Stephen F. Smagula

Background: Despite being established risk factors for poor mental or brain health outcomes in aging, rest-activity rhythm (RAR) disturbances are not routinely monitored or treated. This is, in part, due to a lack of clinician-friendly RAR monitoring systems. Objective: We tested the feasibility and acceptability of personalizing a 6-week behavioral intervention using RAR monitoring from a consumer wearable device (Apple Watch). We selected a target population study of people with dementia and their family caregivers, given that rest-activity pattern disturbances are common in these groups. Methods: This single-arm trial enhanced a behavioral activation rhythm treatment with the Apple Watch–based app myRhythmWatch, providing users and their therapists with objective RAR monitoring for customizing therapy. Therapists used information from the myRhythmWatch app to visualize the participants’ behavioral patterns, identify treatment targets, and track progress. Participants included 21 older adults (15 dementia caregivers: mean age 61.8, SD 8.4 years; 6 people with dementia: mean age 81.45, SD 8.5 years). Feasibility outcomes were as follows: (1) proportion adherent enough to assess RARs (defined as ≥3 consecutive valid days with ≥20 hours per day) and (2) the total number of valid days. Acceptability was measured via the Likert scale to gauge participants’ satisfaction with the intervention. We secondarily examined preintervention and postintervention changes in depression (9-item Patient Health Questionnaire scores) and insomnia (Insomnia Severity Index) scores among a smaller group of 11 caregivers who completed these measures. Results: All 21 participants obtained the minimum data requirement for characterizing an RAR snapshot. Caregivers averaged 35 valid RAR monitoring days, and all 15 caregivers were still using the app at week 6 of the trial. In contrast, people with dementia averaged 30 valid days, and of the 6 people with dementia, only 6 were active users at the end of the trial. On average, caregivers completed 5.7 (SD 0.46) of the 6 therapy sessions offered, and participant satisfaction with program components was “high.” Depression symptoms improved with medium preintervention and postintervention effect sizes ( t ₁₀ =2.417; P =.02; Hedges g =0.67, 95% CI 0.04‐1.28), and there were large effect size improvements in insomnia symptoms ( t ₁₀ =3.377; P =.004; Hedges g =0.94, 95% CI 0.25‐1.61). Conclusions: These findings show that older adults without dementia were highly engaged with RAR monitoring. This supports the feasibility of personalizing interventions for older adults with objective RAR monitoring. Randomized controlled trials are warranted to determine whether adding RAR monitoring improves intervention efficiency, efficacy, or durability. While feasible in a subset of people with dementia, we observed lower use rates indicating that there are more barriers to implementing long-term consumer wearable–based RAR monitoring in people with dementia.

Behavioral activation (BA) is an established treatment for depression in older adults, yet BA has been relatively less examined as a treatment for the negative symptoms (NS) of schizophrenia spectrum disorder (SSD). We here aimed to demonstrate the feasibility and proof‐of‐concept that BA can improve NS and function in older adults with SSD. We also evaluated if changes in putative targets correlate with health improvements. Older adults (n = 19; mean age = 58.6 years [standard deviation = 10]) with SSD were offered 12 weekly BA sessions. Primary outcomes were: feasibility of administration, measured as session attendance; and pre/post NS changes, assessed with the Clinical Assessment Interview for Negative Symptoms (CAINS) total scores. Secondary measures were expressive symptoms (CAINS‐Expressive subscale), adaptive functioning (Role Functioning Scale), and disability (World Health Organization Disability Assessment Schedule 2.0 scores). Target measures were: avolition and anhedonia (CAINS items), BA (Behavioral Activation for Depression Scale‐activation subscale), and actigraphy‐measured inactivity (activity level during most active 10 h) and behavioral rigidity (inter‐daily stability). Analyses evaluated post‐ to pre‐BA changes using Cohen's d and 95% confidence intervals. Participants attended 95% of the sessions. All health outcomes improved, including expressive symptoms (d = −0.69; 95% CI: −1.14, −0.23) and health‐related disability (d = −0.45; 95% CI: −0.80, −0.11). Of target measure changes, notably, improved avolition (d = −0.46; 95% CI: −0.82, −0.10) correlated with clinical benefits, including reduced disability r = 0.48 (p = 0.04). High engagement and health improvements support the use of BA for NS in older patients with SSD. In older adults, BA may reduce NS and improve function, but precision medicine trials are needed to determine how and for whom.

Measures of sleep/wake rhythm disruption were independently associated with higher level of suicidal ideation in this sample of older adults at high risk for suicide.

