24/09/2012

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Exploring Sleep, Fatigue &

Activity Levels

in Neuro-rehabilitation

Analysis - Interpretation - Significance

Vicki Gilman MSc MCSP

Cilinical Director Neural Pathways (UK) Ltd

Introduction

Without adequate sleep we all can become:

– Tired

– Irritable

– Anxious

– Depressed

– Less able to learn and recall semantic

information and skills

– More likely to have persistent insomnia

The individuality of sleep

Eight Hours?

How much do you need?

Sleep requirements differ from person-to-

person

Night owls/morning larks

Polyphasic / uniphasic

Sleep requirements differ by age

Sleep Assessment

Polysomnography (PSG)

– Also known as electroencephalography (EEG)

Actigraphy

Sleep diaries / logs

Sleep questionnaires e.g.

– Pittsburgh Sleep Quality Index (PSQI)

– Insomnia Severity Index (ISI)

– Epworth Sleepiness Scale (ESS)

Benefits of Actigraphy

Correlates with PSG 85 – 95%

Unobtrusive, discreet, well tolerated

Can be worn in ‘natural’ surroundings

Can be worn for weeks / months at a time

Gives us daytime activity information as well as sleep

Does not require specialist lab space

Still does require specialist to analyse and interpret

the data, but not overnight!

We get rich data;

Date 28-Nov-08 29-Nov-08 30-Nov-08 01-Dec-08 02-Dec-08 03-Dec-08 04-Dec-08 05-Dec-08 06-Dec-08 07-Dec-08 08-Dec-08 09-Dec-08 10-Dec-08

Bed time 21:55 00:15 21:00 21:30 21:30 21:45 21:45 22:05 23:35 21:15 21:40 21:40 21:40

Get up time 06:30 08:40 06:35 06:35 06:35 07:00 07:00 08:05 10:30 07:00 07:00 07:00 07:00

Time in bed 08:35 08:25 09:35 09:05 09:05 09:15 09:15 10:00 10:55 09:45 09:20 09:20 09:20

Sleep start 21:55 00:17 21:00 21:40 21:40 22:07 22:07 22:07 23:35 21:47 21:47 21:47 21:47

Sleep end 06:30 08:38 06:35 06:35 06:35 07:00 07:00 07:00 10:19 07:00 07:00 07:00 07:00

Assumed sleep 08:35 08:21 09:35 08:55 08:55 08:53 08:53 08:53 10:44 09:13 09:13 09:13 09:13

Actual sleep time 08:07 07:48 08:49 08:29 08:08 08:26 08:17 08:15 09:20 08:23 08:38 08:18 08:43

Actual sleep (%) 14:24 09:36 00:00 02:24 04:48 21:36 04:48 21:36 00:00 00:00 16:48 02:24 14:24

Actual wake time 00:28 00:33 00:46 00:26 00:47 00:27 00:36 00:38 01:24 00:50 00:35 00:55 00:30

Actual wake (%) 09:36:00 14:24:00 00:00:00 21:36:00 19:12:00 02:24:00 19:12:00 02:24:00 00:00:00 00:00:00 07:12:00 21:36:00 09:36:00

Sleep efficiency 14:24:00 16:48:00 00:00:00 09:36:00 12:00:00 04:48:00 12:00:00 12:00:00 12:00:00 00:00:00 12:00:00 21:36:00 09:36:00

Sleep latency 00:00 00:02 00:00 00:10 00:10 00:22 00:22 00:02 00:00 00:32 00:07 00:07 00:07

Sleep bouts 17 17 17 18 28 20 24 24 26 25 23 25 18

Wake bouts 00:00:00 00:00:00 00:00:00 00:00:00 00:00:00 00:00:00 00:00:00 00:00:00 00:00:00 00:00:00 00:00:00 00:00:00 00:00:00

Mean sleep bout time 00:28:39 00:27:32 00:31:07 00:28:17 00:17:26 00:25:18 00:20:43 00:20:37 00:21:32 00:20:07 00:22:31 00:19:55 00:29:03

Mean wake bout time 00:01:39 00:01:50 00:02:42 00:01:27 00:01:41 00:01:21 00:01:26 00:01:39 00:03:22 00:01:55 00:01:27 00:02:07 00:01:35

Immobile mins 468 463 528 496 481 502 490 474 569 502 514 492 515

Immobile time (%) 90.9 92.4 91.8 92.7 89.9 94.2 91.9 88.9 88.4 90.8 92.9 89 93.1

Moving mins 47 38 47 39 54 31 43 59 75 51 39 61 38

Moving time (%) 9.1 7.6 8.2 7.3 10.1 5.8 8.1 11.1 11.6 9.2 7.1 11 6.9

No of immobile phases 35 28 32 34 44 24 34 45 40 37 33 43 33

Mean length immobility 13.4 16.5 16.5 14.6 10.9 20.9 14.4 10.5 14.2 13.6 15.6 11.4 15.6

One Minute immobility 3 2 1 4 2 1 1 3 4 2 5 9 3

One Min immobility (%) 8.6 7.1 3.1 11.8 4.5 4.2 2.9 6.7 10 5.4 15.2 20.9 9.1

Total activity score 3351 5627 7243 3600 6099 2574 4270 5801 17946 7482 3810 7452 4255

Mean activity score 6.51 11.23 12.6 6.73 11.4 4.83 8.01 10.88 27.87 13.53 6.89 13.48 7.69

