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Sleep Diary

Sleep Diary

Sleep is a physiological need, therefore, sleep deprivation and/or restriction of sleep can cause several health problems, such as increased propensity to cardiovascular and metabolic diseases, general reduction of the immune system, hormonal imbalances and the development of mental illnesses such as depression and anxiety (TASKAR; HIRSHKOWITZ, 2003). However, a large part of the population does not reach adequate total sleep time and/or satisfactory sleep quality (BUYSSE; ANCOLI-ISRAEL; EDINGER; LICHSTEIN et al., 2006) and this scenario is no different in Brazil. Studies indicate that the presence of complaints related to sleep — such as snoring, nightmares, bruxism, kicking the legs while sleeping, sleepwalking and daytime sleepiness — significantly increase every decade (SANTOS-SILVA; BITTENCOURT; PIRES; DE MELLO et al., 2010). Furthermore, it was observed through evaluation with polysomnography that the obstructive sleep apnea syndrome affects about 32.8% of the population (TUFIK; SANTOS-SILVA; TADDEI; BITTENCOURT, 2010). Likewise, 32% of the population is affected by insomnia (CASTRO; POYARES; LEGER; BITTENCOURT et al., 2013). Considering these data, it is important that the population's sleep is assessed with the aim of improving general health and quality of life.

In this aspect, it is possible to assess sleep through polysomnography, which consists of an electroencephalogram, electrooculogram, electromyogram of the chin and legs, electrocardiogram, nasal cannula, abdominal strap, oximeter and snoring sensor. With this, it is possible to objectively determine the percentage of time the patient spends in each sleep stage, as well as determine the presence of sleep disorders such as obstructive apnea, central apnea, periodic leg movement, bruxism, among others. For this reason, polysomnography is the gold standard to identify the sleep pattern, as well as the presence of sleep disorders (CHESSON; FERBER; FRY; GRIGG-DAMBERGER et al., 1997). To perform this exam, there is the option for the patient to go to the sleep clinic and sleep there, and during the sleep period, trained professionals stay in a parallel room reading the patient's data in real time. Despite being considered the gold standard, polysomnography has the disadvantages of interfering with the participant's sleep routine and having a high cost.CHESSON; FERBER; FRY; GRIGG-DAMBERGER et al., 1997). Para a realização deste exame, existe a opção de o paciente se deslocar até a clínica de sono e dormir no local e, durante o período de sono, profissionais capacitados ficam em sala paralela fazendo a leitura dos dados do paciente em tempo real. Apesar de ser considerada o padrão ouro, a polissonografia apresenta as desvantagens de interferir na rotina de sono do participante e possuir custo elevado.

Actigraphy or actimetry is a technique that can also be used for sleep analysis. The actigraph is a piece of equipment similar to a wristwatch and contains an accelerometer, a light sensor and some models even contain temperature sensors. With this, it is possible to non-invasively estimate the patient's sleep periods (SADEH, 2011). The great advantage of the actigraph is the comfort and practicality provided by its use and, for this reason, exams can be longer, but generally the period varies between 7 and 28 days. Thus, actigraphy is also an effective technique for determining the patient's biological rhythm. Similar to polysomnography, a disadvantage of this technique is the relatively high cost and difficulty to analyze a high volume of people at the same time due to the need and possession of the equipment.SADEH, 2011). A grande vantagem do actígrafo é o conforto e praticidade proporcionado pelo seu uso e, por este motivo, os exames podem ser mais longos, mas geralmente o tempo utilizado varia entre 7 e 28 dias. Assim, a actigrafia é também uma técnica eficaz para determinação do ritmo biológico do paciente. De maneira similar à polissonografia, uma desvantagem desta técnica é o custo relativamente alto e dificuldade para analisar um volume elevado de pessoas ao mesmo tempo pela necessidade e possuir o equipamento.

