Sleep Disturbances in Korean Patients with Ankylosing Spondylitis are Associated with Increased Disease Activity

Hye-Jin Jeong; Tae Han Lee; Ji Min Lee; Go Choi; Chang-Nam Son; Ji-Min Kim; Yong Won Cho; Sang-Hyon Kim

doi:10.4078/jrd.2014.21.5.241

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Jeong, Lee, Lee, Choi, Son, Kim, Cho, and Kim: Sleep Disturbances in Korean Patients with Ankylosing Spondylitis are Associated with Increased Disease Activity

Original Article

J Rheum Dis 2014;21(5):241-247.

Published online: 31 October 2014

DOI: https://doi.org/10.4078/jrd.2014.21.5.241

Sleep Disturbances in Korean Patients with Ankylosing Spondylitis are Associated with Increased Disease Activity

Hye-Jin Jeong¹, Tae Han Lee¹, Ji Min Lee¹, Go Choi¹, Chang-Nam Son¹, Ji-Min Kim¹, Yong Won Cho², Sang-Hyon Kim¹

¹Division of Rheumatology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea

²Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea

Corresponding to: Sang-Hyon Kim, Division of Rheumatology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, 56, Dalseong-ro, Jung-gu, Daegu 700-712, Korea. E-mail: mdkim9111@hanmail.net

Received 24 June 2014 Revised 21 September 2014 Accepted 22 September 2014

This is a Free Access article, which permits unrestricted non-commerical use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective

To evaluate the prevalence of sleep disturbance in Korean patients with ankylosing spondylitis (AS), and its association with disease activity and depression.

Methods

Forty patients with AS and eighty healthy controls were included in this study. Sleep quality was assessed using the Korean version of Pittsburgh sleep quality index (PSQI). Depression was assessed by the Korean version of Beck depression inventory second edition (BDI-2). Ankylosing spondylitis disease activity score-C-reactive protein (ASDAS-CRP) was used to evaluate disease activity. Patients were dichotomized into a good sleeper group (PSQI≤5) and a poor sleeper group (PSQI＞5).

Results

The mean total PSQI score of patients with AS was 7.23±3.84. It was higher than that of the control subjects. AS patients had higher scores in all of the PSQI components, except for the use of sleep medication. Sixty percent of the AS patients were classified as poor sleepers. The mean BASDAI, ASDAS-CRP, and BDI-2 scores of the poor sleeper group were higher than that of the good sleeper group. Significantly, higher disease activity according to ASDAS-CRP was associated with poor sleep quality and depression. Multiple regression analysis revealed that the duration of morning stiffness and depression were independent risk factors that influenced poor sleep quality.

Conclusion

Sleep disturbances are prevalent amongst Korean patients with AS. Lower quality of sleep is significantly associated with higher disease activity and depression. Therefore, optimal management to improve sleep quality in patients with AS is important.

Keywords: Ankylosing spondylitis, Disease activity, Sleep quality, Depression

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Figure 1.

Score distribution of each PSQI component in patients with ankylosing spondylitis.

Table 1.

Comparison between patient group and control group

	Patient group (n=40)	Control group (n=80)	p
Age, years	42.18±11.95	43.13±12.97	0.699*
Male, n (%)	34 (85%)	33 (41.3%)	＜0.001^†
Disease duration, months	71.97±73.80	NA
HLA-B27 positivity, n (%)	33 (82.5%)	NA
TNF-α blocker use, n (%)	25 (62.5%)	NA
CRP, mg/L	3.20±5.82	NA
ASDAS-CRP	1.93±0.85	NA
BASDAI	3.67±2.07	NA
BDI-2	14.18±11.41	6.31±6.16	＜0.001*
Total PSQI	7.23±3.84	3.80±2.02	＜0.001*
Subjective sleep quality	1.40±0.59	0.84±0.60	＜0.001*
Sleep latency	1.35±1.23	0.71±0.73	0.004*
Sleep duration	1.20±0.88	0.70±0.80	0.002*
Habitual sleep efficiency	0.45±0.78	0.11±0.42	0.014*
Sleep disturbance	1.20±0.56	0.73±0.52	＜0.001*
Use of sleep medications	0.25±0.70	0.04±0.24	0.072*
Daytime dysfunction	1.40±0.87	0.68±0.68	＜0.001*
Good sleepers (PSQI≤5)	16 (40%)	67 (83.8%)	＜0.001^†
Poor sleepers (PSQI＞5)	24 (60%)	13 (16.3%)

ASDAS: ankylosing spondylitis disease activity score, BASDAI: Bath ankylosing spondylitis disease activity index, BDI: Beck depression inventory, CRP: c-reactive protein, HLA: human leukocyte antigen, NA: not available, PSQI: Pittsburgh sleep quality index, TNF: tumor necrosis factor.

