Sleep Apps and Insomnia

Sleep Apps and Insomnia “I love my sleep app, Sleep Cycle! You set the alarm and it wakes you to a nice melody within 20 min of your chosen time. It...
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Sleep Apps and Insomnia

“I love my sleep app, Sleep Cycle! You set the alarm and it wakes you to a nice melody within 20 min of your chosen time. It wakes you while you are not in a deep sleep!” “Sleepbot is what I've been using for over a year now. It's a really powerful app.” “Only Sleep as Android has worked for me. All the others just didn't seem to do anything. I can't live without Sleep as Android now.” “Sleep as Android wakes me up when I move around which it turns out is a pretty nice way to wake up. It also has a good selection of alarm sounds that won't make you feel as if you've just been stabbed in the brain.” “FANTASTIC!!!! A great app!! I have used for over 15 years to help me to relax or to help me get to sleep. This really does work.” (Pzizz app) “To say it’s changed my life may be pushing it a little, but it’s certainly had a large hand in improving my sleep” (Sleep Cycle app)

What Are Sleep Apps?

A sleep application (“app” for short) is software (i.e., computer program) that can allow a person to track sleep/wake cycles, snoring, and limb movements during sleep, or a sleep app can be used to impact other aspects of sleep such as awakening a person from sleep. Sleep apps use an algorithm—a series of steps that is required for a computer program to perform a task—to detect motion or sound and translate that information into sleep data.

Smartphones

Fitbit Blaze

Fitbit Surge

Apple Watches

MANUFACTURER’S CLAIMS “Fall asleep, stay asleep, and wake up refreshed! Sleep Time doubles as a comprehensive sleep analysis app and alarm clock.” [Sleep Time app by Azumio, Inc.] “Get a good night’s sleep with Fitbit’s new sleep tools” [Fitbit.com] "Place your phone on your nightstand. While you sleep, Sleep Cycle analyzes your sleep. When it’s time, it wakes you up in your lightest sleep phase." [sleepcycle.com Sleep Cycle Alarm Clock] “MotionX-24/7 … measures and correlates resting heart rate, includes advanced sleep cycle monitoring with smart alarms and power naps, and incorporates ‘Get Active’ alerts. All these tools help improve sleep in a natural and non-invasive manner.” [Fullpower Technologies, Inc.]

Insomnia

Insomnia is difficulty initiating and maintaining sleep (DIMS). It is usually secondary to another problem, although it can be a primary problem. It can be transient (i.e., short-lasting) or chronic. Insomnia can result from •Medications (e.g., stimulants) •Poor sleep hygiene •Circadian rhythm disorder •Psychological factors (e.g., depression, stress)

Treatment may involve •improving sleep hygiene •bright light therapy (for circ. Disorders) •addressing psychological factors through approaches such as cognitive behavioral therapy (CBT)

Sleep Apps for Insomnia

Many apps for insomnia claim to improve sleep through various means such as calming sounds (e.g., nature sounds, babbling brook), calming music or music of your choice, binaural beats, or cognitive behavioral therapy.

Pzizz app (by Pzizz Company; pzizz.com) induces sleep through the use of sound effects and music, neurolinguistic programming and binaural beats. On their site, Pzizz explains: “To coax you in a wonderfully relaxed state, helping to calm your mind .… Because it’s very similar each time you use it, your subconscious quickly associates the sound of Pzizz as being something that helps you to relax and sleep.” in other words, the app trains your body to sleep. The Sleep app explains “This app’s pleasant screens are easy to read and won’t make you more agitated … A fully customizable soundboard gives you thousands of possible sleepy combinations.” Long Deep Breathing app [by Tech 2000, Inc.] explains “Calm your mind by doing breathing exercises before bed. This app will guide you in a series of exercises and will help relieve any stress before falling asleep.”

Sleep Genius Relaxation Program [by Sleep Genius, LLC] explains that their app “was scientifically created to reduce stress and anxiety by calming both the mind and the body. Our acoustically modified music induces the relaxation response, targeting the cardiac and respiratory systems as well as synchronizing brain activity … Within minutes you will feel your body relaxing, your breathing and heart rate slowing, and your mind releasing its tension. Try Relaxation before bed to improve your sleep.” CBT-i Coach app [by VA’s National Center for PTSD, Stanford School of Medicine, and Dept. of Defense National Center for Telehealth and Technology] explains “The app will guide users through the process of learning about sleep, developing positive sleep routines, and improving their sleep environments. It provides a structured program that teaches strategies proven to improve sleep and help alleviate symptoms of insomnia.”

