Publication Abstract Display
Type: Published Manuscript
Title: Letter to the Editor - Reply to Gamaldo And McArthur.
Authors: Crum-Cianflone NF, Moore DJ, Hale B, Agan BK, Letendre S
Year: 2012
Publication: Clinical Infectious Diseases
Volume: 55 Issue: 10 Pages: 1430-31
Abstract:We appreciate Drs Gamaldo’s and McArthur's interest in our article examining sleep disturbances among a cohort of early-treated human immunodeficiency virus (HIV) infected persons [1]. In short, we evaluated 193 HIV-infected adults for sleep disturbances utilizing 2 validated instruments. The first was the Pittsburgh Sleep Quality Index (PSQI), which is one of the most widely used standardized measures to assess subjective sleep quality. This 19-item questionnaire asks about sleep over the past month and generates seven component scores (sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of hypnotics, and daytime dysfunction) [2]. The second instrument we utilized was the Epworth Sleepiness Scale (ESS) to assess daytime sleepiness [3]. In the original study by Buysse [2], a global PSQI score >5 distinguished good from poor sleepers (sensitivity of 89.6% and specificity of 86.5%, κ = 0.75, P < .001). As noted in our methods, we used this score as an indicator of insomnia based on prior data showing that a PSQI global score >5 had excellent sensitivity (98.7%) and specificity (84.4%) distinguishing patients with primary insomnia from controls, good correlation with sleep log data, and high test-retest reliability [4]. Other studies have also found that the PSQI is a valid and useful screening tool for assessing insomnia [5, 6]. We agree with Gamaldo and McArthur that the clinical diagnosis of insomnia utilizes different criteria, and that the PSQI and ESS do not provide data regarding the specific sleep disorder (eg, primary insomnia, sleep apnea, organic sleep related movement disorders) causing the sleep disturbance. Clinical assessment and polysomnography (PSG) are the gold standards for determining the precise clinical diagnosis of a sleep disturbance. The objective of the current study was to estimate the prevalence of sleep disturbances among HIV-infected persons using the PSQI and ESS, and to evaluate if these sleep disturbances were associated with detriments in activities of daily living and neuropsychological testing. Our study found that 46% of HIV-infected persons had insomnia (as defined by a PSQI >5), and 30% had daytime drowsiness (as defined by an ESS ≥10). Additionally, we found a significant decline in activities of daily living among those with insomnia (PSQI >5). Our study was not designed to determine the exact clinical diagnosis of the sleep disturbance, and with the large sample size (N = 193) of our study, the cost of completing PSG for each participant was prohibitive. The high frequency of sleep disturbances among HIV patients found in our study emphasizes the need for a better understanding of the etiology and pathophysiology of sleep problems in this population. In addition to sleep assessments, the use of validated survey instruments and detailed sleep evaluations (eg, clinical evaluations, PSG) as suggested in recent guidelines [7] should be pursued in research studies to determine the precise types of sleep disturbances among HIV-infected persons.

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