Insomnia and Obstructive Sleep Apnea

Prevalence, dimensions, and correlates of excessive daytime sleepiness in community-dwelling older adults: the Yilan study, Taiwan

BACKGROUND

Daytime sleepiness is an important health problem. However, the dimensionality of the Epworth Sleepiness Scale (ESS) in older adults remains unclear. This study aimed to determine the prevalence of ESS-defined excessive daytime sleepiness in older adults. Furthermore, the dimensionality of ESS and its respective correlates were also compared.

MATERIALS AND METHODS

This is a community-based survey in which community-dwelling older adults aged ≥ 65 years participated. Excessive daytime sleepiness was assessed using the ESS and was defined as an ESS score of > 10. Exploratory factor analysis was performed to identify the ESS factors. Multiple logistic regression analysis was used to examine the independent correlates of the ESS-defined and factor-specific correlates of excessive daytime sleepiness.

RESULTS

In total, 3978 older adults participated in this study. The mean age was 76.6 ± 6.7 years, with 53.8% ≥ 75 years, and 57.1% were female. The prevalence of ESS-defined excessive daytime sleepiness was 16.0%. An exploratory factor analysis revealed two factors in the ESS, which were designated as 'passive' and 'active' according to the soporific levels of ESS items loaded in each factor. Multiple logistic regression showed that male, illiteracy, depression, disability, short sleep duration and no exposure to hypnotics were risk indicators for ESS-defined excessive daytime sleepiness. However, the correlates for passive and active factor-defined excessive daytime sleepiness differ in pattern, especially in variables related to education, exercise, mental health, and sleep.

CONCLUSIONS

The prevalence of ESS-defined excessive daytime sleepiness is high, and its correlates vary among older adults. This study also suggests a dual ESS structure in community-dwelling older adults.

Difficulty Falling Asleep is Associated with Poorer Therapeutic Outcomes in Unilateral Hypoglossal Nerve Stimulation

Purpose

The coexistence of insomnia and obstructive sleep apnea (OSA) is very prevalent. Hypoglossal nerve stimulation (HGNS) is an established second-line therapy for patients suffering OSA. Studies investigating the effect of the different aspects of insomnia on the therapeutic outcome are largely missing. Therefore, this study aimed to understand the impact of the different aspects of insomnia on the therapeutic outcome under HGNS therapy in clinical routine.

Patients and Methods

This is a retrospective study including 30 consecutive patients aged 55.40 ± 8.83 years (8 female; 22 male) undergoing an HGNS implantation in our tertiary medical center between 2020 and 2023. All patients underwent preoperative polysomnography (PSG) according to AASM. First follow-up PSG was performed 95.40 ± 39.44 days after activation (30 patients) and second follow-up PSG was performed 409.89 ± 122.52 days after activation (18 patients). Among others, the following PSG-related parameters were evaluated: apnea-hypopnea index (n/h) (AHI) and oxygen desaturation index (n/h) (ODI). Insomnia was assessed by the insomnia severity index (ISI) questionnaire. Preoperatively, all patients included filled out each ISI item. Spearman's-rho correlation coefficient was calculated for correlations.

Results

Preoperative score of ISI item 1 (difficulty falling asleep) was 1.93 ± 1.34 and preoperative cumulative ISI score (item1-7) was 18.67 ± 5.32. Preoperative AHI was 40.61 ± 12.02 (n/h) and preoperative ODI was 38.72 ± 14.28 (n/h). In the second follow-up, the mean difference in AHI was ∆ 10.47 ± 15.38 (n/h) and the mean difference in ODI was ∆ 8.17 ± 15.67 (n/h). Strong significant correlations were observed between ISI item 1 (difficulty falling asleep) and both ∆ AHI (r: -0.65, p=0.004) and ∆ ODI (r: -0.7; p=0.001) in the second follow-up.

Conclusion

Difficulty falling asleep may hence negatively influence HGNS therapeutic outcome. Insomnia-related symptoms should be considered in the preoperative patient evaluation for HGNS.

Knowledge and attitude regarding obstructive sleep apnoea among medical and dental practitioners working in North-Eastern Peninsular Malaysia: A comparative cross-sectional study

BACKGROUND

Obstructive Sleep Apnea (OSA) is a temporary airflow obstruction during periods of sleep. Patients with OSA often suffer from poor work performance, compromised sleep quality, and low quality of life which may lead to a life-threatening event. Adequate knowledge and a positive attitude toward OSA among medical and dental practitioners are crucial to the initial diagnosis and treatment.

OBJECTIVE

This study aimed to identify the differences in knowledge and attitude toward OSA between medical and dental practitioners working in North-Eastern Peninsular Malaysia.

METHODS

A comparative cross-sectional study was performed from February 2020 to February 2021. A total of fifty-two medical practitioners and fifty-two dental practitioners working at university-based outpatient clinics, government health clinics, and oral health clinics located in Kelantan State of Malaysia participated in the study, and data were collected by the structured questionnaire including sociodemographic inquiry and OSAKA questionnaire by non-probability stratified random sampling. The Mann-Whitney U test was used to compare knowledge and attitude scores between the two groups.

RESULTS

The mean age of the respondents was 34.6 years. The current study shows that 92.3% of medical doctors and 96.1% of dental doctors were able to correctly answer the question "Most of the patients with OSA snore" a significant finding in our study. Only 1% of medical professionals could answer seventeen questions correctly with a median score of 11, and only 1% of dental professionals could answer sixteen questions correctly with a median score of 9. None of them could provide an accurate answer to all the knowledge questions. Medical and dental practitioners exhibited different knowledge levels on OSA (z- statistics=-4.39, U = 827.00 with p <  0.05, and effect size, r = 0.61). However, no significant differences were found in total knowledge score by gender (p-value>0.05), ethnicity (p-value>0.05), total service years (p-value>0.05), and training attended. In addition, significant differences in attitude levels between medical and dental practitioners have been observed (z-statistics=-3.42, U = 725.00 with p <  0.05, and effect size, r = 0.47). Nevertheless, no significant differences have been seen in total attitude score by ethnicity (p-value >  0.05), total service years (p-value >  0.05), attending training on OSA (p-value >  0.05), and professional status (p-value >  0.05) except gender (p-value <  0.05).

CONCLUSION

A Significant difference is evident concerning knowledge and attitude toward OSA diagnosis and management between medical and dental practitioners working in North-Eastern Peninsular Malaysia. Medical practitioners in this study recorded a higher knowledge and attitude score compared to dental practitioners.

Clinical usefulness of dual orexin receptor antagonism beyond insomnia: Neurological and psychiatric comorbidities

Orexin is a neurotransmitter produced by a small group of hypothalamic neurons. Besides its well-known role in the regulation of the sleep-wake cycle, the orexin system was shown to be relevant in several physiological functions including cognition, mood and emotion modulation, and energy homeostasis. Indeed, the implication of orexin neurotransmission in neurological and psychiatric diseases has been hypothesized via a direct effect exerted by the projections of orexin neurons to several brain areas, and via an indirect effect through orexin-mediated modulation of sleep and wake. Along with the growing evidence concerning the use of dual orexin receptor antagonists (DORAs) in the treatment of insomnia, studies assessing their efficacy in insomnia comorbid with psychiatric and neurological diseases have been set in order to investigate the potential impact of DORAs on both sleep-related symptoms and disease-specific manifestations. This narrative review aimed at summarizing the current evidence on the use of DORAs in neurological and psychiatric conditions comorbid with insomnia, also discussing the possible implication of modulating the orexin system for improving the burden of symptoms and the pathological mechanisms of these disorders. Target searches were performed on PubMed/MEDLINE and Scopus databases and ongoing studies registered on Clinicaltrials.gov were reviewed. Despite some contradictory findings, preclinical studies seemingly support the possible beneficial role of orexin antagonism in the management of the most common neurological and psychiatric diseases with sleep-related comorbidities. However, clinical research is still limited and further studies are needed for corroborating these promising preliminary results.

Brain structural correlates of subjective sleepiness and insomnia symptoms in shift workers

Background

Studies on the brain structures of shift workers are limited; thus, this cross-sectional study aimed to compare the brain structures and the brain structural correlates of subjective sleepiness and insomnia symptoms between shift workers and non-shift workers.

