Longitudinal evaluation of sleep-disordered breathing and sleep symptoms with change in quality of life: the Sleep Heart Health Study (SHHS)

Muscle and visceral fat infiltration: A potential mechanism to explain the worsening of obstructive sleep apnea with age

STUDY OBJECTIVES

Aging is a major risk factor for obstructive sleep apnoea (OSA) and is associated with increased upper airway collapsibility, but the mechanisms are largely unknown. We hypothesized that the increase in OSA severity and upper airway collapsibility with age are partially mediated by upper airway, visceral and muscle fat infiltration.

METHODS

Male subjects underwent full polysomnography, upper airway collapsibility determination (Pcrit) after sleep induction with midazolam, upper airway and abdominal computed tomography. Tongue and abdominal muscle fat infiltration were assessed by the determination of muscle attenuation with computed tomography.

RESULTS

Eighty-four males with a wide range of age (47 ± 13 years, range 22-69 years) and apnea-hypopnea index (AHI) (30 [14-60] events/h, range 1-90 events/h), were studied. Younger and older males were grouped according to the mean age. Despite similar body mass-index (BMI), older subjects had higher AHI, higher Pcrit, larger neck and waist circumference, higher visceral and upper airway fat volumes (P < 0.01) as compared to younger subjects. Age was associated with OSA severity, Pcrit, neck and waist circumference, upper airway fat volume and visceral fat (P < 0.05), but not with BMI. Older subjects had lower tongue and abdominal muscle attenuation as compared to younger subjects (P < 0.001). Age was inversely associated with tongue and abdominal muscle attenuation, indicating muscle fat infiltration.

CONCLUSIONS

The associations between age, upper airway fat volume, visceral and muscle fat infiltration may help to explain the worsening of OSA and increased upper airway collapsibility with aging.

Quantitative study of the effects of early standardized ambulation on sleep quality in patients after hepatectomy

Background

Sleep quality has been always an important problem for patients after hepatectomy. The main purpose of the study is to investigate the effects of early ambulation on sleep quality in patients after liver resection via a quantitative study.

Methods

Patients undergoing liver tumor resection were randomly divided into two groups, and the Pittsburgh Sleep Quality Index (PSQI) was used to assess the postoperative activities and sleep quality.

Results

Patients who started early ambulation after liver resection had significantly better sleep quality, faster recovery of gastrointestinal function and shorter lengths of postoperative hospital stay compared with the control group. And there was no significant difference in the incidence of postoperative complications between the two groups.

Conclusion

Early standardized physical activities are feasible for patients after liver resection, which can significantly improve patient's sleep quality, reduce patient's pain and the nursing workload, and achieve rapid recovery.

Examining the impact of excessive daytime sleepiness on utility scores in patients with obstructive sleep apnoea and/or narcolepsy in five European countries

BACKGROUND

Excessive daytime sleepiness (EDS) is a cardinal symptom of narcolepsy and affects many patients with obstructive sleep apnoea (OSA). EDS is associated with reduced quality of life, increased accident risk, and poor workplace performance. Given the impact of EDS, the ability to predict health-related utility from sleepiness is valuable for examining the cost effectiveness of novel treatments. The aim of this study was to examine the association between EDS and EQ-5D in patients with OSA and/or narcolepsy by modelling EQ-5D utility scores from Epworth Sleepiness Scale (ESS) scores.

METHODS

Data were obtained from the Europe 2016/2017 National Health and Wellness Survey, an online, general population survey, designed to represent the age and gender composition of each country's adult population. Analyses included 2,348 patients self-reporting symptomatic and diagnosed OSA (n = 2,277), narcolepsy (n = 48), or both (n = 23). Multivariable models were used to examine ESS as a predictor of EQ-5D utility while adjusting for covariates of interest. Results were validated following the National Institute for Health and Care Excellence Decision Support Unit guidelines for predictive modelling.

RESULTS

Utility decreased as EDS severity increased (no EDS: 0.711 ± 0.251, mild: 0.685 ± 0.261, moderate: 0.643 ± 0.268, severe: 0.559 ± 0.323). Whereas participants with only OSA or only narcolepsy did not differ in utility, those with both conditions had lower scores (0.685 ± 0.266 and 0.627 ± 0.325 vs. 0.439 ± 0.340, respectively). Piecewise linear regression identified a single breakpoint at ESS score of 11.29. In the final model, for each point increase in ESS score, the corresponding decrease in EQ-5D utility was larger among patients with ESS scores ≥ 12 compared to patients with ESS scores ≤ 11 (model slopes: -0.0131 vs. -0.0026, respectively). Findings from the validation sample confirmed these results.

CONCLUSIONS

This study demonstrates the impact of sleepiness on quality of life (QoL) and its negative impact irrespective of sleep condition (OSA or narcolepsy). The breakpoint identified is relatively consistent with the established ESS cutoff score ≥ 11, which demarcates pathological sleepiness. Furthermore, as EDS severity worsens (increases) on the ESS, the impact on QoL is greater.

In-office communication about excessive daytime sleepiness associated with treated obstructive sleep apnea: insights from an ethnographic study of physician-patient visits

Background

Excessive daytime sleepiness (EDS), a primary symptom of obstructive sleep apnea (OSA), negatively affects functioning and quality of life (QoL). EDS can persist despite primary airway therapy, and often remains unmanaged, potentially due to inadequate provider-patient communication. Ethnographic research was conducted to assess provider-patient communication about EDS.

Methods

Participating physicians (primary care n = 5; pulmonologists n = 5; sleep specialists n = 3) identified adult patients (n = 33) diagnosed with OSA who were prescribed positive airway pressure (PAP) therapy ≥6 months prior and previously reported EDS. Visits and post-visit interviews were video-recorded and analyzed using standardized, validated sociolinguistic techniques.

Results

Despite 55% of patients (18/33) reporting QoL impacts post-visit, this was discussed during 28% (5/18) of visits. Epworth Sleepiness Scale was administered during 27% (9/33) of visits. Many patients (58% [19/33]) attributed EDS to factors other than OSA. Physicians provided EDS education during 24% of visits (8/33). Prior to the visit, 30% (10/33) of patients were prescribed EDS medication, of which 70% (7/10) reported currently experiencing EDS symptoms.

Conclusions

EDS was minimally discussed and rarely reassessed or treated after PAP therapy initiation in this study. Patients often attributed EDS to factors other than OSA. The findings suggest physicians and patients may benefit from dialogue tools, routine use of screening tools, and patient education.

Relationship between Severity and Complexity of Coronary Artery Involvement and Obstructive Sleep Apnea Based on STOP-BANG Questionnaire

Background:

Obstructive sleep apnea (OSA), which has a known correlation with cardiovascular disease, is a possible risk factor of coronary artery disease (CAD) that is preventable.

Aims:

We sought to put lights on the relationship between OSA based on the STOP-BANG questionnaire (SBQ) and the severity and complexity of coronary artery involvement.

Methods:

This cross-sectional, single-center, retrospective study was conducted among 145 patients who underwent selective coronary angiography (SCA) between October 2018 and March 2019, admitted to the Tehran Heart Center, Tehran, Iran. OSA risk was assessed in patients based on SBQ categories. Also, the severity and complexity of coronary artery involvement calculated according to SYNTAX and Gensini scores. Analysis performed by statistical software SPSS 25.

Results:

Based on SBQ risk assessment categories, 22 (15.2%), 64 (44.1%), and 59 (40.7%) of the patients were low, intermediate, and high-risk for OSA, respectively. By comparing the means of coronary artery involvement, there was no significant difference in SYNTAX score 17.15 ± 13.67 (10.56–23.74) in low, 15.67 ± 9.78 (13.19–18.16) in intermediate, and 16.93 ± 9.21 (14.42–19.45) in high-risk groups; P value: 0.754, and Gensini score 66.4 ± 70.75 (35.04–97.77) in low, 66.21 ± 55.05 (52.45–79.96) in intermediate, 74.61 ± 56.33 (59.93–89.3) iin high risk groups; P value: 0.697 with groups of OSA risks. Also, after adjusting confounding factors, there was still no statistically significant difference in terms of coronary involvement scores.

Conclusions:

There was no statistically significant difference in SYNTAX and Gensini scores of different groups of OSA risk categories based on the SBQ. However, our results can't be extended into the connection between OSA and CAD.

