doi:10.1111/psyg.
12474
ORIGINAL ARTICLE
Actigraphic, but not subjective, sleep measures are
associated with cognitive impairment in memory clinic
patients
Nicole CABANEL,1,2 Christa SPEIER,1 Matthias J. MÜLLER3,4 and Bernd KUNDERMANN
1
Vitos Clinic for Psychiatry and Psychotherapy
Giessen, 2Department of Psychiatry and Psychother-
apy, Philipps-University Marburg and 4Justus-Lie-
big University of Giessen and 3Oberberg Group,
Berlin, Germany
Correspondence: Dr. Bernd Kundermann PhD,
Vitos Clinic for Psychiatry and Psychotherapy
Giessen, Licher Strasse 106, 35394 Giessen, Germany.
Email: bernd.kundermann@vitos-giessen-marburg.de
Disclosure: The authors have no potential conflicts
of interest to disclose.
Received 2 June 2017; revision received 2 April 2019;
accepted 20 May 2019.
Key words: actigraphy, cognitive impairment,
dementia, memory clinic, sleep questionnaires.
INTRODUCTION
Dementia is prevalent in old age and characterized by
both cognitive and non-cognitive symptoms. Among
non-cognitive symptoms, sleep disturbances are com-
mon in various dementia subtypes (e.g. Alzheimer’s or
vascular dementia) and are already detectable at the
© 2019 Japanese Psychogeriatric Society
PSYCHOGERIATRICS 2019
1,2
Abstract
Aim: Sleep disturbances are prevalent in various dementia subtypes but
rarely investigated in early clinical stages. Although memory clinics have
become an established institution for the early diagnosis of dementia, sleep
assessment is not part of their routine diagnostics. This study aimed to
examine whether subjective and objective sleep variables are related to
cognitive impairment in patients referred to a memory clinic.
Methods: On two consecutive days, patients underwent routine diagnostic
procedures, including a neuropsychological examination (consortium to estab-
lish a registry for alzheimer’s disease), and had their sleep quality evaluated by
the Pittsburgh Sleep Quality Index and overnight hand-wrist actigraphy.
Results: Data of 31 patients (age, M  SEM: 74.1  1.5; 18 women,
13 men; Clinical Dementia Rating: 0–1) were analysed. One had been diag-
nosed with subjective cognitive impairment, 13 with mild cognitive impair-
ment with or without depression, and 17 with dementia syndrome due to
Alzheimer’s and/or cerebrovascular disease. Compared to patients with
subjective or mild cognitive impairment, dementia patients showed a signifi-
cantly increased nocturnal acceleration magnitude; other differences in sub-
jective and objective sleep measures were not significant. Comparing
patients with subjectively poor (Pittsburgh Sleep Quality Index > 5: n = 9)
and good sleep (Pittsburgh Sleep Quality Index ≤ 5: n = 22) yielded no dif-
ferences in any neuropsychological and clinical variables. In contrast,
patients with low actigraphically recorded sleep efficiency (<85%: n = 11)
exhibited a significantly more impaired cognitive performance than those in
the high sleep efficiency group (≥85%: n = 20). Correlation analyses demon-
strated that actigraphically assessed disturbed sleep continuity accompa-
nied by increased night-time motor activity was substantially associated
with cognitive impairment.
Conclusion: This study highlights that objectively assessed, but not self-
reported, parameters of disturbed sleep are closely related to cognitive dys-
function in the early stages of dementia of different aetiologies. Possible
diagnostic and treatment implications are discussed.
