NightWare and Cardiovascular Health in Adults With PTSD

NightWare Therapeutic Platform for Improving Cardiovascular Health in Adults With Nightmares Associated With PTSD

The purpose of this study is to determine whether NightWare therapeutic intervention improves biomarkers of vascular aging and autonomic function in adults with nightmares related to PTSD.

Study Overview

• Status: Recruiting
• Conditions: Cardiovascular Diseases; Endothelial Dysfunction; Vascular Stiffness; Posttraumatic Stress Disorder; Nightmare; Autonomic Dysfunction
• Intervention / Treatment: Device: NightWare; Device: Sham NightWare

Detailed Description

Posttraumatic stress disorder (PTSD) is linked to accelerated aging and is associated with increased risk of early-onset cardiovascular disease (CVD) in both men and women. The pathophysiological link between PTSD and CVD is complex and multi-factorial that likely involves premature vascular aging (i.e., large elastic arterial stiffening and vascular endothelial dysfunction) and autonomic dysfunction (e.g., reduced cardiovagal baroreflex sensitivity [cBRS] and heart rate variability [HRV]), along with other mechanisms. Vascular aging and autonomic dysfunction are key antecedents in the development of CVD and individuals with PTSD have greater arterial stiffening, endothelial dysfunction and reductions in cBRS and HRV compared to those without PTSD. The mechanisms by which PTSD contributes to greater vascular and autonomic dysfunction are not completely understood. Sleep is important for cellular and tissue repair, free radical detoxification and reducing oxidative stress and inflammation. Sleep disturbance is a hallmark symptom of PTSD and is associated with biomarkers of vascular aging, autonomic dysfunction and increased risk of CVD. Nightmares, a central feature of PTSD associated-sleep disturbance, are a debilitating symptom that can lead to insomnia or sleep deprivation, daytime sleepiness or fatigue, mood disturbances, cognitive impairments, behavioral problems, or other sequela, that ultimately causes clinically significant distress and impairment in social, occupational and physiological function, as well as increased CVD risk. As such, therapeutic strategies and interventions aimed at reducing nightmare-associated sleep disturbances in individuals with PTSD are clinically important for improving sleep quality, cardiovascular health and risk for future age-associated CVD.

Various psychotherapeutic (e.g., imagery rehearsal therapy [IRT]) and pharmacological (e.g., prazosin) interventions are available for treatment of nightmares associated with PTSD. However, the evidence for their efficacy for addressing sleep disturbances is inconsistent, particularly with pharmaceuticals, and implementation barriers and poor adherence exist with psychotherapy. As such, novel alternative approaches, including the use of digital medicine such as app-based and digital platforms are being developed to improve treatment delivery. NightWare™ digital therapeutic system is one such novel platform that was recently granted Breakthrough Device designation by the FDA for the treatment of nightmares in adults with PTSD. NightWare uses a proprietary application on the Apple Watch® to collect biometric data (i.e., heart rate [HR] and body movement) to learn sleep patterns to create a stress Index. When an individual exceeds this index due to entering a nightmare, NightWare intervenes by sending vibrotactile feedback to the Apple Watch, arousing the individual and interrupting the nightmare without waking or disrupting sleep. Through machine learning, NightWare continually refines its model and knowledge of the person's response, consequently leading to fewer nightmare associated awakenings. In unpublished preliminary studies, NightWare was shown to be safe (no change in suicide risk or daytime sleepiness) and a tendency to have greater improvement in objective measures of sleep quality (i.e., Pittsburgh Sleep Quality Index [PSQI] and amendment for PTSD [PSQI-A]) compared to sham (NightWare but intervention disabled, i.e., no vibration). Whether NightWare improves cardiovascular health in adults with PTSD-related nightmares has yet to be studied.

Accordingly, the investigators are proposing a randomized, double-blind, placebo (i.e., sham intervention) controlled parallel pilot study that will provide the first clinical evidence for the efficacy of the NightWare digital therapeutic system to improve cardiovascular health outcomes in adults with PTSD-related nightmares.

