Effects of continuous positive airway pressure on depression and anxiety symptoms in patients with obstructive sleep apnoea: results from the sleep apnoea cardiovascular Endpoint randomised trial and meta-analysis

Sleep and functional outcomes in children and adolescents with epilepsy: A scoping review

AIM

In children and adolescents with epilepsy (CAWE), disturbed sleep and functional difficulties are frequently present, but their relationship is unclear. In this scoping review we aimed to explore associations between sleep and functional outcomes in CAWE.

METHOD

We registered the protocol with open science framework and conducted the review according to the PRISMA Extension for Scoping Reviews. We searched Medline, Embase, PsycINFO and PubMed for original studies reporting on relations between sleep and functional outcomes (adaptive/quality of life, behavioural/mood, cognitive & academic) in CAWE. To assess the quality of studies we used an extended version of the checklist employed by Winsor and colleagues [1].

RESULTS

We identified 14 studies that included 1,785 CAWE and 1,260 control children, with a mean age of 9.94 and 10.13 years, respectively. The studies were highly heterogeneous with respect to samples, epilepsy variables, and methods used to assess sleep and functional outcomes. The quality of studies was medium. Associations between sleep and adaptive/quality of life, behavioural/mood, cognitive and academic outcomes were examined in 2, 10, 6, and 0 studies, respectively. Across studies, in CAWE, greater sleep disturbances were related to worse behavioural/mood outcomes, ranging from depression/anxiety to ADHD symptoms. Sleep disturbances did not consistently relate to cognitive outcomes, but they related to worse adaptive outcomes in both studies that examined their relationship.

CONCLUSIONS

Our study provides evidence of relationship between disturbed sleep and behavioural/mood difficulties, which alerts to the need for careful evaluation and treatment of sleep disturbances in CAWE. Our study also highlights the need to examine relationships between sleep and other functional outcomes in CAWE, as studies conducted in the general population suggest that sleep disturbances may be modifiable and associated with improved functional outcomes.

Long-term effects on clinical event, mental health, and related outcomes of CPAP for obstructive sleep apnea: a systematic review

STUDY OBJECTIVES

We performed a systematic review of long-term health outcomes of continuous positive airway pressure (CPAP) use in adults with obstructive sleep apnea.

METHODS

We updated prior systematic reviews with searches in multiple databases through January 3, 2023. We included randomized controlled trials (RCTs) and adjusted nonrandomized comparative studies that reported prespecified long-term (mostly > 1 year) health outcomes. We assessed risk of bias, conducted meta-analyses, and evaluated strength of evidence.

RESULTS

We found 38 eligible studies (16 trials, 22 observational). All conclusions were of low strength of evidence given study and data limitations. RCTs found no evidence of effect of CPAP on mortality (summary effect size [ES] 0.89; 95% confidence interval [CI] 0.66, 1.21); inclusion of adjusted nonrandomized comparative studies yields an association with reduced risk of death (ES 0.57; 95% CI 0.44, 0.73). RCTs found no evidence of effects of CPAP for cardiovascular death (ES 0.99; 95% CI 0.64, 1.53), stroke (ES 0.99; 95% CI 0.73, 1.35), myocardial infarction (ES 1.05; 95% CI 0.78, 1.41), incident atrial fibrillation (ES 0.89; 95% CI 0.48, 1.63), or composite cardiovascular outcomes (all statistically nonsignificant). RCTs found no evidence of effects for incident diabetes (ES 1.02; 95% CI 0.69, 1.51) or accidents (all nonsignificant) and no clinically significant effects on depressive symptoms, anxiety symptoms, or cognitive function.

CONCLUSIONS

Whether CPAP use for obstructive sleep apnea affects long-term health outcomes remains largely unanswered. RCTs and nonrandomized comparative studies are inconsistent regarding the effect of CPAP on mortality. Current studies are underpowered, with relatively short duration follow-up and methodological limitations.

CITATION

Balk EM, Adam GP, Cao W, Bhuma MR, D'Ambrosio C, Trikalinos TA. Long-term effects on clinical event, mental health, and related outcomes of CPAP for obstructive sleep apnea: a systematic review. J Clin Sleep Med. 2024;20(6):895-909.

Athletic retirement: factors contributing to sleep and mental health problems

Introduction

The aim of this investigation was to determine which factors were associated with symptoms of sleep and mental health disorders in former athletes.

Methods

Former athletes (N = 173, 50% women) who retired from any competition level within the last 20 years participated in an online survey. The survey consisted of the Athlete Sleep Screening Questionnaire (ASSQ), Personal Wellbeing Index-Adult (PWI-A), Center for Epidemiologic Studies Depression Scale-Revised (CESD-R), and Generalised Anxiety Disorder Assessment (GAD-7).

Results

Binary logistic regressions revealed that both age (OR = 0.95 [95% CI:0.92, 0.99], p = 0.007) and gender (OR = 2.28 [95% CI:1.09, 4.79], p = 0.029) were associated with anxiety, with women and younger ex-athletes presenting greater risk of anxiety symptoms. Higher body mass was associated with an increased risk for sleep difficulty (OR = 1.13 [95% CI:1.03, 1.23], p = 0.008), sleep disordered breathing (OR = 1.20 [95% CI:1.10, 1.30], p < 0.001), and compromised wellbeing (OR = 0.89 [95% CI:0.83, 0.96], p = 0.001). Athletes who subjectively placed a lower priority on sport while competing presented greater risk of sleep disordered breathing (OR = 2.00[95% CI:1.05, 3.80], p = 0.035). No associations between recency retirement and any outcome measures were observed.

Discussion

Findings suggest potential predictive factors for difficulty transitioning out of sport. Future longitudinal research should consider the interplay between sport re-engagement and the incidence and chronicity of sleep and mental health disorders.

Depression and comorbid obstructive sleep apnea: Association between positive airway pressure adherence, occurrence of self-harm events, healthcare resource utilization, and costs

OBJECTIVE

Previous studies have shown that treatment of obstructive sleep apnea (OSA) with positive airway pressure (PAP) therapy in patients with depression may improve depression symptoms and response to antidepressant therapy. We investigated the association between PAP therapy adherence, self-harm events, healthcare resource utilization (HCRU), and costs over 2 years in a national sample of patients with pre-existing depression and newly diagnosed comorbid OSA.

METHODS

Administrative claims data were linked to objective PAP therapy usage. Inverse probability treatment weighting was used to compare outcomes over 2 years across PAP adherence levels. The predicted numbers of emergency room (ER) visits and hospitalizations by adherence level were assessed using risk-adjusted generalized linear models.

