The prevalence, cost implications, and management of sleep disorders: an overview

[Quality of life and sleep quality in patients with chronic pruritus]

Pruritus is defined as a symptom that leads to scratching. Clinically, a heterogeneous group of clinical pictures of different etiology must be considered. Pruritus is characterized by varying intensity and duration. Many patients and/or their social environment, which is influenced by this, cite the impact on sleep quality as an accompanying main symptom. The patient's quality of life is affected depending on the severity of the pruritus and often leads to comorbidity such as depressive disorders or sleep disorders as well as to an impact on psychosocial well-being if it becomes chronic. To date, in addition to the medical history, the established examination methods have been the determination of the disease burden by assessing disease activity, e.g., with validated disease-specific scores, plus the assessment of quality of life using a dermatological quality of life index (DLQI). The latest studies show that this is by no means sufficient to determine the severity of disease and, as a result, to identify adequate treatment options.

An automated heart rate-based algorithm for sleep stage classification: Validation using conventional polysomnography and an innovative wearable electrocardiogram device

Background

The rapid advancement in wearable solutions to monitor and score sleep staging has enabled monitoring outside of the conventional clinical settings. However, most of the devices and algorithms lack extensive and independent validation, a fundamental step to ensure robustness, stability, and replicability of the results beyond the training and testing phases. These systems are thought not to be feasible and reliable alternatives to the gold standard, polysomnography (PSG).

Materials and methods

This validation study highlights the accuracy and precision of the proposed heart rate (HR)-based deep-learning algorithm for sleep staging. The illustrated solution can perform classification at 2-levels (Wake; Sleep), 3-levels (Wake; NREM; REM) or 4- levels (Wake; Light; Deep; REM) in 30-s epochs. The algorithm was validated using an open-source dataset of PSG recordings (Physionet CinC dataset, n = 994 participants, 994 recordings) and a proprietary dataset of ECG recordings (Z3Pulse, n = 52 participants, 112 recordings) collected with a chest-worn, wireless sensor and simultaneous PSG collection using SOMNOtouch.

Results

We evaluated the performance of the models in both datasets in terms of Accuracy (A), Cohen's kappa (K), Sensitivity (SE), Specificity (SP), Positive Predictive Value (PPV), and Negative Predicted Value (NPV). In the CinC dataset, the highest value of accuracy was achieved by the 2-levels model (0.8797), while the 3-levels model obtained the best value of K (0.6025). The 4-levels model obtained the lowest SE (0.3812) and the highest SP (0.9744) for the classification of Deep sleep segments. AHI and biological sex did not affect scoring, while a significant decrease of performance by age was reported across the models. In the Z3Pulse dataset, the highest value of accuracy was achieved by the 2-levels model (0.8812), whereas the 3-levels model obtained the best value of K (0.611). For classification of the sleep states, the lowest SE (0.6163) and the highest SP (0.9606) were obtained for the classification of Deep sleep segment.

Conclusion

The results of the validation procedure demonstrated the feasibility of accurate HR-based sleep staging. The combination of the proposed sleep staging algorithm with an inexpensive HR device, provides a cost-effective and non-invasive solution deployable in the home environment and robust across age, sex, and AHI scores.

A greater modified Mediterranean diet score is associated with lower insomnia score among adolescent girls: a cross-sectional study

Background

Previous studies has shown that a low quality diet is related to sleep disorders. A Mediterranean diet is considered to be a high quality diet and has been shown to have beneficial effects on overall health. Thus, the aim of our study was to investigate the association between adherence to Mediterranean dietary pattern and insomnia score among adolescent girls.

Methods

The data for 733 adolescent girls between 12–18 years old was assessed in this cross-sectional study. A 147 item-food frequency questionnaire was used to assess dietary intake. A modified model of Mediterranean diet score was calculated that ranged from 0–9 points. A validated version of Insomnia Severity Index questionnaire was used to assess insomnia. To explore the association between modified Mediterranean (mMED) diet score and insomnia, linear regression was conducted in crude and adjusted models (energy intake adjustmet in Model I, further adjustments were performed for physical activity, father’s and mother’s education in Model II and full adjusted model adjusted for age, body mass index percentiles, and abdominal obesity).

Results

A significant inverse association between mMED diet score and insomnia score was observed using a crude model (β = -0.091, 95% confidence interval (CI): -0.392 to -0.046); P-value = 0.013) and also after adjustment for confounding factors in Model I (β = -0.098, CI: -0.423 to -0.045; P = 0.015), Model II (β = -0.092, CI: -0.410 to -0.029; P-value = 0.024), Model III (β = -0.082, CI: -0.385 to -0.006); P = 0.044).

Conclusion

There was an inverse relationship between adherence to the mMED diet score and insomnia level among Iranian adolescent girls. Prospective studies are needed to confirm these results and clarify whether a causal relationship exists.

Prevalence of Sleep Problems and Its Association With Preterm Birth Among Kindergarten Children in a Rural Area of Shanghai, China

INTRODUCTION

Healthy sleep in children is critical for their physical and mental health. Although growing evidence indicates the linkage between preterm birth and neural network that regulates sleep architecture, findings on the association between preterm birth and sleep problems among children are still contradictory. In this study, we aimed to understand the prevalence of sleep problems in children aged 3-6 years and to explore the association between sleep problems and preterm birth among children in Shanghai, China.

METHODS

We selected 8,586 kindergarten children aged 3-6 years and their mothers in a rural area of Shanghai. Data were collected by questionnaire interview among mothers with informed consent that was signed ahead. Six types of sleep problems (i.e., insufficient sleep, sleepwalk, nightmare, snore, grind teeth, and cry in sleep) were selected in this study. SAS 9.4 was used for data analysis, and p < 0.05 was considered statistically significant.

RESULTS

In this study, the prevalence of preterm birth was 9.88% (848/8,586), with a higher prevalence in boys (10.62%) than girls (9.01%). The prevalence of sleep problems was 89.81% among kindergarten children, with 62.50% for snore, 50.35% for grind teeth, 49.20% for cry in sleep, 41.18% for nightmare, 11.67% for insufficient sleep, and 4.44% for sleepwalk. The age of children, family income, and mother's education were associated with the prevalence of sleep problems in children. Logistic regression indicated that sleep problems in preterm children were comparable with the full-term children [odds ratio = 1.13, 95% confidence interval (0.89-1.45)].

CONCLUSION

Sleep problems were prevalent among children aged 3-6 years in the rural area of Shanghai, and preterm birth was not associated with sleep problems in kindergarten children. We recommend that parents should create limit setting in the home, cultivate similar child-rearing attitudes and beliefs among family members, and encourage children to go to bed earlier.

Economic evaluation of diagnostic sleep studies for obstructive sleep apnoea: a systematic review protocol

BACKGROUND

Obstructive sleep apnoea (OSA) is a significant public health problem affecting a large proportion of the population and is associated with adverse health consequences and a substantial economic burden. Despite the existence of effective treatment, undiagnosed OSA remains a challenge. The gold standard diagnostic tool is polysomnography (PSG), yet the test is expensive, labour intensive and time-consuming. Home-based, limited channel sleep study testing (levels 3 and 4) can advance and widen access to diagnostic services. This systematic review aims to summarise available evidence regarding the cost-effectiveness of limited channel tests compared to laboratory and home PSG in diagnosing OSA.