Higher HEI-2015 Scores Are Associated with Lower Risk of Sleep Disorder: Results from a Nationally Representative Survey of United States Adults

Whether there is an association between dietary quality and sleep disorder in American adults is unclear. We conducted this study to analyze whether dietary quality, using the Healthy Eating Index-2015 (HEI-2015) scores as the measure, was associated with self-reported sleep disorders. Data came from the National Health and Nutrition Examination Survey (2005–2014). Step-weighted logistic regression models were performed to explore the relationships between the HEI-2015 scores and sleep disorder. Weighted quantile sum regression model was used to identify the HEI-2015 components most strongly associated with sleep disorders. According to quartiles, HEI scores were categorized into inadequate (<25%), average (25–75%), and optimal (>75%). Compared to inadequate HEI status, average HEI status (OR: 0.961, 95%CI: 0.959–0.962) and optimal HEI status (OR: 0.913, 95% CI: 0.912–0.915) were associated with reduced risk of sleep disorder after multivariable adjustments. Greens and beans, added sugars, saturated fats, total vegetables and total protein foods were the top five important components for sleep disorders. Our results suggest that there is a statistically significant association between better dietary quality and reduced risk of sleep disorder among United States adults.

Ambulatory circadian monitoring in sleep disordered breathing patients and CPAP treatment

Our aim was to evaluate the circadian rhythm of motor activity, body position and integrated variable TAP (composed by wrist Temperature, motor Activity and body Position) in Sleep Disordered Breathing (SDB), its relation to SDB severity and the effect of continuous positive airway pressure (CPAP) on these circadian rhythms. To do this, we monitored motor activity and body position rhythms of 78 SDB patients (53.3 ± 1.2 years old, 26.9% women) and 32 healthy subjects (51.4 ± 3.2 years old, 43.8% women) for 1 week. On the last day of that week, SDB patients underwent a polysomnography followed by a Maintenance of Wakefulness Test, Multiple Sleep Latency Test and Sustained Attention to Response Task protocol. A subgroup of 18 moderate to severe SDB patients was treated with CPAP and monitored again after 3 months under treatment. A non-parametrical analysis was performed to characterize the circadian patterns to assess differences between groups and associations between sleep and circadian parameters. Circadian variables were altered in SDB, exhibiting a direct relationship to SDB severity. The motor activity pattern showed a clear improvement with CPAP treatment. Thus, circadian ambulatory monitoring, including the integrated variable TAP, could be used to evaluate the circadian alterations caused by SDB and activity pattern to monitor the effect of CPAP treatment.

Digital sleep measures and white matter health in the Framingham Heart Study

AIM

Impaired sleep quality and sleep oxygenation are common sleep pathologies. This study assessed the impact of these abnormalities on white matter (WM) integrity in an epidemiological cohort.

METHODS

The target population was the Framingham Heart Study Generation-2/Omni-1 Cohorts. Magnetic resonance imaging (diffusion tensor imaging) was used to assess WM integrity. Wearable digital devices were used to assess sleep quality: the (M1-SleepImage™ system) and the Nonin WristOx for nocturnal oxygenation. The M1 device collects trunk actigraphy and the electrocardiogram (ECG); sleep stability indices were computed using cardiopulmonary coupling using the ECG. Two nights of recording were averaged.

RESULTS

Stable sleep was positively associated with WM health. Actigraphic periods of wake during the sleep period were associated with increased mean diffusivity. One marker of sleep fragmentation which covaries with respiratory chemoreflex activation was associated with reduced fractional anisotropy and increased mean diffusivity. Both oxygen desaturation index and oxygen saturation time under 90% were associated with pathological directions of diffusion tensor imaging signals. Gender differences were noted across most variables, with female sex showing the larger and significant impact.

CONCLUSIONS

Sleep quality assessed by a novel digital analysis and sleep hypoxia was associated with WM injury, especially in women.

Upper airway stimulation vs other upper airway surgical procedures for OSA: a meta-analysis

PURPOSE

The aim was to compare the outcomes of upper airway stimulation (Stim) and other upper airway surgical procedures (Surg) in the treatment of obstructive sleep apnea (OSA).

METHODS

Data sources included PubMed, Ovid MEDLINE, Cochrane Library, Web of Science, Scopus, and reference lists. Relevant articles were identified from various databases according to the PRISMA guidelines.

RESULTS

Five articles with a total of 990 patients were included. The mean cure rates in the Stim group and the Surg group was 63% and 22%, and the mean success rates was 86% and 51% which were higher in the Stim group (p < 0.001). The apnea-hypopnea index reduction was -23.9 events/ hour (MD, 95% CI -25.53, -22.29) in the Stim group and -15.5 events/hour (MD, 95% CI -17.50, -13.45) in the Surg group which was greater in the Stim group (P < 0.001). Epworth Sleepiness Scale decreased -4.9 (MD, 95% CI -5.45, -4.32) in the Stim group and -5.1 (MD 95% CI -5.88, -4.37) in the Surg group without significant difference between the groups (P = 0.62). Oxygen saturation nadir improvement was 8.5% (MD 95% CI 7.05%, 9.92%) in the Stim group and 2.2% (MD 95% CI-0.22%, 4.58%) in the Surg group which was higher in the Stim group (P < 0.001). Hospital stay and readmission rate were lower in the Stim group. The timing of follow-up ranged from 2 to 13 months.

CONCLUSION

Upper airway stimulation provides improved objective and similar subjective outcomes compared to other upper airway surgical procedures for selected patients with moderate to severe OSA with difficulty adhering to CPAP treatment. However, further studies are essential to confirm outcomes in the long term.

Pressure adjustment is the most useful intervention for improving compliance in telemonitored patients treated with CPAP in the first 6 months of treatment

PURPOSE

Telemonitoring (TMg) for patients treated with continuous positive airway pressure (CPAP) is now routine care in some sleep labs. The purpose of the present study was to identify technical interventions associated with improved CPAP compliance in a real-life cohort of newly telemonitored patients with obstructive sleep apnea (OSA) during the first 6 months of treatment.

METHODS

All patients with moderate-to-severe OSA (apnea-hypopnea index (AHI) ≥ 15/h) who were newly treated with CPAP were included in the study and telemonitored. A group educational session was scheduled after 1 month. Technical interventions were performed at the patient's request and during scheduled visits and the impact of each intervention on CPAP therapy compliance was collected.

RESULTS

Between May 2018 and Dec 2019, 349 patients newly diagnosed with OSA were hospitalized in the sleep lab for CPAP titration and 212 patients were included (mean age 54.6 ± 13.1 years, mean BMI 31.7 ± 5.8 kg/m², mean AHI 42.8 ± 22.0). TMg acceptance rate was 87%. Mean 6-month compliance was 275 ± 154 min, 13% stopped CPAP, and 17% were non-compliant. Correlations were observed between BMI (r = 0.15, p = 0.029), median and 95th percentile leaks (r = -0.23 and -0.18, p = 0.016 and 0.002), and CPAP compliance. During follow-up, 92 interventions were required, mainly for mask change (n = 80). Pressure modification (n = 16) was the only intervention that increased CPAP use > 30 min/night, p = 0.021.

CONCLUSION

Pressure modification was the only adaptation that significantly increased CPAP compliance during the first 6 months. Remote TMg allows providing daily, accurate, and immediate feedback that could help clinicians to confirm that the CPAP treatment is effective.

The effect of CPAP therapy on excessive daytime sleepiness and quality of life in subjects with obstructive sleep apnoea: an AB design study

BACKGROUND

Obstructive sleep apnoea (OSA) is a disorder characterized by apnoeas and hypopnoeas due to repetitive upper airway collapse during sleep. So far, there are no published data regarding quality of life (QoL) and adherence to CPAP among patients with OSA in India. This study aims to measure sleepiness and QoL of patients before and after effective CPAP use in patients with OSA.

METHOD

Newly diagnosed subjects with OSA were included, and socio-demographic risk factors and anthropomorphic measures were collected. Epworth sleepiness scale (ESS) and short sleep apnoea quality of life index (SAQLI) were administered before and after a minimum of 4 weeks of domiciliary CPAP use. While short SAQLI is a disease-specific questionnaire, ESS measures excessive daytime sleepiness.

RESULTS

In 92 subjects age range was 28-74 years, mean age 49.7 ± 11.3 years, and male:female ratio was 70:22. Mean BMI was 32.1 ± 6.4 kg/sq.m; mean neck circumference was 39.4 ± 3.4 cm; 56 subjects had Mallampati score of 3 or 4. One-month follow-up was completed by 34 subjects who reported a mean of 5.8 ± 1.1 hours/night usage of CPAP. Mean ESS score was 11.31 ± 5.6 at baseline vs 6.9 ± 3.3 after 1 month (p = 0.02), and baseline short SAQLI score was at 2.54 ± 1.26 vs 1.38 ± 0.87 after 1 month (p = 0.0001).

CONCLUSIONS

Subjects reported adequate compliance with CPAP at 1 month, and both ESS and short SAQLI showed a significant improvement in these patients. CPAP compliance improved both QoL and sleepiness in patients with OSA.

Effects of Sleep Patterns on the Subjective Health Status in Older Men from the 7th Korea National Health and Nutrition Examination Survey, 2016

Background

Sleeping is a major component of health. The prevalence of sleep disorders is expected to be high in older adults, and sleep habits generally differ on weekdays and weekends. This study aimed to clarify the associations between sleep habits and the subjective health status of older adults.