RESULTS

37,459 patients were included. Relative to non-adherent patients, consistently adherent patients had fewer self-harm events (0.04 vs 0.05, p < 0.001) after 1 year, and significantly (all p < 0.001) fewer ER visits (0.66 vs 0.86) and all-cause hospitalizations (0.13 vs 0.17), and lower total ($11,847 vs $11,955), inpatient hospitalization ($1634 vs $2274), and ER visit ($760 vs $1006) costs per patient in the second year of PAP therapy. Consistently adherent patients showed lower risk for hospitalizations and ER visits.

LIMITATIONS

Using observational claims data, we were unable to assess clinical characteristics including sleep, sleepiness, and daytime symptoms, or important social determinants of health. We were limited in assessing care received outside of the included health plans.

CONCLUSION

Consistent adherence to PAP therapy over 2 years was associated with improved HCRU outcomes for patients with pre-existing depression newly diagnosed with comorbid OSA.

Bi-level VNS therapy with different therapy modes at night and daytime improves seizures and quality of life in a patient with drug-resistant epilepsy

Induction or aggravation of sleep apnea is a known side effect of vagus nerve stimulation (VNS). We report the case of a 44 year old male with drug-resistant epilepsy and depression who did not experience any seizure reduction after 1 year of VNS but a worsening of depression and daytime sleepiness. After confirming VNS-associated sleep apnea we started the first bi-level VNS therapy with standard VNS settings during daytime and reduced settings during nighttime. Anti-seizure medication remained unchanged. Within 12 months his seizure frequency was reduced by 90 % and his depression improved, permitting a cessation of his antidepressant medication. The observations made in this case have contributed to the manufacturer of VNS developing new generator models that can automatically provide bi-level VNS.

Improved depressive symptoms, and emotional regulation and reactivity, in individuals with obstructive sleep apnea after short- and long-term CPAP therapy use

Obstructive Sleep Apnoea (OSA) is associated with high rates of depression; however, if and how treatment of OSA improves depressive symptoms is unclear. To further understand this link we considered the role of emotional regulation - the ability to control and express our emotional responses - thought to be a central component of depression. This study aimed to assess changes in depressive symptoms and emotional responses in individuals with OSA after 4- and 12-months of continuous positive airway pressure (CPAP) treatment. One-hundred and twenty-one OSA participants (50 female, Mage = 51.93; mean AHI = 36.27) were recruited from a tertiary clinical sleep service prior to CPAP initiation, and randomised to either a CPAP group or a 4 month wait-list group. Participants completed the Center for Epidemiological Studies Depression Scale, the Emotional Reactivity Scale and the Difficulties in Emotion Regulation Scale at baseline, and 1-, 2-, and 4-months follow-up. The CPAP group also completed the questionnaires 12-months after CPAP initiation. CPAP use at 1 month and 12 months was 5.1h/night and 4.9h/night, respectively. Significant improvements in depressive symptoms, emotional regulation and reactivity, and subjective sleepiness were observed after 4 months in both groups, however, the within group changes were only significant for those using CPAP. After 12-months of CPAP treatment, these improvements were maintained. There was no association between CPAP treatment adherence and improvements in any outcome. CPAP treatment for 12 months may reduce symptoms of depression and improve emotional regulation in individuals with OSA.

Peripheral arterial tonometry versus polysomnography in suspected obstructive sleep apnoea

BACKGROUND

Polysomnography (PSG) is the gold standard for the diagnosis of obstructive sleep apnoea (OSA). Home sleep apnoea testing with peripheral arterial tonometry (PAT) is a recommended diagnostic alternative for patients with an increased risk for OSA. In a large clinical cohort, we investigated concordance and predictors for discordance in diagnosing OSA using PAT and PSG, and three-year cardiovascular risk in patients with discordant OSA diagnosis.

METHODS

Retrospective monocentric cohort study. Patients with a PAT AHI ≥ 5/h followed by an in-hospital PSG within three months were included. All patients with a PAT AHI ≥ 5/h but a PSG AHI < 5/h were classified as discordant. Patients with PAT and PSG AHI ≥ 5/h were classified as concordant. To ascertain cardiovascular risk, major adverse cardiovascular events (MACE) were analyzed in discordant patients and sex, age, body mass index (BMI) and cardiovascular disease-matched concordant patients over a follow-up time of 3.1 ± 0.06 years.

RESULTS

A total of 940 patients, 66% male with an average age of 55 ± 0.4 years and BMI of 31 ± 0.2 kg/m² were included. Agreement in OSA diagnosis was observed in 80% of patients (55% in mild and 86% in moderate and severe OSA). Factors significantly associated with a discordant diagnosis were female sex, younger age and lower BMI, but not comorbidities. There was no significant difference in MACE (p = 0.920) between discordant patients (n = 155) and matched concordant patients (n = 274) with or without therapy.

CONCLUSIONS

Concordance between PAT and PSG diagnosis of sleep apnoea is good, particularly in moderate and severe OSA. Predictors for discordant results between PAT and PSG were age, sex and BMI. MACE risk is similar in those with OSA diagnosed by PAT or PSG.

Solriamfetol enhances wakefulness and improves cognition and anxiety in a murine model of OSA

BACKGROUND

Obstructive sleep apnea (OSA) is a chronic condition characterized by intermittent hypoxia (IH). Excessive daytime sleepiness (EDS) is a common consequence of OSA and is associated with cognitive deficits and anxiety. Modafinil (MOD) and Solriamfetol (SOL) are potent wake-promoting agents clinically used to improve wakefulness in OSA patients with EDS.

METHODS

Male C57Bl/6J mice were exposed to either IH or room air (RA) controls during the light phase for 16 weeks. Both groups were then randomly assigned to receive once-daily intraperitoneal injections of SOL (200 mg/kg), MOD (200 mg/kg) or vehicle (VEH) for 9 days while continuing IH exposures. Sleep/wake activity was assessed during the dark (active) phase. Novel object recognition (NOR), elevated-plus maze test (EPMT), and forced swim test (FST) were performed before and after drug treatment.

RESULTS

IH exposure increased dark phase sleep percentage and reduced wake bouts lengths and induced cognitive deficits and anxiogenic effects. Both SOL and MOD treatments decreased sleep propensity under IH conditions, but only SOL promoted improvements in NOR performance (explicit memory) and reduced anxiety-like behaviors.

