Exploring older care recipients' sleep status as a predictor for informal carer distress: evidence from New Zealand's interRAI home care assessment data.

OBJECTIVES: Understanding factors affecting informal carers' well-being is important to support healthy ageing at home. Sleep disturbances of care recipients are increasingly recognised as affecting the well-being of both parties. This research assesses the relationship between indicators of care recipients' sleep status and carer distress, as well as carer distress with subsequent admission to residential aged care, using prospectively collected Home Care International Residential Assessment Instrument (interRAI-HC) assessment data. PARTICIPANTS: Data were sourced from 127 832 assessments conducted between 2012 and 2019 for people aged 55 years or older who had support from at least one informal carer. The majority (59.4%) of care recipients were female and 59.1% were defined as having cognitive impairment or dementia (CIoD). SETTING: New Zealand. DESIGN: Logistic regression modelling was used to assess the independent relationships between indicators of care recipients' sleep status (difficulty sleeping and fatigue) and primary caregivers' distress (feeling overwhelmed or distressed). Kaplan meier curves illustrated the subsequent relationship between caregiver distress and care recipients' transitions to aged residential care. RESULTS: Care recipients' sleeping difficulty (32.4%) and moderate-severe fatigue (46.6%) were independently associated with caregiver distress after controlling for key demographic and health factors included in the assessment. Distress was reported by 39.9% of informal caregivers and was three times more likely among those supporting someone with a CIoD. Caregiver distress was significantly associated with care recipients' earlier admission into aged residential care. CONCLUSIONS: Indicators of sleep disturbance among care recipients are associated with increased likelihood of carer distress. This has implications for managing the overall home-care situation and long-term care needs, as well as the well-being of both parties. Findings will inform research and development of measures, services and interventions to improve the sleep and waking health of older people, including those with CIoD and family caregivers.

"I think I could have coped if I was sleeping better": Sleep across the trajectory of caring for a family member with dementia.

Dementia-related sleep changes can lead to disruptions among families living with dementia which can jeopardise carers' wellbeing and ability to provide support. This research explores and represents the sleep of family caregivers across the trajectory of caring, before, during, and after the key period of their care recipient moving into residential care. The focus of this paper is viewing dementia caregiving as a trajectory, characterised by care needs which change over time. Semi-structured interviews were conducted with 20 carers whose family member with dementia had transitioned into residential care within the prior 2 years. Themes constructed from these interviews indicated that sleep was linked to earlier life course patterns as well as to significant moments of transition in the caregiving journey. As dementia progressed, carers' sleep progressively worsened in relation to the less predictable nature of dementia-symptoms, difficulty maintaining routines, and constant responsibilities creating a state of high alert. Carers attempted to facilitate better sleep and wellbeing for their family member, often sacrificing their own self-care. Around the care transition period, some cares reported not realising how sleep deprived they were; for others the busy momentum continued. After the transition, many carers acknowledged that they were exhausted, although many had not realised this while providing home-based care. Post-transition, many carers reported ongoing sleep disruptions associated with poor sleep habits established whilst caring, insomnia or nightmares and grief. Carers were optimistic that their sleep would improve with time and many were enjoying sleeping according to their own preferences. The sleep experience of family carers is unique and includes tensions between their essential need for sleep and the experience of care as self-sacrifice. Findings have implications for timely support and interventions for families living with dementia.

Daytime fatigue as a predictor for subsequent retirement among older New Zealand workers.

OBJECTIVES: There is limited information on the role of fatigue on retirement, either independently or in association with poor sleep. The aim of this study was to examine the prospective association between daytime fatigue, measured as feeling tired or feeling worn out, independently and in relation to dissatisfaction with sleep, and subsequent retirement among 960 older workers in New Zealand. METHODS: Data from 2 consecutive surveys (2008 and 2010) of the New Zealand Health, Work, and Retirement Longitudinal Study were used. Poisson regression was used to investigate whether feeling tired and feeling worn out in 2008, along with dissatisfaction with sleep, were associated with self-reported retirement either due to health reasons or other reasons by 2010. RESULTS: The risk for retirement due to health reasons during a 2-year follow-up was 1.80-fold (95% confidence interval [CI] 1.16-2.45) among those who felt tired and 1.99-fold (95% CI 1.34-2.64) among those who felt worn out when compared to those not tired or not feeling worn out after adjusting for several sociodemographic, work characteristics and self-rated health. The risk for retirement due to health reasons was even higher when participant experienced both tiredness and feeling worn out. Dissatisfaction with sleep did not predict retirement due to health or other reasons. CONCLUSIONS: Our results highlight that workers at risk of subsequent retirement due to health reasons may be identified with rather simple questions on tiredness and feeling worn out even among generally healthy older workers.

