Sleep Disturbance, Daytime Symptoms, and Functional Performance in Patients With Stable Heart Failure

Abstract

Background Sleep disturbance is common among patients with heart failure (HF) who also experience symptom burden and poor functional performance. Objective We evaluated the extent to which sleep-related, daytime symptoms (fatigue, excessive daytime sleepiness, and depressive symptoms) mediate the relationship between sleep disturbance and functional performance among patients with stable HF. Methods We recruited patients with stable HF for this secondary analysis of data from a cross-sectional, observational study. Participants completed unattended ambulatory polysomnography from which the respiratory disturbance index (RDI) was calculated; along with a Six-Minute Walk Test; questionnaires to elicit sleep disturbance (Pittsburgh Sleep Quality Index; Insomnia Symptoms from the Sleep Habits Questionnaire); daytime symptoms (Center for Epidemiologic Studies Depression Scale; Global Fatigue Index; Epworth Sleepiness Scale); and self-reported functional performance (Medical Outcomes Study SF36 V2 Physical Function Scale). We used structural equation modeling with latent variables for the key analysis. Follow-up, exploratory regression analysis with bootstrapped samples was used to examine the extent to which individual daytime symptoms mediated effects of sleep disturbance on functional performance after controlling for clinical and demographic covariates. Results The sample included 173 New York Heart Association Class I-IV HF patients (N = 60/34.7% women; M = 60.7, SD = 16.07 years of age). Daytime symptoms mediated the relationship between sleep disturbance and functional performance. Fatigue and depression mediated the relationship between insomnia symptoms and self-reported functional performance, while fatigue and sleepiness mediated the relationship between sleep quality and functional performance. Sleepiness mediated the relationship between the respiratory index and self-reported functional performance only in people who did not report insomnia. Conclusions Daytime symptoms explain the relationships between sleep disturbance and functional performance in stable HF.

The Correlation Between Fatigue and Sleep Quality among Patients with Heart Failure

“…Some studies showed that fatigue was prevalent among patients with HF, ranging from 45.8 to 100% (Austin et al, 2011, Perez-Moreno et al, 2014, Nasiri et al, 2016, Tang et al, 2010. The participants in this study seemed to have a lower mean global fatigue index/GFI (22.99), ranging from 10 -44 on the MAF than several studies in USA (29.8 to 35.08) (Jeon and Redeker, 2016, Redeker et al, 2010b, Redeker et al, 2012, Fritschi and Redeker, 2015. Findings from another study by Nasiri et al (2016) revealed a lower score of GFI among patients with HF in Iran (5.92).…”

Mechanisms of reduced sleepiness symptoms in heart failure and obstructive sleep apnea

“…Although the reviewed studies provide evidence of a relationship between decreased sleepiness symptoms and the combination of HF (Jeon & Redeker 2016; and low energy (Skotzko, 2009), and do not adequately control for potential confounders. Studies also do not consistently explore beta blockers, which are commonly used in heart failure and contribute to fatigue (Fotino, Thompson-Paul, & Bazzano, 2013;Kishi, Watanabe, & Folkers, 1977) (see Table 1).…”

“…Although the reviewed studies provide evidence of a relationship between decreased sleepiness symptoms and the combination of HF and OSA, further investigation is needed to understand the mechanism. The current epidemiologic studies have methodologic flaws and inconsistencies: they have small samples, do not consistently control for fatigue, use various measures of sleepiness and heart failure definitions, do not compare sleepy (ESS >10) versus non‐sleepy groups in the main analyses , do not consider insomnia, which may worsen symptoms of heart failure such as fatigue (Jeon & Redeker ; Redeker et al, ) and low energy (Skotzko, ), and do not adequately control for potential confounders. Studies also do not consistently explore beta blockers, which are commonly used in heart failure and contribute to fatigue (Fotino, Thompson‐Paul, & Bazzano, ; Kishi, Watanabe, & Folkers, ) (see Table ).…”

Discrepancy between wrist‐actigraph and polysomnographic measures of sleep in patients with stable heart failure and a novel approach to evaluating discrepancy

“…In this sample, approximately half of the total sample ( N = 173) had significant SDB (Redeker, Muench, et al, ), and half had insomnia symptoms that were not explained by SDB (Redeker, Jeon, et al, ). We previously reported the associations between SDB, insomnia, daytime symptoms and function (Jeon & Redeker, ; Redeker, Jeon, et al, ; Redeker, Muench, et al, ), and the associations between nocturia and sleep (Redeker et al, ). This study was approved by the IRB, and all participants provided written informed consent.…”