early risk (or preclinical) stages of mild cognitive
impairment (MCI) with subtle cognitive abnormalities.1
Sleep disturbances in MCI and dementia include
insomnia, hypersomnolence or excessive daytime
sleepiness, circadian sleep–wake rhythm distur-
bances, and sleep-disordered breathing.2
1
N. Cabanel et al.
Evidence of a more specific association between
disturbed sleep and cognitive impairment in elderly
individuals has been derived from cross-sectional stud-
ies in which sleep was measured objectively. A recent
population-based study demonstrated not only stron-
ger abnormalities in polysomnographically measured
sleep continuity (e.g. lower sleep efficiency) and archi-
tecture (e.g. less non-REM stage 3 and REM sleep),
but especially more severe sleep-disordered breathing
in participants with MCI than in healthy individuals.3
Consistent with this, several polysomnographic studies
have shown such cross-sectional differences between
healthy controls and patients with MCI and dementia
and among different dementia subtypes.4–6 Similar
findings obtained by actigraphy demonstrated abnor-
malities in sleep continuity but also showed additional
deterioration in activity/rest cycles.7,8 Interestingly, one
study on non-amnestic MCI patients revealed an asso-
ciation between disrupted sleep continuity as assessed
by actigraphy and poorer performance on specific neu-
ropsychological domains.9 In contrast, group compari-
sons of subjective sleep parameters yielded
inconsistent results with negative or even contrary
findings,3 indicating poorer sleep quality in healthy
elderly subjects than in cognitively impaired subjects.10
Apart from cross-sectional results, several longitu-
dinal studies have addressed the role of sleep in cog-
nitive decline. According to these studies, future risk
of cognitive deterioration or conversion from MCI to
dementia was predictable by different measures of
sleep disturbances as assessed by self-rating
scales,11 actigraphy,12 and polysomnography.13
The results from these previous studies confirm
the close association between sleep disturbances
and cognitive decline and are therefore of clinical rel-
evance for early detection of dementia. Using diag-
nostic tools for sleep disturbances offers the
opportunity to administer appropriate early treat-
ments in prodromal stages to improve or delay clini-
cal or functional impairment, especially in treatable
conditions such as sleep-disordered breathing.14
Memory clinics provide an interdisciplinary
approach to early diagnosis and treatment of cogni-
tively impaired individuals.15 Screenings for sleep dis-
turbances, particularly those involving non-invasive
tools such as self-reports and actigraphy, may be
clinically valuable, but they are not usually regularly
employed in memory clinics. Surprisingly, to our
knowledge, no study has examined their application
2 © 2019 Japanese Psychogeriatric Society
in an unselected patient sample typically referred to a
memory clinic. Such as sample would be heteroge-
neous with regard to the severity of cognitive impair-
ment as well as to the underlying brain pathogenesis
and other mental disorders (especially depressive
disorders16) related to cognitive impairment.
Therefore, we aimed to investigate the association
of objective actigraphic and subjective sleep parame-
ters with dementia severity stages and indices of
cognitive functioning in patients referred to a memory
clinic. Although this study was exploratory, we
hypothesized, in line with previous studies,3,9 that
cognitive impairment would be more related to objec-
tively assessed disturbances of sleep than to those
measured subjectively.
METHODS
Patients and procedures
Thirty-three outpatients who were referred to the mem-
ory clinic of the Vitos Clinic for Psychiatry and Psycho-
therapy Giessen between November 2015 and February
2017 were recruited. They underwent a standardized
examination according to German guidelines on demen-
tia as well as further assessments on two consecutive
days,17 beginning each day at 0900 hours and ending
at 1600 hours. Diagnosis of dementia or any other men-
tal disorders was made by psychiatrists and neurolo-
gists according to the International Classification of
Diseases, 10th edition, criteria. Patients were classified
according to their cognitive syndrome diagnosis as fol-
lows: (i) subjective cognitive impairment (SCI) without
detectable objective neuropsychological impairment;
(ii) MCI based on the Winblad criteria,18 either with or
without another mental disorder (e.g. major depression);
or (iii) dementia with significant functional impairment.
Patients were included in this study if there was an
indication for a diagnostic examination and if they
were referred by a medical specialist, able to con-
sent, and older than 50 years of age. Patients were
excluded if they had received their dementia diagno-
sis more than 2 years earlier.