Methods

Shift workers (n = 63) and non-shift workers (n = 58) completed questionnaires assessing subjective sleepiness and insomnia symptoms. Cortical thickness, cortical surface area, and subcortical volumes were measured by magnetic resonance imaging. The brain morphometric measures were compared between the groups, and interaction analyses using the brain morphometric measures as the dependent variable were performed to test the interactions between the study group and measures of sleep disturbance (i.e., subjective sleepiness and insomnia symptoms).

Results

No differences in cortical thickness, cortical surface area, or subcortical volumes were detected between shift workers and non-shift workers. A single cluster in the left motor cortex showed a significant interaction between the study group and subjective sleepiness in the cortical surface area. The correlation between the left motor cortex surface area and the subjective sleepiness level was negative in shift workers and positive in non-shift workers. Significant interaction between the study group and insomnia symptoms was present for the left/right putamen volumes. The correlation between the left/right putamen volumes and insomnia symptom levels was positive in shift workers and negative in non-shift workers.

Conclusion

Left motor cortex surface area and bilateral putamen volumes were unique structural correlates of subjective sleepiness and insomnia symptoms in shift workers, respectively.

The effects of social support and support types on continuous positive airway pressure use after 1month of therapy among adults with obstructive sleep apnea

BACKGROUND

The relationship between perceived social support and continuous positive airway pressure remains understudied among individuals with obstructive sleep apnea. The aim of this prospective cohort study was to determine if baseline perceived social support and subtypes predict regular continuous positive airway pressure use after 1month of therapy.

METHODS

Adults with obstructive sleep apnea initiating continuous positive airway pressure therapy were recruited from sleep clinics in New York City. Demographics, medical history, and comorbidities were obtained from patient interview and review of medical records. Objective continuous positive airway pressure adherence data was collected at the first clinical follow-up.

RESULTS

Seventy-five participants (32% female; non-Hispanic Black 41%; mean age of 56 ± 14years) provided data. In adjusted analyses, poorer levels of overall social support, and subtypes including informational/emotional support, and positive social interactions were associated with lower continuous positive airway pressure use at 1month. Relative to patients reporting higher levels of support, participants endorsing lower levels of overall social support, positive social interaction and emotional/informational support had 1.6 hours (95% CI: 0.5,2.7, hours; p = .007), 1.3 hours (95% CI: 0.2,2.4; p = .026), and 1.2 hours (95% CI: 0.05,2.4; p = .041) lower mean daily continuous positive airway pressure use at 1month, respectively.

CONCLUSION

Focusing on social support overall and positive social interaction particularly, could be an effective approach to improve continuous positive airway pressure adherence in patients at risk of suboptimal adherence.

Orexin Receptor Antagonism: Normalizing Sleep Architecture in Old Age and Disease

Sleep is essential for human well-being, yet the quality and quantity of sleep reduce as age advances. Older persons (>65 years old) are more at risk of disorders accompanied and/or exacerbated by poor sleep. Furthermore, evidence supports a bidirectional relationship between disrupted sleep and Alzheimer's disease (AD) or related dementias. Orexin/hypocretin neuropeptides stabilize wakefulness, and several orexin receptor antagonists (ORAs) are approved for the treatment of insomnia in adults. Dysregulation of the orexin system occurs in aging and AD, positioning ORAs as advantageous for these populations. Indeed, several clinical studies indicate that ORAs are efficacious hypnotics in older persons and dementia patients and, as in adults, are generally well tolerated. ORAs are likely to be more effective when administered early in sleep/wake dysregulation to reestablish good sleep/wake-related behaviors and reduce the accumulation of dementia-associated proteinopathic substrates. Improving sleep in aging and dementia represents a tremendous opportunity to benefit patients, caregivers, and health systems.

Impact of Insomnia on Hypoglossal Nerve Stimulation Outcomes in the ADHERE Registry

OBJECTIVE

We aimed to determine the preoperative prevalence of insomnia in the Adherence and Outcomes of Upper Airway Stimulation for OSA International Registry (ADHERE) and to examine serial sleep-related data longitudinally, in particular the Insomnia Severity Index (ISI), to compare outcomes between patients with no/subthreshold insomnia (ISI < 15) and moderate/severe insomnia (ISI ≥ 15) at baseline.

METHODS

We analyzed observational data from ADHERE between March 2020 and September 2022. Baseline demographic and mental health (MH) data, apnea hypopnea index (AHI), ISI, and ESS (Epworth Sleepiness Scale) were recorded. At post-titration (PT) and final visits, AHI, ISI, ESS and nightly usage were compared between baseline ISI < 15 and ISI ≥ 15 subgroups.

RESULTS

A baseline ISI was obtained in 928 patients (62% with ISI ≥ 15). Of the 578 and 141 patients reaching the 12- and 24-month time periods to complete PT and final visits, 292 (50.5%) and 91 (64.5%) completed the ISI, respectively. Baseline MH conditions were higher with ISI ≥ 15 than ISI < 15 (p < 0.001). AHI reduction and adherence did not differ between patients with baseline ISI ≥ 15 and ISI < 15. Patients with ISI ≥ 15 experienced greater improvement in ESS than ISI < 15 at post-titration and final visits (p = 0.014, 0.025). All patients had improved nocturnal, daytime, and overall ISI scores at follow-up visits (p < 0.001), especially for those with baseline ISI ≥ 15 compared with ISI < 15 (p < 0.05).

CONCLUSION

HGNS therapy efficacy and adherence were similar between ISI severity subgroups at follow-up visits. Insomnia and sleepiness scores improved in all patients with HGNS therapy and to a greater degree in patients with baseline moderate/severe insomnia.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:471-479, 2024.

Links between Sleep Apnoea and Insomnia in a British Cohort

Poor sleep is a major public health problem with implications for a wide range of critical health outcomes. Insomnia and sleep apnoea are the two most common causes of poor sleep, and recent studies have shown that these disorders frequently co-occur. Comorbid insomnia and sleep apnoea can substantially impair quality of life and increase the overall risk of mortality. However, the causal and physiological links between sleep apnoea and insomnia are unclear. It is also unknown whether having a higher risk for one condition can increase the risk of developing the other. Here, we investigated links between sleep apnoea and insomnia in a British population using a combination of self-reported questionnaires and causal inference. We found that 54.3% of the cohort had moderate insomnia, 9.4% had moderate sleep apnoea, and that 6.2% scored high for both conditions. Importantly, having a higher risk of sleep apnoea was associated with a higher risk of insomnia and vice versa. To determine the causal directionality between sleep apnoea and insomnia, we used Mendelian randomisation and found evidence that sleep apnoea could cause insomnia, but not the reverse. To elucidate how both sleep apnoea and insomnia were linked to each other, we looked at the behavioural markers of poor sleep. We found that feeling fatigued after sleeping and having noticeable sleep problems were linked to a higher burden of both sleep apnoea and insomnia. In conclusion, our results show that sleep apnoea increases the risk of developing insomnia, and both conditions can result in fatigue. We highlight the importance of considering and treating the symptoms of both conditions.

Association of pruritus with sleep in patients with psoriasis and chronic spontaneous urticaria: A cross-sectional study

Background

Pruritus is a frequent complaint associated with various inflammatory dermatoses. Sleep is often disturbed because of pruritus but the impact of severity and diurnal pattern of pruritus has not been studied so far.

Objectives

To estimate the prevalence of nocturnal itch (NI) and its association with itch severity, sleep disturbance and quality of life (QoL) compared with non-NI in chronic plaque psoriasis (CPP) and chronic spontaneous urticaria (CSU).

Methods

We performed a cross-sectional study in patients aged ≥18 years with CPP or CSU for at least 6 weeks. A comprehensive in-house questionnaire designed for study formed the basis for categorizing patients into NI and non-NI. Validated instruments like visual analog scale, pruritus grading system, General Sleep Disturbance Scale, and Dermatology life quality index were used to assess itch severity, sleep, and QoL.

Results

A total of 255 patients (CPP: 131; CSU: 124) were included in this study. Prevalence of NI was 43.5% (95% confidence interval: 34.9%-52.4%) in CPP and 29% (95% confidence interval: 21.2%-37.9%) in CSU. NI was strongly associated with higher pruritus grading system scores in CSU and CPP (regression coefficient = 1.5, P =0.004 and regression coefficient = 1.3, P =0.004, respectively), with impaired sleep (OR = 2.97, P = 0.025) in CPP and with itch-affected sleep in CSU. Itch severity was associated with impaired sleep; however, the association was modified by the presence of NI in CSU patients.

