Attention deficit/hyperactivity disorder in adults with sleep apnea

Effects of aerobic exercise and resistance training on obstructive sleep apnea: a systematic review and meta-analysis

STUDY OBJECTIVES

We investigated the therapeutic effects of exercise in patients with obstructive sleep apnea, aiming to identify the subgroups that benefit the most and determine the optimal exercise protocol.

METHODS

Major databases were searched for randomized controlled trials involving patients with obstructive sleep apnea performing aerobic exercise and/or resistance training. The investigated outcomes included apnea-hypopnea index (AHI), Epworth Sleepiness Scale, body mass index, and peak oxygen consumption during exercise (VO2peak). The pre- and postintervention unstandardized mean difference (USMD) of these parameters was compared between the exercise and control groups.

RESULTS

Twelve studies involving 526 patients were included. Exercise training significantly reduced AHI (USMD = -7.08 events/h, 95% confidence interval: -9.98 to -4.17, P < .00001), Epworth Sleepiness Scale (USMD = -2.37, 95% confidence interval: -3.21 to -1.54, P < .00001), and body mass index (USMD = -0.72 kg/m2, 95% confidence interval: -1.22 to -0.22, P = .005) and enhanced VO2peak (USMD = 3.46 ml·kg-1·min-1, 95% confidence interval: 1.20 to 5.71, P = .003). Subgroup analyses revealed that in continuous positive airway pressure-adherent patients, exercise significantly improved VO2peak but did not reduce AHI and Epworth Sleepiness Scale. A trend was observed that combining resistance training with aerobic exercise resulted in greater AHI reduction and VO2peak enhancement. Notably, exercise improved AHI, Epworth Sleepiness Scale, body mass index, and VO2peak regardless of the baseline AHI or body mass index.

CONCLUSIONS

Exercise, including resistance and aerobic training, should be part of treatment for patients with obstructive sleep apnea of all severities, regardless of obesity status, and even for those who are already under continuous positive airway pressure.

CITATION

Lin C-F, Ho N-H, Hsu W-L, Lin C-H, Wang Y-H, Wang Y-P. Effects of aerobic exercise and resistance training on obstructive sleep apnea: a systematic review and meta-analysis. J Clin Sleep Med. 2024;20(11):1839-1849.

Sleep Problems in Adults With ADHD: Prevalences and Their Relationship With Psychiatric Comorbidity

BACKGROUND

Sleep problems are common in adults with ADHD and may be bidirectionally associated with ADHD severity and other psychiatric symptoms. We investigated the prevalence of positive screenings for various sleep disorders, and their association with psychiatric comorbidities in a large sample of adults with ADHD from a specialized outpatient clinic.

METHODS

We included data of 3,691 adult patients diagnosed with ADHD, who had filled out a screener for sleep disorders (Holland Sleep Disorders Questionnaire (HSDQ)) as part of routine diagnostic assessment. The HSDQ screens for the sleep disorders insomnia, parasomnia, hypersomnia, circadian rhythm sleep disorders (CRSD), restless legs syndrome (RLS)/periodic limb movement disorder (PLMD), and sleep-related breathing disorders (SBD). As delayed sleep phase syndrome (DSPS) is very frequent in ADHD, we additionally screened for DSPS. Psychiatric comorbidities were diagnosed through clinical assessment and the Mini International Neuropsychiatric Interview (M.I.N.I.) Plus, which assesses 26 psychiatric disorders following the classification of the DSM-5. All data were retrieved from the electronic patient files.

RESULTS

Mean age was 35.4 and 49.4% of the patients were female. About 60% of the adults with ADHD screened positive for any sleep disorder. Highest prevalences were found for symptoms of DSPS (36%), insomnia (30%), and RLS/PLMD (29%). Sleep problems in adults with ADHD were associated with comorbid depression, anxiety, substance use disorder, personality disorder, and post-traumatic stress disorder.

CONCLUSION

Adults with ADHD often report sleep problems, which are associated with specific psychiatric comorbidities. Systematic screening for sleep disorders in adult patients with ADHD can contribute to a better understanding of their complaints and may aid improved and integrated treatment for the sleep and psychiatric problems.