^* p-value by t-test.

^† p-value by chi-square test.

Table 2.

Comparison between good sleepers and poor sleepers in the patient group

Variables	Good sleepers (PSQI≤5) n=16	Poor sleepers (PSQI＞5) n=24	p
Age, years	43.06±11.21	41.58±12.61	0.795*
Disease duration, months	59.69±52.81	80.17±85.10	0.733*
Male, n (%)	15 (93.8%)	19 (79.2%)	0.373^†
HLA-B27 positivity, n (%)	14 (87.5%)	19 (79.2%)	0.818^†
TNF-α blocker use, n (%)	11 (68.8%)	14 (58.3%)	0.740^†
BASDAI	2.10±1.59	4.72±1.66	＜0.001*
Fatigue	2.50±1.93	5.50±1.91	＜0.001*
Spinal pain	2.69±2.12	4.88±2.30	0.005*
Peripheral joint pain/swelling	2.00±1.75	4.71±2.61	0.001*
Tenderness	1.38±1.82	3.33±2.54	0.008*
Severity of morning stiffness	2.38±1.99	4.79±2.46	0.003*
Duration of morning stiffness	1.56±1.26	5.42±3.34	＜0.001*
ASDAS-CRP	1.36±0.78	2.31±0.68	＜0.001*
CRP, mg/L	4.00±8.44	2.68±3.22	0.795*
Spinal pain	2.69±2.12	4.88±2.30	0.005*
Duration of morning stiffness	1.56±1.26	5.42±3.34	＜0.001*
Patient global status	2.38±1.40	5.04±2.09	＜0.001*
Peripheral joint pain/swelling	2.00±1.75	4.71±2.61	0.001*
BDI-2	7.00±6.38	18.96±11.59	＜0.001*

ASDAS: ankylosing spondylitis disease activity score, BASDAI: Bath ankylosing spondylitis disease activity index, BDI: Beck depression inventory, CRP: c-reactive protein, HLA: human leukocyte antigen, NS: not significant, PSQI: Pittsburgh sleep quality index, TNF: tumor necrosis factor.

^* p-value by Mann-Whitney U test.

^† p-value by chi-square test.

Table 3.

Sleep quality of patients with ankylosing spondylitis according to disease activity (ASDAS-CRP)

	Inactive (ASDAS＜1.3) N=11	Moderate (1.3≤ ASDAS＜2.1) N=9	High (ASDAS≥2.1) N=20	p
Age, years	41.27±10.99	48.22±11.9983.67±60.81	39.95±12.08	0.282*
Duration, months	69.64±53.01	83.67±60.81	68.00±89.77	0.333*
Male, n (%)	11 (100%)	6 (66.7%)7 (77.8%)	17 (85.0%)	0.118^†
HLA-B27 positivity, n (%)	10 (90.9%)	7 (77.8%)6 (66.7%)	16 (80.0%)	0.728^†
TNF-α blocker use, n (%)	9 (81.8%)	6 (66.7%)2.13±3.01	10 (50.0%)	0.205^†
CRP, mg/L	0.48±0.80	2.13±3.013.17±1.60	5.19±7.51	0.007*
BASDAI	1.75±0.88	3.17±1.605.22±3.07	4.95±1.82	＜0.001*
Total PSQI	4.91±1.86	5.22±3.071.33±0.70	9.40±3.81	0.001*
Subjective sleep quality	1.09±0.30	1.33±0.700.67±1.00	1.60±0.59	0.057*
Sleep latency	0.73±0.64	0.67±1.000.89±0.78	2.00±1.25	0.003*
Sleep duration	0.82±0.75	0.89±0.780.11±0.33	1.55±0.88	0.051*
Habitual sleep efficiency	0.09±0.30	0.11±0.33	0.80±0.95	0.017*
Sleep disturbances	0.91±0.30	0.89±0.33	1.50±0.60	0.002*
Use of sleep medications	0.45±0.93	0	0.25±0.71	0.247*
Daytime dysfunction	0.82±0.75	1.33±1.00	1.75±0.71	0.019*
BDI-2	5.64±6.07	14.56±7.07 j	18.70±12.76	0.004*