Conclusion

Nocturnal itch is prevalent in chronic dermatoses and significant for sleep deficit and impaired QoL. Early screening and management of sleep disturbance among patients presenting with nocturnal itch should be routinely undertaken.

Sex Differences in Neurovascular Control: Implications for Obstructive Sleep Apnea

Patients with obstructive sleep apnea (OSA) have a heightened risk of developing cardiovascular diseases, namely hypertension. While seminal evidence indicates a causal role for sympathetic nerve activity in the hypertensive phenotype commonly observed in patients with OSA, no studies have investigated potential sex differences in the sympathetic regulation of blood pressure in this population. Supporting this exploration are large-scale observational data, as well as controlled interventional studies in healthy adults, indicating that sleep disruption increases blood pressure to a greater extent in females relative to males. Furthermore, females with severe OSA demonstrate a more pronounced hypoxic burden (i.e., disease severity) during rapid eye movement sleep when sympathetic nerve activity is greatest. These findings would suggest that females are at greater risk for the hemodynamic consequences of OSA and related sleep disruption. Accordingly, the purpose of this review is three-fold: (1) to review the literature linking sympathetic nerve activity to hypertension in OSA, (2) to highlight recent experimental data supporting the hypothesis of sex differences in the regulation of sympathetic nerve activity in OSA, and (3) to discuss the potential sex differences in peripheral adrenergic signaling that may contribute to, or offset, cardiovascular risk in patients with OSA.

Self-reported improvement in obstructive sleep apnea symptoms compared to treatment response with mandibular advancement device therapy: a retrospective study

PURPOSE

Mandibular advancement device (MAD) is recognized as the treatment option for management of obstructive sleep apnea (OSA) in mild-moderate cases or those unable to tolerate positive airway pressure therapy. Post-treatment sleep study is recommended to establish MAD efficacy when maximal therapeutic benefit is achieved based on OSA symptom improvement or maximum anatomical protrusion. The aim of this study was to investigate the difference between responders and non-responders in OSA symptom improvement and predictors of treatment success.

METHODS

Medical charts of patients referred to the Orofacial Pain Clinic between 2016 and 2021 for management of OSA with MAD were retrospectively evaluated. Participants with post-treatment sleep study with MAD in situ were included. Participants were categorized as responders according to different criteria: 50% reduction in apnea-hypopnea index (AHI) compared to baseline; post-treatment AHI ≤ 10 with ≥ 50% reduction from baseline; AHI ≤ 5 with ≥ 50% reduction. OSA symptoms included snoring, apneas, sleep quality, tiredness upon awakening, daytime sleepiness, and subjective improvement. Differences in pre- and post-treatment variables within/between groups and predictors were analyzed with t test and logistic regression.

RESULTS

Among 53 participants (30 females), mean age was 64.2 ± 10.7 and pre-treatment was AHI 23.3 ± 17.2. Depending upon the criteria, responders ranged between 26 and 57%. At first follow-up after MAD delivery, non-responders reported less tiredness upon awakening (p = 0.003), better sleep quality (p = 0.005), and greater subjective improvement (p = 0.012) than responders. Among significant OSA symptoms, tiredness upon awakening, poorer sleep quality, and less subjective improvement were consistently found as predictors of treatment response.

CONCLUSION

Subjective improvement, sleep quality, and tiredness upon awakening significantly improved in non-responders at first follow-up compared to responders, according to the strictest definition of treatment response. Therefore, a post-treatment sleep study is crucial to confirm proper management of OSA with MAD.

A First Look at Childhood Abuse in Women with Obstructive Sleep Apnea

Study objectives. Women who experienced childhood sexual abuse have higher rates of obesity, a risk factor for obstructive sleep apnea (OSA). We assessed if prior childhood sexual abuse was more common in women with OSA vs. control, with possible mediation by obesity. Methods . We studied 21 women with OSA (age mean±s.d. 59±12 years, body mass index (BMI) 33±8 kg/m 2 , respiratory event index [REI] 25±16 events/hour, Epworth Sleepiness Scale [ESS] 8±5) and 21 women without OSA (age 53±9 years, BMI 25±5 kg/m 2 , REI (in 7/21 women) 1±1 events/hour, ESS 5±3). We evaluated four categories of trauma (general trauma, physical, emotional, and sexual abuse) with the early trauma inventory self-report-short form (ETISR-SF). We assessed group differences in trauma scores with independent samples t-tests and multiple regressions. Parametric Sobel tests were used to model BMI as a mediator for individual trauma scores predicting OSA in women. Results. Early childhood sexual abuse reported on the ETISR-SF was 2.4 times more common in women with vs. without OSA ( p =0.02 for group difference). Other trauma scores were not significantly different between women with and without OSA. However, BMI was a significant mediator ( p =0.02) in predicting OSA in women who experienced childhood physical abuse. Conclusions. Childhood sexual abuse was more common in a group of women with OSA than those without OSA. Additionally, BMI was a mediator for OSA of childhood physical but not sexual abuse. There may be physiological impacts of childhood trauma in women that predispose them to OSA.

Evaluation of HIF-1 Involvement in the BDNF and ProBDNF Signaling Pathways among Obstructive Sleep Apnea Patients

Obstructive Sleep Apnea (OSA) is a chronic condition characterized by intermittent hypoxia associated with multiple comorbidities, including psychiatric disorders, such as depression, insomnia, and cognitive impairment. The brain-derived neurotrophic factor (BDNF) and proBDNF singling pathways have been shown to be involved in this group of diseases. Furthermore, their expression might be affected by hypoxia-inducible factor 1 (HIF-1), which is an oxygen sensitive transcription factor due to its alpha subunit. Therefore, this study aimed to evaluate the association between HIF-1α, BDNF, and proBDNF protein levels among OSA patients. This study included 40 individuals who underwent polysomnography (PSG) and were divided into the OSA group (n = 20; AHI ≥ 30) and healthy control (n = 20; AHI < 5) based on the apnea−hypopnea index (AHI). All participants had their peripheral blood collected in the evening before and the morning after the PSG. BDNF, proBDNF, and HIF-1α protein concertation measurements were performed using ELISA. No differences were found in BDNF, proBDNF, and HIF-1α protein levels between OSA and the control group, both in the evening and in the morning. In the OSA group, i.e., the linear regression model, the morning BDNF protein level was predicted by age (ß = −0.389, p = 0.023) and the mean SpO2 of desaturations during sleep (ß = −0.577, p = 0.002). This model accounted for 63.3% of the variability in the morning BDNF protein level (F = 14.639, p < 0.001). The morning proBDNF protein level was predicted by age (ß = −0.395, p = 0.033) and HIF-1α morning protein level (ß = −3.192, p = 0.005). This model accounted for 52.4% of the variability in the morning BDNF protein level (F = 9.355, p = 0.002). The obtained results suggest that the HIF-1 transcription factor might be involved in the pathway activated by proBDNF, which may have protective properties from hypoxia in OSA patients.

Sleep and Safety among Healthcare Workers: The Effect of Obstructive Sleep Apnea and Sleep Deprivation on Safety

Almost one billion people worldwide are affected by Obstructive Sleep Apnea (OSA). Affected individuals experience disordered breathing patterns during sleep, which results in fatigue, daytime drowsiness, and/or sleep deprivation. Working under the influence of these symptoms significantly impairs work productivity and leads to occupational accidents and errors. This impact is seen in healthcare workers (HCWs) who are not immune to these conditions. However, poorly controlled OSA in this subset of individuals takes a heavy toll on patient care due to the increased risk of medical errors and can also alter the mental and physical well-being of the affected HCW in various ways. OSA and safety issues have been recognized and mitigated among the airline and transport industries; however, the healthcare industry lags in addressing these concerns. This article reviews hypersomnolence and sleep disorder as key clinical features of OSA and their effect on HCW safety.

Insomnia affects patient‐reported outcome in sleep apnea treated with hypoglossal nerve stimulation

Objective

Comorbid insomnia may impact outcomes of patients with obstructive sleep apnea (OSA) receiving hypoglossal nerve stimulation with respiratory sensing (HNS) therapy. To examine whether the presence of insomnia measured using the Insomnia Severity Index (ISI) is associated with patient‐reported outcomes and objective OSA measures in patients receiving HNS therapy.

Methods

In this retrospective chart review, patients with an HNS implant and ISI score at follow‐up assessment were categorized as having moderate/severe insomnia or no/subthreshold insomnia. OSA‐related data (Apnea Hypopnea Index, AHI; Oxygen Desaturation Index, ODI), Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ), and overall patient satisfaction was compared between these patient categories. Correlations between ISI scores and each of these variables were examined.