Methods

This study analyzed data of 1,678 older adults (695 men and 883 women) aged 65 years or older who had participated in the 2016 Korea National Health and Nutrition Examination Survey (KNHANES VII-1) conducted by the Korea Centers for Disease Control and Prevention. The participants’ subjective health perceptions were analyzed according to their sleep habits.

Results

Weekday and weekend sleep durations were related to subjective health in older men (p<0.05) but not in women. The subjective health perception was significantly better for a 9-hour sleep duration than for a 7-hour sleep duration in older men. Sleeping and waking times on weekdays and weekends were not related to the subjective health of either men or women.

Conclusion

Weekday and weekend sleep durations were related to subjective health perception in older men.

Obstructive Sleep Apnea, Other Sleep Characteristics, and Risk of CKD in the Atherosclerosis Risk in Communities Sleep Heart Health Study

BACKGROUND

Obstructive sleep apnea may be associated with development of CKD through hypoxia, inflammation, and oxidative stress. Individuals with this sleep disorder are also at increased risk for established CKD risk factors, including obesity, hypertension, and type 2 diabetes.

METHODS

We examined the association between obstructive sleep apnea, other sleep characteristics, and risk of incident CKD (stage 3 or higher) in 1525 participants (mean age, 62.5 years; 52.4% women) in the Atherosclerosis Risk in Communities (ARIC) study who completed in-home polysomnography assessments. We used the apnea-hypopnea index (events per hour) to define obstructive sleep apnea severity (normal, <5.0; mild, 5.0-14.9; moderate, 15.0-29.9; and severe, ≥30.0) and defined incident CKD (stage 3 or higher) as eGFR<60 ml/min per 1.73 m² and ≥25% decline from baseline, CKD-related hospitalization or death, or ESKD. Cox proportional hazards regression was used to estimate obstructive sleep apnea severity with risk of incident CKD, adjusting for demographics, lifestyle behaviors, and cardiometabolic conditions.

RESULTS

During 19 years (median) of follow-up, 461 CKD events occurred. After adjustment for demographics and lifestyle behaviors, severe obstructive sleep apnea associated with increased risk of CKD (hazard ratio [HR], 1.51; 95% confidence interval [95% CI], 1.08 to 2.10), which was attenuated after adjustment for body mass index (HR, 1.07; 95% CI, 0.75 to 1.52). No other sleep characteristics associated with incident CKD.

CONCLUSIONS

We found a link between obstructive sleep apnea and an elevated risk of stage 3 CKD or higher, but this association was no longer significant after adjusting for obesity, a risk factor for both conditions. Given the high prevalence of obstructive sleep apnea and CKD among adults, further investigation is warranted.

The role of sham continuous positive airway pressure as a placebo in controlled trials: Best Apnea Interventions for Research Trial

STUDY OBJECTIVES

The main objective of this study was to evaluate the role of sham continuous positive airway pressure (CPAP) compared to conservative medical therapy (CMT) as a control arm in the Best Apnea Interventions for Research (BestAIR) study by assessing differences in subjectively and objectively measured outcomes, adverse events, adherence, and retention rates.

METHODS

BestAIR is a clinical trial aimed to identify important design features for future randomized controlled trials of CPAP. Participants with obstructive sleep apnea were randomized to one of four groups; two control arms (CMT, sham-CPAP) and two active CPAP arms (with and without behavioral interventions). Blood pressure and health-related quality of life outcomes were assessed at baseline, 6 and 12 months. Study outcomes, retention, and adverse event rates were compared between the two control arms. Sham-CPAP adherence and self-efficacy were also compared to active-CPAP adherence (without behavioral intervention).

RESULTS

Our sample included 86 individuals in the control arms and 42 participants in the active-CPAP arm. There were no differences in longitudinal profiles in blood pressure, health-related quality of life outcomes, dropout rates, or adverse events in sham-CPAP group compared to CMT-only group (all ps > 0.05); standardized differences were generally small and with inconsistent directionality across measurements. When compared to active-CPAP, sham-CPAP was associated with 93 fewer minutes/night of usage over 12 months (p = 0.007) and lower outcome expectations (p < 0.05).

CONCLUSION

We observed no evidence of differences in objectively or subjectively measured outcomes with the use of sham-CPAP compared to CMT group. The lower adherence on sham-CPAP and poorer self-efficacy compared to active-CPAP may suggest differences in perceived benefit.

REGISTRATION

NCT01261390 Best Apnea Interventions for Research (BestAIR) www.clinicaltrials.gov.

The economic and societal burden of excessive daytime sleepiness in patients with obstructive sleep apnea

Excessive daytime sleepiness (EDS) is common in patients with obstructive sleep apnea (OSA) and continues to persist in many patients despite adequate OSA treatment. EDS in OSA is associated with decreased quality of life (QOL) as well as increased societal burden, which may impact health care utilization and costs. However, economic burden is often not the primary focus in the treatment of EDS in OSA. This targeted literature review aimed to examine the published literature on the economic burden of EDS in OSA. This review identified available literature using a targeted PubMed search strategy using search terms related to EDS in OSA in adults. Results demonstrate that there are few studies that detailed the direct costs associated with EDS in OSA, though several studies indicated an association between EDS in OSA and indirect economic burdens, including motor vehicle accidents (MVAs), near misses, work productivity, mood, and QOL. Data from the literature confirmed that persistent EDS in OSA following continuous positive airway pressure persists in 12%-65% of patients. Future studies should further describe the direct costs of EDS in OSA, quantify the cost associated with MVAs and lost work productivity, and detail QOL and social impacts of the condition.

A Multifactorial Approach to Sleep and Its Association with Health-Related Quality of Life in a Multiethnic Asian Working Population: A Cross-Sectional Analysis

This study aims to explore if objectively and subjectively measured sleep parameters are associated with physical and mental health-related quality of life in a multiethnic working population in Singapore. We performed a cross-sectional analysis with data from 329 full-time employees enrolled in a workplace cohort study in Singapore. The Short-Form 36v2 (SF-36v2) survey was used to assess health-related quality of life, in terms of physical and mental health. Subjective and objective sleep parameters were measured using the Pittsburgh Sleep Quality Index and wrist actigraphy, respectively. Generalized linear modeling was performed to examine the association between sleep parameters and health-related quality of life. After adjusting for confounders, subjectively measured sleep disturbances were associated with a lower physical health-related quality of life, whereas higher, objectively measured sleep efficiency was associated with greater physical health-related quality of life. Subjectively measured daytime dysfunction was associated with impaired mental health-related quality of life. Using both objective and subjective measurements of sleep, the current study suggests that there is an association between sleep and health-related quality of life. Workplace health-promotion planners in Singapore should consider programmes that educate workers on better sleep hygiene practices in an effort to improve sleep and health-related quality of life.

CPAP and Health-Related Quality of Life in Adults With Coronary Artery Disease and Nonsleepy Obstructive Sleep Apnea in the RICCADSA Trial

STUDY OBJECTIVES

To determine the effect of continuous positive airway pressure (CPAP) treatment on health-related quality of life (HRQoL) in adults with coronary artery disease (CAD) and nonsleepy obstructive sleep apnea (OSA).

METHODS

This was a secondary outcome analysis of the RICCADSA trial, conducted in Sweden between 2005 and 2013. Adults with CAD, nonsleepy OSA (apnea-hypopnea index [AHI] ≥ 15 events/h; Epworth Sleepiness Scale [ESS] score < 10) and complete Short-Form (SF)-36 questionnaires at baseline and after 12 months were included. Patients were randomized to CPAP (n = 102) or no CPAP (n = 104). The primary outcome was the between-group difference in absolute change in the SF-36 components. Within-group changes as well as variables associated with absolute change in the domains in the entire population were also tested.

RESULTS

Mean SF-36 scores were similar at baseline, ranging from 44.9 ± 9.6 to 92.2 ± 15.8 in various domains, and between-group changes from baseline were not statistically significant at 1 year. There was a significant increase in Role physical, Vitality, Role emotional, Mental health and Mental Component Summary (MCS), and a decrease in Bodily pain and General health scores in the CPAP group. The change in Physical Component Summary (PCS) was determined by female sex (beta coefficient -0.19, 95% confidence interval [CI] -7.25 to -0.98, P = .010), baseline AHI (beta coefficient -0.19, 95% CI -0.21 to -0.03, P = .009), CPAP use (h/night) (beta coefficient -0.16, 95% CI -0.93 to -0.06, P = .028), and acute myocardial infarction at baseline (beta coefficient 0.18, 95% CI 0.59 to 5.19, P = .014). Determinants of the change in MCS from baseline were change in the ESS score (beta coefficient -0.14, 95% CI -0.87 to -0.01, P = .054) and change in the Zung Self-rated Depression Scale scores (beta coefficient -0.33, 95% CI -0.58 to -0.24, P < .001).