Non-pharmacological interventions a feasible option for addressing dementia-related sleep problems in the context of family care.

BACKGROUND: Sleep disturbances are challenging symptoms associated with mild cognitive impairment or dementia (MCIoD). This study assessed the feasibility of sleep monitoring and non-pharmacological interventions to improve the sleep of New Zealanders with MCIoD and their family carers. METHODS: A 5-week multi-modal intervention consisting of timed bright light therapy, physical activity, and sleep education was piloted. Sleep was monitored for a week at baseline and conclusion of the trial using actigraphy, diaries, and questionnaires alongside additional health and wellbeing information concerning both care recipients and carers. RESULTS: Fifteen pairs participated, 9 completed the trial. Patterns of attrition and participant feedback are discussed. Case studies showed that six of the care recipients had minor improvements to sleep efficiency. Some also had improved subjective sleep ratings and quality of life. Changes did not clearly translate to family carers. However, five of them also showed some improvements in sleep status and mental health. Health deterioration of care recipients may mask the effects of the intervention. CONCLUSIONS: It is feasible to use non-pharmacological sleep interventions for people with MCIoD and their family carers. Given the limited treatment options, further consideration of such interventions in future research and clinical practice is warranted. TRIAL REGISTRATION: As this study was to assess the feasibility of proposed methods, it was an observational study without case-control groups nor a medical-based intervention, clinical registration was not required. A future full version of the trial would be registered with the Australian New Zealand Clinical Trails Registry.

Sleep/wake behaviour of competitive adolescent athletes in New Zealand: insight into the impact of early morning training.

OBJECTIVE: Sleep plays a crucial role in the health, wellbeing, and development of adolescent athletes' sporting and academic lives. This study aimed to monitor the sleep/wake behaviour of adolescent athletes who have frequent early morning training sessions. METHODS: 13 swimmers (mean age 14.8 ± 1.4; 46% male) and 19 rowers (mean age 16.5 ± 1.1; all male) wore actigraphs and completed sleep diaries over a 2-week training period. Diaries included the Hooper Index and a question regarding device use before bed. Participants also completed chronotype questionnaires. Nights of the week were categorised as taking place before "morning training", "mornings off", "weekend mornings off", and "weekend morning training". Actigraphy and sleep diary variables were compared for different nights of the week. RESULTS: All athletes were classified as "morning type". Average sleep duration across the study was 7h55 (±1h33). Median sleep duration was significantly shorter on nights before weekday morning training (6h44) compared to weekday mornings off (8h45). This was due to an earlier wake time (04:51) while bedtime remained constant (∼22:15). Athletes went to bed later, woke later and slept for longer on nights before weekend mornings off compared to weekday nights. CONCLUSIONS: Early morning training advanced the wake times of the athletes while bedtime remained constant. This shortened sleep below age recommended durations on the nights before early morning training during the week. These findings suggest that weekly average sleep duration does not accurately reflect athletes' nightly sleep given the large variability across a training week.

"My quiet times": Themes of sleep health among people caring for a family member with dementia.