Results

Of the 132 patients, 26% had moderate/severe insomnia at follow‐up assessment. ESS and FOSQ scores were worse in the insomnia group at baseline, follow‐up, and in the change from baseline, but AHI and ODI scores did not differ between patients with and without insomnia. Frequency of overall satisfaction at follow‐up was lower in the insomnia group (58.8% vs. 92.8% with no insomnia, P < .001). Patients with insomnia were more likely to have depression (56% vs. 27% without insomnia, P < .002).

Conclusions

Insomnia is associated with worse patient‐reported outcomes of daytime sleepiness and sleep‐related quality of life in patients with OSA receiving HNS therapy. Depression is more prevalent in patients with comorbid insomnia. The ISI may help physicians to address comorbid insomnia and achieve high patient satisfaction and adherence to HNS therapy.

Level of Evidence

4

To examine whether the presence of insomnia measured using the Insomnia Severity Index (ISI) is associated with patient‐reported outcomes and objective OSA measures in patients receiving HNS therapy in a follow‐up situation. ESS and FOSQ scores were worse in the insomnia group at baseline, follow‐up, and in the change from baseline, but AHI and ODI scores did not differ between patients with and without insomnia. Insomnia is associated with worse patient‐reported outcomes of daytime sleepiness and sleep‐related quality of life in OSA patients receiving HNS therapy.

Alternate Warm and Cold Therapy (AWCT) on Uricemia, Sleep, Pain, Functional Ability, and Quality of Life (USPFQoL) in Patients with Gout: A Path Forward

Objective

To understand the impact of alternate warm and cold therapy (AWCT) on uricemia, sleep, pain, functional ability, and quality of life in gout patients.

Methods

A quasiexperimental, nonequivalent control group, pre and posttest design was adopted among 120 gout patients. The data were collected on demographics, comorbidities, pain level, joint swelling/joint tenderness, patient global assessment of response to treatment (PGART), health-related quality of life (HRQoL) with SF-36, sleep quality by Pittsburgh Sleep Quality Index (PSQI), and serum uric acid and assessed. Descriptive and inferential statistics were used to analyze the data.

Results

Patients had mean age of 58 and 61 years, mean number of comorbidities was 1.8 and 1.4, as well as presence of arthritic comorbidities except gout was 1.1 and 0.8 among study and control group participants, respectively. Pain (p < 0.001), PGART (p=−0.01), HRQoL, sleep quality, and level of SUA (mg/dl) improved significantly (p < 0.01) among the study group over study periods. It affirms that the AWCT is effective in reducing pain, functional disability, and SUA, as well as improving the sleep quality and HRQoL of the gout patients. There was a reduced incidence of gout flares (p < 0.001), and taking additional medicines for pain (p < 0.01) was statistically significant among study participants. Except social functioning, other domains of health were significantly (p < 0.05) affected by the comorbidities like hypertension, diabetes, heart disease, renal disease, and asthma/chronic obstructive pulmonary disease.

Conclusions

Gout is independently associated with higher medical and arthritic comorbidity, and AWCT can be better and cost-effective alternative therapy for gout patients. In addition, it may lead to improved cardiac function, hypertension, and renal insufficiency.

A randomized controlled trial of cognitive behavioral therapy for insomnia and PAP for obstructive sleep apnea and comorbid insomnia: effects on nocturnal sleep and daytime performance

STUDY OBJECTIVES

This study examines the impact of cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure (PAP) therapy for comorbid insomnia and sleep apnea on nocturnal sleep and daytime functioning.

METHODS

A partial factorial design was used to examine treatment pathways with CBT-I and PAP and the relative benefits of each treatment. One hundred eighteen individuals with comorbid insomnia and sleep apnea were randomized to receive CBT-I followed by PAP, self-monitoring followed by CBT-I concurrent with PAP, or self-monitoring followed by PAP only. Participants were assessed at baseline, PAP titration, and 30 and 90 days after PAP initiation. Outcome measures included sleep diary- and actigraphy-measured sleep, Flinders Fatigue Scale, Epworth Sleepiness Scale, Functional Outcome of Sleep Questionnaire, and cognitive emotional measures.

RESULTS

A main effect of time was found on diary-measured sleep parameters (decreased sleep onset latency and wake after sleep onset; increased total sleep time and sleep efficiency) and actigraphy-measured sleep parameters (decreased wake after sleep onset; increased sleep efficiency) and daytime functioning (reduced Epworth Sleepiness Scale, Flinders Fatigue Scale; increased Functional Outcome of Sleep Questionnaire) across all arms (all P < .05). Significant interactions and planned contrast comparisons revealed that CBT-I was superior to PAP and self-monitoring on reducing diary-measured sleep onset latency and wake after sleep onset and increasing sleep efficiency, as well as improving Functional Outcome of Sleep Questionnaire and Flinders Fatigue Scale compared to self-monitoring.

CONCLUSIONS

Improvements in sleep and daytime functioning were found with PAP alone or concomitant with CBT-I. However, more rapid effects were observed on self-reported sleep and daytime performance when receiving CBT-I regardless of when it was initiated. Therefore, concomitant treatment appears to be a favorable approach to accelerate treatment outcomes.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Multidisciplinary Approach to the Treatment of Insomnia and Comorbid Sleep Apnea (MATRICS); URL: https://clinicaltrials.gov/ct2/show/NCT01785303; Identifier: NCT01785303.

CITATION

Tu AY, Crawford MR, Dawson SC, et al. A randomized controlled trial of cognitive behavioral therapy for insomnia and PAP for obstructive sleep apnea and comorbid insomnia: effects on nocturnal sleep and daytime performance. J Clin Sleep Med. 2022;18(3):789-800.

Effect of chronic sleep deprivation and sleep recovery on hippocampal CA3 neurons, spatial memory and anxiety-like behavior in rats

Sleep deprivation-induced degenerative changes in the brain lead to the impairment of memory, anxiety, and quality of life. Several studies have reported the effects of sleep deprivation on CA1 and dentate gyrus regions of the hippocampus; in contrast, there is less known about the impact of chronic sleep deprivation (CSD) and sleep recovery on CA3 neurons and behavior. Hence, the present study aimed to understand the effect of CSD and sleep recovery on hippocampal CA3 neurons and spatial memory, and anxiety-like behavior in rats. Sixty male rats (Sprague Dawley) were grouped as control, environmental control (EC), CSD, 5 days sleep recovery (CSD + 5D SR), and 21 days sleep recovery (CSD + 21D SR). CSD, CSD + 5D SR and, CSD + 21D SR group rats were sleep deprived for 21 days (18 h/day). After CSD, the CSD + 5D SR and CSD + 21D SR rats were sleep recovered for 5- and 21-days respectively. Oxidative stress, dendritic arborization of CA3 neurons, spatial memory, and anxiety-like behavior was assessed. Spatial memory, basal, and apical dendritic branching points/intersections in hippocampal CA3 neurons were reduced, and anxiety-like behavior and oxidative stress increased significantly in the CSD group compared to control (p < 0.001). The CSD + 21D SR showed a significant improvement in spatial memory, reduction in anxiety-like behavior, and oxidative stress when compared to the CSD group (p < 0.05). The basal and apical dendritic branching points/intersections in hippocampal CA3 neurons were increased after CSD + 21D SR, however, it was not significant (p > 0.05). Even though the CSD + 21D SR showed a significant improvement in all the parameters, it did not reach the control level. There was an improvement in all the parameters after CSD + 5D SR but this was not significant compared to the CSD group (p > 0.05). Overall results indicate that the CSD-induced impairment of spatial memory and anxiety-like behavior was associated with oxidative stress and reduced dendritic arborization of hippocampal CA3 neurons. The CSD + 21D SR significantly reduced the damage caused by CSD, but it was not sufficient to reach the control level.