CONCLUSIONS

Assignment to CPAP treatment compared to no CPAP had no significant effect on HRQoL as measured by the SF-36 in adults with CAD and nonsleepy OSA. Although several components of the SF-36 scores were improved within the CPAP group, CPAP use was associated with a decrease in PCS. The improvement in MCS was determined by the improvement in daytime sleepiness and depressive mood.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Identifier: NCT00519597.

CITATION

Wallström S, Balcan B, Thunström E, Wolf A, Peker Y. CPAP and health-related quality of life in adults with coronary artery disease and nonsleepy obstructive sleep apnea in the RICCADSA trial. J Clin Sleep Med. 2019;15(9):1311-1320.

African ethnicity is associated with a higher prevalence of diabetes in obstructive sleep apnea patients: results of a retrospective analysis

PURPOSE

Obstructive sleep apnea (OSA) syndrome is a well-recognized independent risk factor for cardiovascular disease and its prevalence is increasing. OSA symptomology, polysomnographic features, and comorbidities are heterogeneous among patients. Ethnicity is thought to influence OSA phenotypes, but extensive knowledge of OSA ethnic patterns is lacking. The primary aim of the present study was to compare comorbidities in Caucasian and African OSA. Secondary aims were to observe OSA symptomatology, polysomnographic characteristics, and CPAP adherence in these two ethnic groups.

METHODS

In this retrospective study, 1717 patients suffering from moderate/severe OSA were included between 2013 and 2017. Data on demographics, symptomatology, comorbidities, polysomnographic characteristics, and CPAP adherence were collected. Data were analyzed to identify potential differences between Caucasians and Africans.

RESULTS

Despite healthier lifestyles and lower BMI, a higher prevalence of diabetes but less cardiac comorbidities and dyslipidemia was observed in the African population. Younger African patients (< 56 years) suffered more from cognitive impairment than Caucasians and both younger and older Africans complained more of nighttime choking than Caucasians. In analysis of polysomnographic data, Africans had higher apnea-hypopnea index (AHI) in REM sleep, lower supine AHI, lower desaturation time, and lower periodic leg movements index.

CONCLUSIONS

Compared with Caucasians, African OSA showed a particular comorbidity profile. There are younger patients who exhibit more diabetes but less cardiac comorbidities than the Caucasians. African diabetics should be more promptly referred for OSA testing. Moreover, as they suffer more often from choking and cognitive impairment, OSA treatment could positively impact their quality of life.

A review of psychosocial factors and personality in the treatment of obstructive sleep apnoea

Effective treatment of obstructive sleep apnoea (OSA) is primarily determined by adherence to the selected intervention. The most common treatment pathways are mechanical devices such as continuous positive airway pressure (CPAP) or a mandibular advancement device, often combined with weight loss therapy. Weight reduction is usually an adjunct therapy but may be used as a secondary treatment in mild-to-moderate OSA when mechanical treatments cannot be tolerated. To enhance the uptake and adherence to treatment, clinicians may assess patient's personality profiles and psychological readiness. There is a paucity of evidence related to these aspects of patient care and this article outlines the current research in relation to patient presentation, treatment uptake and barriers, and methods to enhance treatment adherence.

This article disseminates personality traits observed in patients with OSA and identifies vulnerable groups who may require additional support to increase treatment adherence. It summarises the current evidence for treatment barriers in patients with OSA. Low self-efficacy in relation to CPAP and weight loss adherence will be explored as well as the potential to predict treatment responders and enhance therapeutic uptake and adherence. Extending personality traits into research and clinical practice could potentially result in more successful CPAP therapy and weight loss treatment outcomes.

Investigation of smell and taste function in patients with obstructive sleep apnoea syndrome

Objective

This study investigated the relationship between disease severity and taste and smell functions in patients with obstructive sleep apnoea syndrome.

Methods

A total of 65 patients with recurrent upper airway obstruction during sleep were included. Participants were divided into four groups according to apnoea-hypopnoea index, obtained on polysomnography. Smell and taste tests were performed on these patients.

Results

A significant difference was observed between the smell thresholds of the groups for the identification test (p = 0.016). In the taste test, significant differences were observed between the groups in terms of sweet, sour, salty and bitter taste test thresholds (p = 0.029, p = 0.0005, p = 0.001 and p = 0.017, respectively).

Conclusion

As sleep apnoea severity increased (according to the apnoea-hypopnoea index) in obstructive sleep apnoea syndrome patients, the taste and smell thresholds decreased due to the effect of neuropathy and inflammation in the upper respiratory tract.

Prevalence of sleep disturbances in Chinese healthcare professionals: a systematic review and meta-analysis

OBJECTIVE

The current review is a systematic, quantitative meta-analysis aimed at examining the pooled prevalence of sleep disturbances in Chinese healthcare professionals. Furthermore, we explore the possible causes of the inconsistencies in the current estimates.

METHODS

Systematic searches of databases were conducted for literature published on English (EMBASE, PubMed and Web of Science) and Chinese (Chinese National Knowledge Infrastructure, Wan Fang database and Chinese Science & Technology journal database) databases until 25 May 2018. Statistical analyses were performed using SPSS and R software, the prevalence of sleep disturbances was pooled using random-effects model.

RESULTS

A total of 52 studies with 31,749 participants were included. The pooled prevalence of sleep disturbances among Chinese healthcare professionals is 39.2% (95% CI: 36.0%-42.7%). Higher sleep disturbance rates are associated with being female, lower cut-off of Pittsburgh Sleep Quality Index (PSQI), later survey year, bigger sample size, the standardized assessment tool, being a nurse, and shift work. Sample size and cut-off of PSQI were significant moderators for heterogeneity.

CONCLUSION

Sleep disturbances are common in Chinese healthcare professionals, and their prevalence is much higher than the general population. Further research is needed to identify effective strategies for preventing and treating sleep disturbances among healthcare professionals.

Comorbidities, Health-Related Quality of Life, and Work Productivity Among People With Obstructive Sleep Apnea With Excessive Sleepiness: Findings From the 2016 US National Health and Wellness Survey

STUDY OBJECTIVES

Few population-based studies have explored how excessive sleepiness (ES) contributes to burden of illness among patients with obstructive sleep apnea (OSA).

METHODS

This study utilized data from the annual, cross-sectional 2016 US National Health and Wellness Survey. Respondents self-reporting an OSA diagnosis were categorized as having ES (Epworth Sleepiness Scale [ESS] score ≥ 11) or not having ES (ESS score < 11). Comorbidities, health-related quality of life (HRQoL), and productivity were examined in three groups: OSA with ES (n = 731), OSA without ES (n = 1,452), and non-OSA controls (n = 86,961).

RESULTS

The OSA with ES group had significantly higher proportions of respondents reporting depression (62.4% versus 48.0%), gastroesophageal reflux disease (39.0% versus 29.4%), asthma (26.3% versus 20.7%), and angina (7.8% versus 6.7%) compared to the OSA without ES group (P < .05). After controlling for covariates, the OSA with ES group had significantly lower (worse) scores for mental component score (41.81 versus 45.65 versus 47.81), physical component score (46.62 versus 48.68 versus 51.36), and SF-6D (0.65 versus 0.69 versus 0.73) compared with OSA without ES and non-OSA controls (all P < .001). The OSA with ES group had significantly higher (greater burden) mean rates of presenteeism (25.98% impairment versus 19.24% versus 14.75%), work impairment (29.41% versus 21.82% versus 16.85%), and activity impairment (31.09% versus 25.46% versus 19.93%) compared with OSA without ES and non-OSA controls (all P < .01) after controlling for covariates.

CONCLUSIONS

OSA with ES is associated with higher prevalence of comorbidities, reduced HRQoL, and greater impairment in productivity compared to OSA without ES and compared to non-OSA controls.

Effects of sleep changes on pain-related health outcomes in the general population: A systematic review of longitudinal studies with exploratory meta-analysis

Emerging longitudinal research has highlighted poor sleep as a risk factor of a range of adverse health outcomes, including disabling pain conditions. In establishing the causal role of sleep in pain, it remains to be clarified whether sleep deterioration over time is a driver of pain and whether sleep improvement can mitigate pain-related outcomes. A systematic literature search was performed using PubMed MEDLINE, Ovid EMBASE, and Proquest PsycINFO, to identify 16 longitudinal studies involving 61,000 participants. The studies evaluated the effect of sleep changes (simulating sleep deterioration, sleep stability, and sleep improvement) on subsequent pain-related outcomes in the general population. A decline in sleep quality and sleep quantity was associated with a two- to three-fold increase in risk of developing a pain condition, small elevations in levels of inflammatory markers, and a decline in self-reported physical health status. An exploratory meta-analysis further revealed that deterioration in sleep was associated with worse self-reported physical functioning (medium effect size), whilst improvement in sleep was associated with better physical functioning (small effect size). The review consolidates evidence that changes in sleep are prospectively associated with pain-related outcomes and highlights the need for further longitudinal investigations on the long-term impact of sleep improvements.