The cross-sectional data presented here were col-
lected during the baseline assessment as part of a
longitudinal study investigating the prediction of cog-
nitive decline in memory clinic patients. This study is
registered in the German Clinical Trials Register
(DRKS00010215) and was approved by the local

ethics committee of the Hessen State Medical Asso-
ciation (Frankfurt, Germany).
Actigraphy
The SOMNOwatch system (Somnomedics,
Randersacker, Germany) was used to assess sleep.
Patients were instructed to wear the actigraph con-
tinuously (except during water activities such as
swimming and bathing) on their non-dominant wrist
from 1600 to 0900 hours the following day, when
they returned to our clinic.
The actigraph recorded the acceleration of move-
ments on three (x, y, z) axes, which were recorded as a
magnitude signal (calibrated in mG) with a sampling rate
of 1 Hz. The digitalized data were translated based on
an established algorithm into sleep continuity measures
using the software DOMINOlight (Somnomedics).19 To
indicate time in bed (TIB), patients were instructed to
push the marker button when going to bed and getting
up. Both times were additionally validated by sleep diary
records. The actogram was visually inspected for
recording failures or to reject any epochs in which the
actigraph had been removed. Classical sleep continuity
variables were derived; sleep efficiency (percentage
ratio of total sleep time to TIB) was the main parameter
because it is a useful general expression of nocturnal
sleep quality.20 A sleep efficiency cut-off of 85% was
used to define subgroups with low (<85%) and high
(≥85%) sleep efficiency. Further sleep variables were
sleep onset latency (time between bed time and sleep
start), total sleep time (total sleep duration during TIB),
sleep period time (period between sleep onset and final
awakening), total wake time (time awake during TIB),
wake after sleep onset (sum of all wake epochs during
the sleep period), and number of awakenings. To quan-
tify motor nocturnal activity during TIB irrespective of
the sleep–wake scorings, we averaged the magnitude
signals of each second during TIB and multiplied this
mean by the number of 30-s epochs.
Self-rating sleep scales
The German version of the Pittsburgh Sleep Quality
Index (PSQI) was used to assess subjective sleep
quality during the preceding 2 weeks; the total possi-
ble score range is 0–21, with higher scores indicating
more dysfunction.21 The standard cut-off of 5 was
applied to discriminate between good and poor
sleepers.22 Furthermore, on the morning after
actigraphy, patients rated the restfulness of their
© 2019 Japanese Psychogeriatric Society
Sleep in memory clinic patients
sleep on a 5-point Likert scale ranging from 1 (very
restful) to 5 (very restless).
Neuropsychological testing
Patients completed the Mini-Mental Status Examination
and the consortium to establish a rationale in alzheimer’s
diagnostic (CERAD-Plus) test battery,23 which includes
subtests assessing categorization abilities (word flu-
ency), semantic processing (Boston Naming Test), verbal
memory (word list learning over three trials with immedi-
ate recall, delayed recall, and delayed recognition),
visuoconstruction (copying geometric figures), figural
memory (figure recall), and attentional-executive func-
tions (Trail Making Test A and B). Two indices of global
cognitive functioning were considered: the Mini-Mental
Status Examination and the CERAD Total Score (total
score range: 0–100).24 Subtest scores were calculated
as Z-scores adjusted for sex, age, and education.
Further assessments
The short version of the Geriatric Depression Scale
was completed as an interview.25 Scores range from
0 to 15, with higher scores indicating more depres-
sive symptomatology. The Clinical Dementia Rating
scale was used to classify dementia severity and to
confirm cognitive syndrome diagnosis.26 Further-
more, sleep-altering medications (e.g. beta-blockers,
antidepressants, antipsychotics, benzodiazepines or
Z-drugs, and anti-dementia drugs) were recorded.
