title: Difficult morning awakening from rapid eye movement sleep and impaired cognitive function in delayed sleep phase disorder patients.
abstract: OBJECTIVE
  Difficult awakening is a key symptom of delayed sleep phase disorder (DSPD), but no studies have quantified awakening thresholds in a sleep laboratory. This study assessed whether cognitive function was impaired after awakening and whether difficult awakening was associated with specific polysomnographic features such as slow wave sleep stage N3.
  
  
  METHODS
  Nine patients with DSPD and nine sex- and age-matched healthy controls were included. Polysomnography was performed at our university hospital from midnight. An alarm clock was activated at 07:00 with sound intensity increasing from 72 to 104 dB. Participants performed a continuous performance test (CPT) the previous afternoon and immediately upon awakening.
  
  
  RESULTS
  Three DSPD patients and zero controls did not wake up to the maximum 104 dB alarm sound; all three patients were in rapid eye movement (REM) sleep when the alarm clock went off (difference in proportions, P = 0.047). In patients, CPT reaction time was prolonged in the morning compared to the afternoon [analysis of variance (ANOVA) interaction, P = 0.01]. DSPD patients made more omission errors than controls regardless of time of the day (ANOVA main effect, P = 0.046).
  
  
  CONCLUSIONS
  Difficult awakening from slow wave sleep was not observed. A subgroup of DSPD patients may have a severe problem waking up from REM sleep. DSPD patients may also have a state-like impairment in cognitive function in the morning and a trait-like impairment not depending on time of day, compared to normal sleepers.
authors.affiliation: Department of Clinical Neurosciences, Norwegian University of Science and Technology, Trondheim, Norway. Electronic address: brandy.solheim@ntnu.no.
authors.forename: Brandy
authors.initials: B
authors.lastname: Solheim
authors.affiliation: Department of Clinical Neurosciences, Norwegian University of Science and Technology, Trondheim, Norway; Department of Psychiatry, St Olavs Hospital, Trondheim, Norway.
authors.forename: Knut
authors.initials: K
authors.lastname: Langsrud
authors.affiliation: Department of Psychiatry, St Olavs Hospital, Trondheim, Norway.
authors.forename: Håvard
authors.initials: H
authors.lastname: Kallestad
authors.affiliation: MI Laboratory and Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway; Department of Physical Medicine and Rehabilitation, St Olavs Hospital, Trondheim, Norway.
authors.forename: Alexander
authors.initials: A
authors.lastname: Olsen
authors.affiliation: Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway.
authors.forename: Bjørn
authors.initials: B
authors.lastname: Bjorvatn
authors.affiliation: Department of Clinical Neurosciences, Norwegian University of Science and Technology, Trondheim, Norway; Department of Neurology and Clinical Neurophysiology, St Olavs Hospital, Trondheim, Norway.
authors.forename: Trond
authors.initials: T
authors.lastname: Sand
mesh_terms: D000293:Adolescent; D000328:Adult; D001143:Arousal / Q000502:physiology*; D016022:Case-Control Studies; D003071:Cognition / Q000502:physiology*; D005260:Female; D006801:Humans; D008297:Male; D017286:Polysomnography; D020178:Sleep Disorders, Circadian Rhythm / Q000503:physiopathology*; D012895:Sleep, REM / Q000502:physiology*; D055815:Young Adult
keywords: Continuous performance test; Delayed sleep phase disorder; Difficult morning awakening; Polysomnography; REM sleep