We performed a systematic review evaluating evidence regarding whether/which 24-h sleep-wake characteristics (e.g. sleep, activity levels, and 24-h rhythms) related to worse BPSDs. We searched PubMed for cross-sectional observational studies of people with dementia examining relationships between actigraphy-measured sleep/wake factors and BPSDs (search completed June 2024). We used the JBI checklists to assess the risk of bias and summarize results within subcategories of sleep/wake (sleep, activity level, and rhythm) and BPSD (composite, agitation, apathy, and mood/affect) dimensions. Thirteen articles met inclusion criteria. Measures of inactivity were most frequently examined and correlated with: (a) greater apathy (6/6 studies); (b) worse depression (only in bivariate analyses in 1 study); (c) more agitation (2/3 studies); and (d) higher composite BPSD scores (1/2 studies). All six studies measuring sleep duration failed to identify associations with BPSDs. Studies examining sleep continuity measures generally found associations, i.e. with a BPSD composite (1 study), agitation (1 study), apathy (1/2 studies), and mood (only in bivariate analyses in 1 study). Studies examining rhythm variables found associations with mood (1 study), mixed evidence for associations with apathy (1 study), and no evidence for association with a BPSD composite (1 study). Actigraphy measures of inactivity are associated with apathy in people with dementia. Due to relatively low numbers of articles, future studies are needed to confirm if inactivity, sleep continuity issues, rhythm disruption, and timing independently relate to BPSDs, and if changes in objective sleep/wake measures, e.g. increase in activity following intervention, signal/mediate improvements in BPSDs.

Background: Consumer wearable devices could, in theory, provide sufficient accelerometer data for measuring the 24-hour sleep/wake risk factors for dementia that have been identified in prior research. To our knowledge, no prior study in older adults has demonstrated the feasibility and acceptability of accessing sufficient consumer wearable accelerometer data to compute 24-hour sleep/wake rhythm measures. Objective: We aimed to establish the feasibility of characterizing 24-hour sleep/wake rhythm measures using accelerometer data gathered from the Apple Watch in older adults with and without mild cognitive impairment (MCI), and to examine correlations of these sleep/wake rhythm measures with neuropsychological test performance. Methods: Of the 40 adults enrolled (mean [SD] age 67.2 [8.4] years; 72.5% female), 19 had MCI and 21 had no cognitive disorder (NCD). Participants were provided devices, oriented to the study software (myRhythmWatch or myRW), and asked to use the system for a week. The primary feasibility outcome was whether participants collected enough data to assess 24-hour sleep/wake rhythm measures (ie, ≥3 valid continuous days). We extracted standard nonparametric and extended-cosine based sleep/wake rhythm metrics. Neuropsychological tests gauged immediate and delayed memory (Hopkins Verbal Learning Test) as well as processing speed and set-shifting (Oral Trails Parts A and B). Results: All participants meet the primary feasibility outcome of providing sufficient data (≥3 valid days) for sleep/wake rhythm measures. The mean (SD) recording length was somewhat shorter in the MCI group at 6.6 (1.2) days compared with the NCD group at 7.2 (0.6) days. Later activity onset times were associated with worse delayed memory performance (β=−.28). More fragmented rhythms were associated with worse processing speed (β=.40). Conclusions: Using the Apple Watch-based myRW system to gather raw accelerometer data is feasible in older adults with and without MCI. Sleep/wake rhythms variables generated from this system correlated with cognitive function, suggesting future studies can use this approach to evaluate novel, scalable, risk factor characterization and targeted therapy approaches.

Study Objectives: To help prioritize target/groups for experimental intervention studies, we characterized cross-sectional associations between 24-hour sleep–wake measures and depression symptoms, and evaluated if similar sleep–wake–depression relationships existed in people with and without higher insomnia severity.Methods: Participants had ≥3 days of actigraphy data (n = 1884; mean age = 68.6/SD = 9.1; 54.1% female). We extracted 18 sleep, activity, timing, rhythmicity, and fragmentation measures from actigraphy. We used individual and multivariable regressions with the outcome of clinically significant depression symptoms (Center for Epidemiologic Studies Depression Scale ≥ 16). We conducted sensitivity analyses in people with higher insomnia severity (top quartile of the Women’s Health Initiative Insomnia Rating Scale total score).Results: From separate models in the overall sample, the odds of having depression symptoms were higher with: later timing (e.g. activity onset time odds ratio [OR]/1 SD = 1.32; 95% confidence interval [CI]: 1.16 to 1.50), lower rhythmicity (e.g. pseudo-F OR/1 SD = 0.75; 95% CI: 0.66 to 0.85), less activity (e.g. amplitude OR/1 SD = 0.83; 95% CI: 0.72 to 0.95), and worse insomnia (OR/1 SD = 1.48, 95% CI: 1.31 to 1.68). In multivariable models conducted among people with lower insomnia severity, later timing, lower rhythmicity, and higher insomnia severity were independent correlates of depression. In people with higher insomnia symptom severity, measures of later timing were most strongly associated with depression symptoms.Conclusions: These correlative observations suggest that experimental studies are warranted to test if: broadly promoting 24-hour sleep–wake functioning reduces depression even in people without severe insomnia, and if advancing timing leads to depression symptom reductions in people with insomnia.