CONCLUSION

Chronic IH, a hallmark feature of OSA, induces EDS in young adult mice that is ameliorated by both SOL and MOD. SOL, but not MOD, significantly improves IH-induced cognitive deficits and promotes anxiolytic effects. Thus, SOL could potentially benefit OSA patients beyond EDS management.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Long-Term Adherence in Overweight Patients with Obstructive Sleep Apnea and Hypertension-A Pilot Prospective Cohort Study

Obstructive sleep apnea (OSA) is associated with increased cardiovascular risk, sedentarism, depression, anxiety and impaired quality of life. The long-term effectiveness of positive airway pressure (PAP) is insufficiently studied and limited by poor patient compliance. The aim of this pilot prospective cohort study was to evaluate long-term adherence in overweight patients with moderate-severe OSA and hypertension and to analyze changes in weight, sleepiness and quality of life. We performed a prospective study that included overweight patients with moderate-severe OSA and hypertension who had not undergone previous PAP therapy. All subjects received a standard physical examination, education regarding lifestyle changes and free PAP therapy for 2 months. After five years, the patients were invited to participate in a telephone-based interview regarding PAP compliance and completed standard questionnaires assessing adherence to medication, physical activity, diet, anxiety and quality of life (QoL). Only 39.58% of the patients were adherent to PAP 5 years (58.42 ± 3.70 months) after being diagnosed with moderate-severe OSA. Long-term PAP use results in sustained weight loss; improved blood pressure control, sleepiness and QOL; and lower anxiety and depression scores. PAP compliance was not associated with a higher level of daily physical activity or a healthier diet.

Calidad de vida relacionada con la salud y adhesión terapéutica a la presión positiva continua en la vía aérea (CPAP) en pacientes con apnea obstructiva del sueño (AOS)

Introduction

The benefits of CPAP in patients with obstructive sleep apnea (OSA) are not achieved without therapeutic adherence (TA). The perception of benefit is one of the main predictors of adherence. However, it is unknown whether the impact of CPAP on health-related quality of life (HRQoL) is related to TA.

Objective

1) To evaluate whether changes in HRQoL after initiating CPAP are associated with AT. 2) To analyze the influence of various TA determinants, including baseline HRQoL.

Methods

Prospective observational and longitudinal study on a cohort of patients with moderate-severe OSA and indication of CPAP. Baseline and after-therapy HRQoL were evaluated using the Quebec Sleep Questionnaire (QSQ), as well as other possible AT determinants. A multivariate analysis was performed.

Results

A total of 364 patients (78% men) were included, with mean age of 55 ± 11 years and apnea-hypopnea index of 42 ± 19/hour. 33.3% without TA. There was no association between HRQoL changes after 3 months of CPAP and AT and between QSQ baseline score and AT. A higher ODI4%, a global improvement and social interactions (QSQ), were associated with AT. Baseline anxiety-depressive symptoms, worsening anxiety, and side effects with CPAP were associated with worse AT.

Conclusions

The impact of CPAP on HRQoL with respect to the perception of social interactions seems to condition TA. The basal impact of the disease, in terms of HRQoL, is not associated with AT.

Comorbid Major Depressive Disorder and Obstructive Sleep Apnea

Introduction

Major depressive disorder (MDD) and obstructive sleep apnoea (OSA) are prevalent in the general population. Moreover, early studies found that the two conditions are associated bidirectionally and lead to poor health outcomes. The prevalence of comorbid MDD in OSA patients could be as high as two-thirds. A sedentary lifestyle and psychological stress in the globalisation age may increase the risk of MDD and OSA.

Method

We reported a case of an MDD patient with OSA as well as discussed the assessment method and also reviewed the treatment of both conditions. We aimed to raise awareness for psychiatrists to differentiate other medical conditions when the symptomatology of MDD is atypical and unresponsive to standard psychiatric treatment.

Conclusion

Early detection and effective treatment for MDD and OSA are essential to achieve patient outcomes. Furthermore, it can reduce complications from both conditions. Therefore, a comprehensive evaluation should be made to determine the diagnoses when physicians suspect overlapping MDD and OSA.

Anxiety, depression and sleepiness in OSA patients treated with barbed reposition pharyngoplasty: a prospective study

PURPOSE

To evaluate the efficacy of barbed reposition pharyngoplasty (BRP) on sleepiness, anxiety, and depression o adult patients with obstructive sleep apnea (OSA).

METHODS

We performed a prospective multicentric study to assess functional outcomes in 20 OSA patients treated with BRP and compare the results with an observational group of 20 subjects. All recruited subjects performed at baseline and 6-months postoperative follow-up Polysomnography (PSG), daytime sleepiness scoring using the Epworth Sleepiness Scale (ESS), and anxiety and depression evaluation via the Beck Anxiety Inventory (BAI) and the Beck Depression Inventory-II (BDI-II) questionnaires.

RESULTS

At follow-up the BRP demonstrated greater improvements in AHI (8.92 ± 2.29 vs. 30.66 ± 2.56; p < 0.001) and ODI (7.65 ± 2.39 vs. 24.55 ± 3.20; p < 0.001) than control at intergroup analysis. Surgical group reported significant data in daytime sleepiness (5.15 ± 1.19 vs. 13.15 ± 1.35; p < 0.001), anxiety (12.65 ± 3.11 vs. 24.2 ± 2.37; p < 0.001), and depression domains (5.85 ± 1.19 vs. 17.55 ± 3.24; p < 0.001). AHI, ODI, and advanced age have been shown to multiple regression as independent predictors of treatment response for mood domains (p < 0.001; p = 0.02; p = 0.041, respectively).

CONCLUSIONS

Patients with OSA may benefit from palate surgery, reducing not only the apnea and hypopnea index, daytime sleepiness but also associated mood comorbidities. However, further studies are needed to confirm our preliminary results to validate the evidence to date reported.

Posttraumatic Stress Disorder and Anxiety-Related Conditions

PURPOSE OF REVIEW

This article provides a synopsis of current assessment and treatment considerations for posttraumatic stress disorder (PTSD) and related anxiety disorder characteristics. Epidemiologic and neurobiological data are reviewed as well as common associated symptoms, including sleep disruption, and treatment approaches to these conditions.