Finally, it is possible to analyze sleep through questionnaires and sleep diaries. The questionnaires have the convenience of being answered only once, and have questions related to conventional sleep. On the other hand, sleep diaries are instruments that must be answered daily and, for this reason, they tend to present more reliable estimates than questionnaires. Thus, the purpose of the sleep diary is to record sleep habits, as well as bedtime and waking hours and activities performed during the day. The main advantage of the sleep diary is the low cost and possibility of evaluating several people at the same time.

Not only that, the sleep diary is strongly recommended for diagnosing insomnia. The American Psychiatric Association characterizes insomnia as a subjective disorder, that is, the diagnosis is made based on the patient's report about the difficulty related to sleep, or waking up without feeling fully recovered. In addition, the evaluation with polysomnography can lead to worsening of sleep quality due to the visit to the laboratory (EDINGER; FINS; SULLIVAN JR; MARSH et al., 1997). Similarly, actigraphy is also not an effective technique for diagnosing insomnia, as patients with this disorder tend to remain immobile for a long time trying to fall asleep, a fact that can lead to misinterpretation of data (CHAMBERS, 1994). The insomnia severity questionnaire is an effective tool to analyze the degree of insomnia severity, but it lacks important information for sleep analysis, such as total sleep time, sleep onset latency, number of awakenings and time awake during the night (MORIN, 1993). For these reasons, the sleep diary is considered the gold standard for subjective sleep analysis.EDINGER; FINS; SULLIVAN JR; MARSH et al., 1997). De maneira similar, a actigrafia também não é uma técnica eficaz para diagnóstico da insônia, pois os pacientes com este distúrbio tendem a ficar imóveis por muito tempo tentando iniciar o sono, fato que pode levar à má interpretação dos dados (CHAMBERS, 1994). O questionário de severidade de insônia é uma ferramenta eficaz para analisar o grau de severidade da insônia, mas carece de informações importantes para análise do sono, como o tempo total de sono, latência para início de sono, número de despertares e tempo acordado durante a noite (MORIN, 1993). Por estes motivos, o diário de sono é considerado o padrão ouro para análise subjetiva do sono.

Thus, some sleep diary models have emerged over the years, and this makes the correct interpretation of data difficult, which in turn leads to difficulty in translating scientific findings into clinical practice. To solve this problem, a commission was assembled with the objective of proposing a standardization for the sleep diary (CARNEY; BUYSSE; ANCOLI-ISRAEL; EDINGER et al., 2012). The conference was attended by several experts in sleep and insomnia. All experts involved agreed that the model would be built specifically for patients complaining of insomnia, but that it would also be useful for use in patients with other sleep disorders, as well as for evaluating the sleep of good sleepers. Thus, three models were built. A template refers to the core of the sleep diary, and contains questions that are considered to be paramount. The other models have extra questions related to daily activities.CARNEY; BUYSSE; ANCOLI-ISRAEL; EDINGER et al., 2012). A conferência contou com a participação de diversos especialistas em sono e insônia. Todos os especialistas envolvidos concordaram que o modelo seria construído especificamente para pacientes com queixas de insônia, mas que também serviria para utilização em pacientes com outros distúrbios de sono, assim como para avaliação de sono de bons dormidores. Assim, foram construídos três modelos. Um modelo se refere ao núcleo do diário de sono, e contém questões que são consideradas primordiais. Os outros modelos possuem questões extras relacionadas às atividades realizadas no dia a dia.

The Sleep Diary Model

The core of the model contains the following questions: (a) What time did you go to bed?; (b) What time did you try to sleep?; (c) How long did it take you to sleep?; (d) How many times did you wake up during sleep?; (e) In total, how long did these awakenings last?; (f) What time did you get out of bed today?; (g) How would you rate the quality of your sleep? (Likert scale with options: very bad, bad, moderate, good and very good); (h) Additional comments. This template must be answered within one hour of waking up and, if this instruction is not followed, that day must not be completed.