This research explores and represents the sleep of people caring for a family member with cognitive impairment or dementia. A thematic analysis was applied to the open-ended comments from 526 carers from a postal survey concerning sleep, health and caregiving. Themes are presented within a framework of five dimensions of sleep health. Themes of sleep duration included striking a balance between 'achieving the hours' whilst also sacrificing sleep to manage responsibilities. Themes of sleep efficiency included symptoms of insomnia ('losing sleep over the situation') and 'sleeping on guard' in case night-time support was required. Timing of sleep was themed as either restricted to 'when the one I care for sleeps' or salvaged as a luxury 'quiet time'. Levels of alertness were represented within themes of being 'tired all of the time' whilst also in a state of 'high alert'. Finally, overall sleep satisfaction ranged from themes concerning 'sleeping fine at the moment' to sleep being 'a big problem'. The sleep experience of family carers is unique and often includes tensions between roles and responsibilities and their own need for sleep and well-being. Findings have implications for community support and healthcare interventions for families affected by dementia.

Sleep HAPi: A Feasibility and Descriptive Analysis of an Early and Longitudinal Sleep Education Intervention for Pregnant Women.

Background: Poor sleep and prior depression are key predictors of perinatal depression, with research suggesting depressive symptoms may emerge in early pregnancy. Sleep is a potentially modifiable risk factor for depression. This pilot study examined the feasibility and acceptability of a six-month sleep education intervention designed to optimize sleep and minimize depressive symptoms throughout pregnancy. Sleep measures and depressive symptoms are described from 12 weeks gestation to 12 weeks postpartum.Participants: A community sample of nulliparous pregnant women with a history of depression were recruited prior to 14 weeks gestation.Methods: An individualized sleep education program was developed and participants engaged in three trimester specific sleep education sessions. Feasibility and acceptability were determined via recruitment and retention rates and participant feedback. Depressive symptoms and sleep were measured at five time points throughout the study.Results: 22 women enrolled in the study and 15 completed the intervention. Participants reported the intervention as highly acceptable. There was minimal change in all dimensions of sleep across pregnancy, but sleep measures were significantly worse at six weeks postpartum and improved by 12 weeks postpartum. Depressive symptoms were significantly lower at the conclusion of the intervention and 12 weeks postpartum compared to trimester 1.Conclusions: This sleep education program appears feasible, acceptable and may be effective in minimizing depressive symptoms in pregnant women with a history of depression. Trials with larger and more diverse samples are warranted and further studies to ascertain efficacy should be undertaken with a control group.

Factors associated with the sleep of carers: A survey of New Zealanders supporting a family member with cognitive impairment or dementia.

Sleep is important for healthy ageing. Data are limited concerning the sleep and health of New Zealand families affected by cognitive impairment or dementia. This postal survey asked about the sleep of 526 family carers and explored predictors of, and outcomes associated with poorer sleep. Linear and binominal logistic regression were used to identify independent predictors and outcomes of carers' sleep status. Using the Insomnia Severity Index, 23.5% of carers scored in the moderate-severe range and 43.0% in the mild range for sleep disturbance. More than a quarter indicated that their family member had difficulties falling asleep, getting up during the night, or waking too early. Over half of care recipients were considered to sleep too much during the day. Independent predictors for carers' reporting greater sleep disturbance included being female, caregiving at night, poorer self-rated health, and the care recipient having more disturbed sleep. Moderate-severe sleep disturbance was independently associated with poorer self-rated health and living standards, use of sleeping medications, as well as considering transitioning their family member into formal care within the year. These findings have implications for the wellbeing and trajectory of family carers as well as for health and aged care services.

Multiple dimensions of sleep are consistently associated with chronically elevated depressive symptoms from late pregnancy to 3 years postnatal in Indigenous and non-Indigenous New Zealand women.