Comorbid Insomnia and Obstructive Sleep Apnea (COMISA): Current Concepts of Patient Management

Obstructive sleep apnea (OSA) and insomnia are the two most common sleep disorders among the general population, and they may often coexist in patients with sleep-disordered breathing (SDB). The higher prevalence of insomnia symptoms in patients with OSA (40–60%) compared to that observed in the general population has thus led researchers to identify a new disorder named comorbid insomnia and OSA (COMISA), whose true burden has been so far largely underestimated. The combined treatment of COMISA patients with positive-airway pressure ventilation (PAP) with cognitive behavioral therapy for insomnia (CBTi) has shown a better patient outcome compared to that obtained with a single treatment. Furthermore, recent evidence has shown that an innovative patient-centered approach taking into consideration patient characteristics, treatment preferences and accessibility to treatment is recommended to optimize clinical management of COMISA patients. However, in this complex mosaic, many other sleep disorders may overlap with COMISA, so there is an urgent need for further research to fully understand the impact of these therapies on outcomes for OSA patients with comorbidity. In light of this need, this review focuses on the major sleep disorders comorbid with OSA and the recent advances in the management of these insomniac patients.

Effect of the new dual orexin receptor antagonist daridorexant on nighttime respiratory function and sleep in patients with mild and moderate obstructive sleep apnea

In this randomized, double-blind, placebo-controlled, two-period crossover study, the effect of the dual orexin receptor antagonist daridorexant was evaluated on nighttime respiratory function and sleep in 28 patients with mild and moderate obstructive sleep apnea (OSA). In each period, 50 mg daridorexant or placebo was administered every evening for 5 days. The primary endpoint was apnea/hypopnea index (AHI) during total sleep time (TST) after the last dosing. Other endpoints included peripheral oxygen saturation (SpO2), sleep duration, latency to persistent sleep (LPS), wake after sleep onset (WASO), and sleep efficiency index (SEI). Pharmacokinetics, safety, and tolerability were also assessed. The mean treatment difference for AHI during TST (i.e. daridorexant - placebo) after the last dosing was 0.74 events/hour (90% confidence interval [CI]: -1.43, 2.92). The corresponding treatment difference for SpO2 during TST was 0.16% [90% CI: -0.21, 0.53]. Overall, there was no clinically relevant effect of daridorexant on AHI or SpO2-related data after single and repeated dosing irrespective of sleep phase (i.e. rapid eye movement [REM] vs non-REM). Moreover, after single and repeated dosing, daridorexant prolonged TST by 39.6 minutes (90% CI: 16.9, 62.3) and 38.8 minutes (19.7, 57.9), respectively, compared with placebo and favorably modulated other sleep-related endpoints (i.e. increased SEI, decreased WASO, and shortened LPS). It attained expected plasma concentrations and was well tolerated in patients with mild and moderate OSA. These results indicate that single and repeated doses of 50 mg daridorexant do not impair nighttime respiratory function and improve sleep in patients with mild and moderate OSA. Clinical Trial Registration: ClinicalTrials.gov NCT03765294. A study to investigate the effects of ACT-541468 on nighttime respiratory function in patients with mild to moderate obstructive sleep apnea. https://clinicaltrials.gov/ct2/show/ NCT03765294.

Assessment of Cardiorespiratory Interactions during Apneic Events in Sleep via Fuzzy Kernel Measures of Information Dynamics

Apnea and other breathing-related disorders have been linked to the development of hypertension or impairments of the cardiovascular, cognitive or metabolic systems. The combined assessment of multiple physiological signals acquired during sleep is of fundamental importance for providing additional insights about breathing disorder events and the associated impairments. In this work, we apply information-theoretic measures to describe the joint dynamics of cardiorespiratory physiological processes in a large group of patients reporting repeated episodes of hypopneas, apneas (central, obstructive, mixed) and respiratory effort related arousals (RERAs). We analyze the heart period as the target process and the airflow amplitude as the driver, computing the predictive information, the information storage, the information transfer, the internal information and the cross information, using a fuzzy kernel entropy estimator. The analyses were performed comparing the information measures among segments during, immediately before and after the respiratory event and with control segments. Results highlight a general tendency to decrease of predictive information and information storage of heart period, as well as of cross information and information transfer from respiration to heart period, during the breathing disordered events. The information-theoretic measures also vary according to the breathing disorder, and significant changes of information transfer can be detected during RERAs, suggesting that the latter could represent a risk factor for developing cardiovascular diseases. These findings reflect the impact of different sleep breathing disorders on respiratory sinus arrhythmia, suggesting overall higher complexity of the cardiac dynamics and weaker cardiorespiratory interactions which may have physiological and clinical relevance.

Sleep Apnea and Insomnia: Emerging Evidence for Effective Clinical Management

Comorbid insomnia and sleep apnea (COMISA) are the most common co-occurring sleep disorders and present many challenges to clinicians. This review provides an overview of the clinical challenges in the management of patients with COMISA, with a focus on recent evidence regarding the evaluation and treatment of COMISA. Innovations in the assessment of COMISA have used profile analyses or dimensional approaches to examine symptom clusters or symptom severity that could be particularly useful in the assessment of COMISA. Recent randomized controlled trials have provided important evidence about the safety and effectiveness of a concomitant treatment approach to COMISA using cognitive-behavioral therapy for insomnia (CBT-I) with positive airway pressure (PAP). Furthermore, patient-centered considerations that integrate patient characteristics, treatment preferences, and accessibility to treatment in the context of COMISA are discussed as opportunities to improve patient care. Based on these recent advances and clinical perspectives, a model for using multidisciplinary, patient-centered care is recommended to optimize the clinical management of patients with COMISA.

Association of adherence to the Mediterranean diet and physical activity habits with the presence of insomnia in patients with obstructive sleep apnea

PURPOSE

Insomnia and obstructive sleep apnea (OSA) are among the most prevalent sleep disorders and frequently co-occur, defining the sleep apnea-insomnia syndrome. However, data exploring associations between insomnia and lifestyle habits in patients with OSA are lacking. Therefore, the aim of the present study was to investigate potential associations between insomnia presence and individual lifestyle parameters in patients with mild/moderate-to-severe OSA evaluated by attended polysomnography.

METHODS

These are secondary analyses, using data from a cross-sectional study among 269 Greek patients with OSA. Clinical, anthropometric, socioeconomic, and lifestyle data were collected for all participants. Insomnia presence was evaluated through the validated psychometric instrument "Athens Insomnia Scale" (AIS). Adherence to the Mediterranean diet was estimated with the MedDietScale index and physical activity habits were assessed through a validated questionnaire. Backward stepwise multiple logistic regression analysis was used to estimate the association between lifestyle habits (i.e., adherence to the Mediterranean diet and physical activity) and the likelihood of having insomnia, while adjusting for potential confounders.

RESULTS

Of 269 patients newly diagnosed with OSA (aged 21-70 years; 73% men), 146 (54%) were categorized as having insomnia. In multivariable models, higher adherence to the Mediterranean diet and engagement in physical activity for ≥ 30 min/day were both associated with a lower likelihood of having insomnia (odds ratio (95% confidence intervals): 0.40 (0.18-0.91) and 0.49 (0.28-0.86), respectively).

CONCLUSIONS

Results add to the limited data on the role of lifestyle in insomnia and should be further explored both in epidemiological and clinical studies.

Diagnostic and Therapeutic Approach to Sleep Disorders, High Blood Pressure and Cardiovascular Diseases: A Consensus Document by the Italian Society of Hypertension (SIIA)

Hypertension is a major contributor to fatal/nonfatal cardiovascular diseases, and timely identification and appropriate management of factors affecting hypertension and its control are mandatory public health issues. By inducing neurohormonal alterations and metabolic impairment, sleep disorders have an impact on a variety of cardiovascular risk factors, including hypertension, and ultimately increase the risk of cardiovascular events. There is evidence that qualitative and quantitative sleep disorders are associated with resistant hypertension and with impaired circadian blood pressure variations. However, sleep disturbances are often unrecognized, or heterogeneity exists in their management by non-specialists in the field. This document by the Italian Society of Hypertension summarizes the updated evidence linking sleep disorders to hypertension and cardiovascular diseases, the major underlying mechanisms, and the possible management strategies. A simplified, evidence-based diagnostic and therapeutic algorithm for comorbid hypertension and common sleep disorders, namely obstructive sleep apnoea and insomnia, is proposed.

Prevalence of Insomnia in Two Saskatchewan First Nation Communities

Insomnia is a common problem in Canada and has been associated with increased use of health care services and economic burden. This paper examines the prevalence and risk factors for insomnia in two Cree First Nation communities in Saskatchewan, Canada. Five hundred and eighty-eight adults participated in a baseline survey conducted as part of the First Nations Sleep Health Collaborative Project. The prevalence of insomnia was 19.2% among participants with an Insomnia Severity Index score of ≥15. Following the definition of nighttime insomnia symptoms, however, the prevalence of insomnia was much higher, at 32.6%. Multivariate logistic regression modeling revealed that age, physical health, depression diagnosis, chronic pain, prescription medication use for any health condition, and waking up during the night due to terrifying dreams, nightmares, or flashbacks related to traumatic events were risk factors for insomnia among participants from two Saskatchewan Cree First Nation communities.