• Study Type: Interventional
• Enrollment (Anticipated): 50
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Kerrie Moreau, PhD; Phone Number: 303-724-1914; Email: kerrie.moreau@cuanschutz.edu

Study Locations

• United States
  • Colorado
    • Aurora, Colorado, United States, 80045
      • Recruiting
      • University of Colorado Anschutz Medical Campus
      • Contact: Kerrie L Moreau, PhD; Phone Number: 303-724-1914; Email: kerrie.moreau@ucdenver.edu
    • Denver, Colorado, United States, 80045
      • Recruiting
      • University of Colorado CCTSI CTRC
      • Contact: Kerrie Moreau, PhD; Phone Number: 303-724-1914; Email: kerrie.moreau@ucdenver.edu

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 20 years to 97 years (Adult, Older Adult)
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

1. Diagnosis of PTSD via American Psychiatric Association PTSD diagnostic criteria in the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
2. Self-report having repetitive nightmares contributing to disrupted sleep
3. age >22 years (rationale is because the device has only been used in adults in 22 years and older);
4. resting blood pressure (BP, <160/100 mmHg);
5. fasted glucose <126 mg/d;
6. non-smokers;
7. no use of vitamin supplements or anti-inflammatory medications, or willing to stop 1 month prior to the vascular visit;
8. Pittsburgh Sleep Quality Index (PSQI) score 6 or higher;
9. Epworth Sleepiness Scale (ESS): Question #8 score above "0" will prompt an additional question: Does individual drive ("get behind the wheel") when they are drowsy? The answer must be "No" to be enrolled in the study due to safety concerns;
10. Wireless Internet and two power outlets where they sleep;
11. Willingness not to use any other application which collects heart rate data on the phone and watch that is used for NightWare.

Exclusion Criteria:

1. uncontrolled hypertension;
2. current or preexisting CVD or cancers (with the exception of past skin cancers) or active infection;
3. diabetes;
4. thyroid dysfunction, defined as an ultrasensitive TSH <0.5 or >5.0 mU/L; volunteers with abnormal TSH values will be re-considered for participation in the study after follow-up evaluation by the PCP with initiation or adjustment of thyroid hormone replacement; or other problems that would interfere with participation in the study;
5. pregnancy or currently breast feeding;
6. current use (or within previous 6 months) of hormone therapy in postmenopausal women;
7. current substance (including marijuana) or alcohol use disorder (past 12 months) per the SCID-5 (see methods of Research Strategy). Adults with past substance or alcohol use disorders will be allowed to participate.
8. Prazosin use; however, participant may be included if tapered by prescribing provider. Taper must be completed and individual must be off prazosin for 2 days prior to enrollment;
9. Participants will be excluded if they report elevated acute risk for suicidal self-directed violence warranting immediate intervention (e.g., suicidal ideation with intent, evaluated by the Columbia-Suicide Severity Rating Scale [C-SSRS]).
10. Current use of varenicline, beta-blockers (unless ophthalmic solutions), or non-dihydropyridines;
11. Shift workers (due to circadian rhythm disruption);
12. Moderate or Severe obstructive sleep apnea (either diagnosed or determined during screening with the WatchPat [AHI≥15];
13. Diagnosis of narcolepsy;
14. Known sleepwalking;

16) Acting out of dreams prior to PTSD trauma; 17) Diagnosis or suspicion of dementia

