Older schizophrenia patients have more disrupted sleep and circadian rhythms than age-matched comparison subjects
Introduction
Individuals with schizophrenia commonly complain of disturbed nighttime sleep both in inpatient (Morgan and Drew, 1970, Rotenberg et al., 2000) and outpatient settings (Haffmans et al., 1994, Sweetwood et al., 1976). Laboratory polysomnographic studies confirm that nighttime sleep of patients with schizophrenia is highly fragmented (Tandon et al., 1992, Tandon et al., 1988, Nofzinger et al., 1993, Neylan et al., 1992, Goldman et al., 1996, Lauer et al., 1997, Keshavan and Tandon, 1993). In addition, REM and non-REM sleep abnormalities have been described in both medicated and unmedicated patients (Lauer et al., 1997, Jus et al., 1973, Ganguli et al., 1987, Hudson et al., 1993, Kempenaers et al., 1988, Stern et al., 1969). Studies suggest that these differences in nighttime sleep architecture are related to important clinical outcomes, medications, and specific psychiatric symptoms (Benson and Zarcone, 1994, Zarcone, 1979, Keshavan et al., 1994, Tandon et al., 1988, Goldman et al., 1996, Kajimura et al., 1996, Hoffmann et al., 2000).
In addition to subjective and objective nighttime sleep disruption, some studies suggest circadian rhythms of hormones and activity patterns are also disrupted in schizophrenia patients (Rao et al., 1994, Wirz-Justice et al., 2001, Wirz-Justice et al., 1997). Based upon analysis with the traditional cosine fitting method, a descriptive study from our laboratory showed that older patients with schizophrenia have disturbed circadian activity rhythms, disrupted nighttime sleep and excessive daytime sleep (Martin et al., 2001). Like other studies in the field, this original descriptive study was limited by the absence of sleep and circadian rhythm data from comparison subjects and by the method used to analyze circadian activity rhythms. Previous studies have not compared sleep/wake recordings or circadian rhythms of older community dwelling schizophrenia patients to matched comparison subjects, so it has not been possible to determine if the disruption in sleep/wake patterns was a result of the psychiatric disorder or a result of aging independent of the psychiatric disorder. Since the publication of our original report, we studied a group of age- and gender-matched normal comparison subjects (NCS) to address this limitation. We also employed a newly developed sophisticated method for circadian rhythm modeling, which enabled examination of additional circadian rhythm characteristics (Martin et al., 2000, Marler et al., 2004).
The current study examined differences between the older patients with schizophrenia we originally studied (Martin et al., 2001) and a group of matched NCS in daytime and nighttime actigraphically estimated sleep/wake and circadian rhythms of activity. We hypothesized that: (a) patients would sleep more at night, but would have poorer nighttime sleep quality than NCS; (b) during the day, patients would be sleepier than NCS; (c) patients would have less robust circadian activity rhythms than NCS; and (d) worse nighttime sleep quality and less robust circadian rhythms would be associated with lower levels of light exposure during the daytime hours. Secondary analyses were undertaken to examine the impact of education, working and living situation on sleep within the schizophrenia patients as well.
Section snippets
Participants
Twenty-eight previously studied older patients with schizophrenia (14 men, 14 women, mean age = 58.3 years) were included. Schizophrenia patients were screened using the Structured Clinical Interview for DSM-III-R/DSM-IV (SCID; Spitzer and Williams, 1986), which was administered by geriatric psychiatry or psychology fellows. Patients met diagnostic criteria (DSM-III-R or DSM-IV) for schizophrenia (American Psychiatric Association, 1987, American Psychiatric Association, 1994). Diagnosis was
Nighttime sleep/wake
Patients with schizophrenia went to bed earlier and spent more time in bed than NCS. This extended time in bed was the result of both more time asleep and more time awake. The percent of time in bed asleep was lower for patients than NCS, and patients woke up more often and were awake longer than NCS (multivariate F = 9.95, p < .0005; see Table 2). Results did not change when education was included as a covariate.
Daytime sleep/wake
Patients with schizophrenia were awake less, slept more, fell asleep more often and
Discussion
To our knowledge, this is the first study comparing objectively measured sleep/wake and circadian rhythms of older schizophrenia patients to the sleep/wake and circadian rhythms of age- and gender-matched NCS. This study showed that older patients with schizophrenia went to bed an hour earlier and slept over 1/2 h later in the morning than NCS of the same age. This extended time in bed (9.8 vs. 7.9 h) was accounted for by additional sleep (8.5 vs. 7.5 h), but also by nearly 1 h of additional
Acknowledgements
This work was supported by NIMH MH49671, NCI CA85264, NIA AG08415, NIMH MH45131, NIMH MH43693, GCRC NIH M01 RR00827, the Research Service of the Veterans Affairs San Diego Healthcare System, Department of Veterans Affairs VISN22 Mental Illness Research, Education and Clinical Center (MIRECC), the Research Service of the Veterans Affairs San Diego Healthcare System and a dissertation grant from the Foundation for Sleep Disorders Research. This work was part of the Doctoral Dissertation of
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