RECENT FINDINGS

PTSD is no longer considered an anxiety-related disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition classification and instead is associated with trauma/stressor-related disorders. PTSD symptoms are clustered into four domains including intrusive experiences, avoidance, mood, and arousal symptoms. Despite this reclassification, similarities exist in consideration of diagnosis, treatment, and comorbidities with anxiety disorders. PTSD and anxiety-related disorders are heterogeneous, which is reflected by the neural circuits involved in the genesis of symptoms that may vary across symptom domains. Treatment is likely to benefit from consideration of this heterogeneity.Research in animal models of fear and anxiety, as well as in humans, suggests that patients with PTSD and generalized anxiety disorder have difficulty accurately determining safety from danger and struggle to suppress fear in the presence of safety cues.Empirically supported psychotherapies commonly involved exposure (fear extinction learning) and are recommended for PTSD. Cognitive-behavioral therapy has been shown to be effective in other anxiety-related disorders. Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are commonly used in the treatment of PTSD and anxiety disorders in which pharmacologic intervention is supported. Treating sleep disruption including sleep apnea (continuous positive airway pressure [CPAP]), nightmares, and insomnia (preferably via psychotherapy) may improve symptoms of PTSD, as well as improve mood in anxiety disorders.

SUMMARY

PTSD has a lifetime prevalence that is close to 10% and shares neurobiological features with anxiety disorders. Anxiety disorders are the most common class of mental conditions and are highly comorbid with other disorders; treatment considerations typically include cognitive-behavioral therapy and pharmacologic intervention. Developing technologies show some promise as treatment alternatives in the future.

Effect of Continuous Positive Airway Pressure on Symptoms and Prevalence of Insomnia in Patients With Obstructive Sleep Apnea: A Longitudinal Study

Objective

Obstructive sleep apnea (OSA) and insomnia are the two most common sleep disorders. Continuous positive airway pressure (CPAP) is considered first-line treatment for OSA. In the present study, we assess the effect of CPAP on symptoms and prevalence of insomnia in patients with OSA. We hypothesized a decrease in insomnia symptoms from CPAP initiation to follow-up, and that this decrease would depend on CPAP adherence.

Materials and methods

The sample included 442 patients diagnosed with OSA [mean age 54.9 years (SD = 12.1), 74.4% males] who started treatment with CPAP at a university hospital. OSA was diagnosed according to standard respiratory polygraphy. Mean apnea-hypopnea index (AHI) was 30.1 (SD = 21.1) at baseline. Insomnia was assessed prior to CPAP treatment (baseline) and at follow-up after a median of 19.9 weeks (range 6–52 weeks) with the Bergen Insomnia Scale (BIS). CPAP adherence was defined as an average use of ≥ 4 h per night, whereas non-adherence was defined as < 4 h per night.

Results

There was a significant decrease in BIS scores from baseline (mean = 18.8, SD = 9.8) to follow-up (mean = 12.9, SD = 9.9), p < 0.001. Cohen’s d(0.65) indicated a moderate effect size. The reduction in BIS scores was depending on CPAP adherence (interaction effect F(1,440) = 12.4, p < 0.001), with larger reduction in the adherent group than in the non-adherent group. The proportion of patients with chronic insomnia was significantly reduced from 51.1% at baseline to 33.0% at follow-up (p < 0.001).

Conclusion

Overall, there was a significant reduction in insomnia symptoms from baseline to follow-up. The improvement was significant in both adherence groups, but the degree of improvement was larger among patients who were adherent to CPAP. Furthermore, there was a significant reduction in the prevalence of chronic insomnia at follow-up compared to baseline. This suggests that CPAP effectively reduces both the presence of insomnia and the severity of insomnia symptoms in some patients with OSA.

Depression scores improve with continuous positive airway pressure in specialized sleep clinics: real-world data

STUDY OBJECTIVES

To assess changes in Hospital Anxiety and Depression Scale (HADS) scores after continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea.

METHODS

Consecutive patients attending the Alfred Health sleep clinic, diagnosed with obstructive sleep apnea, and prescribed CPAP were recruited. The primary outcome was a change in the HADS depression (HADS-D) and anxiety (HADS-A) subscales from the time of diagnosis to follow-up. Secondary analysis compared high (> 4 hours) and low (< 4 hours) CPAP adherence groups and change in depression cases, defined by HADS-D ≥ 8, and anxiety cases, defined by HADS-A ≥ 11.

RESULTS

We included 108 participants in the final analysis. Adherence groups were well matched in baseline mood, sleepiness, and apnea variables. Overall age (mean ± standard deviation) was 56.1 ± 12.8 years, and there was a median (interquartile ratio) apnea-hypopnea-index of 42.7 (27.5-58.1) or median (interquartile ratio) oxygen-desaturation-index of 43.0 (26.0-74.0). The median duration of CPAP therapy was 1.3 years. The HADS-D decreased after CPAP by -1.4 (adjusted 95% confidence interval, -2.1 to -0.6; P = .001). Patients with high-CPAP adherence (n = 84) had a tendency towards a greater reduction in HADS-D (-1.5) compared with those with low-CPAP adherence (n = 24; -0.3; adjusted P = .19). Depression cases (HADS-D ≥ 8) decreased by 13.1% in the high-CPAP-adherence group (P = .03) and increased by 4.1% in the low-CPAP-adherence group (P = .71). The HADS-A decreased after CPAP by -1.8 (adjusted 95% confidence interval, -1.8 to -0.4; P = .004). There was no significant difference between adherence groups or anxiety cases (HADS-A > 11).

CONCLUSIONS

Specialized obstructive sleep apnea treatment with CPAP reduces depression scores, with a trend toward greater reduction in those with high CPAP adherence.

Association of obstructive sleep apnea risk with depression and anxiety symptoms in women with polycystic ovary syndrome

STUDY OBJECTIVE

To determine whether obstructive sleep apnea (OSA) risk is associated with depression and anxiety symptoms in women with polycystic ovary syndrome (PCOS).

METHODS

This is a cross-sectional study of women with PCOS, by the Rotterdam criteria, seen at a single academic center between June 2017 and June 2020. Depression symptoms, anxiety symptoms and OSA risk were assessed with self-administered Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7) and Berlin questionnaires, respectively. Univariate and multivariate logistic regression analyses were used to determine the odds of moderate/severe symptoms of depression (PHQ-9 ≥ 10) and anxiety (GAD-7 ≥ 10) in the high-risk versus low-risk OSA groups. The primary multivariate model adjusted for age, body mass index (BMI), free testosterone and insulin resistance.

RESULTS

Of the 200 participants, the mean age was 28.0 years and 38% screened high-risk for OSA. Women who screened high-risk OSA had over three times the odds of moderate/severe depression (OR 3.19, 95% CI 1.76-5.78, P<0.001) and over two times the odds of having moderate/severe anxiety (OR 2.49, 95% CI 1.34-4.64, P=0.004). These associations were only slightly attenuated in the adjusted models: aOR for moderate/severe depression was 3.06 (95% CI 1.36-6.88, P=0.01) and aOR for moderate/severe anxiety was 2.39 (95% CI 1.03-5.59, P=0.04).