METHODS

Eligible studies will be identified using a comprehensive strategy across the following databases from inception onwards: MEDLINE, PsychINFO, SCOPUS, CINAHL, Cochrane Library, Emcare and Web of Science Core Collection and ProQuest databases. The search will include a full economic evaluation (i.e. cost-effectiveness, cost-utility, cost-benefit, cost-consequences and cost-minimisation analysis) that assesses limited channel tests and PSG. Two reviewers will screen, extract data for included studies and critically appraise the articles for bias and quality. Meta-analyses will be conducted if aggregation of outcomes can be performed. Qualitative synthesis using a dominance ranking matrix will be performed for heterogeneous data.

DISCUSSION

This systematic review protocol uses a rigorous, reproducible and transparent methodology and eligibility criteria to provide the current evidence relating to the clinical and economic impact of limited channel and full PSG OSA diagnostic tests. Evidence will be examined using standardised tools specific for economic evaluation studies.

TRIAL REGISTRATION

PROSPERO (CRD42020150130).

Current Status and Future Challenges of Sleep Monitoring Systems: Systematic Review

Background

Sleep is essential for human health. Considerable effort has been put into academic and industrial research and in the development of wireless body area networks for sleep monitoring in terms of nonintrusiveness, portability, and autonomy. With the help of rapid advances in smart sensing and communication technologies, various sleep monitoring systems (hereafter, sleep monitoring systems) have been developed with advantages such as being low cost, accessible, discreet, contactless, unmanned, and suitable for long-term monitoring.

Objective

This paper aims to review current research in sleep monitoring to serve as a reference for researchers and to provide insights for future work. Specific selection criteria were chosen to include articles in which sleep monitoring systems or devices are covered.

Methods

This review investigates the use of various common sensors in the hardware implementation of current sleep monitoring systems as well as the types of parameters collected, their position in the body, the possible description of sleep phases, and the advantages and drawbacks. In addition, the data processing algorithms and software used in different studies on sleep monitoring systems and their results are presented. This review was not only limited to the study of laboratory research but also investigated the various popular commercial products available for sleep monitoring, presenting their characteristics, advantages, and disadvantages. In particular, we categorized existing research on sleep monitoring systems based on how the sensor is used, including the number and type of sensors, and the preferred position in the body. In addition to focusing on a specific system, issues concerning sleep monitoring systems such as privacy, economic, and social impact are also included. Finally, we presented an original sleep monitoring system solution developed in our laboratory.

Results

By retrieving a large number of articles and abstracts, we found that hotspot techniques such as big data, machine learning, artificial intelligence, and data mining have not been widely applied to the sleep monitoring research area. Accelerometers are the most commonly used sensor in sleep monitoring systems. Most commercial sleep monitoring products cannot provide performance evaluation based on gold standard polysomnography.

Conclusions

Combining hotspot techniques such as big data, machine learning, artificial intelligence, and data mining with sleep monitoring may be a promising research approach and will attract more researchers in the future. Balancing user acceptance and monitoring performance is the biggest challenge in sleep monitoring system research.

Short Sleep, Insomnia, and Cardiovascular Disease

PURPOSE OF REVIEW

This review summarizes key findings linking insomnia, short sleep duration, and cardiovascular health.

RECENT FINDINGS

Early studies associations between insomnia with short sleep and cardiovascular disease Recent studies have incorporated objective data to assess sleep and identify comorbid sleep disorders (e.g. sleep apnea). Use of objective metrics has facilitated understanding of the impacts of insufficient sleep on autonomic dysregulation, metabolic syndrome, coronary artery disease and overall cardiovascular mortality. Emerging research suggests treatment of insomnia (CBT-I) may be beneficial in terms of reducing cardiovascular disease risk.

SUMMARY

From short term effects on the autonomic nervous system to lasting effects on metabolic syndrome and coronary artery disease, there is growing evidence to support a physiologic pathway by which insomnia with short sleep contributes to cardiovascular disease. More research is needed to understand the effect of insomnia treatment on cardiovascular risk.

Identifying Cases of Sleep Disorders through International Classification of Diseases (ICD) Codes in Administrative Data

OBJECTIVES

Prevalence, and associated morbidity and mortality of chronic sleep disorders have been limited to small cohort studies, however, administrative data may be used to provide representation of larger population estimates of disease. With no guidelines to inform the identification of cases of sleep disorders in administrative data, the objective of this study was to develop and validate a set of ICD-codes used to define sleep disorders including narcolepsy, insomnia, and obstructive sleep apnea (OSA) in administrative data.

METHODS

A cohort of adult patients, with medical records reviewed by two independent board-certified sleep physicians from a sleep clinic in Calgary, Alberta between January 1, 2009 and December 31, 2011, was used as the reference standard. We developed a general ICD-coded case definition for sleep disorders which included conditions of narcolepsy, insomnia, and OSA using: 1) physician claims data, 2) inpatient visit data, 3) emergency department (ED) and ambulatory care data. We linked the reference standard data and administrative data to examine the validity of different case definitions, calculating estimates of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

From a total of 1186 patients from the sleep clinic, 1045 (88.1%) were classified as sleep disorder positive, with 606 (51.1%) diagnosed with OSA, 407 (34.4%) with insomnia, and 59 (5.0%) with narcolepsy. The most frequently used ICD-9 codes were general codes of 307.4 (Nonorganic sleep disorder, unspecified), 780.5 (unspecified sleep disturbance) and ICD-10 codes of G47.8 (other sleep disorders), G47.9 (sleep disorder, unspecified). The best definition for identifying a sleep disorder was an ICD code (from physician claims) 2 years prior and 1 year post sleep clinic visit: sensitivity 79.2%, specificity 28.4%, PPV 89.1%, and NPV 15.6%. ICD codes from ED/ambulatory care data provided similar diagnostic performance when at least 2 codes appeared in a time period of 2 years prior and 1 year post sleep clinic visit: sensitivity 71.9%, specificity 54.6%, PPV 92.1%, and NPV 20.8%. The inpatient data yielded poor results in all tested ICD code combinations.

CONCLUSION

Sleep disorders in administrative data can be identified mainly through physician claims data and with some being determined through outpatient/ambulatory care data ICD codes, however these are poorly coded within inpatient data sources. This may be a function of how sleep disorders are diagnosed and/or reported by physicians in inpatient and outpatient settings within medical records. Future work to optimize administrative data case definitions through data linkage are needed.

Hypnosis Intervention Effects on Sleep Outcomes: A Systematic Review

STUDY OBJECTIVES

Sleep improvement is a promising target for preventing and modifying many health problems. Hypnosis is considered a cost-effective and safe intervention with reported benefits for multiple health conditions. There is a growing body of research assessing the efficacy of hypnosis for various health conditions in which sleep was targeted as a primary or secondary outcome. This review aimed to investigate the effects of hypnosis interventions on sleep, to describe the hypnotic procedures, and to evaluate potential adverse effects of hypnosis.

METHODS

We reviewed studies (prior to January 2017) using hypnosis in adults for sleep problems and other conditions comorbid with sleep problems, with at least one sleep outcome measure. Randomized controlled trials and other prospective studies were included.

