Kristina Leyden, RN, MSN, FNP-C The University of Texas Health Science Center at Houston 6901...
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Transcript of Kristina Leyden, RN, MSN, FNP-C The University of Texas Health Science Center at Houston 6901...
Activity-Rest Circadian Rhythms in COPD
Kristina Leyden, RN, MSN, FNP-CThe University of Texas Health Science Center at Houston 6901 Bertner AvenueHouston, TX 77030Sandra K. Hanneman, PhD, RN, FAANCynthia McCarley, RN, DSNNikhil S. Padhye, PhDMichael H. Smolensky, PhD
Background
COPD – Airway inflammationProgressive dyspneaActivity intolerance
(Global Strategy for the Diagnosis, 2009)
Persons active during day and sleep during night -Airway tone Airway inflammation
(Clark & Hetzel, 1977)
Increased severity of COPD=Worsening Dyspnea
Worsening dyspnea = Activity intolerance Increases
(Watz, Waschki, Meyer, & Magnussen, 2009)
What we know
Circadian pacemaker synchronizes circadian rhythms to 24 hours by activity-rest routine coupled to light-dark cycle (Ancoli-Israel, Martin, Kripke, Marler, & Klauber, 2002; Van Someren, 2000)
Alterations in circadian rhythms, including activity-rest rhythm, occur with aging(Ancoli-Israel et al., 2002; Czeisler et al., 1992; Swaab, Fliers, & Partiman, 1985; Van Someren, 2000)
COPD primarily disease in adults over age of 65 (American Lung Association, December 2007)
Relationships
Little known about relationships among COPD symptoms and activity-rest circadian rhythm
Questions
Are there circadian rhythm profiles in activity-rest in patients living at home with COPD?
What are relationships among activity-rest, dyspnea, fatigue, and lung function circadian profiles?
Significance
Knowledge of activity-rest circadian rhythm profile in patients with COPD may suggest times during night and day when patients would benefit optimally from pharmacological and/or non-pharmacological intervention
Parent Study (McCarley et al., 2007)
10 community-dwelling older men and women with moderate to severe COPD and without history of sleep disturbancesDaily self-assessments over 8 consecutive days in the home setting
DyspneaFatigueLung function
Study participants wore actigraph for 8-day monitoring period
Parent Study Results (McCarley et al., 2007)
Significant circadian rhythms (p < .05): Dyspnea (40%)
(Visual analog scale)Fatigue (60%)
(Visual analog scale)Lung function (60%)
(PEFR meter)
Parent Study Results (cont.)
Dyspnea and fatigue moderately correlated (r = .48; p < .01)
Dyspnea and lung function significantly negatively correlated (r = -.11; p < .05)Fatigue and lung function significantly negatively correlated (r = -.15; p < .01)(McCarley, Hanneman, Padhye, & Smolensky, 2007)
Aim of Secondary Analysis
To describe circadian rhythm profiles of activity-rest routines and sleep patterns in patients with COPD
In participants from the previously reported study on circadian rhythm profiles of dyspnea, fatigue, and lung function
Hypotheses
1. Variable 24-hour activity-rest pattern explains variability in circadian rhythms of:
a. Dyspneab. Fatiguec. Lung function
2. Increased sleep latency, night arousals, and daytime sleep contribute to variability in circadian rhythms
Methods
Secondary analysisActigraphy data that were collected prospectively from participants enrolled in parent study
Single-groupTime series
Methods
Approval from University of Texas Health Science Center-Houston IRBAll participants provided written informed consent
Sample
9 older adults10 in parent study, data available for only 9 (90%)
Study Participant CharacteristicsCharacteristics of the Study Participants (N=9)
ParticipantAge in Years Gender
Home O2 Use Study dates
1 64 F 24 HR 11/01/02-11/09/02
2 79 F 24 HR 06/19/02-06/28/02
3 64 F NO 07/25/02-08/02/02
4 61 F NO 11/18/02-11/27/02
5 77 F SLEEP 01/23/03-02/01/03
6 57 M SLEEP 01/24/03-02/01/03
7 81 M NO 01/27/03-02/09/03
8 77 M 24 HR 02/21/03-03/01/03
9 64 F SLEEP 03/02/03-03/10/03
Mean+SD* 69+9
*SD, Standard Deviation; 02, Oxygen
Study Participant Characteristics
Participants reported:Diurnal activityNighttime sleepSocial routineClinically stable
No medication change or hospitalization in 6 weeks preceding data collection
Instrument
Basic Mini-Motionlogger (Ambulatory Monitoring, Inc., Ardsley, NY)
Measures activity counts through piezoelectric bimorph-ceramic cantilevered beam Senses degree of motionElicits voltage in response to varying magnitudes of movementDetects movement with sensitivity of 0.003g
Data Collection
Actigraph programmed for 1-minute epoch lengthsNon-dominant wrist at beginning of data collection and removed at end of studyRemoved only for submersion of wrist in water
Data Analysis
Zero-crossing methodAction4 and Action-W, version 2 software (Ambulatory Monitoring, Inc.)