Circadian Impairment of Distal Skin Temperature Rhythm in Patients With Sleep-Disordered Breathing: The Effect of CPAP

Study objectives

Our aim was to evaluate the circadian rhythm of distal skin temperature (DST) in sleep-disordered breathing (SDB), its relation to excessive daytime sleepiness and the effect of continuous positive airway pressure (CPAP) on DST.

Methods

Eighty SDB patients (53.1 ± 1.2 years old, 27.6% women) and 67 healthy participants (52.3 ± 1.6 years old, 26.9% women) wore a temperature data logger for 1 week. On the last day of that week, SDB patients underwent a polysomnography followed by a Maintenance of Wakefulness Test (MWT), Multiple Sleep Latency Test, and Sustained Attention to Response Task protocol to objectively quantify daytime sleepiness. A subset of 21 moderate to severe SDB patients were treated with CPAP during at least 3 months and revaluated with the same procedure. A nonparametric analysis was performed to characterize DST to assess differences between groups and associations among DST, polysomnography, and daytime sleepiness measures.

Results

SDB patients showed an unstable, fragmented, flattened, phase-advanced, and less robust DST rhythm as compared to healthy participants. The more severe the SDB, the worse the DST pattern was, as indicated by the correlation coefficient. Sleepiness, according to MWT sleep latencies, was also associated with the higher fragmentation, lower amplitude, and less robustness of the DST rhythm. Treatment with CPAP improved DST pattern regularity and robustness.

Conclusion

DST is altered in SDB, exhibiting a direct relationship to the severity of this condition, and improves with CPAP treatment. DST independently correlates with sleepiness, thus, its measurement may contribute to the understanding of the pathophysiology of sleepiness in these patients.

Quality of life in obstructive sleep apnea is related to female gender and comorbid insomnia

PURPOSE

Obstructive sleep apnea (OSA) is a common sleep disorder affecting health-related quality of life (QoL), and OSA severity is not a reliable indicator for QoL. The aim of this study was (1) to evaluate the impact of gender on QoL and (2) to identify the predictors of QoL in OSA patients.

METHODS

World Health Organization Quality of Life Scale short form (WHOQOL-Bref) was used for evaluating QoL in OSA patients undergoing polysomnography in sleep laboratory of a university hospital.

RESULTS

Out of 197 patients (age 50.4 ± 12.1 years, AHI 38.5 ± 28.4/h), 139 (70.6%) were men and 79.2% had moderate-to-severe OSA. Female gender, increased BMI, higher Epworth sleepiness score (ESS), and lower oxygen saturations were associated significantly with poor QoL in terms of all domains (physical, psychological, social relationship, and environmental) of WHOQOL-Bref questionnaire. The indicators of OSA severity (AHI and ODI) correlated negatively only with the physical domain. The subjects with comorbid insomnia and OSA had lower physical and social scores than subjects with no insomnia, and women with insomnia had significantly worse QoL scores in all domains than the others. In the multivariate linear regression analysis, female gender, comorbid insomnia, increased sleepiness, and higher BMI were significantly associated with poor QoL.

CONCLUSIONS

Female gender, comorbid insomnia, and daytime sleepiness were the outstanding factors affecting health-related QoL negatively in OSA. Besides, the impact of OSA on QoL may be explained by the presence of daytime sleepiness rather than OSA severity.

Telemonitoring in continuous positive airway pressure-treated patients improves delay to first intervention and early compliance: a randomized trial

OBJECTIVE

Telemonitoring (TM) has been used in continuous positive airway pressure (CPAP)-treated patients to improve compliance, but results have been inconsistent. The purpose of this study was to assess the impact of TM on the delay to the first technical intervention after CPAP initiation. The impact of TM on mean compliance during the first 3 months of treatment was measured as a secondary outcome.

METHODS

Patients diagnosed with moderate to severe obstructive sleep apnea syndrome were prospectively included and randomized to receive usual care (UC) or TM. In both arms, an educational session was scheduled 1 month after CPAP initiation, and medical visits were planned after 1.5 and 3 months. In the TM arm, we added a universal TM unit (T4P) to the CPAP device.

RESULTS

Delay to first intervention was significantly shorter in the TM group (29 ± 25 vs 47 ± 30 days, p = 0.02). The first intervention in the TM group was motivated by detection of problems by the TM system in 39% of patients. Compliance at 3 months was significantly better in the TM group (5.7 ± 1.6 vs 4.2 ± 1.9 h/night, p = 0.018).

CONCLUSION

This is the first randomized study showing that TM reduces delay to first technical intervention in CPAP-treated patients. This early activation of troubleshooting was associated with improved compliance at 3 months. Since CPAP side effects at 1 month have been shown to predict lower 12-month CPAP compliance, TM seems to be an excellent tool for improvement of long-term CPAP acceptance.

Fatigue and sleepiness determine respiratory quality of life among veterans evaluated for sleep apnea

Background

In those with symptoms indicative of obstructive sleep apnea (OSA), respiratory-specific health-related quality of life (HRQL) may be an important patient-centered outcome. The aim of this study was to assess the associations between sleepiness, fatigue, and impaired general and respiratory-specific HRQL among persons with suspected OSA.

Methods

We evaluated military veterans consecutively referred for suspected OSA with sleep studies yielding apnea-hypopnea index (AHI) values. They also completed the sleepiness (Epworth Sleepiness Scale [ESS]), and fatigue (Fatigue Severity Scale [FSS]) questionnaires, as well as two HRQL instruments (the generic Short-Form SF-12v2 yielding the Physical Component Scale [PCS] and the respiratory-specific Airways Questionnaire [AQ]-20R). Multiple linear regression tested the associations between ESS and FSS (standardized as Z scores for scaling comparability) with AQ-20R, accounting for AHI, SF-12v2-PCS and comorbid respiratory conditions other than OSA.

Results

We studied 1578 veterans (median age 61.1 [IQR 16.8] years; 93.9% males). Of these, 823 (52%) met AHI criteria for moderate to severe OSA (AHI ≥15/h). The majority reported excessive daytime sleepiness (53%; median ESS 11 [IQR 9]) or fatigue (61%; median FSS 42 [IQR 23]). The median AQ-20R was 4 [IQR 1–8]. Controlling for AHI, SF-12v2-PCS, respiratory co-morbid conditions, body mass index, and demographics, both ESS and FSS were significantly associated with poorer AQ-20R: for each; ESS, 1.6 points (95% CI 1.4–1.9), and for FSS, 2.5 points (95% CI, 2.3–2.7).

Conclusions

Greater daytime sleepiness and fatigue are associated with poorer respiratory-specific HRQL, over and above the effects of OSA, respiratory comorbidity, and generic physical HRQL.

Assessment of Change in Palatal Sensation in Obstructive Sleep Apnea Patients by Using Two-Point Palatal Discrimination

Objectives.

Patients with obstructive sleep apnea syndrome (OSAS) have impaired responses to inspiratory resistive loading during sleep. This may be due, in part, to a change in the upper airway sensation. Therefore, we hypothesized that patients with OSAS have diminished upper airway sensation due to snoring.

Methods.

A total of 53 participants were selected based on clinical evaluation and polysomnography. Two-point discrimination was measured with modified calipers in the tongue and soft palate.

Results.

A total of 10 participants were included in the control group, 12 participants in the simple snoring group, and 27 participants in the OSAS group. There were 12 patients in the impaired sensation group of the OSAS group. On comparing polysomnography, patients with impairment of their palatal sensory input in two-point discrimination (TPD) had a more protracted duration of the longest snoring episode than those with simple snoring and normal sensation. Patients with decreased sensory input in TPD had longer average duration of snoring episodes and relative snoring time than those with simple snoring and normal sensory input in cold uvular TPD. Comparison of the cold uvular TPD for normal sensation and impaired sensation in patients with OSAS after treatment showed a different trend.

Conclusion.

Impaired sensation of the soft palate was correlated with the longest snoring episode duration, average snoring episode duration, and relative snoring time. It is helpful in detecting the early stage of neural degradation in OSAS patients by assessing snoring components of polysomnography and TPD in the soft palate.

Habitual Sleep Duration, Unmet Sleep Need, and Excessive Daytime Sleepiness in Korean Adults

Background and Purpose

Sleep need differs between individuals, and so the same duration of sleep will lead to sleep insufficiency in some individuals but not others. The aim of this study was to determine the separate and combined associations of both sleep duration and unmet sleep need with excessive daytime sleepiness (EDS) in Korean adults.