RESULTS

One hundred thirty-nine nonduplicate abstracts were screened, and 24 of the reviewed papers were included for qualitative analysis. Overall, 58.3% of the included studies reported hypnosis benefit on sleep outcomes, with 12.5% reporting mixed results, and 29.2% reporting no hypnosis benefit; when only studies with lower risk of bias were reviewed the patterns were similar. Hypnosis intervention procedures were summarized and incidence of adverse experiences assessed.

CONCLUSIONS

Hypnosis for sleep problems is a promising treatment that merits further investigation. Available evidence suggests low incidence of adverse events. The current evidence is limited because of few studies assessing populations with sleep complaints, small samples, and low methodological quality of the included studies. Our review points out some beneficial hypnosis effects on sleep but more high-quality studies on this topic are warranted.

Sleep quality of endometrial cancer survivors and the effect of treatments

Objective:

Sleep disorders affect 54.9% of gynaecologic cancer survivors. The effect of treatment methods on sleep quality is not clear. This study evaluated the sleep quality of survivors of endometrial cancer and compared the effects of different treatments on sleep quality.

Materials and Methods:

Patients were categorised as surgery (group 1), surgery + brachytherapy (BRT) (group 2), surgery + external beam radiation therapy (EBRT) (group 3), and surgery + EBRT + BRT + chemotherapy (group 4). Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) questionnaire. The PSQI was completed by the participants before surgery, 1, 3, and 6 months after each treatment was completed. The PSQI scores were compared between the different measurement times and different study groups.

Results:

This study enrolled 114 patients with a mean age of 58.1±11 years. The number of participants in each group was 53 (46.5%), 14 (12.3%), 12 (10.5%), and 35 (30.7%), respectively. At baseline, 28 (24.6%) patients reported poor sleep quality. The mean PSQI score reached the maximum level at the second measurement and decreased slightly during follow-up and the change in the PSQI score was significant (p=0.001). Group 3 and group 4 had significantly higher scores from baseline (p<0.008). At time point 3, the differences between the groups were significant. At time point 4, the most prominent effect of treatment on sleep quality was observed in patients with combined chemo-radiotherapy when compared with the other study groups.

Conclusion:

Most survivors of endometrial cancer are affected by poor sleep quality during their treatment. To improve these patients’ quality of life, this disorder must be considered at each visit and tailored care plans should be developed to meet the women’s needs. Further studies are needed to evaluate the long-term results of sleep quality on patients with endometrial cancer.

The association between maternal postnatal depressive symptoms and offspring sleep problems in adolescence

BACKGROUND

Sleep problems are associated with increased risk of physical and mental illness. Identifying risk factors is an important method of reducing public health impact. We examined the association between maternal postnatal depression (PND) and offspring adolescent sleep problems.

METHOD

The sample was derived from Avon Longitudinal Study of Parents and Children (ALSPAC) participants. A sample with complete data across all variables was used, with four outcome variables. A sensitivity analysis imputing for missing data was conducted (n = 9633).

RESULTS

PND was associated with increased risk of sleep problems in offspring at ages 16 and 18 years. The most robust effects were sleep problems at 18 years [adjusted odds ratio (OR) for a 1 s.d. increase in PND, 1.26, 95% confidence interval (CI) 1.15-1.39, p < 0.001] and waking more often (adjusted OR 1.14, 95% CI 1.05-1.25, p = 0.003). This remained after controlling for confounding variables including antenatal depression and early sleep problems in infancy.

CONCLUSIONS

PND is associated with adolescent offspring sleep problems. Maternal interventions should consider the child's increased risk. Early sleep screening and interventions could be introduced within this group.

The relationship between micronutrient status and sleep patterns: a systematic review

OBJECTIVE

To review articles on the relationship of dietary and circulating micronutrients with sleep patterns, and to identify issues surrounding implications for future research and public health practice.

DESIGN

A systematic review was conducted. PubMed, Embase and Scopus were searched through January 2016.

SETTING

Both experimental and observational studies were included. However, studies that focused on secondary sleep impairment due to comorbidities were excluded.

SUBJECTS

Individuals in different age groups, from infants to older adults.

RESULTS

A total of twenty-six articles were selected. In the articles reviewed, researchers generally supported a potential role of micronutrients, particularly Fe and Mg, in the development of sleep stages among infants and in reversing age-related alterations in sleep architecture in older adults. Micronutrient status has also been linked to sleep duration, with sleep duration positively associated with Fe, Zn and Mg levels, and negatively associated with Cu, K and vitamin B12 levels. The mechanisms underlying these relationships include the impact of micronutrients on excitatory/inhibitory neurotransmitters and the expression of circadian genes.

CONCLUSIONS

Although the number of studies on the relationship between micronutrient status and sleep remains low, evidence has emerged that suggests a link between dietary/circulating micronutrients and sleep. Future research is needed to investigate the dose-dependent as well as the longitudinal relationships between micronutrient levels and human sleep across populations, test the interactions among micronutrients on sleep outcomes, and ultimately examine the clinical relevance of micronutrients on sleep health.

Effects of Psychological and Social Work Factors on Self-Reported Sleep Disturbance and Difficulties Initiating Sleep

STUDY OBJECTIVES

This prospective cohort study examined previously underexplored relations between psychological/social work factors and troubled sleep in order to provide practical information about specific, modifiable factors at work.

METHODS

A comprehensive evaluation of a range of psychological/social work factors was obtained by several designs; i.e., cross-sectional analyses at baseline and follow-up, prospective analyses with baseline predictors (T1), prospective analyses with average exposure across waves as predictor ([T1 + T2] / 2), and prospective analyses with change in exposure from baseline to follow-up as predictor. Participants consisted of a sample of Norwegian employees from a broad spectrum of occupations, who completed a questionnaire at two points in time, approximately two years apart. Cross-sectional analyses at T1 comprised 7,459 participants, cross-sectional analyses at T2 included 6,688 participants. Prospective analyses comprised a sample 5,070 of participants who responded at both T1 and T2. Univariable and multivariable ordinal logistic regressions were performed.

RESULTS

Thirteen psychological/social work factors and two aspects of troubled sleep, namely difficulties initiating sleep and disturbed sleep, were studied. Ordinal logistic regressions revealed statistically significant associations for all psychological and social work factors in at least one of the analyses. Psychological and social work factors predicted sleep problems in the short term as well as the long term.

CONCLUSIONS

All work factors investigated showed statistically significant associations with both sleep items, however quantitative job demands, decision control, role conflict, and support from superior were the most robust predictors and may therefore be suitable targets of interventions aimed at improving employee sleep.

Progress in elucidating the pathophysiological basis of nonrapid eye movement parasomnias: not yet informing therapeutic strategies

Nonrapid eye movement (NREM) or arousal parasomnias are prevalent conditions in children and young adults, apparently provoked by any medical, physical, mental, or pharmacologic/toxic agent disturbing normal biorhythm and causing sleep fragmentation or abundant amount of slow wave sleep. The nadir and the ascending slope of the first sleep cycle of night sleep are the typical periods when NREM parasomnias, especially sleepwalking may occur on sleep-microstructural level; microarousals are the typical moments allowing NREM parasomnias. While sleep-disturbing factors have a clear precipitating effect, a genetic predisposition appears necessary in most cases. A candidate gene for sleepwalking has been identified on chromosome 20q12-q13.12 in one sleepwalking family. NREM parasomnias have a genetic and clinical link with nocturnal-frontal lobe epilepsies; possibly through an abnormality of the acetylcholine-related sleep-control system. The association of NREM parasomnias with the human leukocyte antigen system might be the sign of an autoimmune background to be further clarified. In the treatment of arousal parasomnias, the main tools are adequate sleep hygiene and the management of underlying conditions. Their pharmacotherapy has remained unresolved; the best options are clonazepam and some of the antidepressants, while a psychotherapy approach is also justified.