Pharmacological Management of Insomnia

Insomnia is a highly prevalent condition associated with significant morbidity, reduction in quality of life, and increase in healthcare costs, and is a risk factor for multiple physical and mental disorders. The primary treatment modality is cognitive behavioral therapy for insomnia (CBT-I) but this is associated with difficulties with access and higher cost as well as poor response in some patients. Therefore, pharmacotherapy for insomnia is common and hypnotic agents are among the most frequently prescribed medications in the United States. Older medications for insomnia are limited by their side effect burden and narrow therapeutic window. Newer hypnotics, on the other hand, have been shown to have a better safety profile and longer term efficacy. While some studies have shown that long-term hypnotic use is associated with adverse outcomes, the current evidence is equivocal. The decision to treat chronic insomnia disorder with long-term hypnotics should be individualized and balance the potential risks of continuing hypnotic medication use with the risks of untreated persistent insomnia and associated functional limitations. This clinical review discusses the currently available medication options to treat insomnia, their mechanisms of action, dosing, and side effect profiles. This review also provides guidance on long-term management of hypnotics and the use of these medications in the elderly, those with medical comorbidities, and other special populations.

Validation of insomnia questionnaires in the general population: The Nord-Trøndelag Health Study (HUNT)

The primary aim was to validate questionnaire-based insomnia diagnoses from a modified Karolinska Sleep Questionnaire (KSQ) and the Insomnia Severity Index (ISI), by age category (< or >65 years), against a semi-structured face-to-face interview. Secondary aims were to split validity by diagnostic certainty of the interview and to compare prevalence estimates of questionnaire- and interview-based diagnoses. A total of 232 out of 1,200 invited (19.3%) from the fourth Nord-Trøndelag Health Study (HUNT4) completed questionnaires, including the KSQ and ISI, shortly before attending a face-to-face diagnostic interview for insomnia based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Both a tentative (DSM-5 criteria A-E) and a definite (criteria A-H) interview diagnosis was evaluated. Cohen's kappa statistic quantified questionnaire validity. In all, 33% (95% confidence interval 27-39%) of participants had definite insomnia: 40% of women and 21% of men. The ISI (cut-off 12) and several KSQ-based diagnoses showed very good validity (κ ≤0.74) against the tentative, versus good validity (κ ≤0.61) against the definite interview diagnosis. Short questionnaires, requiring a daytime symptom at least three times a week, may underestimate insomnia prevalence. Validity was consistently higher for persons aged below versus above 65 years (definite insomnia: κ ≤0.64 vs. κ ≤0.56). Our results have implications for epidemiological population-based studies utilising insomnia questionnaires.

Insomnia and daytime sleepiness predict 20-year mortality in older male adults: data from a population-based study

Data regarding the possible relationship of insomnia and EDS with mortality are inconclusive. The aim of this study was to investigate the association between these sleep complaints and the risk of long-term (20 years) all-cause mortality in older adults. Between April 2000 and March 2001, 750 subjects aged 65 years and older, who resided in the seventh district of Udine, were recruited. Data on sociodemographic characteristics, past medical history, and pharmacological treatment were collected. Dementia was diagnosed using a comprehensive neurological and neuroradiological assessment. Older adults were interviewed by neuropsychologists trained in sleep disturbances in order to assess the presence of sleep complaints. Vital status was followed over 20 years until March 2020. Older male adults affected by insomnia and EDS were significantly more likely to die over the follow-up period. Indeed, males reporting poor sleep and daytime somnolence had a 60% and 48% higher chance of dying than subjects who were not affected by these sleep complaints, respectively. The HR was attenuated after adjusting for confounding variables among insomniacs, whereas that of somnolent men strengthened. Differently from men, insomnia and EDS did not have any impact on mortality in older women. In conclusion, older male adults affected by insomnia and EDS had a significant increased risk of mortality, which is independent of cancer, depression, dementia, cardiovascular diseases, and sleeping pill use.

Pharmacovigilance Assessment of Cardiac Implications of Nicotine Replacement Therapy Among Smokers

PURPOSE

The purpose of this quantitative comparative study was to examine the possible relationship between nicotine replacement therapy (NRT) and cardiac disorder risk by comparing the rates of cardiac disorder risk of NRT with cardiac disorder risk of non-replacement drugs among smokers seeking smoking cessation.

METHODS

The study used retrospective quantitative design, which involved the collection of secondary data from the adverse event reporting system (FAERS) database of the U.S Food and Drug Administration (FDA). Rates of cardiac disorder were compared between the NRT group and non- NRT (varenicline and bupropion) group. Statistical analyses involved using a 2x2 contingency table and logistic regression to calculate odds ratio (reporting odds ratio (ROR)).

RESULTS AND DISCUSSION

Unadjusted ROR was 0.45 (95% confidence interval [CI] 0.28, 0.70). With age and sex as confounding factors, the smokers in the NRT group still had lower odds of having cardiac disorder risk than the non-NRT group (adjusted ROR=0.44, 95% CI 0.28, 0.70).

CONCLUSION

Our study findings showed lower cardiac disorder risk with the NRT group compared to the non-NRT (varenicline and bupropion) group. While the study did not aim to undermine either using NRT or non-NRT for smoking cessation therapy to prevent smoking illness, the study results offer informed findings that could potentially improve current smoking cessation management using NRT intervention among smokers and enhance smokers' health outcome. Despite the negative signal detection of cardiac disorder risk with NRT as compared to non-NRT in final findings, we still recommend further research on the causal relationship between NRT and non-NRT and cardiac disorder risk.

Differences in electroencephalographic spectra during pre-sleep wakefulness, N1, and R sleep between comorbid insomnia and obstructive sleep apnea

PURPOSE

The neuropsychobiological effects of the comorbidity of insomnia and obstructive sleep apnea are not well studied. Our objective was to compare electroencephalographic spectra of patients with comorbid insomnia and sleep apnea syndrome to those of patients with sleep apnea syndrome alone during pre-sleep wakefulness and the N1 and R sleep periods.

METHOD

We performed electroencephalography and polysomnography on 10 patients with comorbid insomnia and sleep apnea and 10 with only sleep apnea. Electroencephalography spectra analysis was performed for absolute power in clinical bands in six derivations.

RESULTS

Compared to sleep apnea patients, comorbid patients had lower sleep efficiency and total sleep time, higher beta-1 power in the left frontal and central derivations during pre-sleep wakefulness, higher delta power in the left frontal and central derivations during the N1 stage, and higher beta-2 power in the left frontal and central, and right central derivations during the R stage.

CONCLUSIONS

Data suggest that patients with insomnia and sleep apnea, compared to patients with only sleep apnea, presented higher left high-frequency rhythms during pre-sleep wakefulness and R sleep stage, and may be for increased emotional and cognitive-related activity, while in stage N1, presented higher left delta power, which suggest some slowing after sleep deprivation.

Perceived racial discrimination and risk of insomnia among middle-aged and elderly Black women

STUDY OBJECTIVE

To assess whether perceived racial discrimination is associated with insomnia among Black women.

METHODS

Data on everyday and lifetime racism and insomnia symptoms were collected from questionnaires administered in the Black Women's Health Study, an ongoing prospective cohort of Black women recruited in 1995 from across the United States. In 2009, participants completed five questions on the frequency of discriminatory practices in daily life (everyday racism) and six questions on ever experiencing unfair treatment in key institutional contexts (lifetime racism). In 2015, the Insomnia Severity Index was used to assess insomnia symptoms. We estimated odds ratios and 95% confidence intervals for associations of racism with insomnia, using multivariable logistic regression models adjusted for potential confounders.

RESULTS

The 26 139 participants in the analytic sample were 40-90 years old (median = 57 years, SD = 9.6 years). Higher levels of everyday racism and lifetime racism were positively associated with subthreshold (ptrend < .01) and clinical insomnia (ptrend < .01). Results remained unchanged after further adjustment for sleep duration and shift work.

