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Insomnia symptoms and the risk of all-cause mortality among stroke survivors
BMC Public Health volume 24, Article number: 3376 (2024)
Abstract
Background
Insomnia is more frequently reported in stroke survivors but its independent role in mortality in stroke survivors is unknown. The purpose of this study was to investigate the association of insomnia symptoms with all-cause mortality among stroke survivors.
Methods
The Health and Retirement Study, a survey of Americans older than 50 years and their spouses of any age from 2002 to 2018 was used. Only participants with a history of stroke were included. The exposure variable of interest was insomnia symptoms including difficulty initiating sleep, difficulty maintaining sleep, waking up too early, and nonrestorative sleep. The outcome was all-cause mortality. Cox proportional hazards regression models were employed to investigate the association between insomnia symptoms and all-cause mortality.
Results
A total of 3,501 stroke survivors were included of which 55% were females. Over a mean follow-up of 6 years, 1,782 deaths occurred. Difficulty initiating sleep (HR = 1.87, 95% CI: 1.07, 3.25) and difficulty maintaining sleep (1.89, 95% CI: 1.09, 3.29) were associated with all-cause mortality only among male stroke survivors younger than 65 years old while nonrestorative sleep (HR = 1.31, 95% CI: 1.05, 1.62) was associated with all-cause mortality only among male stroke survivors aged 65 years and older. Furthermore, male stroke survivors younger than 65 years of age and older than 65 with insomnia symptom scores ranging from 5 to 8 (mean = 6.2) had a higher but statistically nonsignificant risk of all-cause mortality (HR = 1.56, 95% CI: 0.81, 3.01 and HR = 1.08 95% CI: 0.85, 1.38, respectively) compared to their counterparts without insomnia symptoms. There was no association between insomnia symptoms and all-cause mortality among female stroke survivors.
Conclusion
Insomnia symptoms were associated with an increased risk of death especially in male stroke survivors younger than 65 years of age. Future studies should explore the benefit of insomnia symptom management in stroke survivors.
Introduction
Sleep is essential for human health and its disruption could lead to adverse health outcomes. In a recent study, being diagnosed with a sleep disorder (i.e., sleep apnea, insomnia, restless leg syndrome) was associated with a 50% increased all-cause mortality over 5 years compared to no diagnosis of sleep disorder [1]. Insomnia is a sleep disorder defined as a persistent difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep, and results in some form of daytime impairment [2]. A systematic review reported a higher risk of mortality in patients with insomnia disorder when compared to those without insomnia (HR = 1.66, 95% CI: 1.25–2.19) [3]. Another study found more specifically, that difficulty initiating sleep and non-restorative sleep were associated with an increased risk of all-cause mortality [4]. Several other studies have linked insomnia to long-term mortality in the general population [5,6,7,8].
Previous studies have noticed differences by sex in the association between insomnia and death. Difficulty initiating sleep was found to be associated with increased mortality in males (HR = 1.25, 95% CI: 1.04–1.50), but not in females (HR = 0.89, 95% CI: 0.79, 1.00)(9). However, being an “early waker” was not associated with increase mortality in both males (HR = 1.04, 95% CI: 0.88–1.22) and females (HR = 0.81, 95% CI: 0.75, 0.91) (9–10). Furthermore, in the Atherosclerosis Risk in Communities Study, insomnia was not associated with an increased risk for death (OR 1.01, CI: 0.85–1.21) in both sexes [11].
Insomnia has been linked to multiple dysfunctions such as increased inflammation, glucose intolerance, dysregulation of the hypothalamic-pituitary axis, and increased sympathetic nervous system activity [12,13,14,15]. However, studies suggest that these conditions cannot totally explain the observed association between insomnia symptoms and total mortality [9]. The mechanism by which insomnia increases the risk of death may also include daytime impairments, such as depressed mood, anxiety, fatigue, and ill health [3].
Insomnia is highly prevalent, affecting approximately 32 to 41% of stroke survivors [16]. Both insomnia and insomnia symptoms are higher in stroke survivors compared to the general population [17]. Insomnia could negatively affect stroke rehabilitation including post-stroke depression, recurrent stroke, and death but the independent role of insomnia in mortality is less studied in this vulnerable group [18]. Most of the previous studies were conducted in the general population (3, 4, 9–10). The objective of this study was to determine the independent role of insomnia in mortality within community-dwelling stroke survivors and whether this association is modified by age and sex.
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