderly.
58:10So if you say if it gives you an
58:13output that you have no deep sleep,
58:15it doesn't mean that there's no good sleep.
58:18We see the problem in the sleep clinic
58:19already where patients come here.
58:20Oh, my ring said that I'm doing that,
58:22right? Yes, of course, yeah.
58:25You know, maybe you're not.
58:28OK, so doctor minor sounds like a
58:30conflict of interest waiting to happen.
58:33Some data in older folks
58:34so that the. Algorithms
58:37can be better thresholded right now. If
58:40you're sleeping like a rock,
58:42you are an N3 if you move just a bit.
58:45You're in light sleep, so.
58:48The output is, not.
58:51Properly calibrated, I guess.
58:54OK, very good. Well, all right.
58:57Well, thank you everyone for a great
59:00questions and thanks Brian for a great talk.
59:03And thank you all for attending and
59:05we're looking forward to our next
59:07session which will be in just about a
59:09month in December before the holidays.
59:11Take care everybody,
59:12great seeing you and. Meet soon.