Sleep Apps vs. Polysomnography

Sleep Workers’ Feedback “The apps have trouble differentiating between REM and wake. Without movement they tend to fail even more. We are also seeing a huge failure rate with the sleepwatch used by the military.” “I've mostly noticed they [sleep apps] have problems tracking sometimes, or synching, and accuracy is all over the map.” “My wife's Fitbit gives you feedback on your sleep but she often says it's not accurate. It says she slept at times she knows she was awake.” “I had a patient a while back who used it, and SWORE they were hardly sleeping, because ‘the app said so’."

Sleep App vs. PSG Study by Sushanath Bhat et al. Bhat S, Ferraris A, Gupta D, et al. Is There a Role For Smartphone Sleep Apps? Comparison of Sleep Cycle Detection by a Smartphone Application To Polysomnography Journal of Clinical Sleep Medicine 2015;11:709-715

Sleep App vs. PSG Sleep Time App by Azumio (Palo Alto, CA).

This app provides users with a graph showing wake, light sleep, deep sleep, and it purports to awaken a sleeper during the lightest phase of sleep ±30 min of a set alarm time

Sleep App vs. PSG Study participants (healthy with no sleep problems) slept in the lab while simultaneously being recorded by the sleep app and by polysomnography (PSG) monitoring. The PSG and app data were compared.

Sleep App vs. PSG One issue is that PSG uses 30-sec epochs, but the Sleep Time app does not divide the sleep data by epochs. Bhat used 15 min epoch to compare. Just as with 30-sec epoch, the 15-min epoch was scored as the sleep stage that made up most of the epoch. With this technique, Bhat found the following.

Sleep App vs. PSG PSG

Sleep Time App

The app and PSG were compared for

Stage 1, Stage 2

Light sleep

Stage 3, REM

Deep sleep

•Sleep efficiency •Sleep latency •Sleep stages percentages

Wake

Wake

Sleep App vs. PSG •

Sleep efficiency – App and PSG were similar (86.5 vs. 86.6%)



Sleep latency – App overestimated sleep latency by ~16 min



Sleep stages percentages – App underestimated light sleep by ~28% – App overestimated deep sleep by ~11%

Sleep App vs. PSG The Sleep Time app was very sensitive in detecting sleep: ~90% of the epochs that PSG scored as sleep (regardless of the stage), the app also scored as sleep (i.e., light/deep sleep). However, the app was not very specific for detecting wake: only 50% of the epochs that PSG scored as wake, the app also scored as wake.

Sleep App vs. PSG The Sleep Time app tends to overscore sleep and does not detect wake very well. Therefore, as sleep efficiency decreases (i.e., a person has increased wakefulness), the accuracy of the app decreases. This would be problematic for a person with insomnia.

Sleep App vs. PSG Study by Hawley Montgomery-Downs et al. Montgomery-Downs HE, Insana SP, Bond JA Movement Toward a Novel Activity Monitoring Device Sleep and Breathing 2012;16:913-917

Sleep App vs. PSG Fitbit (Fitbit Inc., San Francisco, CA)

This app is primarily an activity monitor. It also collects information that is translated into sleep/wake information.

Sleep App vs. PSG ActiWatch-64 (Phillips Respironics, Bend, Oregon).

This actigraph device detects motion and converts this data into sleep/wake information.

Sleep App vs. PSG Study participants (healthy with no sleep problems) slept in the lab while simultaneously wearing a Fitbit device and an actigraphy monitor while undergoing a PSG study. The app, actigraph, and PSG data were compared.

Sleep App vs. PSG The Fitbit device uses 1-minute epochs (the lowest possible) whereas PSG and the ActiWatch-64 device use 30 second epochs. Therefore, to value of the Fitbit epoch was doubled to correspond to the PSG and ActiWatch-64 data.

Sleep App vs. PSG Both monitors overestimated sleep efficiency (i.e., overscored sleep) and total sleep time. The sensitivity of both devices for sleep was highly accurate (>95% for both devices). For each sleep stage (N1, N2, N3, and REM), Fitbit had a slightly higher sensitivity (range, 91.4%–98.8%), compared to the ActiWatch-64 (86.1%– 96.8%). The specificity of both devices was poor for detecting wake (e.g., 11.8% for Fitbit and 37.5% ActiWatch-64)..

Sleep App vs. PSG PSG

Fitbit

ActiWatch64

Sleep efficiency

79.5%

94.0%

88.8%

Total sleep time

370.9 min

438.0 min

413.9 min

Sleep App vs. PSG Montomery-Downs suggests that the Fitbit device provides acceptable monitoring, but only for healthy people without sleep disorders.