Statistical analysis
Data were statistically analyzed by R version 3.1.2
(R Foundation for Statistical Computing, Vienna, Aus-
tria). Descriptive statistics were frequencies and
means  SEM. Fisher’s exact test was used to analyze
categorical data. Group comparisons for continuous
variables, which involved dividing the sample based on
clinical dementia stages or cut-offs for disturbed sleep,
were conducted by using Mann–Whitney tests; correla-
tion analyses were made by calculating Spearman’s
rho (rs). Significance level was set at α < 0.05.
RESULTS
Patients’ demographic and clinical
characteristics
Of the 33 patients enrolled, only 31 patients could be
analyzed because two were missing actigraphy data
3
N. Cabanel et al.
(one had an actigraph with a technical defect, and
the other removed the actigraph before going to
bed). Table 1 lists the patients’ demographic and
clinical characteristics. Less than half of patients
(n = 9) showed poor sleep as defined by the PSQI
and based on actigraphic sleep efficiency measures.
A 2 × 2 contingency table yielded no significant cor-
respondence (P = 1.0) between classification
according to subjective and actigraphic criteria. The
majority of patients (n = 18, 58%) rated their sleep
during the actigraphy night as restful or even very
restful. These ratings were highly correlated to PSQI
scores (rs = 0.491, P = 0.006), but not to any acti-
graphic sleep measure (P > 0.2 for all measures).
Group comparisons
Subjective and actigraphic sleep parameters in
patients with dementia compared with patients
with mild cognitive impairment and subjective
cognitive impairment
To examine whether differences in cognitive impair-
ment severity are distinguishable based on subjective
and actigraphic sleep measures, the sample was
divided into two subgroups according to cognitive
syndrome diagnosis: patients with SCI/MCI (Clinical
Table 1 Sample characteristics (n = 31)
Variable
Age (years), mean  SEM
Women/men (n)
Education (years), mean  SEM
Mini-Mental Status Examination, mean  SEM
Geriatric Depression Scale, mean  SEM
ICD-10 F-diagnosis (n)
Alzheimer’s dementia (F00.x)
Vascular dementia (F01.x)
Other personality and behavioural disorders due to
known physiological condition (F07.8)
Major depressive disorder (F32-33)
No ICD-10 F-diagnosis (Z03.x)
Cognitive syndrome diagnosis: SCI/MCI/dementia (n)
Clinical Dementia Rating: 0/0.5/1 (n)
Prescribed ≥1 sleep altering drug: no/yes (n)
PSQI global score, mean  SEM
Poor vs good sleep (PSQI: >5/≤5) (n)
Subjective restfulness of sleep during actigraphy
night (raw score), mean  SEM
Actigraphic sleep efficiency (%), mean  SEM
Low vs high actigraphic sleep efficiency (<85%/
≥85%) (n)
†
n = 30 due to one missing value. ICD-10, International Classification of Dis-
eases, 10th edition; MCI, mild cognitive impairment; PSQI, Pittsburgh Sleep
Quality Index; SCI, subjective cognitive impairment.
4 © 2019 Japanese Psychogeriatric Society
Dementia Rating ≤ 0.5) (n = 14) and patients with
dementia syndromes (Clinical Dementia Rating = 1)
of various (neurodegenerative and/or vascular) aetiol-
ogies (n = 17). No significant group differences were
found with respect to the proportion of subjective
poor sleep parameters (PSQI > 5 in SCI/MCI
vs dementia: 4 vs 5 patients, P = 1.0) or classical
actigraphic sleep parameters. However, compared to
the SCI/MCI group, dementia patients exhibited a
significantly increased acceleration magnitude during
TIB (Σ mG: 33 338.1  7430.6 vs 16 024.2  2025.6,
P = 0.024) and an increased acceleration magnitude
related to TIB (Σ mG/TIB in min: 57.4  10.7 vs
31.6  3.9, P = 0.045). The groups did not differ with
regard to control variables (i.e. age, education, sex
ratio, severity of depression, and medication) (P > 0.1
for all variables).