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: NightWare; In individuals randomized to the active condition, when the stress index is reached during sleep, NightWare will intervene with varying degrees of vibratory stimulation to the watch over a variable length of time to arouse the person out of the nightmare without awaking.	Device: NightWare; A wearable digital therapeutic platform consisting of an Apple Watch and iPhone pre-provisioned with Nightware intervention app that will deliver a mild vibration to the watch after detecting individual having a nightmare based on Nightware proprietary algorithm, arousing the individual and disrupting nightmare without awakening.
Sham Comparator: Sham NightWare; In individuals randomized to the sham condition, the NightWare intervention will not be enabled.	Device: Sham NightWare; NightWare device will not deliver an intervention (i.e., no vibration)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in large elastic artery stiffness -carotid artery	Carotid artery compliance using carotid artery ultrasound	Measured before and after 6 weeks of NightWare and sham conditions
Change in endothelial function	Brachial artery flow-mediated dilation (FMD) using ultrasound	Measured before and after 6 weeks of NightWare and sham conditions
Change in 1utonomic function - BRS	Cardiovagal baroreflex sensitivity (cBRS)	Measured before and after 6 weeks of NightWare and sham conditions

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in large elastic artery stiffness	Carotid-femoral pulse wave velocity (PWV)	Measured before and after 6 weeks of NightWare and sham conditions
Change in autonomic function - HRV	Heart rate variability	Measured before and after 6 weeks of NightWare and sham conditions

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in PSQI	sleep questionnaire	Measured before and after 6 weeks of NightWare and sham conditions
Change in PSQI-A	sleep questionnaire	Measured before and after 6 weeks of NightWare and sham conditions
Change in Epworth sleepiness scale (ESS)	sleep questionnaire	Measured before and after 6 weeks of NightWare and sham conditions
Change in CESD	Depression questionnaire	Measured before and after 6 weeks of NightWare and sham conditions
Change in SF-36	Perceived psychosocial and health functioning questionnaire	Measured before and after 6 weeks of NightWare and sham conditions
Change in PCL-5	Presence and severity of PTSD symptoms questionnaire	Measured before and after 6 weeks of NightWare and sham conditions
Change in Nightmare disorder index	NDI questionnaire	Measured before and after 6 weeks of NightWare and sham conditions
Change in CSSR-S	Suicide risk assessment	Measured before and after 6 weeks of NightWare and sham conditions
Change in Norepinephrine	Marker of sympathetic activity	Measured before and after 6 weeks of NightWare and sham conditions
Change in Oxidized LDL	Marker of oxidative stress	Measured before and after 6 weeks of NightWare and sham conditions
Change in Total antioxidant status	Marker of oxidative stress	Measured before and after 6 weeks of NightWare and sham conditions
Change in Interleukin-6	Marker of inflammation	Measured before and after 6 weeks of NightWare and sham conditions
Change in C-Reactive Protein	Marker of inflammation	Measured before and after 6 weeks of NightWare and sham conditions

Collaborators and Investigators

• Sponsor: University of Colorado, Denver
• Collaborators: National Institute on Aging (NIA)
• Investigators: Principal Investigator: Kerrie Moreau, PhD, University of Colorado - Anschutz Medical Campus

Study record dates

Study Major Dates

• Study Start (Actual): June 24, 2022
• Primary Completion (Anticipated): April 30, 2024
• Study Completion (Anticipated): April 30, 2024

Study Registration Dates

• First Submitted: May 2, 2022
• First Submitted That Met QC Criteria: May 4, 2022
• First Posted (Actual): May 9, 2022

Study Record Updates

• Last Update Posted (Actual): May 11, 2023
• Last Update Submitted That Met QC Criteria: May 10, 2023
• Last Verified: May 1, 2023

More Information

Terms related to this study

• Keywords: sleep; aging; inflammation; oxidative stress; sex/gender
• Additional Relevant MeSH Terms: Mental Disorders; Nervous System Diseases; Trauma and Stressor Related Disorders; Stress Disorders, Traumatic; Cardiovascular Diseases; Stress Disorders, Post-Traumatic; Primary Dysautonomias; Autonomic Nervous System Diseases
• Other Study ID Numbers: 21-5027; R21AG075544 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: Yes
• product manufactured in and exported from the U.S.: No