Improvement of attention deficit disorder symptoms after treatment of obstructive sleep apnea in an adult: a case report and mini review

Sparse literature exists on the effects of obstructive sleep apnea (OSA) treatment on symptoms of attention deficit hyperactivity disorder (ADHD) in adults. This article aims to bring to the fore the relationship between ADHD and OSA in adults and the implications of the treatment of OSA on the symptoms of ADHD. A case of an adult who was previously diagnosed with attention deficit disorder in childhood with symptom improvement following OSA treatment is reported. Considering the complex relationship between ADHD and sleep problems, the recommendation to screen for OSA and other sleep problems among persons being assessed for ADHD should be upheld. This article advocates for more research on the effect of the treatment of OSA on ADHD symptoms.

CITATION

Awadalla TO, Igwe O, Okeafor CU, Attarian HP. Improvement of attention deficit disorder symptoms after treatment of obstructive sleep apnea in an adult: a case report and mini review. J Clin Sleep Med. 2024;20(5):825-827.

University Students' Sleep and Mental Health Correlates in South Korea

Sleep closely relates to emotional instability. Recent studies report an increase in young adults’ poor sleep and associated mental health problems, including attention deficit hyperactivity disorder (ADHD), anxiety, depression, and so on. However, the information on related modifiable factors of these variables is still lacking. This cross-sectional study examined the association of sleep patterns and sleep quality with ADHD and depression in university students. A total of 290 participants aged 18−27 (Mean = 22.0, SD = 2.1) completed a structured questionnaire consisting of the Pittsburgh Sleep Quality Index (PSQI), the Adult ADHD, and the Center for Epidemiologic Studies Depression scales (CES-D). Of the participants, more than half (52.7%) slept 6 to 8 h per night, and 37% slept less than 6 h. Only 10% reported they went to bed before midnight; 40% went to sleep after 2 am. The mean PSQI score was 5.9 (SD = 2.9) for total participants and significantly correlated with ADHD scores and with depression scores. After adjusting for covariates, PSQI significantly aligned with increased risk for ADHD (β = 0.29, p = 0.036) and depression (β = 0.67; p < 0.001). Late bedtime was a significant factor for depression only. Sleep quality rather than sleep pattern significantly related to ADHD scores, whereas both sleep quality and bedtime aligned with depression scores. Additional studies are needed to develop strategic interventions for university students with ADHD and depression as well as underlying mechanisms.

Interactions between Obstructive Sleep Apnea Syndrome Severity, Obesity, Sex Difference and Attention-Deficit/Hyperactivity Disorder on Health-Related Quality of Life: A Non-Interventional Prospective Observational Study

Obstructive sleep apnea syndrome (OSAS) severity, obesity, sex difference, and attention-deficit/hyperactivity disorder (ADHD) had a complex impact on health-related quality of life (HRQoL). However, the interactive effects among these features on HRQoL remained to be clarified. This study aimed to investigate the individual and interactive associations between the four characteristics of interest and HRQoL as determined by 36-Item Short Form Health Survey, Pittsburgh Sleep Quality Index (PSQI), and Epworth Sleepiness Scale (ESS). This non-interventional, prospective, observational study enrolled a total of 132 patients with suspected OSAS for analysis. While OSAS severity and ADHD detected by adult ADHD Self-Report Scale, termed as screened ADHD, interact with each other, all the four studied features were individually associated with HRQoL. After adjusting for potential physiological and polysomnographic confounders, screened ADHD was independently correlated with PSQI > 5 (OR = 4.126, 95% CI, 1.490−11.424), mental component score < 50 (OR = 5.873, 95% CI, 2.262−15.251) and ESS > 10 (OR = 3.648, 95% CI, 1.738−7.657). Our results show that ADHD detection is necessary and should be incorporated into clinical practice for OSAS management.

A Systematic Review of Sleep and Circadian Rhythms in Children with Attention Deficit Hyperactivity Disorder

OBJECTIVE

Children and adults with ADHD often report sleep disturbances that may form part of the etiology and/or symptomatology of ADHD. We review the evidence for sleep changes in children with ADHD.

