Predictors of health-related quality of life in patients with obstructive sleep apnoea

The Sleepiness-Depression Link in Obstructive Sleep Apnea: Preliminary Results on the Mediation of Impulsivity

BACKGROUND

Emotional impulsivity has been found to be relevant in explaining the association between sleep problems and depressive symptoms, suggesting the potential role of impulsivity as a key underlying mechanism of this link. The objective of this study was to take a preliminary step in understanding the mediating role of impulsivity in the relation between excessive daytime sleepiness (EDS) and depression in patients with obstructive sleep apnea syndrome (OSAS) and to compare psychological and demographic characteristics between different levels of daytime sleepiness.

METHODS

A total of 138 patients with OSAS underwent polygraphic cardiorespiratory monitoring and completed a series of questionnaires investigating perceived sleepiness, depression, impulsivity, and other psychological characteristics. A mediational model was tested in order to assess whether impulsivity mediated the relation between sleepiness and depressive symptoms while controlling for the effects of age, sex, BMI, and oxygen saturation parameters.

RESULTS

the mediation model showed that there was a significant indirect effect of impulsivity in the sleepiness-depression link (αβ = 0.084 [0.0243-0.1617]).

CONCLUSIONS

The here-presented results showed that the sleepiness-depression link is not direct as previous studies asserted, but instead it may be better explained by impulsivity. Research and practical implications are discussed.

Association between self-reported sedentary behavior and health-related quality of life among infertile women with polycystic ovary syndrome

BACKGROUND

High sedentary behavior and poor health-related quality of life (HRQoL) were common among women with polycystic ovary syndrome (PCOS). However, the association of sedentary behavior with HRQoL among infertile women with PCOS is still unknown. This study aimed to investigate the association of sedentary behavior with HRQoL among them.

METHODS

A cross-sectional study was conducted with 283 participants recruited from infertility outpatient clinic. A self-administered, structured questionnaire including the modified PCOS health-related QoL questionnaire (MPCOSQ), the International Physical Activity Questionnaire short form (IPAQ-SF), the Patient Health Questionnaire-9 (PHQ-9), and the Generalized Anxiety Disorder-7 (GAD-7) was used. Anthropometric and laboratory indictors related to PCOS were also collected. Multivariable linear regression analyses were performed to identify the associations. Bonferroni correction was utilized for multiple testing correction.

RESULTS

Sedentary behavior was associated with reduced HRQoL among this group. Specifically, over seven hours per day of sedentary behavior was strongly associated with total and several aspects of HRQoL (β ranged from - 0.378 to - 0.141, all P < 0.0063) after adjusting for physical activity, anxiety and depression. In addition, elevated BMI (β = - 0.407, P < 0.001) and anxiety (β ranged from - 0.410 to - 0.245, all P < 0.0063) were associated with poor HRQoL, while physical activity and depression were not.

CONCLUSION

Sedentary behavior is an important behavior among infertile women with PCOS as it was associated with poorer HRQoL. Future interventions seeking to improve HRQoL should be considered to reduce sedentary behavior and psychological burden as primary intervention targets.

Continuous positive airway pressure and adverse cardiovascular events in obstructive sleep apnea: are participants of randomized trials representative of sleep clinic patients?

STUDY OBJECTIVES

Randomized controlled trials (RCTs) have shown no reduction in adverse cardiovascular (CV) events in patients randomized to continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA). This study examined whether randomized study populations were representative of OSA patients attending a sleep clinic.

METHODS

Sleep clinic patients were 3,965 consecutive adults diagnosed with OSA by in-laboratory polysomnography from 2006 to 2010 at a tertiary hospital sleep clinic. Characteristics of these patients were compared with participants of five recent RCTs examining the effect of CPAP on adverse CV events in OSA. The percentage of patients with severe (apnea-hypopnea index, [AHI] ≥ 30 events/h) or any OSA (AHI ≥ 5 events/h) who met the eligibility criteria of each RCT was determined, and those criteria that excluded the most patients identified.

RESULTS

Compared to RCT participants, sleep clinic OSA patients were younger, sleepier, more likely to be female and less likely to have established CV disease. The percentage of patients with severe or any OSA who met the RCT eligibility criteria ranged from 1.2% to 20.9% and 0.8% to 21.9%, respectively. The eligibility criteria that excluded most patients were preexisting CV disease, symptoms of excessive sleepiness, nocturnal hypoxemia and co-morbidities.