The other two models have the following instructions: the morning model must be completed in full upon waking, while the night model must have the shared questions answered upon waking, and the questions related to everyday activities must be answered before going to bed. The questions included in these templates are:

Shared questions: (a) What time did you go to bed?; (b) What time did you try to start sleep?; (c) How long did it take you to fall asleep?; (d) How many times did you wake up during the night, without considering your final awakening?; (e) In total, how long did these awakenings last?; (f) What time was your last awakening? (g) After your last awakening, how long were you in bed trying to fall asleep again?; (h) Did you wake up earlier than planned? (i) If yes, how much earlier?; (j) What time did you get out of bed today?; (k) In total, how long did you sleep?; (l) How would you rate the quality of your sleep? (Likert scale with options: very bad, bad, moderate, good and very good); (m) How rested or refreshed did you feel when you woke up today? (Likert scale with options: not at all rested, little rested, rested, well rested, very well rested); (n) How many times did you take a nap?; (o) In total, how long did the naps last?: (a) A que horas você foi para a cama?; (b) A que horas você tentou iniciar o sono?; (c) Quanto tempo levou para você pegar no sono?; (d) Quantas vezes você acordou durante a noite, sem considerar seu despertar final?; (e) No total, quanto tempo duraram estes despertares?; (f) A que horas foi o seu último despertar? (g) Após seu último despertar, quanto tempo você ficou na cama tentando adormecer novamente?; (h) Você acordou mais cedo do que o planejado? (i) Se sim, quanto tempo mais cedo?; (j) A que horas você saiu da cama hoje?; (k) No total, quanto tempo você dormiu?; (l) Como você classificaria a qualidade de seu sono? (Escala Likert com as opções: muito ruim, ruim, moderado, bom e muito bom); (m) O quão descansado ou recuperado você se sentiu quando acordou hoje? (Escala Likert com as opções: nem um pouco descansado, pouco descansado, descansado, bem descansado, muito bem descansado); (n) Quantas vezes você cochilou?; (o) No total, quanto tempo duraram os cochilos?.

Extra questions: (a) How many servings of alcoholic beverages did you drink?; (b) What time did you eat the last portion?; (c) How many servings of caffeinated beverages (coffee, tea, soft drinks or energy drinks) did you drink?; (d) What time did you eat the last portion?; (e) Have you ingested any medications prescribed or on your own to help you with sleep? If yes, list the medication(s), dosage and time of ingestion; (f) Comments (if applicable).: (a) Quantas porções de bebidas alcoólicas você ingeriu?; (b) A que horas você ingeriu a última porção?; (c) Quantas porções de bebidas cafeinadas (café, chá, refrigerante ou energético) você ingeriu?; (d) A que horas você ingeriu a última porção?; (e) Você ingeriu algum medicamento prescrito ou por conta própria para te ajudar com o sono? Se sim, liste o(s) medicamento(s), dosagem e horário de ingestão; (f) Comentários (se aplicável).

In other words, in the morning model, both the shared questions and the extra questions must be answered within one hour after waking up. In the night model, shared questions must be answered within one hour of waking up and extra questions must be answered before going to bed.

For how many days should the sleep diary be filled in?

The sleep diary must be used for a sufficient period so that the data obtained are not misinterpreted, interfering with the analysis performed. It is important to emphasize that each objective will require a different analysis. Therefore, there is still no consensus on how long the sleep diary should be used. Some authors used the sleep diary for less than a week (KAWADA, 2008), while other authors used it for 7 days or more (MONK; BUYSSE; KENNEDY; POTTS et al., 2003; SHORT; GRADISAR; LACK; WRIGHT et al., 2012).KAWADA, 2008), enquanto outros autores usaram por 7 dias ou mais (MONK; BUYSSE; KENNEDY; POTTS et al., 2003; SHORT; GRADISAR; LACK; WRIGHT et al., 2012).