CONCLUSIONS

Higher levels of perceived racism were associated with increased odds of insomnia among middle-aged and elderly Black women. Thus, perceived racism may contribute to multiple racial health disparities resulting from insomnia. Helping minority populations cope with their experiences of discrimination may decrease the significant public health impact of sleep disruption and subsequent diagnoses.

The effect of cognitive and behavioral therapy for insomnia on week-to-week changes in sleepiness and sleep parameters in patients with comorbid insomnia and sleep apnea: a randomized controlled trial

Study Objectives

While cognitive and behavioral therapy for insomnia (CBTi) is an effective treatment in patients with comorbid moderate and severe obstructive sleep apnea (OSA), there is concern that the bedtime restriction component of CBTi might dangerously exacerbate daytime sleepiness in such patients. We examined randomized controlled trial data to investigate the effect of OSA severity, and pretreatment daytime sleepiness on week-to-week changes in daytime sleepiness and sleep parameters during CBTi and no-treatment control.

Methods

One hundred and forty-five patients with untreated physician-diagnosed OSA (apnea–hypopnea index ≥15) and psychologist-diagnosed insomnia (ICSD-3) were randomized to a 4-week CBTi program (n = 72) or no-treatment control (n = 73). The Epworth sleepiness scale (ESS) and sleep diaries were completed during pretreatment, weekly CBTi sessions, and posttreatment. Effects of OSA severity, pretreatment daytime sleepiness, and intervention group on weekly changes in daytime sleepiness and sleep parameters were investigated.

Results

The CBTi group reported a 15% increase in ESS scores following the first week of bedtime restriction (M change = 1.3 points, 95% CI = 0.1–2.5, p = 0.031, Cohen’s d = 0.27) which immediately returned to pretreatment levels for all subsequent weeks, while sleep parameters gradually improved throughout CBTi. There were no differences in changes in daytime sleepiness during treatment between CBTi and control groups or OSA-severity groups. Higher pretreatment ESS scores were associated with a greater ESS reduction during CBTi.

Conclusions

CBTi appears to be a safe and effective treatment in the presence of comorbid moderate and severe OSA. Nevertheless, patients living with comorbid insomnia and sleep apnea and treated with CBTi should be monitored closely for increased daytime sleepiness during the initial weeks of bedtime restriction therapy.

Clinical Trial Registration

Treating comorbid insomnia with obstructive sleep apnoea (COMISA) study: A new treatment strategy for patients with combined insomnia and sleep apnoea, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id = 365184 Australian New Zealand Clinical Trials Registry: ACTRN12613001178730. Universal Trial Number: U1111-1149-4230.

Chronic insomnia remitting after maxillomandibular advancement for mild obstructive sleep apnea: a case series

Background

Chronic insomnia and obstructive sleep apnea are both common sleep disorders. Chronic insomnia is thought to result from stress-related physiologic hyperarousal (somatic arousal) that makes it difficult for an individual to fall or stay asleep. Obstructive sleep apnea is thought to result from obstructive respiratory events causing arousals, sleep fragmentation, and recurrent oxygen desaturation. Although the two disorders seem different, they predispose to the same long-term, stress-related illnesses, and when they occur in the same individual, each affects the other’s response to treatment; they interact. This report of three cases describes patients with both chronic insomnia and obstructive sleep apnea in whom the chronic insomnia remitted with no specific treatment following treatment of obstructive sleep apnea with maxillomandibular advancement.

Case presentations

Our three Caucasians patients each presented with severe, chronic insomnia associated with somatic arousal and fatigue occurring either alone, in association with bipolar disorder, or with temporomandibular joint syndrome. Polysomnography revealed that each patient also had mild obstructive sleep apnea, despite only one snoring audibly. One patient experienced a modest improvement in her somatic arousal, insomnia severity, and fatigue with autotitrating nasal continuous positive airway pressure, but the other two did not tolerate nasal continuous positive airway pressure. None of the patients received treatment for insomnia. All three patients subsequently underwent maxillomandibular advancement to treat mild obstructive sleep apnea and experienced prolonged, complete resolution of somatic arousal, chronic insomnia, and fatigue. The patient with bipolar disorder also experienced complete remission of his symptoms of depression during the 1 year he was followed postoperatively.

Conclusions

These three cases lend support to the hypothesis that chronic insomnia and obstructive sleep apnea share a pathophysiology of chronic stress. Among patients with obstructive sleep apnea, the stress response is directed at inspiratory airflow limitation during sleep (hypopnea, snoring, and inaudible fluttering of the throat). Therefore, when chronic insomnia and obstructive sleep apnea occur in one individual, aggressive treatment of obstructive sleep apnea may lead to a reduction in chronic stress that causes the patient’s chronic insomnia to remit.

Pregnant pause: should we screen for sleep disordered breathing in pregnancy?

Physiological and hormonal changes in pregnancy can contribute towards sleep disordered breathing in pregnant women (SDBP). When present, SDBP increases the risk of several adverse maternal and fetal outcomes independent of factors such as age, weight and pre-existing maternal comorbidities. SDBP is underdiagnosed and may be hard to recognise because the presentation can be difficult to differentiate from normal pregnancy and the severity may change over the course of gestation. Timely intervention seems likely to help reduce adverse outcomes, but the relative benefits of intervention are still unclear. The definition of what constitutes a sleep-related breathing “disorder” in pregnancy may be different to the general population and so traditional thresholds for intervention may not be relevant in pregnancy. Any modifications to the disease definition in this group, or implementation of more intensive screening, may result in overdiagnosis. Further research is needed to help clinicians evaluate the balance of benefits and harms in this process. Until this is clearer there is a strong imperative for shared decision making in screening and treatment decisions, and screening programmes should be monitored to assess whether improved outcomes can be achieved at the healthcare system level.

Untreated sleep disordered breathing in pregnancy poses risks to maternal and fetal wellbeing, but thresholds for and effectiveness of intervention are unclear. Clinicians should use shared decision making for screening and treatment decisions.http://ow.ly/N0oN30noWnx

Insomnia and depressive symptoms in relation to unhealthy eating behaviors in bariatric surgery candidates

BACKGROUND

Alongside obesity, insomnia and depression are common public health problems. Sleep problems are currently believed to be associated with excessive food intake and metabolic disturbances. Therefore, we aimed to explore a relationship between insomnia, depressive symptoms and eating habits as well as metabolic parameters in bariatric surgery candidates.

METHODS

A total of 361 unrelated obese subjects were included in this study. Severity of sleep problems was measured with Athens Insomnia Scale (AIS) and the severity of depressive symptoms was assessed with the Beck Depression Inventory (BDI-II). Obstructive sleep apnea (OSA) was assessed by the Apnea Hypopnoea Index (AHI). Information was obtained about demographics, eating habits and lifestyle. Blood samples were collected to measure concentration of lipids (cholesterol, triglyceride, HDL-cholesterol, LDL-cholesterol), and glucose.

RESULTS

The median (interquartile range) score for AIS in the study participants was 5 (3-8) with a range of 0-24 and 47% (171) participants scored ≥6 (met criteria for diagnosis of insomnia). Statistically significant correlations were found between the AIS scores and serum triglycerides and glucose concentrations, and BDI-II total scores. The highest scores on AIS and BDI-II were found in participants with high frequency of snack food consumption, in physically inactive individuals as well as in those who self-reported eating at night or who declared more than 3 intense emotions associated with a desire-to-eat. Adjusted multivariate logistic regression analysis revealed that clinical insomnia was most strongly associated with daily consumption of snack foods, with the odds ratio of 3.26 (95% CI: 1.74-6.11), while depressive symptoms were strongly associated with both eating in response to ≥3 specific emotions with OR = 2.93 (95% CI: 1.26-6.78) as well as with daily consumption of snack foods with OR = 2.87 (95% CI: 1.16-5.14).

CONCLUSIONS

The results indicate that insomnia and depression in obese individuals are associated with eating habits, and suggest that in some patients these associations appears as major factors affecting obesity development.

Evidence-Based Psychotherapy in Primary Care

The functional and financial effects of untreated psychiatric disorders within primary care have led to the development of novel service delivery models to improve access to high-quality, evidence-based mental health treatments. Cognitive-behavioral therapy (CBT) is an efficacious and effective psychotherapeutic approach for treating a broad range of mental health conditions. CBT is a practical, skill-building approach that emphasizes self-efficacy and self-management of symptoms while working toward defined and measurable treatment goals. Although significant barriers to the full dissemination of CBT remain, collaborative care and integrated behavioral health programs embedded within primary care clinics can enhance treatment outcomes by using CBT. Identifying core CBT principles used in the treatment of anxiety (e.g., exposure), depression (e.g., behavioral activation), and insomnia (e.g., stimulus control) is an important step toward improving the quality of care for these conditions. High-impact, low-intensity CBT programs hold promise in improving access to this evidence-based treatment across a broader population.