Data Analysis (cont.)
Data sets trimmed at 8 days for consistency of comparisons across participantsActivity counts reported as:
Minimum valueMaximum valueMedian
Data not normally distributed
Data Analysis (cont.)
Activity-rest data fit to 24-hour cosinor modelSignificant activity-rest circadian rhythm defined as p<.001 with zero-amplitude testR2 used to evaluate goodness-of-fit of data to cosinor model
Statistical significance expected due to large number of data pointsR2 > .10 (Higher R2, stronger fit, stronger rhythm)
ResultsMinimum, maximum, and median 8-day activity counts (N=9)
Participant Minimum Maximum Median1 0 6703 6862 0 6756 10443 0 7892 10934 280 10290 17605 17 6754 9876 0 8200 16657 1106 8297 21008 0 6319 14649 7 7478 1060
Group median 0 7478 1318
Activity-rest Circadian RhythmMean 8-day Activity-rest Cosinor Parameters (N=9)
Participant Mesor Amplitude Acrophase* R2 p
1 111 1317 14:38 0.41 0.000
2 148 64 12:54 0.17 0.000
3 138 84 14:26 0.36 0.000
4 129 73 12:43 0.25 0.000
5 95 38 11:39 0.09 0.000
6 138 72 17:07 0.24 0.000
7 98 81 14:21 0.54 0.000
8 141 24 18:41 0.06 0.242
9 96 58 12:53 0.18 0.000Group mean 122 201 14:22 0.26 0.027
SD 22 419 2:15 0.16 0.081
*Acrophase reported in military time
SD standard deviation
Relations Among Dyspnea, Fatigue, Lung Function, and Activity-Rest Circadian Rhythms
Rhythm Characteristics of Dyspnea, Fatigue, PEFR, and Activity-rest by Single Cosinor Analysis a
Dyspnea Fatigue PEFR Activity-restParticipant Mesor Ampb Acroc R2d pe Mesor Ampb Acroc R2d pe MesorAmpb Acroc R2d pe Mesor Ampb Acroc R2d pe
1 90 3314:5
9 0.17 0.04 98 3220:5
0 0.55 <.01 98 7 15:42 0.16 0.05 111 1317 14:38 0.41 0.000
2 100 3 11:26 0.06 0.31 148 64 12:54 0.17 0.000
3 113 44 4:28 0.25 0.01 119 61 4:16 0.46 <.01 100 7 20:06 0.18 0.03 138 84 14:26 0.36 0.000
4 98 1519:4
1 0.02 0.66 101 5721:4
5 0.48 <.01 100 7 9:52 0.67 <.01 129 73 12:43 0.25 0.000
5 105 3522:4
1 0.27 <.01 107 4423:0
5 0.49 <.01 97 11 13:51 0.52 <.01 95 38 11:39 0.09 0.000
6 102 14 6:19 0.28 <.01 102 11 5:58 0.17 0.03 98 18 18:29 0.39 <.01 138 72 17:07 0.24 0.000
7 99 6 19:12 0.10 0.11 98 81 14:21 0.54 0.000
8 100 214:5
5 0.02 0.77 100 3 9:49 0.05 0.39 100 2 14:36 0.02 0.72 141 24 18:41 0.06 0.241
9 99 1019:1
3 0.03 0.59 95 2517:5
8 0.08 0.23 100 3 9:23 0.09 0.16
10 97 1117:0
7 0.04 0.52 97 1919:3
8 0.21 0.02 99 5 15:19 0.41<.01 96 58 12:53 0.18 0.000
Mean 101 2114:5
5 0.14 0.32 102 3215:2
4 0.31 0.08 99 4 14:47 0.33 0.14 1815 779 14:22 0.29 0.027Note: Participants 2 and 7 did not consistently report dyspnea and fatigue. Participant 9 did not have retrievable actigraph data. Participant 9 has corrected acrophase for PEFR of 1829. All means corrected. P <.05 for Dyspnea, Fatigue, PEFR. P <.001 for Activity-rest.aModified from McCarley, et al. (2007)bAmplitudecAcrophasedGoodness of fit/strength of rhythmeSignificance level
Relations Among Dyspnea, Fatigue, Lung Function, and Activity-Rest Circadian Rhythms