Aiming to identify the appropriate usage time for adolescents, a study was carried out with participants from different locations and cultures (Australia, Qatar, United Kingdom and United States) (SHORT; ARORA; GRADISAR; TAHERI et al., 2017). The results show that the minimum registration time appears to be 5 nights, but this result is dependent on the country of origin. In addition, the study did not have Brazilian or Latin American participantsSHORT; ARORA; GRADISAR; TAHERI et al., 2017). Os resultados demonstram que o tempo de registro mínimo parece ser de 5 noites, mas este resultado é dependente do país de origem. Além disto, o estudo não contou com participantes brasileiros ou da américa latina.

Similarly, another study evaluated university students with the aim of identifying the adequate time to use the sleep diary (DE ALANTARA BORBA; KINGS; DE MELO LIMA; FACUNDO et al., 2020). To this end, participants filled out a sleep diary for 28 days. As expected, the results suggest that the longer the period of application of the sleep diary, the more reliable the data obtained will be. However, it is possible to use it for only 7 days, if desired.DE ALCANTARA BORBA; REIS; DE MELO LIMA; FACUNDO et al., 2020). Para tal, os participantes preencheram o diário de sono durante 28 dias. Conforme esperado, os resultados sugerem que quanto maior for o período de aplicação do diário de sono, mais confiáveis serão os dados obtidos. Contudo, é possível utilizá-lo por apenas 7 dias, se assim for desejado.

Electronic sleep diary or printed sleep diary, which one is better?

With the advent of technology, it is possible to have access to filling out the sleep diary in the palm of your hand on a smartphone or tablet. Thus, the electronic sleep diary has some advantages, such as: (a) self-monitoring of sleep, allowing the patient to have the opportunity to share decision-making with physicians; (b) increase the probability of filling out the sleep diary through automatic reminders; (c) prevent patients from performing retroactive filling; (d) reduces the time to obtain and analyze data (GARTENBERG; THORNTON; MASOOD; PFANNENSTIEL et al., 2013; STONE; SHIFFMAN; SCHWARTZ; BRODERICK et al., 2002).GARTENBERG; THORNTON; MASOOD; PFANNENSTIEL et al., 2013; STONE; SHIFFMAN; SCHWARTZ; BRODERICK et al., 2002).

In order to analyze the difference between data obtained through the electronic and printed sleep diary, 15 healthy adult volunteers underwent a study (TONETTI; MINGOZZI; NATALE, 2016). The results found suggest that there is no difference between data recorded in electronic sleep diary and printed sleep diary. Therefore, considering the advantages of the electronic sleep diary, it appears to be superior to the printed sleep diary. However, a limitation of the study was the use of healthy adults, which prevents the generalization of the results to populations with sleep disorders or patients of other age groups.TONETTI; MINGOZZI; NATALE, 2016). Os resultados encontrados sugerem que não há diferença entre os dados registrados em diário de sono eletrônico e diário de sono impresso. Portanto, considerando as vantagens do diário de sono eletrônico, este parece ser superior ao diário de sono impresso. Contudo, uma limitação do estudo foi a utilização de adultos saudáveis, o que impede a generalização dos resultados para populações com distúrbios de sono ou pacientes de outras faixas etárias.

In order to facilitate the process of filling out and analyzing data, Condor offers an application that allows the patient to fill out the sleep diary on their personal cell phone. The benefits of its use are the convenience offered to the patient, the impossibility of retroactive filling, automatic analysis of sleep-related variables, real-time monitoring and generation of automatic graphics that help in the visualization of the results.

Final considerations

The sleep diary is an effective tool for identifying the sleep pattern of both good sleepers and patients with sleep disorders. In addition, because it is low cost and easy to use, it allows evaluating a large volume of people at the same time. It is especially indicated for diagnosing insomnia, as polysomnography and actigraphy are not specific for this disorder. Not only, the use of the sleep diary in digital format is more advantageous when compared to the diary printed on paper.

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