kristina leyden, rn, msn, fnp-c the university of texas health science center at houston 6901...
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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
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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)
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Increased severity of COPD=Worsening Dyspnea
Worsening dyspnea = Activity intolerance Increases
(Watz, Waschki, Meyer, & Magnussen, 2009)
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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)
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Relationships
Little known about relationships among COPD symptoms and activity-rest circadian rhythm
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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?
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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
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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
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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)
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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)
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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
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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
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Methods
Secondary analysisActigraphy data that were collected prospectively from participants enrolled in parent study
Single-groupTime series
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Methods
Approval from University of Texas Health Science Center-Houston IRBAll participants provided written informed consent
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Sample
9 older adults10 in parent study, data available for only 9 (90%)
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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
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Study Participant Characteristics
Participants reported:Diurnal activityNighttime sleepSocial routineClinically stable
No medication change or hospitalization in 6 weeks preceding data collection
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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
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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
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Data Analysis
Zero-crossing methodAction4 and Action-W, version 2 software (Ambulatory Monitoring, Inc.)
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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
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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)
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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
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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
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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
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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
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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)
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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)
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Limitations (cont.)
Acrophase remained relatively constant across the subjectsNo diaries or activity logs usedFully described environment
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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
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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