INTRODUCTION: Poor sleep and depressive symptoms are common throughout the perinatal period, but little is known about the extended time course of depression and the sleep dimensions associated with these trajectories. OBJECTIVE: This study investigated different depression trajectories in New Zealand Maori and non-Maori women from late pregnancy to 3 years postnatal. Relationships between multiple dimensions of sleep and these depression trajectories were also investigated. METHODS: Data from 856 women (30.6% Maori and 69.4% non-Maori) from the longitudinal Moe Kura cohort study were used. Depressive symptoms and multiple dimensions of sleep (quality, duration, latency, continuity and daytime sleepiness) were collected at 36 weeks' gestation, 12 weeks postnatal and 3 years postnatal. Trajectory analysis was completed using latent class analysis. RESULTS: Latent class analysis revealed two distinct groups of depressive symptom trajectories: 'chronic high' and 'stable mild' for both Maori and non-Maori women. Maori women in both trajectories were more likely than non-Maori women to have clinically significant depressive symptoms at every time point. Poorer sleep quality, latency, continuity and greater daytime sleepiness were consistently associated with the chronic high depressive symptom trajectory at all three time points, after controlling for sociodemographic factors. CONCLUSION: A significant proportion of Maori and non-Maori women experience chronically high depressive symptoms during the perinatal period and the following years. Across this extended time frame, Maori women have a higher probability of experiencing clinically significant depressive symptoms compared to non-Maori women. These persistent patterns of depressive symptoms occur concurrently with multiple dimensions of poor sleep. Given the well-described impact of maternal depression on the mother, child, family and community, this highlights the importance of healthcare professionals asking about mothers' sleep quality, continuity, latency and daytime sleepiness as potential indicators of long-term mood outcomes.

A pilot longitudinal sleep education intervention from early pregnancy and its effect on optimizing sleep and minimizing depressive symptoms.

OBJECTIVES: Investigate the efficacy of a pilot longitudinal sleep education program for optimizing sleep and minimizing depressive symptoms in nulliparous pregnant women. DESIGN: Early and longitudinal sleep education intervention pilot study. SETTING: Community-based convenience sample of New Zealand women. PARTICIPANTS: 15 nulliparous women who were involved in a pilot of a longitudinal sleep education intervention during pregnancy (N = 15) were compared to a comparison group (n = 76) from another observational study with the same time points. Groups were matched on depression history and parity. INTERVENTION: A longitudinal sleep education program was developed. Women in the intervention group participated in three individualized and trimester specific education sessions designed to increase sleep knowledge and improve sleep practices. The comparison group received no sleep education. MEASUREMENTS: Self-reports of depressive symptoms and five dimensions of sleep (duration, quality, continuity, latency, daytime sleepiness) were compared between groups using linear mixed model analysis of variance. RESULTS: At the conclusion of the intervention, the intervention group had fewer depressive symptoms with none experiencing clinically significant depressive symptoms, while 21% of the comparison group were considered to have clinically significant depressive symptoms. The intervention group also had better sleep quality, sleep initiation and sleep continuity than the comparison group at late pregnancy. CONCLUSIONS: Findings suggest that a longitudinal sleep education intervention commencing early in pregnancy may be effective in optimizing sleep and minimizing depressive symptoms for nulliparous women with a history of depression. Further investigation of sleep education interventions to improve maternal mental health in pregnancy and postnatally is warranted.

Development and evaluation of a matrix for assessing fatigue-related risk, derived from a national survey of nurses' work patterns.

BACKGROUND: Multiple aspects of nurses' rosters interact to affect the quality of patient care they can provide and their own health, safety and wellbeing. OBJECTIVES: (1) Develop and test a matrix incorporating multiple aspects of rosters and recovery sleep that are individually associated with three fatigue-related outcomes - fatigue-related clinical errors, excessive sleepiness and sleepy driving; and (2) evaluate whether the matrix also predicts nurses' ratings of the effects of rosters on aspects of life outside work. DESIGN: Develop and test the matrix using data from a national survey of nurses' fatigue and work patterns in six hospital-based practice areas with high fatigue risk. METHODS: Survey data included demographics, work patterns (previous 14 days), choice about shifts, and the extent to which work patterns cause problems with social life, home life, personal relationships, and other commitments (rated 1 = not at all to 5 = very much). Matrix variables were selected based on univariate associations with the fatigue-related outcomes, limits in the collective employment contract, and previous research. Each variable was categorised as lower (score 0), significant (score 1), or higher risk (score 2). Logistic multiple regression modelling tested the independent predictive power of matrix scores against models including all the (uncategorised) work pattern and recovery sleep variables with significant univariate associations with each outcome variable. Model fit was measured using Akaike and Bayesian Information Criterion statistics. RESULTS: Data were included from 2358 nurses who averaged at least 30 h/week in the previous fortnight in one of the target practice areas. Final matrix variables were: total hours worked; number of shift extensions >30 min, night shifts; breaks < 9 h; breaks ≥ 24 h; nights with sleep 11pm to 7am; days waking fully rested; and roster change. After controlling for gender, ethnicity, years of nursing experience, and the extent of shift choice, the matrix score was a significant independent predictor of each of the three fatigue-related outcomes, and for all four aspects of life outside work. For all outcome variables, the model including the matrix score was a better fit to the data than the equivalent model including all the (uncategorised) work pattern variables. CONCLUSIONS: A matrix that predicts the likelihood of nurses reporting fatigue-related safety outcomes can be used to compare the impact of rosters both at work and outside work. It can be used for roster design and management, and to guide nurses' choices about the shifts they work.