CONCLUSIONS

Among women with PCOS, those at high-risk of OSA experienced elevated depression and anxiety symptoms compared to those at low-risk for OSA, independent of the effects of age, BMI, hyperandrogenism and insulin resistance.

Endotypes and phenotypes in obstructive sleep apnea

PURPOSE OF REVIEW

The purpose of this review is to describe the variability of obstructive sleep apnea (OSA), both from a standpoint of underlying mechanisms and in terms of clinical manifestations.

RECENT FINDINGS

Recent data suggest that not all patients with sleep apnea get their disease for the same reason. As such, no one variable is effective at defining which patients do or do not have sleep apnea. Identifying the mechanism(s) underlying OSA for an individual is helpful as it can help to determine whether personalized therapy could be developed based on an individual's characteristics. In addition, these underlying mechanisms may be helpful in predicting response to therapy and prognosticating regarding future complications.

SUMMARY

OSA is a heterogeneous disease with highly varying underlying mechanisms. OSA has variable clinical manifestations with definable subsets having risk of particular complications. Future studies will be helpful to identify mechanisms underlying OSA using clinically accessible tools and then using these data to focus individualized treatment approaches.

Diagnostic accuracy and suitability of instruments that screen for obstructive sleep apnoea, insomnia and sleep quality in cardiac patients: a meta-analysis

BACKGROUND

A number of clinical guidelines recommend that all cardiac rehabilitation patients should be screened for potential sleep disorders with a validated screening instrument. There is currently no consensus on what specific tools should be used.

OBJECTIVE

To identify tools that are practical to use in the clinical environment and have high diagnostic accuracy.

METHODS

We systematically searched online databases to identify patient reported outcome instruments that have been used in published research studies to assess the likelihood of obstructive sleep apnoea (OSA) in cardiac patients. In studies that provided diagnostic data, these data were extracted and verified via an evidence-based diagnostic calculator. Where sufficient numbers of studies were available, a meta-analysis was conducted to determine pooled estimates of specificity, sensitivity and diagnostic odds ratios. Selected papers were qualitatively assessed using the Standards for Reporting Diagnostic accuracy studies (STARD).

RESULTS

Of the 21 instruments identified, six detected likelihood of OSA, two assessed daytime sleepiness, five assessed insomnia and eight examined sleep quality. A meta-analysis of 14 studies that assessed diagnostic accuracy of moderate OSA, revealed moderate sensitivity for the Berlin Questionnaire, Sens = 0.49 (95% CI 0.45-0.52) and good sensitivity for the Stop-BANG, Sens = 0.93 (95% CI 0.87-0.96) but poor specificity at standard cut-off criteria.

CONCLUSION

There are promising practical tools available to screen patients with OSA and other sleep disorders in cardiac rehabilitation settings, but specificity could be improved. Additional assessment of sleep quality may enhance prognostic ability with both OSA and insomnia screening.

Mood, sleepiness, and weight gain after three years on CPAP therapy for sleep apnoea

Background: The prevalence of obstructive sleep apnoea syndrome (OSAS) keeps on rising. Daytime sleepiness resulting from fragmented sleep is the prime symptom, and obesity the major risk factor for OSAS. Quality of life with OSAS is often affected by depressive symptoms and anxiety. Nasal continuous positive airway pressure (CPAP) therapy reduces daytime sleepiness, but the results on the effect on mood, physical activity, and weight are controversial especially on long-term therapy. Purpose of this study was to evaluate these factors and predictors of weight gain during long-term CPAP therapy.

Methods: Consecutive patients (n = 223), referred to sleep study with suspected OSAS, were enrolled. Patients underwent a cardiorespiratory polygraphy at baseline and a battery of questionnaires was completed, both at baseline, and after three years of follow-up. Total of 149 (67%; M 65, F 84) patients completed the follow-up. Of the 149 patients, 76 (51.0%; M 32, F 44) used CPAP.

Results: In this study, depressive symptoms, anxiety, and sleepiness were alleviated during CPAP therapy. However, therapy did not have an influence on cravings of different food categories, or exercise habits and exercise duration. From the various factors studied, solely higher adherence to CPAP therapy was associated with weight gain.

Conclusions: This research provides further evidence that long-term CPAP therapy in patients with OSAS not only decreases sleepiness and improves sleep quality but could also alleviate depressive symptoms and anxiety. In addition, our study reinforces that CPAP therapy alone is not sufficient for weight management in patients with OSAS. Regardless of comprehensive battery of questionnaires, we were unable to establish markers predicting weight gain during therapy. We advise on life-style counselling and weight management program to all patients with obesity on CPAP therapy.

Snoring and depression symptoms in pregnant women

OBJECTIVE

Pregnant patients are vulnerable to both depression and sleep-disordered breathing, and both convey risks for maternal and fetal outcomes. Previous research has indicated that sleep-disordered breathing is associated with depression, but further information related to the risk of depression based on timing of onset of snoring is needed.

DESIGN

When presenting to clinic for their initial prenatal visit, pregnant patients completed a packet of questionnaires, which included measures related to depression (Edinburgh Postnatal Depression Scale) and snoring. Habitual snoring was defined as snoring 3 or more nights per week.

RESULTS

In total, 1367 women were included and 34.1% reported habitual snoring, either chronic (24.4%) or pregnancy-onset (9.8%), with increased frequency of pregnancy-onset habitual snoring in later stages of pregnancy. Unadjusted analyses suggested increased odds of depressive symptoms in chronic and pregnancy-onset habitual snoring groups relative to nonsnorers (odds ratio [OR]: 2.01, 95% confidence interval [CI]: 1.39, 2.92, P < .01; OR: 2.50, 95% CI: 1.54, 4.07, P < .01, respectively). These findings were maintained after adjusting for maternal age, marital status, gestational age, and parity (chronic habitual snoring OR: 1.69, 95% CI: 1.14, 2.53, P < .01; pregnancy-onset habitual snoring OR: 2.79, 95% CI: 1.35, 5.78, P < .01).

CONCLUSIONS

Maternal snoring may be a risk factor for prenatal depressive symptoms. Pregnancy-onset habitual snoring confers additional risk for depression compared to not snoring during pregnancy.

