OBJECTIVES Delirium is a serious medical condition with increased incidence in at‐risk surgical populations. We sought to determine if melatonin use reduces the incidence of delirium in individuals undergoing major cardiac surgery. DESIGN Randomized double‐blind placebo‐controlled clinical trial (two arms, 1:1 allocation, parallel design). SETTING The trial took place in two metropolitan hospitals (public tertiary and private) in Perth, Western Australia. PARTICIPANTS We recruited 210 adults aged 50 years or older who were due to undergo coronary artery bypass grafting or valve replacement surgery. INTERVENTION Participants were randomly assigned (1:1) to 7 days of treatment with melatonin 3 mg at night or matching placebo, starting 2 days before the surgery. MEASUREMENTS The primary outcome of interest was incident delirium within 7 days of surgery as assessed via daily clinical assessment that included the Confusion Assessment Method. Secondary outcomes of interest included duration and severity of delirium, length of hospital stay, cognitive function, and mood and anxiety symptoms at discharge and 3 months after the surgery. RESULTS The groups were well balanced for demographic and clinical parameters. Forty‐two participants developed delirium, but it was evenly distributed between the groups (melatonin 21/98, 21.4%; placebo 21/104, 20.2%; adjusted odds ratio [OR] = .78; 95% confidence interval [CI] = .35‐1.75). The median duration of delirium was 3 (interquartile range [IQR] = 2‐4) and 2 (IQR = 1‐3) days for people treated with melatonin and placebo, respectively (z = −1.03; P = .304). A similar proportion of participants experienced severe episodes of delirium in each group (melatonin 9/21, 42.9% vs placebo 6/21, 28.6%; χ2 = .93; P = .334; adjusted OR = 1.98; 95% CI = .40‐9.78). The groups did not differ in terms of length of stay, mood, anxiety, and cognitive performance. CONCLUSION The findings of this randomized double‐blind placebo‐controlled trial do not support the prophylactic use of melatonin to prevent delirium after major cardiac surgery. J Am Geriatr Soc 68:112–119, 2019

Background/Objectives: Later chronotype has been associated with poorer glycemic control in type 2 diabetes. It is unclear whether this is a direct relationship, or if personality factors or social jetlag ([SJL], ie, chronic circadian misalignment reflecting the discrepancy between the entrained phase of the circadian clock and socially-determined behavioural cycles) play a role. This study aimed to determine the relationships among chronotype, SJL, personality factors and glycemic control in type 2 diabetes, independently of sleep disturbances and daily caloric distribution. Methods: In sum, 252 type 2 diabetes patients attending an annual review outpatients' clinic completed questionnaires, including the Munich Chronotype Questionnaire to assess chronotype and SJL, the Pittsburgh Sleep Quality index (PSQI), the Big Five Personality Inventory and the Center for Epidemiologic Studies Depression Scale. Chart review provided information on diabetes duration, Hemoglobin A1c (HbA1c), body mass index (BMI) and other clinical variables. Caloric intake was assessed via 24-h dietary recall. Results: Hierarchical linear regression revealed that SJL, but not chronotype or personality factors, was a significant predictor of HbA1c levels (b ¼ 0.16, p < 0.05). There was a significant relationship between later chronotype and HbA1c levels, but only in patients who had more than 90 min SJL (r ¼ 0.51, p ¼ 0.002). Younger age was associated with a higher HbA1c (r ¼ À0.23, p < 0.001), and this effect was partially mediated through SJL (Pm ¼ 0.22). Conclusions: We identify SJL as a novel factor that may impact on glycemic control in type 2 diabetes. Further study is needed to determine whether interventions aimed at reducing SJL may lead to improvements in glycemic control.

Circadian rhythms are endogenously generated recurring patterns of around 24 hours with well-established roles in physiology and behaviour. These circadian clocks are important in both the aetiology and treatment of various psychiatric and metabolic diseases. To maintain physiological homeostasis and optimal functioning, living life synchronised to these clocks is desirable; modern society, however, promotes a ‘24/7’ lifestyle where activity often occurs during the body’s ‘biological night’, resulting in mistimed sleep and circadian misalignment. This circadian desynchrony can increase the risk of disease and can also influence treatment response. Clinicians should be aware of the influence that circadian desynchrony can have on health and disease, in order to potentially develop new therapeutic strategies and to incorporate chronotherapeutics into current treatment strategies to enhance their utility.

Objectives This study aimed to test if a behavioural activation (BA) programme was more effective than usual care at reducing the risk of conversion to major depression over 52 weeks among adults aged 65 years or older living in rural Western Australia. Secondary aims were to test if participants assigned to the BA intervention experienced greater decline in the severity of depressive and anxiety symptoms than older adults treated with usual care over 26 and 52 weeks, as well as greater improvement in physical and mental health‐related quality of life. Methods Randomised controlled clinical trial that started recruitment in February 2016 in rural Western Australia. We used the electoral roll to invite adults aged 65 years or over living in suitable regions of Western Australia to take part in the study. We recruited those who consented and screened positive to at least one of the two Whooley questions: feeling down/depressed/hopeless or little interest or pleasure over the past month. Participants were randomly assigned to usual care or usual care plus a phone‐delivered BA program (1:1). The intervention consisted of a self‐managed BA program supported by three 45‐min phone sessions delivered by a BA therapist over a period of 8 weeks. We used the DSM‐5 criteria to establish the presence of a major depressive episode, and Patient Health Questionnaire, Generalised Anxiety Disorder Scale and SF‐36 to assess symptoms of depression, anxiety and quality of life. Results Of the 309 older adults randomised, 307 started the trial: 153 usual care and 154 BA (computer‐generated random permuted even blocks ranging in size from 8 to 20). Six participants developed a major depressive episode during follow‐up, four of them in the usual care group (odds ratio of depression associated with the intervention = 0.49, 95% CI = 0.04, 3.49—blind assessment). Seventy‐three (23.8%) participants were lost over 52 weeks—there were no differences between usual care and intervention group. Intention‐to‐treat analyses using mixed regression models found modest non‐significant effects of the BA intervention, while complete‐case analyses showed that participants treated with BA compared with usual care experienced significant improvements in depression and anxiety symptoms over 52 weeks, as well as improved mental health quality of life. Conclusions Few participants developed a major depressive episode during follow‐up. The BA intervention was associated with improved symptoms of depression and anxiety, although the clinical significance of these benefits remains unclear.

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