ASDAS: ankylosing spondylitis disease activity score, BASDAI: Bath ankylosing spondylitis disease activity index, BDI: Beck depression inventory, CRP: c-reactive protein, HLA: human leukocyte antigen, PSQI: Pittsburgh sleep quality index, TNF: tumor necrosis factor.

^* p-value by Kruskal-Wallis test.

^† p-value by chi-square test.

Table 4.

Correlation coefficients between components of PSQI and demographics and disease-related variables

Variables	Total PSQI	Subjective sleep quality	Sleep latency	Sleep duration	Habitual sleep efficiency	Sleep disturbance	Use of sleep medication	Daytime dysfunction
Age	−0.115	−0.014	−0.274	0.023	−0.058	−0.066	0.004	−0.044
Disease duration	0.236	0.298	0.088	0.316*	0.247	0.146	0.035	0.137
BASDAI	0.691^†	0.638^†	0.490^†	0.553^†	0.354*	0.683^†	0.022	0.642^†
Fatigue	0.690^†	0.580^†	0.415^†	0.574^†	0.334*	0.596^†	0.151	0.711^†
Spinal pain	0.439^†	0.547^†	0.327*	0.354*	0.120	0.555^†	−0.147	0.443^†
Peripheral joint pain/swellin	g 0.604^†	0.607^†	0.404^†	0.559^†	0.331*	0.601^†	0.010	0.456^†
Tenderness	0.366*	0.339*	0.341*	0.196	0.108	0.492^†	−0.037	0.361*
Severity of morning stiffnes	s 0.657^†	0.539^†	0.441^†	0.549^†	0.437^†	0.575^†	0.067	0.584^†
Duration of morning stiffnes	ss 0.674^†	0.434^†	0.485^†	0.519^†	0.529^†	0.496^†	0.157	0.625^†
ASDAS-CRP	0.557^†	0.446^†	0.471^†	0.400*	0.486^†	0.504^†	−0.122	0.491^†
CRP	−0.151	−0.161	−0.109	−0.075	0.093	−0.319*	−0.124	−0.113
Spinal pain	0.439^†	0.547^†	0.327*	0.354*	0.120	0.555^†	−0.147	0.443^†
Duration of morning stiffnes	ss 0.674*	0.434^†	0.485^†	0.519^†	0.529^†	0.496^†	0.157	0.625^†
Patient global status	0.620^†	0.507^†	0.482^†	0.401*	0.384*	0.628^†	0.004	0.605^†
Peripheral joint pain/swelling	0.604^†	0.607^†	0.404^†	0.559^†	0.331*	0.601^†	0.010	0.456^†
BDI-2	0.742^†	0.644^†	0.478^†	0.531^†	0.508^†	0.568^†	0.277	0.583^†

^* p＜0.05

^† p＜0.01.

Table 5.

Stepwise multiple regression analysis between components of PSQI and demographics and disease-related variables

Dependent variable	Independent variable	B	S.E.	β	t	p	Tolerance	VIF
Total PSQI	Duration of morning stiffness	0.563	0.174	0.490	3.236	0.003	0.345	2.899
	BDI-2	0.124	0.051	0.372	2.450	0.020	0.342	2.921
	R²=0.763, Durbin-Watson=1.845
	p＜0.001
	Regression equation=1.47+0.563×	Morning	stiffness dura	ation+0.124×	× BDI

ASDAS: ankylosing spondylitis disease activity score, B: regression coefficient, BDI: Beck depression inventory, β: standardized beta coefficient, CRP: c-reactive protein, PSQI: Pittsburgh sleep quality index, R2: coefficient of determination, S.E: standard error, VIF: variance inflation factor.

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