CPAP increases physical activity in obstructive sleep apnea with cardiovascular disease

STUDY OBJECTIVES

Uncertainty exists over whether continuous positive airway pressure (CPAP) treatment improves moderate to vigorous physical activity levels in those with obstructive sleep apnea. We aimed to determine effects of CPAP on moderate to vigorous physical activity among participants with co-occurring cardiovascular disease and obstructive sleep apnea.

METHODS

The Sleep Apnea cardioVascular Endpoints (SAVE) trial recruited participants with confirmed cardiovascular disease history and obstructive sleep apnea, 45-75 years old. The 2,687 participants (1,346 randomized to CPAP plus usual care and 1,341 to usual care alone) were followed up for a mean of 3.7 years. Self-reported physical activity was recorded at baseline, 6, 24, and 48 months using the Godin-Shepard Leisure Time Exercise Questionnaire (LTEQ). We also determined effects on any limitation of physical activity reported on the physical functioning subscale of the 36-item short form questionnaire (SF-36) and proportions of participants reaching guideline recommended physical activity levels.

RESULTS

Among 2,601 participants with available data, those in the CPAP group reported significantly more physical activity compared to the usual care group, with approximately 20% higher reported moderate activities on the LTEQ during follow-up (adjusted mean 95% confidence interval) scores: 8.7, 7.5-9.9 vs 7.3, 6.1-8.5; P = .003). Those in the CPAP group also reported less limitation in physical activity (adjusted between-group difference in SF-36 physical functioning subscale score 1.66, 95% confidence interval 0.87-2.45; P < 0.001), and more reported sufficient levels of physical activity to meet recommendations.

CONCLUSIONS

CPAP has positive effects on improving physical activity levels, consistent with long-term health benefits.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Continuous Positive Airway Pressure Treatment of Obstructive Sleep Apnea to Prevent Cardiovascular Disease (SAVE); URL: https://clinicaltrials.gov/ct2/show/NCT00738179; Identifier: NCT00738179; and Registry: Australian New Zealand Clinical Trials Registry; Name: Sleep Apnea cardioVascular Endpoints study-An investigation of continuous positive airway pressure for the treatment of obstructive sleep apnea to prevent cardiovascular disease; URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=83062&isReview=true; Identifier: ACTRN12608000409370.

What is a Clinically Meaningful Target for Positive Airway Pressure Adherence?

Although good adherence to continuous positive airway pressure (PAP) traditionally is defined as greater than or equal to 4 hours/night, the origins and rationale for this remain unclear. Research studies report variation in optimal duration of PAP adherence, depending on outcome of interest. Evidence demonstrates benefit with PAP for daytime sleepiness, quality of life, neurocognitive outcomes, depression, and hypertension, predominantly in symptomatic, moderate-severe obstructive sleep apnea. Recent randomized controlled trials, however, have failed to demonstrate a reduction in cardiovascular and mortality risks. This review explores the question of what can be considered a clinically meaningful outcome for PAP adherence.

Vital Signs During the COVID-19 Outbreak: A Retrospective Analysis of 19,960 Participants in Wuhan and Four Nearby Capital Cities in China

Background

The implications of city lockdown on vital signs during the COVID-19 outbreak are unknown.

Objective

We longitudinally tracked vital signs using data from wearable sensors and determined associations with anxiety and depression.

Methods

We selected all participants in the HUAWEI Heart Study from Wuhan and four nearby large provincial capital cities (Guangzhou, Chongqing, Hangzhou, Zhengzhou) and extracted all data from 26 December 2019 (one month before city lockdown) to 21 February 2020. Sleep duration and quality, daily steps, oxygen saturation and heart rate were collected on a daily basis. We compared the vital signs before and after the lockdown using segmented regression analysis of the interrupted time series. The depression and anxiety cases were defined as scores ≥8 on the Hospital Anxiety and Depression Scale depression and anxiety subscales [HADS-D and HADS-A] in 727 participants who finished the survey.

Results

We included 19,960 participants (mean age 36 yrs, 90% men). Compared with pre-lockdown, resting heart rate dropped immediately by 1.1 bpm after city lockdown (95% confidence interval [CI]: -1.8, -0.4). Sleep duration increased by 0.5 hour (95% CI: 0.3, 0.8) but deep sleep ratio decreased by 0.9% (95% CI: -1.2, -0.6). Daily steps decreased by 3352 steps (95% CI: -4333, -2370). Anxiety and depression existed in 26% and 17% among 727 available participants, respectively, and associated with longer sleep duration (0.2 and 0.1 hour, both p < 0.001).

Conclusions

Lockdown of Wuhan in China was associated with an adverse vital signs profile (reduced physical activity, heart rate, and sleep quality, but increased sleep duration). Wearable devices in combination with mobile-based apps may be useful to monitor both physical and mental health.

Clinical trial registration

The trial is registered at Chinese Clinical Trial Registry (ChiCTR) website (ChiCTR-OOC-17014138).

Continuous positive airway pressure treatment and anxiety in adults with coronary artery disease and nonsleepy obstructive sleep apnea in the RICCADSA trial

BACKGROUND

Anxiety and obstructive sleep apnea (OSA) coexist among adults with coronary artery disease (CAD) following revascularization. Continuous positive airway pressure (CPAP) is the first line treatment of OSA patients with daytime sleepiness. The current study evaluated the effect of CPAP on anxiety in CAD patients with nonsleepy OSA.

METHODS

Two hundred forty-four revascularized CAD patients with nonsleepy OSA (apnea-hypopnea index ≥15/h, Epworth Sleepiness Scale score <10) were randomly assigned to CPAP or no-CPAP between 2005 and 2010. Zung Self-rating Anxiety Scale (SAS) was administered at baseline and after 3 and 12 months with higher scores suggesting more anxiety.

RESULTS

A total of 208 patients with complete SAS scores at baseline and 12-month follow-up were included (CPAP, n = 103; no-CPAP, n = 105). In the intention-to-treat analysis, CPAP had no significant effect on the SAS scores. On-treatment analysis revealed a significant increase in the median of delta SAS score (+3.75) after three months among the participants using the device 2.8 h/day or more while there was a decline in the median of delta SAS score (-1.25) in the non-adherent or no-CPAP group (p = 0.031). The increase in the SAS score (+1.25) in the adherent group, and the decline (-1.25 points) in the non-adherent/no-CPAP group remained significant after one year (p = 0.011). Baseline SAS score predicted non-adherence [adjusted odds ratio 1.11; 95% confidence interval (CI) 1.04-1.18; p = 0.003], and there was an association between the increase in the SAS scores and accumulated CPAP hours/day [standardized β = 0.144 (95% CI 0.005-0.695), p = 0.047].