Zolpidem use and motor vehicle collisions in older drivers

OBJECTIVE

Prescription sleep medication use is most prevalent among women and older adults. Morning drowsiness and impaired coordination are side effects of sleep medications that may affect driving safety. The association between current use of zolpidem-containing medications and motor vehicle collisions (MVCs) was evaluated among drivers of advanced age.

METHODS

Participants were current drivers aged ≥70 years residing in north-central Alabama, spoke English, had a valid driver's license, and had driven within the past three months (n = 2000). Current zolpidem use was determined by pill bottle review. The participant's five-year MVC history was determined from Alabama Department of Public Safety accident reports. The five-year MVC and at-fault MVC rate ratios (RR) were estimated comparing zolpidem users with nonusers in the overall sample and a priori-defined age and sex subgroups.

RESULTS

The unadjusted RR (95% confidence interval [CI]) of MVCs comparing zolpidem users with nonusers was attenuated after adjustment (1.46 [1.02-2.08] and 1.38 [0.97-1.98], respectively). Among women, the unadjusted and adjusted RRs (95% CI) were 1.65 (1.03-2.66) and 1.61 (1.00-2.60), respectively. The unadjusted and adjusted RRs (95% CI) among those aged 80 years or more were 2.24 (1.19-4.57) and 2.35 (1.20-4.61), respectively. There were no statistically significant associations among men or participants less than 80 years old. Similar patterns were present for at-fault MVCs.

CONCLUSION

Current zolpidem users, specifically women and individuals aged 80 years or more, had higher MVC rates than nonusers. Practitioners should consider behavioral treatment before initiating low doses of zolpidem and increasing it as needed to achieve restorative sleep in women and individuals aged 80 years or more to reduce the risk of zolpidem-associated MVCs.

Engagement in muscular strengthening activities is associated with better sleep

Few studies have examined whether engagement in muscular strengthening activities is associated with sleep duration, which was the purpose of this study. Data from the population-based 2005–2006 National Health and Nutrition Examination Survey were used, which included an analytic sample of 4386 adults (20–85 yrs). Sleep duration and engagement in muscle strengthening activities was self-reported. After adjustments (including aerobic-based physical activity), those engaging in muscular strength activities, compared to those not engaging in muscular strengthening activities, had an 19% increased odds of meeting sleep guidelines (7–8 h/night) (Odds Ratio = 1.19, 95% Confidence Interval: 1.01–1.38, P = 0.04). Promotion of muscular strengthening activities by clinicians should occur not only for improvements in other aspects of health (e.g., cardiovascular benefits), but also to help facilitate optimal sleep duration.

American Academy of Sleep Medicine (AASM) Position Paper for the Use of Telemedicine for the Diagnosis and Treatment of Sleep Disorders

The American Academy of Sleep Medicine's (AASM) Taskforce on Sleep Telemedicine supports telemedicine as a means of advancing patient health by improving access to the expertise of Board-Certified Sleep Medicine Specialists. However, such access improvement needs to be anchored in attention to quality and value in diagnosing and treating sleep disorders. Telemedicine is also useful to promote professionalism through patient care coordination and communication between other specialties and sleep medicine. Many of the principles and key concepts adopted here are based on U.S. industry standards, with special consideration given to the body of work by the American Telemedicine Association (http://www.americantelemed.org/), and abide by standards endorsed by the American Medical Association (http://www.ama-assn.org/). Practitioners who wish to integrate sleep telemedicine into their practice should have a clear understanding of the salient issues, key terminology, and the following recommendations from the AASM. The Taskforce recommends the following: • Clinical care standards for telemedicine services should mirror those of live office visits, including all aspects of diagnosis and treatment decisions as would be reasonably expected in traditional office-based encounters. • Clinical judgment should be exercised when determining the scope and extent of telemedicine applications in the diagnosis and treatment of specific patients and sleep disorders. • Live Interactive Telemedicine for sleep disorders, if utilized in a manner consistent with the principles outlined in this document, should be recognized and reimbursed in a manner competitive or comparable with traditional in-person visits. • Roles, expectations, and responsibilities of providers involved in the delivery of sleep telemedicine should be defined, including those at originating sites and distant sites. • The practice of telemedicine should aim to promote a care model in which sleep specialists, patients, primary care providers, and other members of the healthcare team aim to improve the value of healthcare delivery in a coordinated fashion. • Appropriate technical standards should be upheld throughout the telemedicine care delivery process, at both the originating and distant sites, and specifically meet the standards set forth by the Health Insurance Portability and Accountability Act (HIPAA). • Methods that aim to improve the utility of telemedicine exist and should be explored, including the utilization of patient presenters, local resources and providers, adjunct testing, and add-on technologies. • Quality Assurance processes should be in place for telemedicine care delivery models that aim to capture process measures, patient outcomes, and patient/provider experiences with the model(s) employed. • Time for data management, quality processes, and other aspects of care delivery related to telemedicine encounters should be recognized in value-based care delivery models. • The use of telemedicine services and its equipment should adhere to strict professional and ethical standards so as not to violate the intent of the telemedicine interaction while aiming to improve overall patient access, quality, and/or value of care. • When billing for telemedicine services, it is recommended that patients, providers, and others rendering services understand payor reimbursements, and that there be financial transparency throughout the process. • Telemedicine utilization for sleep medicine is likely to rapidly expand, as are broader telehealth applications in general; further research into the impact and outcomes of these are needed. This document serves as a resource by defining issues and terminology and explaining recommendations. However, it is not intended to supersede regulatory or credentialing recommendations and guidelines. It is intended to support and be consistent with professional and ethical standards of the profession.

Behavioral sleep-wake homeostasis and EEG delta power are decoupled by chronic sleep restriction in the rat

STUDY OBJECTIVES

Chronic sleep restriction (CSR) is prevalent in society and is linked to adverse consequences that might be ameliorated by acclimation of homeostatic drive. This study was designed to test the hypothesis that the sleep-wake homeostat will acclimatize to CSR.

DESIGN

A four-parameter model of proportional control was used to quantify sleep homeostasis with and without recourse to a sleep intensity function.

SETTING

Animal laboratory, rodent walking-wheel apparatus.

SUBJECTS

Male Sprague-Dawley rats.

INTERVENTIONS

Acute total sleep deprivation (TSD, 1 day × 18 or 24 h, N = 12), CSR (10 days × 18 h TSD, N = 5, or 5 days × 20 h TSD, N = 6).

MEASUREMENTS AND RESULTS

Behavioral rebounds were consistent with model predictions for proportional control of cumulative times in wake, nonrapid eye movement (NREM) and rapid eye movement (REM). Delta (D) energy homeostasis was secondary to behavioral homeostasis; a biphasic NREM D power rebound contributed to the dynamics (rapid response) but not to the magnitude of the rebound in D energy. REM behavioral homeostasis was little affected by CSR. NREM behavioral homeostasis was attenuated in proportion to cumulative NREM deficit, whereas the biphasic NREM D power rebound was only slightly suppressed, indicating decoupled regulatory mechanisms following CSR.