Comparison of cognitive functioning in patients
with poor and good sleep as defined by either
subjective or actigraphic sleep parameters
Group comparisons between patients with PSQI > 5
(n = 9) and PSQI ≤ 5 (n = 22) revealed no significant
differences in global measures of cognitive function-
ing. In contrast, comparisons of patients with acti-
graphic low and high sleep efficiency indicated that
the latter group performed significantly better on the
Mini-Mental Status Examination and the CERAD Total
Score (Fig. 1). Accordingly, the low sleep efficiency
74.1  1.5
group performed poorer on the following CERAD-Plus
18/13
11.5  0.6 subtests: verbal memory (immediate recall of word
24.7  0.6 list, trial 3), semantic word fluency, and phonetic word
6.9  0.5 fluency (Fig. 2). There were no significant differences
13 in control variables (P > 0.1 for all variables).
4
8
Correlation analyses
5 The relationship between subjective sleep quality
1
measures and both indices of global cognitive func-
1/13/17
3/11/17 tioning remained non-significant (Table 2). Several
14/17 significant associations between actigraphic and
4.8  0.6 global cognitive measures were observed. At first,
9/22
2.2  0.2† later going-to-bed times were associated with better
cognitive functioning. CERAD Total Score was found
83.0  1.9 to have substantial correlations with the parameters
11/20
of sleep continuity (total wake time, wake after sleep
onset, and sleep efficiency) and the indices of motor
activity (movement magnitude signals during TIB).
Among these measures of sleep continuity and motor
 Sleep in memory clinic patients

Figure 1 Group comparison of

patients with actigraphic low
(<85%, n = 11) and high
(≥85%, n = 20) sleep effi-
ciency with regard to global
cognitive functioning as mea-
sured by the Mini-Mental Sta-
tus Examination and CERAD
Total Score (mean  SEM).
*P < 0.05, **P < 0.01.

activity, no significant associations with control vari- Table 2 Correlations (rs) between sleep parameters and global
ables were found. cognitive functioning by the Mini-Mental Status Examination
(MMSE) and CERAD Total Score (CTS)
Sleep parameters MMSE CTS
Pittsburgh Sleep Quality Index global −0.076 −0.098
DISCUSSION score
In the present study, the primary finding was that Restfulness of sleep during actigraphy −0.191 −0.241
night raw score†
actigraphic parameters of disturbed sleep continuity Time of going to bed (hh:mm) 0.597* 0.327
(i.e. lower sleep efficiency, longer total wake times, and Time of getting out of bed (hh:mm) 0.278 0.136
wake times after sleep onset) and increased nocturnal Time in bed (TIB) (min) −0.277 −0.207
Sleep onset latency (min) 0.088 0.175
activity were strongly associated with cognitive impair-
Total sleep time (min) −0.044 0.176
ment in memory clinic patients, but these relationships Sleep period time (min) −0.229 −0.239
Total wake time (min) −0.217 −0.477*
Wake after sleep onset (min) −0.181 −0.475*
Number of awakenings (n) 0.030 −0.256
Sleep efficiency (%) 0.154 0.471*
Acceleration magnitude during TIB (Σ −0.313 −0.532*
mG)

* P < 0.01. † n = 30 due to one missing value.

were not confirmed for subjective sleep measures.

Figure 2 Group comparison of patients with actigraphic low
(<85%, n = 11) and high (≥85%, n = 20) sleep efficiency (SE) with
regard to subtests of the Consortium to Establish a Registry for
Alzheimer’s Disease (CERAD-Plus) test battery (Z-scores,
mean  SEM). *P < 0.05.