CONCLUSION

Our results suggest that anxiety should be considered in the management of CAD patients with nonsleepy OSA following revascularization.

CLINICAL TRIAL REGISTRATION

NCT00519597.

Oxygen desaturation during flexible bronchoscopy with propofol sedation is associated with sleep apnea: the PROSA-Study

BACKGROUND

Obstructive sleep apnea (OSA) is characterized by repetitive episodes of complete or partial obstruction of the upper airways during sleep. Conscious sedation for flexible bronchoscopy (FB) places patients in a sleep-like condition. We hypothesize that oxygen desaturation during flexible bronchoscopy may help to detect undiagnosed sleep apnea.

METHODS

Single-centre, investigator-initiated and driven study including consecutive patients undergoing FB for clinical indication. Patients completed the Epworth Sleepiness Scale (ESS), Lausanne NoSAS score, STOP-BANG questionnaire and the Berlin questionnaire and underwent polygraphy within 7 days of FB. FB was performed under conscious sedation with propofol. Oxygen desaturation during bronchoscopy was measured with continuous monitoring of peripheral oxygen saturation with ixTrend (ixellence GmbH, Germany).

RESULTS

145 patients were included in the study, 62% were male, and the average age was 65.8 ± 1.1 years. The vast majority of patients (n = 131, 90%) proved to fulfill OSA criteria based on polygraphy results: 52/131 patients (40%) had mild sleep apnea, 49/131 patients (37%) moderate sleep apnea and 30/131 patients (23%) severe sleep apnea. Patients with no oxygen desaturation had a significantly lower apnea-hypopnea index than patients with oxygen desaturation during bronchoscopy (AHI 11.94/h vs 21.02/h, p = 0.011). This association remained significant when adjusting for the duration of bronchoscopy and propofol dose (p = 0.023; 95% CI 1.382; 18.243) but did not hold when also adjusting for age and BMI.

CONCLUSION

The severity of sleep apnea was associated to oxygen desaturation during flexible bronchoscopy under conscious sedation. Patients with oxygen desaturation during bronchoscopy might be considered for sleep apnea screening.

TRIAL REGISTRATION

The Study was approved by the Ethics Committee northwest/central Switzerland, EKNZ (EK 16/13) and was carried out according to the Declaration of Helsinki and Good Clinical Practice guidelines. Due to its observational character, the study did not require registration at a clinical trial registry.

Effect of continuous positive airway pressure on symptoms of anxiety and depression in patients with obstructive sleep apnea

Purpose

The objective was to assess the effect of continuous positive airway pressure (CPAP) on symptoms of anxiety and depression in patients with obstructive sleep apnea (OSA). We hypothesized a decrease in symptoms at follow-up, but that improvement relied on CPAP adherence.

Methods

The sample comprised 468 patients (mean age 55.5 years (SD = 12.0), 72% men) with OSA who received CPAP at a Norwegian hospital. OSA was diagnosed according to standard respiratory polygraphy. Mean baseline respiratory event index (REI) was 28.4 (SD = 20.6). Symptoms of anxiety and depression were assessed prior to CPAP treatment and at follow-up after a median of 20 weeks, range 6–52 weeks, with the Hospital Anxiety and Depression Scale (HADS). Patients were classified as CPAP adherent (≥ 4 h per night) or non-adherent (< 4 h per night).

Results

There was a significant decrease in anxiety scores from baseline (mean = 5.16, SD = 3.94) to follow-up (mean = 4.76, SD = 3.81), p < 0.001. Similarly, depression scores decreased from baseline (mean = 4.31, SD = 3.66) to follow-up (mean = 3.89, SD = 3.69), p < 0.001. Cohen’s d (0.19 and 0.18, respectively) indicated small effect sizes. The reduction in anxiety scores did not depend on CPAP adherence (no interaction effect F(1, 466) = 0.422, p = 0.516), whereas the reduction in depression scores were seen only in the CPAP adherent group (interaction effect F(1, 466) = 7.738, p = 0.006).

Conclusions

We found a decrease in symptoms of anxiety and depression from baseline to follow-up of CPAP treatment. The improvement in symptoms of depression was depending on CPAP adherence. This underlines the importance of adherence for optimal effect of CPAP treatment.

Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea

BACKGROUND

Although highly effective in the treatment of obstructive sleep apnoea (OSA), continuous positive airway pressure (CPAP) is not universally accepted by users. Educational, supportive and behavioural interventions may help people with OSA initiate and maintain regular and continued use of CPAP.

OBJECTIVES

To assess the effectiveness of educational, supportive, behavioural, or mixed (combination of two or more intervention types) strategies that aim to encourage adults who have been prescribed CPAP to use their devices.

SEARCH METHODS

Searches were conducted on the Cochrane Airways Group Specialised Register of trials. Searches are current to 29 April 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that assessed intervention(s) designed to inform participants about CPAP/OSA, to support them in using CPAP, or to modify their behaviour to increase use of CPAP devices.

DATA COLLECTION AND ANALYSIS

We assessed studies to determine their suitability for inclusion in the review. Data were extracted independently and were entered into RevMan for analysis. 'Risk of bias' assessments were performed, using the updated 'Risk of bias 2' tool, for the primary outcome, CPAP usage. Study-level 'Risk of bias' assessments were performed using the original 'Risk of bias' tool. GRADE assessment was performed using GRADEpro.