CONCLUSIONS

We conclude that sleep homeostasis is achieved through behavioral regulation, that the NREM behavioral homeostat is susceptible to attenuation during CSR and that the concept of sleep intensity is not essential in a model of sleep-wake regulation.

STUDY OBJECTIVES

Chronic sleep restriction (CSR) is prevalent in society and is linked to adverse consequences that might be ameliorated by acclimation of homeostatic drive. This study was designed to test the hypothesis that the sleep-wake homeostat will acclimatize to CSR.

DESIGN

A four-parameter model of proportional control was used to quantify sleep homeostasis with and without recourse to a sleep intensity function.

SETTING

Animal laboratory, rodent walking-wheel apparatus.

SUBJECTS

Male Sprague-Dawley rats.

INTERVENTIONS

Acute total sleep deprivation (TSD, 1 day × 18 or 24 h, N = 12), CSR (10 days × 18 h TSD, N = 5, or 5 days × 20 h TSD, N = 6).

MEASUREMENTS AND RESULTS

Behavioral rebounds were consistent with model predictions for proportional control of cumulative times in wake, nonrapid eye movement (NREM) and rapid eye movement (REM). Delta (D) energy homeostasis was secondary to behavioral homeostasis; a biphasic NREM D power rebound contributed to the dynamics (rapid response) but not to the magnitude of the rebound in D energy. REM behavioral homeostasis was little affected by CSR. NREM behavioral homeostasis was attenuated in proportion to cumulative NREM deficit, whereas the biphasic NREM D power rebound was only slightly suppressed, indicating decoupled regulatory mechanisms following CSR.

CONCLUSIONS

We conclude that sleep homeostasis is achieved through behavioral regulation, that the NREM behavioral homeostat is susceptible to attenuation during CSR and that the concept of sleep intensity is not essential in a model of sleep-wake regulation.

Sustained sleep fragmentation induces sleep homeostasis in mice

STUDY OBJECTIVES

Sleep fragmentation (SF) is an integral feature of sleep apnea and other prevalent sleep disorders. Although the effect of repetitive arousals on cognitive performance is well documented, the effects of long-term SF on electroencephalography (EEG) and molecular markers of sleep homeostasis remain poorly investigated. To address this question, we developed a mouse model of chronic SF and characterized its effect on EEG spectral frequencies and the expression of genes previously linked to sleep homeostasis including clock genes, heat shock proteins, and plasticity-related genes.

DESIGN

N/A.

SETTING

Animal sleep research laboratory.

PARTICIPANTS

Sixty-six C57BL6/J adult mice.

INTERVENTIONS

Instrumental sleep disruption at a rate of 60/h during 14 days.

MEASUREMENTS AND RESULTS

Locomotor activity and EEG were recorded during 14 days of SF followed by recovery for 2 days. Despite a dramatic number of arousals and decreased sleep bout duration, SF minimally reduced total quantity of sleep and did not significantly alter its circadian distribution. Spectral analysis during SF revealed a homeostatic drive for slow wave activity (SWA; 1-4 Hz) and other frequencies as well (4-40 Hz). Recordings during recovery revealed slow wave sleep consolidation and a transient rebound in SWA, and paradoxical sleep duration. The expression of selected genes was not induced following chronic SF.

CONCLUSIONS

Chronic SF increased sleep pressure confirming that altered quality with preserved quantity triggers core sleep homeostasis mechanisms. However, it did not induce the expression of genes induced by sleep loss, suggesting that these molecular pathways are not sustainably activated in chronic diseases involving SF.

Discrimination and sleep: a systematic review

An increasing body of literature indicates that discrimination has a negative impact on health; poor sleep may be an underlying mechanism. The primary objective of this review was to examine existing studies on the relationship between discrimination and sleep to clarify (a) the potential role of discrimination in shaping population patterns of sleep and sleep disparities, and (b) the research needed to develop interventions at individual and institutional levels. We identified articles from English-language publications in PubMed and EBSCO databases from inception through July 2014. We employed a broad definition of discrimination to include any form of unfair treatment and all self-reported and objectively assessed sleep outcomes, including duration, difficulties, and sleep architecture. Seventeen studies were identified: four prospective, 12 cross-sectional, and one that utilized a daily-diary design. Fifteen of the 17 studies evaluated interpersonal discrimination as the exposure and the majority of studies included self-reported sleep as the outcome. Only four studies incorporated objective sleep assessments. All 17 studies identified at least one association between discrimination and a measure of poorer sleep, although studies with more detailed consideration of either discrimination or sleep architecture revealed some inconsistencies. Taken together, existing studies demonstrate consistent evidence that discrimination is associated with poorer sleep outcomes. This evidence base can be strengthened with additional prospective studies that incorporate objectively measured aspects of sleep. We outline important extensions for this field of inquiry that can inform the development of interventions to improve sleep outcomes, and consequently promote well-being and reduce health inequities across the life course.

Melatonin, the Hormone of Darkness: From Sleep Promotion to Ebola Treatment

Melatonin is a hormone secreted by the enigmatic pineal gland in response to darkness, hence the name hormone of darkness. It has generated a great deal of interest as a therapeutic modality for various diseases particularly sleep disorders. This pleiotropic molecule has anti-inflammatory, antioxidant and anticoagulopathic properties in addition to its endothelial protective effects. In this article we discuss melatonin secretion and mechanisms of action as well as therapeutic rationale. We also highlight the potential utility of melatonin in the deadly modern-day Ebola epidemic.

The effect of nocturnal wear of complete dentures on sleep and oral health related quality of life: study protocol for a randomized controlled trial

BACKGROUND

Edentulism and sleep disturbance are chronic conditions that are common in older people and have serious adverse consequences for their functioning and quality of life. Edentulism can disturb sleep through the alteration of the craniofacial structure and surrounding soft tissue. However, the effect of prosthetic rehabilitation of edentulism on sleep quality is still not well understood. The objectives of this study are to test whether nocturnal denture wear affects sleep quality, daytime sleepiness, and the oral health related quality of life of edentate older people with moderate to severe sleep apnea, and to identify modifiers of effect of nocturnal denture wear.

METHODS/DESIGN

We will carry out a single-blind randomized cross-over trial. Seventy edentate older people with moderate to severe obstructive sleep apnea will be enrolled. The study participants will be assigned to wear and not wear their dentures on alternate periods of 30 days. The outcome measures will be sleep quality (assessed by portable polysomnography), daytime sleepiness (assessed by the Epworth Sleepiness Scale), and oral health related quality of life (assessed by validated questionnaire). A number of characteristics (sociodemographic, oropharyngeal morphology, oral and prosthesis characteristics, and perceived general health quality of life) will be assessed by means of clinical examination, 3D imaging of the craniofacial structure, and validated questionnaires at baseline. Linear mixed effects regression models for repeated measures will be fitted to test the study hypotheses. The main analyses will be based on the intention-to-treat principle. To assess the robustness of the findings to potential incomplete adherence, sensitivity analyses will be conducted while applying the per-protocol principle.

DISCUSSION

This practice-relevant evidence could represent a preventive approach to improve sleep characteristics of the older population and improve their well-being and quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01868295.