Self-reported sleep problems and their relationship to life and living of Maori and non-Maori in advanced age.

OBJECTIVE: Life expectancy is increasing. Sleep problems are more likely with advancing age however, are largely overlooked, and the longitudinal health impact of reported sleep problems is unclear. In this study, relationships were examined between reporting prior or current sleep problems with health outcomes, among Maori and non-Maori of advanced age. METHOD: Data were available from 251 Maori and 398 non-Maori adults (79-90 years) from Wave 1 (W1) of Te Puawaitanga o Nga Tapuwae Kia Ora Tonu. Life and Living in Advanced Age: A Cohort Study in NZ (LiLACS NZ). Four years later (W5), data were available from 85 Maori and 200 non-Maori participants. Relationships between reporting problem sleep at W1 and cohort and health outcomes at W5 were investigated using generalised linear models and Cox proportional hazards models. RESULTS: Over 25% reported sleep problems at both waves. Mortality was associated with problem sleep for Maori but not non-Maori. Within the whole group, W1 problem sleepers were more likely to still have problems at W5, compared with nonproblem sleepers at W1. They also had poorer indicators of physical health and pain at W5. Problem sleepers at W5 had poorer concurrent mental health and increased likelihood of hospital admittance in the last year. CONCLUSION: Sleep health is an important characteristic of ageing well, particularly for Maori. Early recognition and management of sleep problems could improve physical and mental health with advancing age.

Maternal sleep disturbances in late pregnancy and the association with emergency caesarean section: A prospective cohort study.

OBJECTIVES: To investigate the association between measures of sleep quality, sleep duration and sleep disorder symptoms in late pregnancy and likelihood of emergency caesarean section. DESIGN: Population-based prospective cohort study SETTING: New Zealand PARTICIPANTS: 310 Maori (Indigenous New Zealanders) and 629 non-Maori women MEASUREMENTS: Multivariable logistic regression models were used to investigate the association between type of delivery (emergency caesarean section vs. spontaneous vaginal delivery) and self-reported sleep duration, sleep quality and sleep-related symptoms, (e.g. snoring, breathing pauses during sleep, legs twitching/jerking) in the third trimester of pregnancy. Models were adjusted by ethnicity (ref=non-Maori), age (ref=16-19 y), parity (ref=nulliparous), clinical indicators (any vs. none), area deprivation (ref=least deprived quintile), BMI and for some models smoking. RESULTS: Women who reported poor quality sleep as measured by the General Sleep Disturbance Scale in later pregnancy had almost twice the odds of delivering via emergency caesarean than women with good sleep quality (OR=1.98, 95% CI 1.18-3.31). Reporting current breathing pauses during sleep (OR=3.27, 95% CI 1.38-7.74) or current snoring (OR=1.65, 95% CI 1.00-2.72) were also independently associated with a higher likelihood of an emergency caesarean. Short sleep duration and leg twitching/jerking were not independently associated with emergency caesarean section in this study. CONCLUSIONS: Supporting healthy sleep during pregnancy could be a novel intervention to reduce the risks associated with emergency caesarean section. Research on the effectiveness of sleep interventions for reducing caesarean section risk is required.

Fatigue risk management for cabin crew: the importance of company support and sufficient rest for work-life balance-a qualitative study.