METHODS

Systematic review with narrative synthesis assessing sleep and circadian function in children aged 5 to 13 years old with a diagnosis of ADHD.

RESULTS

148 studies were included for review, incorporating data from 42,353 children. We found that sleep disturbances in ADHD are common and that they may worsen behavioral outcomes; moreover, sleep interventions may improve ADHD symptoms, and pharmacotherapy for ADHD may impact sleep.

CONCLUSION

Sleep disturbance may represent a clinically important feature of ADHD in children, which might be therapeutically targeted in a useful way. There are a number of important gaps in the literature. We set out a manifesto for future research in the area of sleep, circadian rhythms, and ADHD.

A Study to Assess the Relationship between Attention Deficit Hyperactivity Disorder and Obstructive Sleep Apnea in Adults

The association between obstructive sleep apnea (OSA) and attention deficit hyperactivity disorder (ADHD) is well-established in children. However, there is a paucity of literature regarding this association in adults. The aim of this study was to determine if ADHD is more common in adult patients with OSA. All patients referred to a sleep center for sleep evaluation were administered the Adult ADHD Self-Report Scale and diagnostic polysomnogram. The ADHD screen is considered positive if 4 of 6 questions in part A of the screening questionnaire were answered abnormally. The study population consisted of 194 participants, predominantly male (62%), Caucasian (54%), and Hispanic (44%). OSA was identified in 160 (83%) of participants, with 116 (60%) having moderate to severe OSA. The ADHD screen was positive in 37 (19%) of participants. There was no significant association between the severity of OSA and presence of ADHD symptoms. Patients with OSA who screened positive for ADHD had higher Epworth Sleepiness Scale scores than those that did not. These data suggest that ADHD is more prevalent in patients with OSA, but do not demonstrate a relationship between OSA severity and ADHD symptoms. Interestingly, sleepiness is more prominent in patients with ADHD.

Adult ADHD and Comorbid Somatic Disease: A Systematic Literature Review

OBJECTIVE

To systematically review, synthesize, and appraise available evidence, connecting adult ADHD with somatic disease.

METHOD

Embase, Psychinfo, and Medline databases were searched for studies published from 1994 to 2015 addressing adult ADHD and somatic comorbidity. Somatic conditions were classified according to International Classification of Diseases (ICD-10) codes. Levels of evidence were graded as inconclusive, tentative, or well documented.

RESULTS

Most of the 126 studies included in the qualitative synthesis were small and of modest quality. Obesity, sleep disorders, and asthma were well-documented comorbidities in adult ADHD. Tentative evidence was found for an association between adult ADHD and migraine and celiac disease. In a large health registry study, cardiovascular disease was not associated with adult ADHD.

CONCLUSION

There are few large systematic studies using standardized diagnostic criteria evaluating adult ADHD and somatic comorbidities. Significant associations are found between adult ADHD and several somatic diseases, and these are important to consider when assessing and treating either adult ADHD or the somatic diseases.

Sleep disorders in patients with ADHD: impact and management challenges

Attention deficit/hyperactivity disorder (ADHD) is one of the most commonly diagnosed disorders in childhood, enduring through adolescence and adulthood and presenting with symptoms of inattention, hyperactivity, and/or impulsivity and significantly impairing functioning. Primary sleep disorders such as sleep-disordered breathing, restless leg syndrome, circadian rhythm sleep disorder, insomnia, and narcolepsy are commonly comorbid in these individuals but not often assessed and are therefore often left untreated. Sleep disturbances in individuals with ADHD can result in significant functional impairments that affect mood, attention, behavior, and ultimately school/work performance and quality of life. Previous reviews have described findings related to sleep but have neglected to examine potential impacts of these sleep disorders and ADHD on daytime functioning. This review investigates empirical findings pertaining to sleep abnormalities and related cognitive, behavioral, emotional, and physical impairments in individuals with ADHD and comorbid primary sleep disorders across the life span. It discusses implications to management and highlights existing limitations and recommended future directions.