Mindfulness-based intervention for prodromal sleep disturbances in older adults: design and methodology of a randomized controlled trial

Sleep problems are prevalent among older adults, often persist untreated, and are predictive of health detriments. Given the limitations of conventional treatments, non-pharmacological treatments such as mindfulness-based interventions (MBIs) are gaining popularity for sleep ailments. However, nothing is yet known about the impact of MBIs on sleep in older adults with prodromal sleep disturbances. This article details the design and methodology of a 6-week parallel-group RCT calibrated to test the treatment effect of the Mindful Awareness Practices (MAPs) program versus sleep hygiene education for improving sleep quality, as the main outcome, in older adults with prodromal sleep disturbances. Older adults with current sleep disturbances will be recruited from the urban Los Angeles community. Participants will be randomized into two standardized treatment conditions, MAPs and sleep hygiene education. Each condition will consist of weekly 2-hour group-based classes over the course of the 6-week intervention. The primary objective of this study is to determine if mindfulness meditation practice as engaged through the MAPs program leads to improved sleep quality relative to sleep hygiene education in older adults with prodromal sleep disturbances.

Valerian: no evidence for clinically relevant interactions

In recent popular publications as well as in widely used information websites directed to cancer patients, valerian is claimed to have a potential of adverse interactions with anticancer drugs. This questions its use as a safe replacement for, for example, benzodiazepines. A review on the interaction potential of preparations from valerian root (Valeriana officinalis L. root) was therefore conducted. A data base search and search in a clinical drug interaction data base were conducted. Thereafter, a systematic assessment of publications was performed. Seven in vitro studies on six CYP 450 isoenzymes, on p-glycoprotein, and on two UGT isoenzymes were identified. However, the methodological assessment of these studies did not support their suitability for the prediction of clinically relevant interactions. In addition, clinical studies on various valerian preparations did not reveal any relevant interaction potential concerning CYP 1A2, 2D6, 2E1, and 3A4. Available animal and human pharmacodynamic studies did not verify any interaction potential. The interaction potential of valerian preparations therefore seems to be low and thereby without clinical relevance. We conclude that there is no specific evidence questioning their safety, also in cancer patients.

A review of signals used in sleep analysis

This article presents a review of signals used for measuring physiology and activity during sleep and techniques for extracting information from these signals. We examine both clinical needs and biomedical signal processing approaches across a range of sensor types. Issues with recording and analysing the signals are discussed, together with their applicability to various clinical disorders. Both univariate and data fusion (exploiting the diverse characteristics of the primary recorded signals) approaches are discussed, together with a comparison of automated methods for analysing sleep.

Risk factors associated with sleep disturbance following traumatic brain injury: clinical findings and questionnaire based study

BACKGROUND

Sleep disturbance is very common following traumatic brain injury (TBI), which may initiate or exacerbate a variety of co-morbidities and negatively impact rehabilitative treatments. To date, there are paradoxical reports regarding the associations between inherent characteristics of TBI and sleep disturbance in TBI population. The current study was designed to explore the relationship between the presence of sleep disturbance and characteristics of TBI and identify the factors which are closely related to the presence of sleep disturbance in TBI population.

METHODS

98 TBI patients (72 males, mean age ± SD, 47 ± 13 years, range 18-70) were recruited. Severity of TBI was evaluated based on Glasgow Coma Scale (GCS). All participants performed cranial computed tomography and were examined on self-reported sleep quality, anxiety, and depression.

RESULTS

TBI was mild in 69 (70%), moderate in 15 (15%) and severe in 14 (15%) patients. 37 of 98 patients (38%) reported sleep disturbance following TBI. Insomnia was diagnosed in 28 patients (29%) and post-traumatic hypersomnia in 9 patients (9%). In TBI with insomnia group, 5 patients (18%) complained of difficulty falling asleep only, 8 patients (29%) had difficulty maintaining sleep without difficulty in initial sleep and 15 patients (53%) presented both difficulty falling asleep and difficulty maintaining sleep. Risk factors associated with insomnia were headache and/or dizziness and more symptoms of anxiety and depression rather than GCS. In contrast, GCS was independently associated with the presence of hypersomnia following TBI. Furthermore, there was no evidence of an association between locations of brain injury and the presence of sleep disturbance after TBI.

CONCLUSION

Our data support and contribute to a growing body of evidence which indicates that TBI patients with insomnia are prone to suffer from concomitant headache and/or dizziness, report more symptoms of anxiety and depression and severe TBI patients are likely to experience hypersomnia.

Pathological gambling, problem gambling and sleep complaints: an analysis of the National Comorbidity Survey: Replication (NCS-R)

The purpose of this study is to investigate the relationship between sleep disturbances and gambling behavior. Data from the National Comorbidity Survey-Replication (NCS-R) was used to examine the relationship between three specific sleep complaints (difficulty initiating sleep [DIS], difficulty maintaining sleep [DMS], and early morning awakening [EMA]) and gambling behavior. Bivariate logistic regression models were used to control for potentially confounding psychiatric disorders and age. Almost half of respondents with problem gambling behavior (45.9%) and two thirds (67.7%) of respondents with pathological gambling behavior reported at least one sleep compliant. Compared to respondents with no gambling pathology, respondents with pathological gambling were significantly more likely to report at least one sleep complaint (Adjusted Odds Ratio [AOR] = 3.444, 95% CI = 1.538-7.713), to report all sleep complaints (AOR = 3.449, 95% CI = 1.503-7.914), and to report any individual complaint (DIS: OR = 2.300, 95% CI = 1.069-4.946; DMS: AOR = 4.604, 95% CI = 2.093-10.129; EMA: AOR = 3.968, 95% CI = 1.856-8.481). The relationship between problem gambling and sleep complaints were more modest (any sleep complaint: AOR = 1.794, 95% CI = 1.142-2.818; all three sleep complaints: AOR = 2.144, 95% CI = 1.169-3.931; DIS: AOR = 1.961, 95% CI = 1.204-3.194; DMS: AOR = 1.551, 95% CI = 0.951-2.529; EMA: AOR = 1.796, 95% CI = 1.099-2.935). Given the individual and societal ramifications linked with the presence of sleep problems, this study presents another health-related repercussion associated with gambling pathology rarely discussed in the literature.

Primary sleep disorders seen at a Neurology service-based sleep clinic in India: Patterns over an 8-year period

There is an increasing awareness for recognition of sleep disorders in India; however, there is still a huge gap in the number of people suffering from various sleep disorders, in the community versus those visiting hospital clinics for the same. Ours is a neurology services-based sleep disorders clinic, which has evolved successfully over the last decade. In this study, we aimed to evaluate the changes in referral patterns and distribution of various sleep disorders in the patients presenting to the clinic.

Meta-analysis: melatonin for the treatment of primary sleep disorders

STUDY OBJECTIVES

To investigate the efficacy of melatonin compared to placebo in improving sleep parameters in patients with primary sleep disorders.

DESIGN

PubMed was searched for randomized, placebo-controlled trials examining the effects of melatonin for the treatment of primary sleep disorders. Primary outcomes examined were improvement in sleep latency, sleep quality and total sleep time. Meta-regression was performed to examine the influence of dose and duration of melatonin on reported efficacy.