Knowledge about cabin crew fatigue associated with ultra-long range (ULR) flights is still limited. Current ULR scheduling for cabin crew is therefore predominantly based on flight crew data. Cabin crews' views on fatigue, and their strategies for mitigating it, have seldom been sought. To better understand the causes and consequences of cabin crew fatigue, semi-structured focus group discussions were held. Thematic analysis was undertaken with data from 25 cabin crew. Participants indicated that the consequences of fatigue are twofold, affecting 1) cabin crew health and wellbeing and 2) safety (cabin, passenger and personal) and cabin service. While the primary causes of fatigue were sleep loss and circadian disruption, participants also identified other key factors including: insufficient rest, high workload, the work environment, a lack of company support, and insufficient fatigue management training. They highlighted the importance of sufficient rest, not only for obtaining adequate recovery sleep but also for achieving a work-life balance. They also highlighted the need for company support, effective communication, and management's engagement with cabin crew in general. We recommend that priority is given to fatigue management training for cabin crew, which may also enhance perceived company support and assist with achieving a better work-life balance.

Predictors Linking Obesity and the Gut Microbiome (the PROMISE Study): Protocol and Recruitment Strategy for a Cross-Sectional Study on Pathways That Affect the Gut Microbiome and Its Impact on Obesity.

BACKGROUND: The prevalence of obesity has increased substantially over recent decades and is associated with considerable health inequalities. Although the causes of obesity are complex, key drivers include overconsumption of highly palatable, energy-dense, and nutrient-poor foods, which have a profound impact on the composition and function of the gut microbiome. Alterations to the microbiome may play a critical role in obesity by affecting energy extraction from food and subsequent energy metabolism and fat storage. OBJECTIVE: We report the study protocol and recruitment strategy of the PRedictors linking Obesity and the gut MIcrobiomE (PROMISE) study, which characterizes the gut microbiome in 2 populations with different metabolic disease risk (Pacific and European women) and different body fat profiles (normal and obese). It investigates (1) the role of gut microbiome composition and functionality in obesity and (2) the interactions between dietary intake; eating behavior; sweet, fat, and bitter taste perception; and sleep and physical activity; and their impact on the gut microbiome, metabolic and endocrine regulation, and body fat profiles. METHODS: Healthy Pacific and New Zealand (NZ) European women aged between 18 and 45 years from the Auckland region were recruited for this cross-sectional study. Participants were recruited such that half in each group had either a normal weight (body mass index [BMI] 18.5-24.9 kg/m2) or were obese (BMI ≥30.0 kg/m2). In addition to anthropometric measurements and assessment of the body fat content using dual-energy x-ray absorptiometry, participants completed sweet, fat, and bitter taste perception tests; food records; and sleep diaries; and they wore accelerometers to assess physical activity and sleep. Fasting blood samples were analyzed for metabolic and endocrine biomarkers and DNA extracted from fecal samples was analyzed by shotgun sequencing. Participants completed questionnaires on dietary intake, eating behavior, sleep, and physical activity. Data were analyzed using descriptive and multivariate regression methods to assess the associations between dietary intake, taste perception, sleep, physical activity, gut microbiome complexity and functionality, and host metabolic and body fat profiles. RESULTS: Of the initial 351 women enrolled, 142 Pacific women and 162 NZ European women completed the study protocol. A partnership with a Pacific primary health and social services provider facilitated the recruitment of Pacific women, involving direct contact methods and networking within the Pacific communities. NZ European women were primarily recruited through Web-based methods and special interest Facebook pages. CONCLUSIONS: This cross-sectional study will provide a wealth of data enabling the identification of distinct roles for diet, taste perception, sleep, and physical activity in women with different body fat profiles in modifying the gut microbiome and its impact on obesity and metabolic health. It will advance our understanding of the etiology of obesity and guide future intervention studies involving specific dietary approaches and microbiota-based therapies. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000432213; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370874. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/14529.

Fatigue and nurses' work patterns: An online questionnaire survey.