Obstructive sleep apnea: management considerations in psychiatric patients

Psychiatric disorders and obstructive sleep apnea (OSA) are often comorbid. However, there is limited information on the impact of psychotropic medications on OSA symptoms, on how to manage psychiatric pharmacotherapy in patients presenting with OSA, or on the effectiveness and challenges of OSA treatments in patients with comorbid mental illness. As such, the objective of this article is to provide an overview of some epidemiological aspects of OSA and treatment considerations in the management of OSA in individuals with comorbid psychiatric disorders. Predefined keywords were used to search for relevant literature in electronic databases. Data show that OSA is particularly prevalent in patients with psychiatric disorders. The medical care that patients with these comorbidities require can be challenging, as some of the psychiatric medications used by these patients may exacerbate OSA symptoms. As such, continuous positive airway pressure continues to be the first-line treatment, even in patients with psychiatric comorbidity. However, more controlled studies are required, particularly to determine continuous positive airway pressure compliance in patients with mental illness, the impact of treating OSA on psychiatric symptoms, and the impact of the use of psychotropic medications on OSA symptoms.

Excessive daytime sleepiness in patients with ADHD--diagnostic and management strategies

The links between attention-deficit hyperactivity disorder (ADHD) and sleep disorders remain unclear. Specific sleep disorders are a frequent comorbid condition associated with ADHD according to a categorical approach. However, sleep disorders can also induce ADHD-like symptoms according to a dimensional approach and are thought to be the consequence of excessive daytime sleepiness. It may thus be difficult for clinicians to differentiate the diagnosis of ADHD comorbid with a sleep disorder from sleep disorders with ADHD-like symptoms. This distinction could be important for the appropriate management of patients with dual complaints of trouble maintaining attention and daytime sleepiness. This paper summarizes the main sleep disorders associated with ADHD: sleep-related breathing disorders, sleep-related movement disorders, circadian rhythm sleep-wake disorders, and central disorders of hypersomnolence (aka hypersomnias). The history of presenting symptoms should be taken into account since ADHD is a neurodevelopmental disorder whereas ADHD symptoms comorbid with sleep disorder are not. Finally, we propose a model to clarify the links between ADHD, ADHD symptoms, and excessive daytime sleepiness induced by sleep disorders. Clinicians should therefore routinely assess, monitor, and manage the sleep problems of patients with ADHD who have both comorbidities and should search for the presence of ADHD symptoms in subjects with sleep disorders.

Sleep-related breathing disorder is associated with hyperactivity in preschoolers

INTRODUCTION

Sleep problems are a prominent feature in children with attention deficit hyperactivity disorder (ADHD). Unlike existing studies that focused on extreme samples (i.e. normal vs. ADHD), our study investigated the associations of sleep-related behaviours and ADHD features in nonclinical Chinese preschoolers.

METHODS

All participants were recruited via advertisements and screened for eligibility through a telephone interview prior to an onsite visit. The maternal reports of the Conners' Parent Rating Scale (CPRS) and Pediatric Sleep Questionnaire (PSQ) were acquired from 110 Chinese preschoolers aged six years. Regression models were used to examine the association between CPRS and PSQ scores.

RESULTS

The results obtained from regression models on the CPRS and PSQ scores of the 110 participants showed that none of the sleep-related behavioural measures (i.e. sleep-related breathing disorder [SRBD], snoring, daytime sleepiness, restless legs syndrome) was associated with inattention in our sample. However, worse SRBD was associated with higher hyperactivity.

CONCLUSION

Our study underpins the importance of understanding the relationship between sleep-related behaviours and ADHD characteristics before the usual age of clinical diagnosis in children with ADHD.

Psychiatric disorders and sleep issues

Sleep issues are common in people with psychiatric disorders, and the interaction is complex. Sleep disorders, particularly insomnia, can precede and predispose to psychiatric disorders, can be comorbid with and exacerbate psychiatric disorders, and can occur as part of psychiatric disorders. Sleep disorders can mimic psychiatric disorders or result from medication given for psychiatric disorders. Impairment of sleep and of mental health may be different manifestations of the same underlying neurobiological processes. For the primary care physician, key tools include recognition of potential sleep effects of psychiatric medications and familiarity with treatment approaches for insomnia in depression and anxiety.