MAIN RESULTS

Forty-one studies (9005 participants) are included in this review; 16 of these studies are newly identified with updated searches. Baseline Epworth Sleepiness Scale (ESS) scores indicate that most participants suffered from excessive daytime sleepiness. The majority of recruited participants had not used CPAP previously. When examining risk of bias for the primary outcome of hourly machine usage/night, 58.3% studies have high overall risk (24/41 studies), 39.0% have some concerns (16/41 studies), and 2.4% have low overall risk (1/41 studies). We are uncertain whether educational interventions improve device usage, as the certainty of evidence was assessed as very low. We were unable to perform meta-analyses for number of withdrawals and symptom scores due to high study heterogeneity. Supportive interventions probably increase device usage by 0.70 hours/night (95% confidence interval (CI) 0.36 to 1.05, N = 1426, 13 studies, moderate-certainty evidence), and low-certainty evidence indicates that the number of participants who used their devices ≥ 4 hours/night may increase from 601 to 717 per 1000 (odds ratio (OR), 1.68, 95% CI 1.08 to 2.60, N = 376, 2 studies). However, the number of withdrawals may also increase from 136 to 167 per 1000 (OR 1.27, 95% CI 0.97 to 1.66, N = 1702, 11 studies, low-certainty evidence). Participants may experience small improvements in symptoms (ESS score -0.32 points, 95% CI -1.19 to 0.56, N = 470, 5 studies, low-certainty evidence), and we are uncertain whether quality of life improves with supportive interventions, as the certainty of evidence was assessed as very low. When compared with usual care, behavioural interventions produce a clinically-meaningful increase in device usage by 1.31 hours/night (95% CI 0.95 to 1.66, N = 578, 8 studies, high-certainty evidence), probably increase the number of participants who used their machines ≥ 4 hours/night from 371 to 501 per 1000 (OR 1.70, 95% CI 1.20 to 2.41, N = 549, 6 studies, high-certainty evidence), and reduce the number of study withdrawals from 146 to 101 per 1000 (OR 0.66, 95% CI 0.44 to 0.98, N = 939, 10 studies, high-certainty evidence). Behavioural interventions may reduce symptoms (ESS score -2.42 points, 95% CI -4.27 to -0.57, N = 272, 5 studies, low-certainty evidence), but probably have no effect on quality of life (Functional Outcomes of Sleep Questionnaire (FOSQ), standardised mean difference (SMD) 0.00, 0.95% CI -0.26 to 0.26, N = 228, 3 studies, moderate-certainty evidence). We are uncertain whether behavioural interventions improve apnoea hypopnoea index (AHI), as the certainty of evidence was assessed as very low. We are uncertain if mixed interventions improve device usage, increase the number of participants using their machines ≥ 4 hours/night, reduce study withdrawals, improve quality of life, or reduce anxiety symptoms, as the certainty of evidence for these outcomes was assessed to be very low. Symptom scores via the ESS could not be measured due to considerable heterogeneity between studies.

AUTHORS' CONCLUSIONS

In CPAP-naïve people with OSA, high-certainty evidence indicates that behavioural interventions yield a clinically-significant increase in hourly device usage when compared with usual care. Moderate certainty evidence shows that supportive interventions increase usage modestly. Very low-certainty evidence shows that educational and mixed interventions may modestly increase CPAP usage. The impact of improved CPAP usage on daytime sleepiness, quality of life, and mood and anxiety scores remains unclear since these outcomes were not assessed in the majority of included studies. Studies addressing the choice of interventions that best match individual patient needs and therefore result in the most successful and cost-effective therapy are needed.

Obstructive Sleep Apnea in Psychiatric Inpatients

The aim of this study was to identify the prevalence of heightened risk for obstructive sleep apnea (OSA) and its clinical predictors in a heterogeneous diagnostic group of hospitalized psychiatric patients. Ninety-one consecutive psychiatric inpatients were administered the STOP-BANG and Epworth Sleepiness Scale (ESS) inventories. Medical and demographic information was gathered from inpatient clinical charts. Predictors of high OSA risk score were analyzed by a multivariate regression model. A total of 58.2% (53 patients) were determined to have a high risk for OSA. The predictors of high OSA risk were use of mood stabilizers, use of CNS depressants, use of CNS stimulants, and excessive daytime sleepiness measured by ESS. The risk of OSA was high in psychiatric inpatients, and particularly elevated in older patients and those taking commonly utilized psychiatric medications.

A Retrospective Study to Identify Novel Factors Associated with Post-stroke Anxiety

BACKGROUND AND PURPOSE

Post-stroke anxiety (PSA) is common and disabling. PSA should be considered as an important outcome in stroke. However, there is a lack of understanding of factors that may be linked to PSA. The purpose of this study was to determine the frequency of PSA and sociodemographic and clinical factors associated with PSA in a cohort of racially and ethnically diverse stroke patients.

METHODS

We conducted a retrospective study of ischemic and hemorrhagic stroke patients seen in a stroke outpatient clinic from August 1, 2017 to June 30, 2018. Patients were eligible if a Generalized Anxiety Disorder 7-Item (GAD-7) instrument was available. GAD-7 scores greater than or equal to 10 indicated the presence of moderate to severe PSA. Multivariable logistic regression was used to identify independent sociodemographic and clinical factors associated with PSA.

RESULTS

Records from 289 stroke patients with a GAD-7 instrument were analyzed. PSA was common (21%; GAD-7 ≥ 10). Fifty-seven percent of females had a GAD-7 greater than or equal to 10 compared to 41% of females who had a GAD-7 less than 10 (P = .03). Multivariable analysis found that self-reported nonmarried status (odds ratio, 3.27; 95% confidence interval, 1.44-7.44), excessive fatigue (odds ratio, 4.46; 95% confidence interval, 1.87-10.63), and depression (odds ratio, 1.24; 95% confidence interval, 1.16-1.33) were independently associated with PSA.

CONCLUSIONS

PSA may occur more frequently in those who report non-married, excessive fatigue, or depression. Trials of PSA interventions should consider the potential impact of social support, depression, and comorbid conditions contributing to post-stroke fatigue, including sleep apnea.

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is very common but is frequently undiagnosed. Symptoms include loud snoring, nocturnal awakening, and daytime sleepiness. Motor vehicle accidents due to drowsy driving are a particular concern. Evaluation and treatment should focus on symptomatic patients, both to alleviate symptoms and to potentially decrease cardiovascular risk. In recent years, a strategy of home sleep apnea testing followed by initiation of autotitrating continuous positive airway pressure therapy in the home has greatly reduced barriers to diagnosis and treatment and has also facilitated routine management of OSA by primary care providers.

Redesigning Care for OSA

Constrained by a limited supply of specialized personnel, health systems face a challenge in caring for the large number of patients with OSA. The complexity of this challenge is heightened by the varied clinical presentations of OSA and the diversity of treatment approaches. Innovations such as simplified home-based care models and the incorporation of nonspecialist providers have shown promise in the management of uncomplicated patients, producing comparable outcomes to the resource-intensive traditional approach. However, it is unclear if these innovations can meet the needs of all patients with OSA, including those with mild disease, atypical presentations, and certain comorbid medical and mental health conditions. This review discusses the diversity of needs in OSA care, the evidence base behind recent care innovations, and the potential limitations of each innovation in meeting the diversity of care needs. We propose how these innovations can fit within the stepped care and hub and spoke models in a way that addresses the full spectrum of OSA, and we discuss future research directions to assess the deployment of these innovations.