BACKGROUND: Fatigue resulting from shift work and extended hours can compromise patient care and the safety and health of nurses, as well as increasing nursing turnover and health care costs. OBJECTIVES: This research aimed to identify aspects of nurses' work patterns associated with increased risk of reporting fatigue-related outcomes. DESIGN: A national survey of work patterns and fatigue-related outcomes in 6 practice areas expected to have high fatigue risk (child health including neonatology, cardiac care/intensive care, emergency and trauma, in-patient mental health, medical, and surgical nursing). METHODS: The 5-page online questionnaire included questions addressing: demographics, usual work patterns, work in the previous two weeks, choice about shifts, and four fatigue-related outcomes - having a sleep problem for at least 6 months, sleepiness (Epworth Sleepiness Scale), recalling a fatigue-related error in clinical practice in the last 6 months, and feeling close to falling asleep at the wheel in the last 12 months. The target population was all registered and enrolled nurses employed to work in public hospitals at least 30 h/week in one of the 6 practice areas. Participation was voluntary and anonymous. RESULTS: Respondents (n = 3133) were 89.8% women and 8% Maori (indigenous New Zealanders), median age 40 years, range 21-71 years (response rate 42.6%). Nurses were more likely than New Zealand adults in general to report chronic sleep problems (37.73% vs 25.09%, p < 0.0001) and excessive sleepiness (33.75% vs 14.9%, p < 0.0001). Fatigue-related error(s) in the last 6 months were recalled by 30.80% and 64.50% reported having felt sleepy at the wheel in the last 12 months. Logistic regression analyses indicated that fatigue-related outcomes were most consistently associated with shift timing and sleep. Risk increased with more night shifts and decreased with more nights with sleep between 11 p.m. and 7 a.m. and on which nurses had enough sleep to feel fully rested. Risk also increased with roster changes and more shift extensions greater than 30 min and decreased with more choice about shifts. Comparisons between intensive care/cardiac care and in-patient mental health nursing highlight that fatigue has different causes and consequences in different practice areas. CONCLUSIONS: Findings confirm the need for a more comprehensive and adaptable approach to managing fatigue. We advocate an approach that integrates safety management and scientific principles with nursing and management expertise. It should be data-driven, risk-focused, adaptable, and resilient in the face of changes in the services required, the resources available, and the overall goals of the healthcare system.

Monitoring the sleep patterns of people with dementia and their family carers in the community.

OBJECTIVES: Gold-standard overnight polysomnography does not reliably capture highly variable sleep patterns across the 24-hour day that are common with dementia and often problematic for carers. We evaluated the reliability of automatically scored actigraphy data as an alternative. METHODS: Actigraphy recordings were analysed from 15 community-dwelling people with dementia (135 days total) and 14 of their family carers (124 days total). Manual scoring used participant sleep diaries to identify sleep periods. Automated scoring used the manufacturer's algorithm to score entire records. RESULTS: For people with dementia, automated scoring identified more sleep fragmentation at night and increased sleep during the day, with comparable sensitivity but lower specificity than for carers. CONCLUSIONS: Automated scoring offers reasonable agreement with manual scoring and may better describe the fragmented nature of dementia-related sleep, which can be challenging to record accurately in a sleep diary. Automated scoring reduces participant burden and could improve research and treatment protocols.

Monitoring the Effectiveness of Fatigue Risk Management: A Survey of Pilots' Concerns.

INTRODUCTION: Airlines are required to monitor the effectiveness of their pilot fatigue risk management. The present survey sought the views of all pilots at Delta Air Lines on fatigue-related issues raised by their colleagues participating in regular airline safety audits. METHODS: All 13,217 pilots from 9 aircraft fleets were invited to participate in an anonymous online survey. Questions related to aspects of scheduling, fatigue mitigations, and fatigue safety culture. RESULTS: There were 1108 pilots who completed the survey (response rate = 8.4%). On 7/9 fleets, most pilots thought 5- to 7-d rotations were too long (exceptions: B747, median = 14 d; A330 median = 8.5 d). In the previous year, on average across all fleets, 60.6% of pilots had worked up to or beyond their personal rotation limit (minimum, B747 = 6.3%; maximum, MD88/90 = 75.9%). Rotations where duty periods start progressively earlier were considered highly fatiguing by 73.8% of pilots, compared to 14.7% for rotations where duty periods started progressively later and 1.6% for rotations with successive duty periods starting at the same time. The median optimum break length between rotations was 3-4 d. On 7/9 fleets, fewer than 20% of pilots tried to build their monthly schedules with back-to-back rotations (exceptions: B747, 43.8%; A330, 34.3%). Awareness of fatigue and perceptions of company fatigue risk management activities varied widely among fleets. DISCUSSION: The findings identify possible improvements in fatigue risk management and highlight that care is needed when extrapolating from one operational context to another. As a safety assurance exercise, we recommend repeating the survey biannually, or sooner if warranted by specific circumstances.Gander P, Mangie J, Phillips A, Santos-Fernandez E, Wu LJ. Monitoring the effectiveness of fatigue risk management: a survey of pilots' concerns. Aerosp Med Hum Perform. 2018; 89(10):889-895.