Methods

The participants comprised 2,769 Korean adults aged 19 years or older. They completed questionnaires about their sleep habits over the previous month. The question regarding sleep need was "How much sleep do you need to be at your best during the day?" Unmet sleep need was calculated as sleep need minus habitual sleep duration. Participants with a score of >10 on the Epworth Sleepiness Scale were considered to have EDS.

Results

The overall prevalence of EDS was 11.9%. Approximately one-third of the participants (31.9%) reported not getting at least 7 hours of sleep. An unmet sleep need of >0 hours was present in 30.2% of the participants. An adjusted multivariate logistic regression analysis revealed a significant excess risk of EDS in the groups with unmet sleep needs of ≥2 hours [odds ratio (OR), 1.80; 95% confidence interval (CI), 1.27–2.54] and 0.01–2 hours (OR, 1.42; 95% CI, 1.02–1.98). However, habitual sleep duration was not significantly related to EDS.

Conclusions

EDS was found to be associated with unmet sleep need but not with habitual sleep duration when both factors were examined together. We suggest that individual unmet sleep need is more important than habitual sleep duration in terms of the relation to EDS.

Quality of life in patients with obstructive sleep apnea: Relationship with daytime sleepiness, sleep quality, depression, and apnea severity

The aim of this study was to investigate the relative contributions of daytime sleepiness, sleep quality, depression, and apnea severity to mental and physical quality of life (QoL) in obstructive sleep apnea (OSA) patients. This was a cross-sectional study. Participants were adults diagnosed with OSA. Medical Outcomes Study-Short Form 36 (SF-36), Epworth Sleepiness Scale (ESS), Medical Outcomes Study-Sleep Scale, and Beck Depression Inventory (BDI) were used. The factors predicting the physical and mental QoL were evaluated using multiple linear regression analysis. Seven hundred ninety three OSA patients participated in the study. The average age was 48.9 years (SD = 11.7 years). The mean apnea-hypopnea index (AHI) was 29.5 hour(-1) (SD = 20.6 hour(-1)). The SF-36 scores were 72.6 (SD = 18.5). The BDI, sleep quality, and age were related to both mental and physical QoL. However, ESS, minimal arterial oxygen saturation, gender, and body mass index were associated with the physical but not mental QoL. The BDI was the strongest predictor of both physical and mental QoL. AHI was related to neither physical nor mental QoL. The potential factors affecting QoL are different between physical and mental dimensions of QoL. Depressive mood was the strongest predictor of both the physical and mental QoL.

Development of the National Healthy Sleep Awareness Project Sleep Health Surveillance Questions

OBJECTIVES

For the first time ever, as emphasized by inclusion in the Healthy People 2020 goals, sleep health is an emphasis of national health aims. The National Healthy Sleep Awareness Project (NHSAP) was tasked to propose questions for inclusion in the next Behavioral Risk Factor Surveillance System (BRFSS), a survey that includes a number of questions that target behaviors thought to impact health, as a means to measure community sleep health. The total number of questions could not exceed five, and had to include an assessment of the risk for obstructive sleep apnea (OSA).

METHODS

An appointed workgroup met via teleconference and face-to-face venues to develop an inventory of published survey questions being used to identify sleep health, to develop a framework on which to analyze the strengths and weaknesses of current survey questions concerning sleep, and to develop recommendations for sleep health and disease surveillance questions going forward.

RESULTS

The recommendation was to focus on certain existing BRFSS questions pertaining to sleep duration, quality, satisfaction, daytime alertness, and to add to these other BRFSS existing questions to make a modified STOP-BANG questionnaire (minus the N for neck circumference) to assess for risk of OSA.

CONCLUSIONS

Sleep health is an important dimension of health that has previously received less attention in national health surveys. We believe that 5 questions recommended for the upcoming BRFSS question banks will assist as important measures of sleep health, and may help to evaluate the effectiveness of interventions to improve sleep health in our nation.

Clinical effectiveness and cost-effectiveness results from the randomised controlled Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and long-term economic analysis of oral devices and continuous positive airway pressure

BACKGROUND

Obstructive sleep apnoea-hypopnoea (OSAH) causes excessive daytime sleepiness (EDS), impairs quality of life (QoL) and increases cardiovascular disease and road traffic accident risks. Continuous positive airway pressure (CPAP) treatment is clinically effective but undermined by intolerance, and its cost-effectiveness is borderline in milder cases. Mandibular advancement devices (MADs) are another option, but evidence is lacking regarding their clinical effectiveness and cost-effectiveness in milder disease.

OBJECTIVES

(1) Conduct a randomised controlled trial (RCT) examining the clinical effectiveness and cost-effectiveness of MADs against no treatment in mild to moderate OSAH. (2) Update systematic reviews and an existing health economic decision model with data from the Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and newly published results to better inform long-term clinical effectiveness and cost-effectiveness of MADs and CPAP in mild to moderate OSAH.

TOMADO

A crossover RCT comparing clinical effectiveness and cost-effectiveness of three MADs: self-moulded [SleepPro 1™ (SP1); Meditas Ltd, Winchester, UK]; semibespoke [SleepPro 2™ (SP2); Meditas Ltd, Winchester, UK]; and fully bespoke [bespoke MAD (bMAD); NHS Oral-Maxillofacial Laboratory, Addenbrooke's Hospital, Cambridge, UK] against no treatment, in 90 adults with mild to moderate OSAH. All devices improved primary outcome [apnoea-hypopnoea index (AHI)] compared with no treatment: relative risk 0.74 [95% confidence interval (CI) 0.62 to 0.89] for SP1; relative risk 0.67 (95% CI 0.59 to 0.76) for SP2; and relative risk 0.64 (95% CI 0.55 to 0.76) for bMAD (p < 0.001). Differences between MADs were not significant. Sleepiness [as measured by the Epworth Sleepiness Scale (ESS)] was scored 1.51 [95% CI 0.73 to 2.29 (SP1)] to 2.37 [95% CI 1.53 to 3.22 (bMAD)] lower than no treatment (p < 0.001), with SP2 and bMAD significantly better than SP1. All MADs improved disease-specific QoL. Compliance was lower for SP1, which was unpopular at trial exit. At 4 weeks, all devices were cost-effective at £20,000/quality-adjusted life-year (QALY), with SP2 the best value below £39,800/QALY.

META-ANALYSIS

A MEDLINE, EMBASE and Science Citation Index search updating two existing systematic reviews (one from November 2006 and the other from June 2008) to August 2013 identified 77 RCTs in adult OSAH patients comparing MAD with conservative management (CM), MADs with CPAP or CPAP with CM. MADs and CPAP significantly improved AHI [MAD -9.3/hour (p < 0.001); CPAP -25.4/hour (p < 0.001)]. Effect difference between CPAP and MADs was 7.0/hour (p < 0.001), favouring CPAP. No trials compared CPAP with MADs in mild OSAH. MAD and CPAP reduced the ESS score similarly [MAD 1.6 (p < 0.001); CPAP 1.6 (p < 0.001)].

LONG-TERM COST-EFFECTIVENESS

An existing model assessed lifetime cost-utility of MAD and CPAP in mild to moderate OSAH, using the revised meta-analysis to update input values. The TOMADO provided utility estimates, mapping ESS score to European Quality of Life-5 Dimensions three-level version for device cost-utility. Using SP2 as the standard device, MADs produced higher mean costs and mean QALYs than CM [incremental cost-effectiveness ratio (ICER) £6687/QALY]. From a willingness to pay (WTP) of £15,367/QALY, CPAP is cost-effective, although the likelihood of MADs (p = 0.48) and CPAP (p = 0.49) being cost-effective is very similar. Both were better than CM, but there was much uncertainty in the choice between CPAP and MAD (at a WTP £20,000/QALY, the probability of being the most cost-effective was 47% for MAD and 52% for CPAP). When SP2 lifespan increased to 18 months, the ICER for CPAP compared with MAD became £44,066. The ICER for SP1 compared with CM was £1552, and for bMAD compared with CM the ICER was £13,836. The ICER for CPAP compared with SP1 was £89,182, but CPAP produced lower mean costs and higher mean QALYs than bMAD. Differential compliance rates for CPAP reduces cost-effectiveness so MADs become less costly and more clinically effective with CPAP compliance 90% of SP2.

CONCLUSIONS

Mandibular advancement devices are clinically effective and cost-effective in mild to moderate OSAH. A semi-bespoke MAD is the appropriate first choice in most patients in the short term. Future work should explore whether or not adjustable MADs give additional clinical and cost benefits. Further data on longer-term cardiovascular risk and its risk factors would reduce uncertainty in the health economic model and improve precision of effectiveness estimates.

TRIAL REGISTRATION

This trial is registered as ISRCTN02309506.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 67. See the NIHR Journals Library website for further project information.