Mean score in active periods 71.3 148.08 154.11 92.31 112.94 83.03 99.3 98.32 239.28 146.71 97.69 122.16 111.97

Fragmentation index 17.7 14.7 11.3 19.1 14.6 10 11 17.8 21.6 14.6 22.3 31.9 16

Avg wake movement 309.2 255.2 328.3 246.9 278 278 221.6 248.5 234.6 272.8 307.4 268.3 400.3

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Normal data – healthy female aged 38

Healthy ‘normal’ data

Normal data – healthy female aged 38

Healthy ‘normal’ data

Sleep in People with Brain

Pathology

• Heterogeneous group, depending on:

– Location of injury/pathology

– Severity of injury/pathology

– Length of time since onset of pathology/injury

– Anoxia post injury

– Age

– Rehabilitation trajectory

– Acute care delivery

– Continuing care delivery

– Number and type of interventions……..

Activity levels in People

with Brain Pathology

However,

Actigraphy not just useful for identifying sleep

issues in this group

Useful for exploring daytime activity patterns as

well

Well tolerated

Used by carers as well

Actigraph + expert analysis =

Objective evidence

– Examining circadian rhythms

– Monitor routines

– The balance of sleep and activity over a 24 hour period

– Similarities and differences between 24 hour periods

– Consistency of routines, including imposed routines for less able

individuals

– Compliance with advice regarding routines, rest and activity periods

– Guide timing & balance the impact of rehabilitation interventions

– Inform sleep treatment interventions

– Assist in determining level of function / dependency

– Provide objective evidence of progress

Case

Examples

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Dementia patient data

Dementia patient data

Loss of Routine

Patient with RBD

Care

delivery

Patient with RBD

Carer of patient with

RBD

Carer of patient

with RBD

24/09/2012

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Brain Injury

Client: Male, ABI at 28 years old

Analysis: of sleep and activity aged 38

Background: Moved into care home as

elderly parents could no longer cope at

home. High level of physical dependency,

very dysarthric, cognitive issues including

poor memory, insight difficulties alongside

behavioural issues. Care home report he

sleeps well. Client and family report he

does not sleep well. Continued difference

of opinion acts as a behavioural trigger.

Question: How well is he sleeping?

Very good routine

Progressive

Condition

Client: female with

progressive myoclonic

epilepsy since childhood.

Analysis: at age 25

Background: recent

change in sleep, fatigue

energy and behaviour

reported

Question: is sleep

disturbed could routine and

interventions be better

managed?

Routine still evident

Client: Female ABI aged 20

Analysis: at age 30

Background: A semi

independent wheelchair user with

cognitive and behaviour issues.

Achieving gradually greater

independence in daily tasks over

past few years in a variety of slow

stream rehab settings. Moving

toward independent community

living with support

Question: How consistent is her

routine, could it be improved with

consequent functional gains?

Anoxic

Brain Injury

Poor

Routine

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Brain Injury

Client: Male, ABI at 22 years old

Analysis: of sleep & activity age 24

Background: Regained high level

of function, living with family, &

working but reporting pain, fatigue,

angry outbursts, difficulty keeping

up socially with peers, some

attention and memory problems.

Appears to have made a good

recovery but professionals feel

there are issues to uncover

Question: What do routines and

patterns look like for this client?

Acquired Brain Injury

Client: Male, ABI at 28 years old

Analysis: of sleep & activity age 34

Background: Wheelchair user, high levels of physical and psychological

dependency, hemiparesis, dysexecutive presentation, dysarthria,

behavioural issues, loss of routine, wide range of ineterests and cognitive

abilities, recent loss of some physical abilities due to tonal problems.

Placed in a private rehabilitation unit via interim payment for rehabilitation.

Experts proposed a very intensive package of rehabilitation with a tightly

structured and timetabled day

Question: What will the impact of rehabilitation be? How much is enough,

how much is too much?

Baseline

Analysis and recommendation

Achieving a good behavioural/routine and more settled environment should promote a reduction in

night time activity and improved sleep outcomes with consequential benefits during the day.

Average actual time asleep is short

Usual pattern of arising in the mornings around 9 am is good

Six significantly disturbed night patterns, no data available in care notes described “settled nights”

and there was no outbursts recorded. Subject likes to watch television at night and can switch it on

and off independently.

Lots of activity continuously, whilst awake.

No identifiable rest periods in the day.

Identifiable behavioural episode on 18 March at 9 pm. A further two outbursts are recorded on 21

March at 1 pm and 4 pm.

Would benefit from a modified environment with minimal stimulation in the night.

.

Impacts

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Why actigraphy analysis?

These data can provide objective evidence

Provides evidence of disturbed OR stable activity patterns /

sleep

Provides rich data about sleep, daily routines, consistency

and fatigue – usually over a 2 week period but can be much

longer

Can be used to guide interventions in a number of ways

Can be useful as expert evidence

Actigraphy analysis is a reliable, well tolerated and cost-

effective means of obtaining objective evidence

It’s better than video surveillance!

For the neurological client this measurement and

analysis technique is only available through Neural

Pathways – as we have a unique mix of specialist

neuro-rehabilitators working together with a PhD

researcher for full analysis and academic support.

Thank- You and Sleep Well!

Any questions?

PLEASE CONTACT: Dr David Lee or Vicki Gilman

Neural Pathways UK Ltd

Tel: (0191) 423 6240

e-mail david.lee@neural-pathways.co.uk

vicki.gilman@neural-pathways.co.uk