Shared responsibility for managing fatigue: Hearing the pilots.

In commercial aviation, fatigue is defined as a physiological state of reduced mental or physical performance capability resulting from sleep loss, extended wakefulness, circadian phase, and/or workload. The International Civil Aviation Organisation mandates that responsibility for fatigue risk management is shared between airline management, pilots, and support staff. However, to date, the majority of research relating to fatigue mitigations in long range operations has focused on the mitigations required or recommended by regulators and operators. Little research attention has been paid to the views or operational experience of the pilots who use these (or other) mitigations. This study focused on pilots' views and experiences of in-flight sleep as the primary fatigue mitigation on long range flights. It also sought information about other fatigue mitigation strategies they use. Thematic analysis was used to explore written comments from diary and survey data collected during long range and ultra-long range trips (N = 291 pilots on three different aircraft types, 17 different out-and-back trips, and four airlines based on three continents). The findings indicate that the recommended fatigue mitigation strategies on long-haul flights (particularly in-flight sleep) are effective and well-utilised, consistent with quantitative findings from the same trips. Importantly however, the analyses also highlight areas that require further investigation, including flight preparation strategies in relation to the uncertainty of in-flight break allocation. There were two strategies for sleep prior to a flight: maximising sleep if pilots were expecting later breaks in the flight; or minimising sleep if they were expecting breaks earlier or at unfavourable times in the circadian cycle. They also provide a broader view of the factors that affect the amount and quality of pilots' in-flight sleep, about which evidence has previously been largely anecdotal. The study underscores the value of including the views and experience of pilots in fatigue risk management.

Equivalence Testing as a Tool for Fatigue Risk Management in Aviation.

BACKGROUND: Many civilian aviation regulators favor evidence-based strategies that go beyond hours-of-service approaches for managing fatigue risk. Several countries now allow operations to be flown outside of flight and duty hour limitations, provided airlines demonstrate an alternative method of compliance that yields safety levels "at least equivalent to" the prescriptive regulations. Here we discuss equivalence testing in occupational fatigue risk management. We present suggested ratios/margins of practical equivalence when comparing operations inside and outside of prescriptive regulations for two common aviation safety performance indicators: total in-flight sleep duration and psychomotor vigilance task reaction speed. Suggested levels of practical equivalence, based on expertise coupled with evidence from field and laboratory studies, are ≤ 30 min in-flight sleep and ± 15% of reference response speed. METHODS: Equivalence testing is illustrated in analyses of a within-subjects field study during an out-and-back long-range trip. During both sectors of their trip, 41 pilots were monitored via actigraphy, sleep diary, and top of descent psychomotor vigilance task. Pilots were assigned to take rest breaks in a standard lie-flat bunk on one sector and in a bunk tapered 9 from hip to foot on the other sector. RESULTS: Total in-flight sleep duration (134 ± 53 vs. 135 ± 55 min) and mean reaction speed at top of descent (3.94 ± 0.58 vs. 3.77 ± 0.58) were equivalent after rest in the full vs. tapered bunk. DISCUSSION: Equivalence testing is a complimentary statistical approach to difference testing when comparing levels of fatigue and performance in occupational settings and can be applied in transportation policy decision making.Wu LJ, Gander PH, van den Berg M, Signal TL. Equivalence testing as a tool for fatigue risk management in aviation. Aerosp Med Hum Perform. 2018; 89(4):383-388.