Sleep App vs. PSG Study by Adrian Ong and M. Boyd Gillespie Ong AA, Gillespie MB. Overview of smartphone applications for sleep analysis. World Journal of Otorhinolaryngology-Head and Neck Surgery 2016. http://dx.doi.org/10.1016/j.wjorl.2016.02.001

Sleep App vs. PSG Ong and Gillespie reviewed 51 sleep apps, which they obtained from a search of the Apple and Google Play app stores. The excluded apps that recorded sleep talking or snoring, were to be used in smart alarm clocks, that were primarily health trackers, or geared for nonconsumer use (e.g., healthcare workers).

Sleep App vs. PSG Some of the sleep apps Ong and Gillespie used in their study were

Absalt EasyWakeup Classic (FreeTerra) Absalt EasyWakeup Pro (FreeTerra) Good Night’s Sleep Alarm (Ateam Inc.) MotionX 24/7 (MotionX) Sleep Analyzer Android (Brains Infotech) Sleep As Android (Urbanoid Team) Sleep as Android Unlock (Urbanoid Team) Sleep Better (Runtastic) SleepBot (SleepBot) Sleep Cycle (Northcube AB) Sleep Time (Azumio) Sleep Time+ (Azumio) Smart Alarm Clock (Plus Sports) Smart Sleep Manager (C2 Incorporated)

Sleep App vs. PSG Among the sleep apps they reviewed, >65% reported on sleep architecture (i.e., sleep latency, time awake, sleep duration, time in light/deep sleep) and a few apps reported information on REM sleep.

Sleep App vs. PSG Sleep Structure

Apps on Apple site (n = 33)

Apps on Google site (n – 27)

Duration

100%

100%

Awake

70%

74%

Light sleep

64%

78%

Deep sleep

70%

78%

REM sleep

18%

11%

Sleep efficiency

45%

70%

Sleep debt

9%

11%

Sleep App vs. PSG Other Features

Apps on Apple site (n = 33)

Apps on Google site (n – 27)

Records movement during sleep

24%

11%`

Records snoring

45%

11%

Smart alarm

73%

56%

Provides white noise to aid sleep onset

27%

30%

Allows users to input wake-up mood or sleep-related activity (i.e., sleep diary)

36%

63%

Cognitive Behavioral Therapy The goal of cognitive behavioral therapy is to help a person learn to recognize negative patterns of thought, evaluate their validity, and replace them with healthier ways of thinking and, consequently, behaving. It was originally used to treat depression, but its use has been expanded to treat insomnia, anxiety, and other disorders (e.g., PTSD).

Cognitive Behavioral Therapy Cognitive behavioral therapy (CBT), when used for people with insomnia, typically involves combinations of the following therapies: • Cognitive therapy: (i.e., confronting attitudes and beliefs that hinder sleep such as “I will end up staying awake all night; I can’t sleep”) • Relaxation training: performing exercises with the goal of relaxing your mind and body

Cognitive Behavioral Therapy • Sleep hygiene training: correcting bad habits that contribute to poor sleep • Sleep restriction: severely limiting the time in bed and then gradually increasing the time in bed

• Stimulus control: “training” the body to associate bed with “sleep” (e.g., going to bed only when sleepy, waking at the same time daily, leaving the bed when unable to sleep, avoiding naps, using the bed only for sleep)

Sleep Time Plus App Screen

Sleep Time App Screen

Sleep Cycle App Screen

PROS AND CONS OF SLEEP APPS FOR INSOMNIA Pros

Cons

More convenient to enter information into an app than to enter it manually in a sleep diary

In general, apps do not measure how long a person is in a particular sleep stage

Apps can give some objective measure of a patient’s sleep/wake cycles

Apps typically do not use 30-sec epochs when collecting data. This factor can cause problems in objective scientific studies investigating the accuracy of an app vs. PSG

Based on information from a sleep app, patients who have an undiagnosed sleep disorder that may be contributing to insomnia complaints (e.g., delayed sleep phase syndrome) may ask their physician for a sleep study.

A smartphone is placed on a person’s bed; therefore, the softness or firmness of a mattress and body movements may be inaccurately recorded by the app

PROS AND CONS OF SLEEP APPS FOR INSOMNIA Pros

Cons

Manufacturers’ claims not scientifically backed

The wording of sleep app advertisements may lead consumers to believe that the app is providing fully accurate information

Conclusion Apps are becoming increasingly popular as people look for easy-to-use tools to self-monitor aspects of their health, including sleep. An increasing number of patients are coming to their physicians with questions, based on information they are reading from their sleep app data. Sleep apps can not be used instead of PSG to diagnose a sleep disorder. However, some app information (e.g., sleep diary), used in conjunction with a PSG study, may be useful.

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