PARTICIPANTS

Adults and children diagnosed with primary sleep disorders.

INTERVENTIONS

Melatonin compared to placebo.

RESULTS

Nineteen studies involving 1683 subjects were included in this meta-analysis. Melatonin demonstrated significant efficacy in reducing sleep latency (weighted mean difference (WMD) = 7.06 minutes [95% CI 4.37 to 9.75], Z = 5.15, p<0.001) and increasing total sleep time (WMD = 8.25 minutes [95% CI 1.74 to 14.75], Z = 2.48, p = 0.013). Trials with longer duration and using higher doses of melatonin demonstrated greater effects on decreasing sleep latency and increasing total sleep time. Overall sleep quality was significantly improved in subjects taking melatonin (standardized mean difference = 0.22 [95% CI: 0.12 to 0.32], Z = 4.52, p<0.001) compared to placebo. No significant effects of trial duration and melatonin dose were observed on sleep quality.

CONCLUSION

This meta-analysis demonstrates that melatonin decreases sleep onset latency, increases total sleep time and improves overall sleep quality. The effects of melatonin on sleep are modest but do not appear to dissipate with continued melatonin use. Although the absolute benefit of melatonin compared to placebo is smaller than other pharmacological treatments for insomnia, melatonin may have a role in the treatment of insomnia given its relatively benign side-effect profile compared to these agents.

Obstructive sleep apnea and the subsequent risk of depressive disorder: a population-based follow-up study

STUDY OBJECTIVES

Empirical findings on the prospective link between obstructive sleep apnea (OSA) and subsequent depression are mixed. This nationwide, population-based study thus aimed at assessing the risk of depressive disorder within the first year following a diagnosis with OSA. Gender effects were further examined.

DESIGN

Cohort study.

SETTING

Taiwan.

PATIENTS

This study used data from the Longitudinal Health Insurance Database 2000. A total of 2,818 patients diagnosed with OSA between 2002 and 2008 were evaluated, and 14,090 matched non-OSA enrollees used as a comparison cohort.

MEASUREMENTS AND RESULTS

Each patient was followed for one year to identify subsequent depressive disorder. We found that during the one-year follow-up, the incidence of depressive disorder per thousand person-years was about twice as high among patients with OSA (18.10, 95% CI = 13.62-23.61) as those without OSA (8.23, 95% CI = 6.83-9.84). The Cox proportional hazards model revealed that patients with OSA were independently associated with a 2.18 times (95% CI = 1.55-3.08) increased risk of subsequent depressive disorder within a year, compared to those without OSA. As epidemiological studies have consistently documented an increased risk for depression in women, we hypothesized and confirmed higher risks of depressive disorder among female patients with OSA (2.72, 95% CI = 1.68-4.40) than their male counterparts (1.81, 95% CI = 1.09-3.01).

CONCLUSION

A prospective link between OSA and subsequent depressive disorder within one year was confirmed by the current study. The risk was particularly evident among women. Regular psychiatric screening among patients with OSA is suggested to prompt the timely detection of depression.

COMMENTARY

A commentary on this article appears in this issue on page 425.

Circadian dysfunction may be a key component of the non-motor symptoms of Parkinson's disease: insights from a transgenic mouse model

Sleep disorders are nearly ubiquitous among patients with Parkinson's disease (PD), and they manifest early in the disease process. While there are a number of possible mechanisms underlying these sleep disturbances, a primary dysfunction of the circadian system should be considered as a contributing factor. Our laboratory's behavioral phenotyping of a well-validated transgenic mouse model of PD reveals that the electrical activity of neurons within the master pacemaker of the circadian system, the suprachiasmatic nuclei (SCN), is already disrupted at the onset of motor symptoms, although the core features of the intrinsic molecular oscillations in the SCN remain functional. Our observations suggest that the fundamental circadian deficit in these mice lies in the signaling output from the SCN, which may be caused by known mechanisms in PD etiology: oxidative stress and mitochondrial disruption. Disruption of the circadian system is expected to have pervasive effects throughout the body and may itself lead to neurological and cardiovascular disorders. In fact, there is much overlap in the non-motor symptoms experienced by PD patients and in the consequences of circadian disruption. This raises the possibility that the sleep and circadian dysfunction experienced by PD patients may not merely be a subsidiary of the motor symptoms, but an integral part of the disease. Furthermore, we speculate that circadian dysfunction can even accelerate the pathology underlying PD. If these hypotheses are correct, more aggressive treatment of the circadian misalignment and sleep disruptions in PD patients early in the pathogenesis of the disease may be powerful positive modulators of disease progression and patient quality of life.

Pittsburgh and Epworth sleep scale items: accuracy of ratings across different reporting periods

This study examined the ecological validity of sleep experience reports across different lengths of reporting periods. The accuracy of item responses on the Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) across 3-, 7-, and 28-day reporting periods was examined in relation to electronic daily item ratings. Primary care clinic patients (N = 119) were recruited, and were not required to have sleep problems to participate. Analyses found few differences in item scores when electronic daily ratings were compared with recall ratings, regardless of the length of the reporting period. However, within-subjects analyses indicated low levels of accuracy in recall of sleep items for specific days in the last week. Thus, for the purpose of between-subject comparisons, patients generally can provide accurate recall of sleep experiences; studies requiring finer-grained analysis across time and within-subjects require daily diary methodology.

Sleep problems: an emerging global epidemic? Findings from the INDEPTH WHO-SAGE study among more than 40,000 older adults from 8 countries across Africa and Asia

OBJECTIVE

To estimate the prevalence of sleep problems and the effect of potential correlates in low-income settings from Africa and Asia, where the evidence is lacking.

DESIGN

Cross-sectional.

SETTING

Community-wide samples from 8 countries across Africa and Asia participating in the INDEPTH WHO-SAGE multicenter collaboration during 2006-2007. The participating sites included rural populations in Ghana, Tanzania, South Africa, India, Bangladesh, Vietnam, and Indonesia, and an urban area in Kenya.

PARTICIPANTS

There were 24,434 women and 19,501 men age 50 yr and older.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

Two measures of sleep quality, over the past 30 days, were assessed alongside a number of sociodemographic variables, measures of quality of life, and comorbidities. Overall, 16.6% of participants reported severe/extreme nocturnal sleep problems, with a striking variation across the 8 populations, ranging from 3.9% (Purworejo, Indonesia and Nairobi, Kenya) to more than 40.0% (Matlab, Bangladesh). There was a consistent pattern of higher prevalence of sleep problems in women and older age groups. In bivariate analyses, lower education, not living in partnership, and poorer self-rated quality of life were consistently associated with higher prevalence of sleep problems (P < 0.001). In multivariate logistic regression analyses, limited physical functionality or greater disability and feelings of depression and anxiety were consistently strong, independent correlates of sleep problems, in both women and men, across the 8 sites (P < 0.001).

CONCLUSIONS

A large number of older adults in low-income settings are currently experiencing sleep problems, which emphasizes the global dimension of this emerging public health issue. This study corroborates the multifaceted nature of sleep problems, which are strongly linked to poorer general well-being and quality of life, and psychiatric comorbidities.