Sleep Disturbance, Diabetes, and Cardiovascular Disease in Postmenopausal Veteran Women

PURPOSE OF THE STUDY

To compare the prevalence and cardiometabolic health impact of sleep disturbance among postmenopausal Veteran and non-Veteran participants in the Women's Health Initiative (WHI).

DESIGN AND METHODS

The prevalence of five categories of sleep disturbance--medication/alcohol use for sleep; risk for insomnia; risk for sleep disordered breathing [SDB]; risk for comorbid insomnia and SDB (insomnia + SDB); and aberrant sleep duration [SLD]--was compared in 3,707 Veterans and 141,354 non-Veterans using logistic or multinomial regression. Cox proportional hazards models were used to evaluate the association of sleep disturbance and incident cardiovascular disease (CVD) and Type 2 diabetes in Veterans and non-Veterans.

RESULTS

Women Veterans were more likely to have high risk for insomnia + SDB relative to non-Veteran participants. However, prevalence of other forms of sleep disturbance was similar across groups. Baseline sleep disturbance was not differentially associated with cardiometabolic health outcomes in Veteran versus non-Veteran women. Risks for SDB and insomnia + SDB were both linked to heightened risk of CVD and diabetes; SLD was consistently linked with greater risk of CVD and diabetes in non-Veterans but less strongly and consistently in Veterans.

IMPLICATIONS

Efforts to identify and treat sleep disturbances in postmenopausal women are needed and may positively contribute to the attenuation of cardiometabolic morbidity risk. Increased awareness of women Veterans' vulnerability to postmenopausal insomnia + SDB may be particularly important for health care providers who treat this population.

Retrospective, nonrandomized controlled study on autoadjusting, dual-pressure positive airway pressure therapy for a consecutive series of complex insomnia disorder patients

PURPOSE

Emerging evidence shows that positive airway pressure (PAP) treatment of obstructive sleep apnea (OSA) and upper airway resistance syndrome (UARS) in chronic insomnia patients (proposed "complex insomnia" disorder) leads to substantial decreases in insomnia severity. Although continuous PAP (CPAP) is the pressure mode most widely researched, intolerance to fixed pressurized air is rarely investigated or described in comorbidity patients. This retrospective study examined dual pressure, autoadjusting PAP modes in chronic, complex insomnia disorder patients.

PATIENTS AND METHODS

Chronic insomnia disorder patients (mean [SD] insomnia severity index [ISI] =19.11 [3.34]) objectively diagnosed with OSA or UARS and using either autobilevel PAP device or adaptive servoventilation (ASV) device after failing CPAP therapy (frequently due to intolerance to pressurized air, poor outcomes, or emergence of CSA) were divided into PAP users (≥20 h/wk) and partial users (<20 h/wk) for comparison. Subjective and objective baseline and follow-up measures were analyzed.

RESULTS

Of the 302 complex insomnia patients, PAP users (n=246) averaged 6.10 (1.78) nightly hours and 42.71 (12.48) weekly hours and partial users (n=56) averaged 1.67 (0.76) nightly hours and 11.70 (5.31) weekly hours. For mean (SD) decreases in total ISI scores, a significant (group × time) interaction was observed (F[1,300]=13.566; P<0.0001) with PAP users (-7.59 [5.92]; d=1.63) showing superior results to partial users (-4.34 [6.13]; d=0.81). Anecdotally, patients reported better tolerability with advanced PAP compared to previous experience with CPAP. Both adaptive servoventilation and autobilevel PAP showed similar ISI score improvement without statistical differences between devices. Total weekly hours of PAP use correlated inversely with change in insomnia symptoms (r=-0.256, P<0.01).

CONCLUSION

Insomnia severity significantly decreased in patients using autoadjusting PAP devices, but the study design restricts interpretation to an association. Future research must elucidate the interaction between insomnia and OSA/UARS as well as the adverse influence of pressure intolerance on PAP adaptation in complex insomnia patients. Randomized controlled studies must determine whether advanced PAP modes provide benefits over standard CPAP modes in these comorbidity patients.

Diagnosis and Treatment of Insomnia Comorbid with Obstructive Sleep Apnea

Insomnia is often comorbid with obstructive sleep apnea. It reduces positive airway pressure (PAP) therapy acceptance and adherence. Comorbid patients show greater daytime impairments and poorer health outcomes. The insomnia often goes undiagnosed, undertreated, or untreated. Pharmacotherapy is not recommended for long-term treatment. Although care should be taken administering behavioral therapies to patients with elevated sleepiness, cognitive behavior therapy for insomnia (CBTi) is an effective and durable nondrug therapy that reduces symptoms and may increase the effectiveness of PAP therapy. Sleep clinics should be alert to comorbid insomnia and provide adequate diagnostic tools and clinicians with CBTi expertise.

Evaluating the treatment of obstructive sleep apnea comorbid with insomnia disorder using an incomplete factorial design

Chronic insomnia disorder is a prevalent condition and a significant proportion of these individuals also have obstructive sleep apnea (OSA). These two sleep disorders have distinct pathophysiology and are managed with different treatment approaches. High comorbidity rates have been a catalyst for emerging studies examining multidisciplinary treatment for OSA comorbid with insomnia disorder. In this article, we describe a randomized clinical trial of cognitive behavioral treatment for insomnia (CBT-I) and positive airway pressure (PAP) for OSA. Participants are randomized to receive one of three treatment combinations. Individuals randomized to treatment Arm A receive sequential treatment beginning with CBT-I followed by PAP, in treatment Arm B CBT-I and PAP are administered concurrently. These treatment arms are compared to a control condition, treatment Arm C, where individuals receive PAP alone. Adopting an incomplete factorial study design will allow us to evaluate the efficacy of multidisciplinary treatment (Arms A & B) versus standard treatment alone (Arm C). In addition, the random allocation of individuals to the two different combined treatment sequences (Arm A and Arm B) will allow us to understand the benefits of the sequential administration of CBT-I and PAP relative to concurrent treatment of PAP and CBT-I. These findings will provide evidence of the clinical benefits of treating insomnia disorder in the context of OSA.

Sleep hygiene behaviors among midlife women with insomnia or sleep-disordered breathing: the SWAN sleep study

BACKGROUND

Insomnia and sleep-disordered breathing (SDB) are the most common sleep disorders among midlife women. Although promoting sleep hygiene behaviors may be a useful behavioral approach for the management of insomnia or SDB, the frequency with which women engage in these behaviors is unclear.

METHODS

Participants were from the Study of Women's Health Across the Nation (SWAN) Sleep Study (N=321; age range=48-58 years). Out of the full sample, 10.3% (n=33) met Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition diagnostic criteria for insomnia, 15.3% (n=49) had clinically significant SDB (apnea-hypopnea index ≥15), and 4.7% (n=15) met criteria for both insomnia and SDB, resulting in an overall prevalence of 15.0% (n=48) for insomnia and 19.9% (n=64) for SDB. Participants provided diary-based assessments of sleep hygiene behaviors for 14-35 days. Two positive behaviors (sufficient exercise, regular morning out-of-bed time) and four negative behaviors (taking long daytime naps, caffeine consumption near bedtime, alcohol consumption near bedtime, smoking) were examined. These behaviors were compared between women with and without insomnia or SDB following adjustment for sociodemographic factors and mental and physical health indices.

RESULTS

Women with insomnia engaged in significantly fewer negative sleep hygiene behaviors than women without insomnia (1.61±0.15 vs. 2.09±0.09 behaviors; p<0.01); specifically, women with insomnia were less likely to take long naps (odds ratio [OR]=0.30, 95% confidence interval [CI]: 0.12-0.74) or consume caffeine near bedtime (OR=0.44, 95% CI: 0.20-0.98). In contrast, women with SDB were less likely to be physically active than women without SDB (OR=0.52, 95% CI: 0.27-0.98), but no other differences in sleep hygiene behaviors were observed.

CONCLUSIONS

These data suggest that insomnia in midlife women is not associated with poor sleep hygiene. Increasing physical activity may be a valuable recommendation for midlife women with SDB.