Racial/Ethnic Differences in Sleep Disturbances: The Multi-Ethnic Study of Atherosclerosis (MESA)

OBJECTIVES

There is limited research on racial/ethnic variation in sleep disturbances. This study aimed to quantify the distributions of objectively measured sleep disordered breathing (SDB), short sleep duration, poor sleep quality, and self-reported sleep disturbances (e.g., insomnia) across racial/ethnic groups.

DESIGN

Cross-sectional study.

SETTING

Six US communities.

PARTICIPANTS

Racially/ethnically diverse men and women aged 54-93 y in the Multi-Ethnic Study of Atherosclerosis Sleep Cohort (n = 2,230).

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

Information from polysomnography-measured SDB, actigraphy-measured sleep duration and quality, and self-reported daytime sleepiness were obtained between 2010 and 2013. Overall, 15.0% of individuals had severe SDB (apnea-hypopnea index [AHI] ≥ 30); 30.9% short sleep duration (< 6 h); 6.5% poor sleep quality (sleep efficiency < 85%); and 13.9% had daytime sleepiness. Compared with Whites, Blacks had higher odds of sleep apnea syndrome (AHI ≥ 5 plus sleepiness) (sex-, age-, and study site-adjusted odds ratio [OR] = 1.78, 95% confidence interval [CI]: 1.20, 2.63), short sleep (OR = 4.95, 95% CI: 3.56, 6.90), poor sleep quality (OR = 1.57, 95% CI: 1.00, 2.48), and daytime sleepiness (OR = 1.89, 95% CI: 1.38, 2.60). Hispanics and Chinese had higher odds of SDB and short sleep than Whites. Among non-obese individuals, Chinese had the highest odds of SDB compared to Whites. Only 7.4% to 16.2% of individuals with an AHI ≥ 15 reported a prior diagnosis of sleep apnea.

CONCLUSIONS

Sleep disturbances are prevalent among middle-aged and older adults, and vary by race/ethnicity, sex, and obesity status. The high prevalence of sleep disturbances and undiagnosed sleep apnea among racial/ethnic minorities may contribute to health disparities.

Quality measures for the care of adult patients with obstructive sleep apnea

ABSTRACT

Obstructive sleep apnea (OSA) is a prevalent disorder associated with a multitude of adverse outcomes when left untreated. There is significant heterogeneity in the evaluation and management of OSA resulting in variation in cost and outcomes. Thus, the goal for developing these measures was to have a way to evaluate the outcomes and reliability of the processes involved with the standard care approaches used in the diagnosis and management of OSA. The OSA quality care measures presented here focus on both outcomes and processes. The AASM commissioned the Adult OSA Quality Measures Workgroup to develop quality care measures aimed at optimizing care for adult patients with OSA. These quality care measures developed by the Adult OSA Quality Measures Workgroup are an extension of the original Centers for Medicare & Medicaid Services (CMS) approved Physician Quality Reporting System (PQRS) measures group for OSA. The measures are based on the available scientific evidence, focus on public safety, and strive to improve quality of life and cardiovascular outcomes for individual OSA patients. The three outcomes that were selected were as follows: (1) improve disease detection and categorization; (2) improve quality of life; and (3) reduce cardiovascular risk. After selecting these relevant outcomes, a total of ten process measures were chosen that could be applied and assessed for the purpose of accomplishing these outcomes. In the future, the measures described in this document may be reported through the PQRS in addition to, or as a replacement for, the current OSA measures group. The overall objective for the development of these measures is that implementation of these quality measures will result in improved patient outcomes, reduce the public health burden of OSA, and provide a measurable standard for evaluating and managing OSA.

Quality of life among untreated sleep apnea patients compared with the general population and changes after treatment with positive airway pressure

Obstructive sleep apnea leads to recurrent arousals from sleep, oxygen desaturations, daytime sleepiness and fatigue. This can have an adverse impact on quality of life. The aims of this study were to compare: (i) quality of life between the general population and untreated patients with obstructive sleep apnea; and (ii) changes of quality of life among patients with obstructive sleep apnea after 2 years of positive airway pressure treatment between adherent patients and non-users. Propensity score methodologies were used in order to minimize selection bias and strengthen causal inferences. The enrolled obstructive sleep apnea subjects (n = 822) were newly diagnosed with moderate to severe obstructive sleep apnea who were starting positive airway pressure treatment, and the general population subjects (n = 742) were randomly selected Icelanders. The Short Form 12 was used to measure quality of life. Untreated patients with obstructive sleep apnea had a worse quality of life when compared with the general population. This effect remained significant after using propensity scores to select samples, balanced with regard to age, body mass index, gender, smoking, diabetes, hypertension and cardiovascular disease. We did not find significant overall differences between full and non-users of positive airway pressure in improvement of quality of life from baseline to follow-up. However, there was a trend towards more improvement in physical quality of life for positive airway pressure-adherent patients, and the most obese subjects improved their physical quality of life more. The results suggest that co-morbidities of obstructive sleep apnea, such as obesity, insomnia and daytime sleepiness, have a great effect on life qualities and need to be taken into account and addressed with additional interventions.

Associations of allostatic load with sleep apnea, insomnia, short sleep duration, and other sleep disturbances: findings from the National Health and Nutrition Examination Survey 2005 to 2008

PURPOSE

To examine whether allostatic load (AL), a measure of cumulative physiologic dysregulation across biological systems, was associated with sleep apnea, insomnia, and other sleep disturbances.

METHODS

Data from the National Health and Nutrition Examination Survey 2005-2008 were used. AL was measured using nine biomarkers representing cardiovascular, inflammatory, and metabolic system functioning. A total of 3330 US adults aged 18 years and older were included in this study.

RESULTS

The prevalence of high AL (AL score  ≥3) was the highest among African Americans (26.3%), followed by Hispanic Americans (20.3%), whites (17.7%), and other racial/ethnic group (13.8%). After adjustment for sociodemographic and lifestyle factors, high AL was significantly associated with sleep apnea (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.40-2.63), snoring (OR, 2.20; 95% CI, 1.79-2.69), snorting/stop breathing (OR, 2.16; 95% CI, 1.46-3.21), prolonged sleep latency (OR, 1.42; 95% CI, 1.08-1.88), short sleep duration (<6 hours) (OR, 1.35; 95% CI, 1.00-1.82), and diagnosed sleep disorder (OR, 2.26; 95% CI, 1.66-3.08). There was no clear evidence that observed associations varied by sociodemographic characteristics.

CONCLUSIONS

This study suggests significant associations of high AL with sleep apnea, sleep apnea symptoms, insomnia component, short sleep duration, and diagnosed sleep disorder among US adults.

Impact of CPAP on activity patterns and diet in patients with obstructive sleep apnea (OSA)

STUDY OBJECTIVES

Patients with severe OSA consume greater amounts of cholesterol, protein, and fat as well as have greater caloric expenditure. However, it is not known whether their activity levels or diet change after treatment with CPAP. To investigate this issue, serial assessments of activity and dietary intake were performed in the Apnea Positive Pressure Long-term Efficacy Study (APPLES); a 6-month randomized controlled study of CPAP vs. sham CPAP on neurocognitive outcomes.

METHODS

Subjects were recruited into APPLES at 5 sites through clinic encounters or public advertisement. After undergoing a diagnostic polysomnogram, subjects were randomized to CPAP or sham if their AHI was ≥ 10. Adherence was assessed using data cards from the devices. At the Tucson and Walla Walla sites, subjects were asked to complete validated activity and food frequency questionnaires at baseline and their 4-month visit.

RESULTS

Activity and diet data were available at baseline and after 4 months treatment with CPAP or sham in up to 231 subjects (117 CPAP, 114 Sham). Mean age, AHI, BMI, and Epworth Sleepiness Score (ESS) for this cohort were 55 ± 13 [SD] years, 44 ± 27 /h, 33 ± 7.8 kg/m(2), and 10 ± 4, respectively. The participants lacking activity and diet data were younger, had lower AHI and arousal index, and had better sleep efficiency (p < 0.05). The BMI was higher among women in both CPAP and Sham groups. However, compared to women, men had higher AHI only in the CPAP group (50 vs. 34). Similarly, the arousal index was higher among men in CPAP group. Level of adherence defined as hours of device usage per night at 4 months was significantly higher among men in CPAP group (4.0 ± 2.9 vs. 2.6 ± 2.6). No changes in consumption of total calories, protein, carbohydrate or fat were noted after 4 months. Except for a modest increase in recreational activity in women (268 ± 85 vs. 170 ± 47 calories, p < 0.05), there also were no changes in activity patterns.

CONCLUSION

Except for a modest increase in recreational activity in women, OSA patients treated with CPAP do not substantially change their diet or physical activity habits after treatment. .