Rhythm Characteristics of Dyspnea, Fatigue, PEFR, and Activity-rest by Single Cosinor Analysis a
Dyspnea Fatigue PEFR Activity-restParticipant Mesor Ampb Acroc R2d pe Mesor Ampb Acroc R2d pe MesorAmpb Acroc R2d pe Mesor Ampb Acroc R2d pe
1 90 3314:5
9 0.17 0.04 98 3220:5
0 0.55 <.01 98 7 15:42 0.16 0.05 111 1317 14:38 0.41 0.000
2 100 3 11:26 0.06 0.31 148 64 12:54 0.17 0.000
3 113 44 4:28 0.25 0.01 119 61 4:16 0.46 <.01 100 7 20:06 0.18 0.03 138 84 14:26 0.36 0.000
4 98 1519:4
1 0.02 0.66 101 5721:4
5 0.48 <.01 100 7 9:52 0.67 <.01 129 73 12:43 0.25 0.000
5 105 3522:4
1 0.27 <.01 107 4423:0
5 0.49 <.01 97 11 13:51 0.52 <.01 95 38 11:39 0.09 0.000
6 102 14 6:19 0.28 <.01 102 11 5:58 0.17 0.03 98 18 18:29 0.39 <.01 138 72 17:07 0.24 0.000
7 99 6 19:12 0.10 0.11 98 81 14:21 0.54 0.000
8 100 214:5
5 0.02 0.77 100 3 9:49 0.05 0.39 100 2 14:36 0.02 0.72 141 24 18:41 0.06 0.241
9 99 1019:1
3 0.03 0.59 95 2517:5
8 0.08 0.23 100 3 9:23 0.09 0.16
10 97 1117:0
7 0.04 0.52 97 1919:3
8 0.21 0.02 99 5 15:19 0.41<.01 96 58 12:53 0.18 0.000
Mean 101 2114:5
5 0.14 0.32 102 3215:2
4 0.31 0.08 99 4 14:47 0.33 0.14 1815 779 14:22 0.29 0.027Note: Participants 2 and 7 did not consistently report dyspnea and fatigue. Participant 9 did not have retrievable actigraph data. Participant 9 has corrected acrophase for PEFR of 1829. All means corrected. P <.05 for Dyspnea, Fatigue, PEFR. P <.001 for Activity-rest.aModified from McCarley, et al. (2007)bAmplitudecAcrophasedGoodness of fit/strength of rhythmeSignificance level
DiscussionPeak timed activity near those found by others
(Brown, et al., 1990)
Correlate with phase advance of activity levels found in older population
(Brown et al., 1990; Kripke et al., 2005; Yoon, Kripke, Youngstedt, & Elliott, 2003)
Lower mesor and higher amplitude in activity counts in this population
(Kripke et al., 2005; Van Someren, 2000)
Limitations
Conflicting literature on best model to analyze actigraphy-rest circadian rhythms
Single cosinor used to compare parameters with literature5-parameter cosinor model, with alpha (width of rhythm) and beta (steepness of curve), may better explain activity-rest pattern (Ancoli-Israel et al., 2003)
Limitations (cont.)
Acrophase remained relatively constant across the subjectsNo diaries or activity logs usedFully described environment
Contribution to gaps and recommendations
Significant, robust activity-rest circadian rhythm in 7/9 (78%)Further studies recommended to confirm findings and compare with older community-dwelling adults without COPDUnderstanding patterns for better symptom managementAdministration of medication when airway tone decreased may lead to better management
Conclusion
Lack of circadian rhythm in pulmonary variables suggestive AR did not synchronize circadian pacemakerFurther study needed to confirm or determine mechanism for the role of AR patterns as synchronizer