Control variables did not differ in group comparisons
or correlate to global cognitive functioning. This find-
ing is noteworthy because no study has yet demon-
strated this relationship in a heterogeneous sample
typically referred to a memory clinic, including
patients with early dementia of different aetiologies
as well as MCI and geriatric depression, which were
previously shown to be neuropsychologically compa-
rable.27 Nevertheless, our finding of a relationship
between actigraph-measured sleep disturbances
(lower sleep efficiency, increased total wake time,
and wake after sleep onset) and cognitive impairment
is corroborated by previous studies that separately
investigated homogenous patient groups, such as
those with MCI or geriatric depression,9,28,29 and
cognitively intact elderly (i.e. without MCI and

© 2019 Japanese Psychogeriatric Society 5

N. Cabanel et al.
dementia).30 We did not find significant differences in
sleep continuity parameters between patients classi-
fied as having a dementia syndrome and those cate-
gorized as having SCI or MCI, probably because of
the clinical and aetiological heterogeneity within both
subgroups. Interestingly, increased nocturnal activity
in the demented subgroup was found; in addition to
the binary sleep–wake differentiation, this could be of
importance for the clinical assessment of patients
with progressed disease stages.
As a secondary result, we found an association
between later times of going to bed and a poorer gen-
eral cognitive functioning as indicated by the Mini-
Mental Status Examination, which was previously
shown in a large cross-sectional study on community-
dwelling older adults.31 One could speculate that this
finding reflects a phase advance of sleep–wake
rhythm in patients with cognitive impairment (MCI or
dementia) due to Alzheimer’s disease, which involves
neurodegenerative processes that can affect the sup-
rachiasmatic nucleus pacemaker2
According to previous reports, no subjective sleep
measures were related to cognitive performance,
irrespective of their differences in time frame.3,30 This
could be explained by the limited appropriateness of
self-reports in this patient population,32 potentially
due to poor symptom awareness or cognitive deficits
contributing to a disagreement between subjective
and actigraphic sleep measures.10,33
With regard to pathophysiological considerations,
there is evidence for an association—probably a bidi-
rectional association—between disturbed sleep and
both amyloid deposition and tau pathology.34 Unfor-
tunately, only the minority of our patients underwent
lumbar puncture to measure cerebrospinal fluid bio-
markers. Therefore, our data cannot support or reject
such hypotheses.
This study had some limitations, including the
small sample size. More importantly, the use of
actigraphy for only one night did not allow for the
evaluation of important measures such as circadian
activity rhythm patterns or across-night sleep vari-
ability.35 However, our application of actigraphy for
one night was guided by feasibility aspects—that is,
we implemented a non-invasive and straightforward
screening method for sleep disturbances in the daily
routine of a memory clinic.
The clinical implications are summarized as
follows:
6 © 2019 Japanese Psychogeriatric Society
1 In patients referred to a memory clinic, subjective
sleep measures are not substantially related to clini-
cal and cognitive features and, therefore, are likely
to underestimate objective sleep disturbances.
2 The poorer the cognitive function, the more likely a
patient has objectively disturbed sleep that can be
detected by actigraphy.
3 To account for the considerable night-to-night vari-
ability of actigraphic sleep parameters in this
patient group, it is recommended that they
undergo actigraphy for several days to obtain a
reliable and objective estimation of the severity of
sleep–wake disturbances.33 The clinical impor-
tance of evaluating night-to-night variability for
early detection and prognosis was supported by a
recent study that showed an increased risk of fur-
ther cognitive decline in patients with a greater var-
iability in sleep efficiency and total sleep time.12
4 In certain cases, such as in patients with
suspected obstructive sleep apnoea with clinical
signs witnessed by their relatives or caregivers,
more specialized diagnostic procedures, including
polysomnography, are required.
5 The early detection and accurate diagnoses of
sleep disturbances enables appropriate treatment
approaches including behavioural therapy, bright
light therapy, and pharmacotherapy.36
ACKNOWLEDGMENTS
We thank Dr Corinna Leonhardt and Meike Engel,
MSc, for performing neuropsychological tests and
clinical ratings. We thank Stanislava Fockenberg,
neurologist, and Diaa Rashid, neurologist, for rec-
ruiting patients and conducting their physical and
neurological examinations
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