Sleep and gambling severity in a community sample of gamblers

Although sleep has been extensively studied in substance related disorders, it has yet to be examined as thoroughly in gambling-related disorders. The purpose of this study is to examine the relationship between gambling severity and sleep disturbances in a sample of non-treatment seeking gamblers (N = 96) using the Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS). Mean ESS scores for recreational, problem, and pathological gamblers were 4.13, 5.81, and 8.69, respectively, with a significant difference between pathological gamblers and both problem (P = .007) and recreational gamblers (P < .001). Mean PSQI scores for recreational, problem, and pathological gamblers were 3.35, 5.30, and 5.44, respectively, with a significant difference in sleep quality between recreational and problem gamblers (P = .018), as well as recreational and pathological gamblers (P = .008). As the first study to use objective sleep measures, these findings will not only increase awareness of this relationship, but also provide a foundation on which others can investigate the benefits of screening and adjunct treatment for sleep disorders in the gambling population.

Data-driven modeling of sleep states from EEG

Sleep analysis is critical for the diagnosis, treatment, and understanding of sleep disorders. However, the current standards for sleep analysis are widely considered oversimplified and problematic. The ability to automatically annotate different states during a night of sleep in a manner that is more descriptive than current standards, as well as the ability to train these models on a patient-by-patient basis, would provide a complementary approach for sleep analysis. We present a method that discovers latent structure in sleep EEG recordings, by extracting symbols from the continuous EEG signal and learning "topics" for a recording. These sleep topics are derived in a fully automatic and data-driven manner, and can represent the data with mixtures of states. The proposed method allows for identification of states in a patient-specific way, as opposed to the one-size-fits-all approach of the current standard. We demonstrate on a publicly available dataset of 15 sleep recordings that not only do the states discovered by this approach encompass the standard sleep stage structure, they provide additional information about sleep architecture with the potential to provide new insights into sleep disorders.

Clinical diagnosis and misdiagnosis of sleep disorders

Sleep disorders are common in all sections of the population and are either the main clinical complaint or a frequent complication of many conditions for which patients are seen in primary care or specialist services. However, the subject is poorly covered in medical education. A major consequence is that the manifestations of the many sleep disorders now identified are likely to be misinterpreted as other clinical conditions of a physical or psychological nature, especially neurological or psychiatric disorders. To illustrate this problem, examples are provided of the various possible causes of sleep loss, poor quality sleep, excessive daytime sleepiness and episodes of disturbed behaviour at night (parasomnias). All of these sleep disorders can adversely affect mental state and behaviour, daytime performance or physical health, the true cause of which needs to be recognised by clinicians to ensure that appropriate treatment is provided. As conventional history taking in neurology and psychiatry pays little attention to sleep and its possible disorders, suggestions are made concerning the enquiries that could be included in history taking schedules to increase the likelihood that sleep disorders will be correctly identified.

Reactive oxygen species contribute to sleep apnea-induced hypertension in rats

In clinical studies, sleep apnea is associated with hypertension, oxidative stress, and increased circulating endothelin-1 (ET-1). We previously developed a model of sleep apnea by exposing rats to eucapnic intermittent hypoxia (IH-C) during sleep, which increases both blood pressure and plasma levels of ET-1. Because similar protocols in mice increase tissue and plasma markers of oxidative stress, we hypothesized that IH-C generation of reactive oxygen species (ROS) contributes to the development of ET-1-dependent hypertension in IH-C rats. To test this, male Sprague-Dawley rats were instrumented with indwelling blood pressure telemeters and drank either plain water or water containing the superoxide dismutase mimetic, Tempol (4-hydroxy-2,2,6,6-tetramethyl-piperidine-1-oxyl, 1 mM). Mean arterial pressure (MAP) and heart rate (HR) were recorded for 3 control days and 14 treatment days with rats exposed 7 h/day to IH-C or air/air cycling (Sham). On day 14, MAP in IH-C rats treated with Tempol (107 +/- 2.29 mmHg) was significantly lower than in untreated IH-C rats (118 +/- 9 mmHg, P < 0.05). Tempol did not affect blood pressure in sham-operated rats (Tempol = 101 +/- 3, water = 101 +/- 2 mmHg). Immunoreactive ET-1 was greater in plasma from IH-C rats compared with plasma from sham-operated rats but was not different from Sham in Tempol-treated IH-C rats. Small mesenteric arteries from IH-C rats but not Tempol-treated IH-C rats had increased superoxide levels as measured by ferric cytochrome c reduction, lucigenin signaling, and dihydroethidium fluorescence. The data show that IH-C increases ET-1 production and vascular ROS levels and that scavenging superoxide prevents both. Thus oxidative stress appears to contribute to increases in ET-1 production and elevated arterial pressure in this rat model of sleep apnea-induced hypertension.

Knowledge, opinions, and clinical experience of general practice dentists toward obstructive sleep apnea and oral appliances

Undiagnosed obstructive sleep apnea (OSA) can contribute to hypertension, cardiovascular disease, stroke, and detract from overall quality of life. Dentists can play an important role in detecting, making recommendations for, and treating OSA with oral appliances (OAs). A survey of 18 questions of knowledge and opinion of, educational background for, and clinical experience with OSA and OAs was mailed to 500 general practice dentists in Indiana, United States. Two hundred survey returns produced 192 valid responses. Responders reported strong positive opinions toward OSA and OAs. However, 58% of dentists could not identify common signs and symptoms of OSA, and 55% of dentists did not know the mechanism for mandibular advance devices. Only 39% of dentists could identify snoring, mild OSA, and intolerance to continuous positive airway pressure as possible indications for OA treatment. Respondents reported a general lack of education about both OSA and OAs. Only 31 (16%) were taught about this issue in dental school; 77 (40%) knew little or nothing about OA treatment for OSA patients; 57 (30%) learned from postgraduate training. Cooperation and referrals between dentists and physicians were rated as "poor." Of the responders, 54% never consulted with physicians for a suspected OSA patient in their practice; 75% of dentists reported they have never been referred patients by physicians; and 80% of dentists never or less than five times prescribed OAs to OSA patients. Results suggest a need for increased education and training regarding OSA and OAs in dental school, as well as increased cooperation between dentists and physicians for better patient care.

The relative efficacy of two brief treatments for sleep problems in young learning disabled (mentally retarded) children: a randomised controlled trial

BACKGROUND

Settling and night waking problems are particularly prevalent, persistent, and generally considered difficult to treat in children with a learning disability, although intervention trials are few. Scarce resources, however, limit access to proven behavioural treatments.

AIMS

To investigate the efficacy of a media based brief behavioural treatment of sleep problems in such children by comparing (1) face-to-face delivered treatment versus control and (2) booklet delivered treatment versus controls.

METHODS

The parents of 66 severely learning disabled children aged 2-8 years with settling and/or night waking problems took part in a randomised controlled trial with a wait-list control group. Behavioural treatments were presented either conventionally face-to-face or by means of a 14 page easy to read illustrated booklet. A composite sleep disturbance score was derived from sleep diaries kept by parents.

RESULTS

Both forms of treatment were almost equally effective compared with controls. Two thirds of children who were taking over 30 minutes to settle five or more times per week and waking at night for over 30 minutes four or more times per week improved on average to having such settling or night waking problems for only a few minutes or only once or twice per week (H = 34.174, df = 2, p<0.001). These improvements were maintained after six months.

CONCLUSIONS

Booklet delivered behavioural treatments for sleep problems were as effective as face-to-face treatment for most children in this population.