The association between sleep duration and self-rated health in the Korean general population

STUDY OBJECTIVES

Sleep duration is recognized as one of the most common issues in modern society. Self-rated health is a commonly used subjective health measure based on a single question asking individuals to rate their general health on a four- or five-point scale. However, few studies have examined the relationship between sleep duration and self-rated health. Here, we examined the association between sleep duration and poor self-rated health, using a large representative sample of the general Korean adult population.

DESIGN

We conducted a cross-sectional study of 15,252 participants in the Korea National Health and Nutrition Examination Survey IV (2007-2009) who were aged 19 years and older. Sleep duration was categorized as ≤ 5, 6, 7, 8, or ≥ 9 hours. The main outcome of interest was poor self-rated health (n = 3,705, 19.7%). Multiple logistic regression analysis was performed to examine the association between sleep duration and self-rated health.

RESULTS

We found both short (≤ 5 h) and long (≥ 9 h) sleep duration to be associated with poor self-rated health independent of sociodemographic, health risk, and health status variables. Compared with 7-h sleep duration, the multivariate odds of poor self-rated health were 1.358 times higher (95% CI 1.167-1.580) with short sleep duration and 1.322 times higher (95% CI 1.091-1.601) with long sleep duration. This association persisted in subgroup analyses of gender, body mass index, and age by gender.

CONCLUSIONS

In a large representative sample of the Korean general adult population, compared with sleep duration of 7 hours, we found a positive association between short and long sleep duration and poor self-rated health in Korean adults. Furthermore, the association between sleep duration and poor self-rated health was consistently present in subgroups divided by gender, age, and BMI.

Association between physical activity and insomnia symptoms in rural communities of southeastern Missouri, Tennessee, and Arkansas

PURPOSE

The purpose of this study is to examine whether physical activity is associated with less insomnia symptoms in the rural communities.

METHODS

This study used cross-sectional data collected from a 2005 telephone survey for evaluation of a community walking trails intervention to promote physical activity in rural communities including 6 communities in the Missouri Ozark region and 6 communities in Arkansas and Tennessee (n = 1,234). The exposure variable is self-reported regular current physical activity. The outcome includes symptoms of insomnia operationalized as having trouble falling asleep, staying asleep, and waking up too early nearly every day. Logistic regression was used to calculate prevalence odds ratios (PORs) and 95% confidence intervals (95% CI).

FINDINGS

The study sample includes mostly white (95%), married (62%), overweight/obese (61%) women with a high school degree and a mean age of 54. Fourteen percent of participants reported having insomnia symptoms. Self-report of currently being physically active regularly was associated with decreased odds of insomnia symptoms (adjusted POR: .37; 95% CI, 0.14-0.99) among participants with under or normal body weight, after controlling for age, gender, education level, marital status, and chronic diseases. There was also a negative linear correlation between the number of days and total minutes of vigorous physical activity and insomnia symptoms.

CONCLUSIONS

In these rural communities, we observed a significant relationship between regular physical activity and decreased insomnia symptoms.

Depression, physical activity, energy consumption, and quality of life in OSA patients before and after CPAP treatment

BACKGROUND

A variety of studies have demonstrated improvement in quality of life and depressive symptoms in obstructive sleep apnea (OSA) patients after continuous positive airway pressure (CPAP) treatment. However, very little is known about the effect of OSA treatment on physical activity and energy consumption.

OBJECTIVES

The aim of this study was to evaluate the changes in depression, physical activity, energy expenditure, and quality of life (QoL) in OSA patients before and after CPAP therapy.

METHODS

Forty-one patients with OSA as revealed by polysomnography, were included to the study. They responded to the generic World Health Organization Quality of Life (WHOQoL) questionnaire, to the specific-disease Quebec Sleep Questionnaire, and to Center for Epidemiologic Studies Depression Scale (CES-D) in order to evaluate QoL and the incidence of depression. In addition, all patients wore an accelerometer which measured physical activity and energy expenditure during a week. At least 6 months after initiation of CPAP treatment (mean time, 9 months) we re-examined 24 patients who met the compliance with the treatment criteria.

RESULTS

Patients after CPAP therapy had significantly higher scores in all domains of the Quebec Sleep Questionnaire and in the domains of physical health/level of independence and psychological health/spirituality of the WHOQoL. Depression scores were also better in CES-D after treatment. However, despite the improvement in QoL and psychological status, CPAP therapy had no impact on physical activity and energy expenditure.

CONCLUSIONS

CPAP therapy improves QoL and lessens depressive symptoms in our group of well-treated OSA patients. However, physical activity and energy expenditure did not present statistically significant improvement in the same group of OSA patients.

Sleep quality as a potential mediator between psychological distress and diabetes quality of life in veterans with type 2 diabetes

OBJECTIVE

The goal of this study was to explore sleep quality as a potential mediator between depression symptoms and diabetes quality of life (DQOL), and anxiety symptoms and DQOL.

METHOD

Participants were 83 male and 3 female veterans with type 2 diabetes (Mage = 62.4). Self-report measures were completed during the baseline assessment of a larger intervention study conducted at the VA Boston Healthcare System.

RESULTS

Depression symptoms, anxiety symptoms, and sleep quality were all associated with DQOL. Additionally, sleep quality had a partial indirect effect on the relationships between depression symptoms and DQOL, and between anxiety symptoms and DQOL.

CONCLUSIONS

These findings suggest that sleep quality may have an important role in the way that psychological distress affects diabetes quality of life.

The association between sleep problems and perceived health status: a Japanese nationwide general population survey

OBJECTIVE

Sleep problems in humans have been reported to impact seriously on daily function and to have a close association with well-being. To examine the effects of individual sleep problems on physical and mental health, we conducted a nationwide epidemiological survey and examined the associations between sleep problems and perceived health status.

METHODS

Cross-sectional surveys with a face-to-face interview were conducted in August and September, 2009, as part of the Nihon University Sleep and Mental Health Epidemiology Project (NUSMEP). Data from 2559 people aged 20 years or older were analyzed (response rate 54.0%). Participants completed a questionnaire on perceived physical and mental health statuses, and sleep problems including the presence or absence of insomnia symptoms (i.e., difficulty initiating sleep [DIS], difficulty maintaining sleep [DMS], and early morning awakening [EMA]), excessive daytime sleepiness (EDS), poor sleep quality (PSQ), short sleep duration (SSD), and long sleep duration (LSD).

RESULTS

The prevalence of DIS, DMS, and EMA was 14.9%, 26.6%, and 11.7%, respectively, and 32.7% of the sample reported at least one of them. At the complaint level, the prevalence of EDS, PSQ, SSD, and LSD was 1.4%, 21.7%, 4.0%, and 3.2%, respectively. Multiple logistic regression analyses revealed that DMS, PSQ, SSD, and LSD were independently associated with poor perceived physical health status; DIS, EDS, and PSQ were independently associated with poor perceived mental health status.

CONCLUSIONS

This study has demonstrated that sleep problems have individual significance with regard to perceived physical or mental health status.

Mapping of the Insomnia Severity Index and other sleep measures to EuroQol EQ-5D health state utilities

BACKGROUND

This study sought to map the Insomnia Severity Index (ISI) and symptom variables onto the EQ-5D.

METHODS

A cross-sectional survey was conducted among adult US residents with self-reported sleep problems. Respondents provided demographic, comorbidity, and sleep-related information and had completed the ISI and the EQ-5D profile. Respondents were classified into ISI categories indicating no, threshold, moderate, or severe insomnia. Generalized linear models (GLM) were used to map the ISI's 7 items (Model I), summary scores (Model II), clinical categories (Model III), and insomnia symptoms (Model IV), onto the EQ-5D. We used 50% of the sample for estimation and 50% for prediction. Prediction accuracy was assessed by mean squared errors (MSEs) and mean absolute errors (MAEs).

RESULTS

Mean (standard deviation) sleep duration for respondents (N = 2,842) was 7.8 (1.9) hours, and mean ISI score was 14.1 (4.8). Mean predicted EQ-5D utility was 0.765 (0.08) from Models I-III, which overlapped with observed utilities 0.765 (0.18). Predicted utility using insomnia symptoms was higher (0.771(0.07)). Based on Model I, predicted utilities increased linearly with improving ISI (0.493 if ISI = 28 vs. 1.00 if ISI = 0, p < 0.01). From Model II, each unit decrease in ISI summary score was associated with a 0.022 (p < 0.001) increase in utility. Predicted utilities were 0.868, 0.809, 0.722, and 0.579, respectively, for the 4 clinical categories, suggesting that lower utility was related to greater insomnia severity. The symptom model (Model IV) indicated a concave sleep-duration function of the EQ-5D; thus, utilities diminished after an optimal amount of sleep. The MSEs/MAEs were substantially lower when predicting EQ-5D > 0.40, and results were comparable in all models.

CONCLUSIONS

Findings suggest that mapping relationships between the EQ-5D and insomnia measures could be established. These relationships may be used to estimate insomnia-related treatment effects on health state utilities.