CONCLUSIONS

A minority of sleep clinic patients diagnosed with OSA meet the eligibility criteria of RCTs of CPAP on adverse CV events in OSA. OSA populations in these RCTs differ considerably from typical sleep clinic OSA patients. This suggests that the findings of such OSA treatment-related RCTs are not generalizable to sleep clinic OSA patients.Randomized Intervention with Continuous Positive Airway Pressure in CAD and OSA (RICCADSA) trial, https://clinicaltrials.gov/ct2/show/NCT00519597, ClinicalTrials.gov number, NCT00519597.Usefulness of Nasal Continuous Positive Airway Pressure (CPAP) Treatment in Patients with a First Ever Stroke and Sleep Apnea Syndrome, https://clinicaltrials.gov/ct2/show/NCT00202501, ClinicalTrials.gov number, NCT00202501.Effect of Continuous Positive Airway Pressure (CPAP) on Hypertension and Cardiovascular Morbidity-Mortality in Patients with Sleep Apnea and no Daytime Sleepiness, https://clinicaltrials.gov/ct2/show/NCT00127348, ClinicalTrials.gov number, NCT00127348.Continuous Positive Airway Pressure (CPAP) in Patients with Acute Coronary Syndrome and Obstructive Sleep Apnea (OSA) (ISAACC), https://clinicaltrials.gov/ct2/show/NCT01335087, ClinicalTrials.gov number, NCT01335087.

Sleep and quality of life in lung cancer patients and survivors

BACKGROUND

Lung cancer patients and survivors are vulnerable to disturbed sleep and impaired quality of life (QOL) across the continuum of illness. Few studies have sought to identify predictors of QOL using well-validated measures of both sleep quality and QOL in this population.

PURPOSE

The purpose of this study was to examine factors associated with lung cancer that are predictive of QOL in adult lung cancer patients and survivors in the outpatient setting.

METHOD

Cross-sectional data collected exclusively in the outpatient setting from three lung cancer clinics in the Northeastern United States were pooled and analyzed. The pooled sample (N = 103) data included cancer type and stage, body mass index, Pittsburgh Sleep Quality Index, and Functional Assessment of Cancer Treatment-Lung information.

RESULTS

Significant correlations between sleep quality, lung cancer symptom severity, and QOL were observed. Sleep quality and lung cancer symptoms were found to be statistically significant predictors of QOL. No significant differences in QOL were found based on cancer type or recruitment source. Demographic factors and cancer stage were also not predictive of overall QOL.

CONCLUSIONS

Lung cancer symptoms and sleep quality were important determinants of QOL in this pooled sample of lung cancer patients and survivors.

IMPLICATIONS FOR PRACTICE

Patients and survivors of lung cancer require routine screening for sleep disturbance, lung cancer symptoms, and QOL needs. Nurse practitioners can help improve QOL in this population by screening for and treating sleep disturbance and lung cancer symptoms.

Association of Obstructive Sleep Apnea With the Risk of Affective Disorders

Importance

Obstructive sleep apnea (OSA) is a common subtype of sleep breathing disorder; however, the association between OSA and the psychological health of affected individuals has not been fully evaluated.

Objective

To investigate the association between OSA and development of affective disorders.

Design, Setting, and Participants

This study used a nationwide representative cohort sample from the Korea National Health Insurance Service-National Sample Cohort database comprising data from 1 025 340 patients. The study included 197 patients with OSA diagnosed between January 2004 and December 2006 and 780 individuals without OSA who were matched using propensity score matching. Data were analyzed from September 28, 2018, to March 30, 2019.

Main Outcomes and Measures

Affective disorder events over a 9-year follow-up period. Kaplan-Meier survival curves with log-rank tests and Cox proportional hazards regression models were used to calculate cumulative incidence and hazard ratios (HRs) of affective disorders for each group.

Results

Of the total population of 985 (860 male [87.3%], 540 [54.8%] were aged <45 years), the incidences per 1000 person-years of affective disorders were 49.57 and 27.18 in the OSA and comparison groups, respectively. A total of 1371.7 person-years in the OSA group and 6328.6 person-years in the comparison group were evaluated for affective disorder events. After adjustment for sociodemographic factors (age, residential area, and household income), disability, and comorbidities, the adjusted HRs for patients with OSA developing affective disorders in patients with OSA during the 9-year follow-up period was 2.04 (95% CI, 1.53-2.70). In a subgroup analysis, the adjusted HRs for patients with OSA who developed depressive and anxiety disorders were 2.90 (95% CI, 1.98-4.24) and 1.75 (95% CI, 1.26-2.44), respectively. Moreover, female patients with OSA had a significant likelihood of prospective development of depression and anxiety (adjusted HR for depression, 3.97 [95% CI, 1.54-10.19]; adjusted HR for anxiety, 2.42 [95% CI, 1.17-5.02]) compared with male patients with OSA (adjusted HR for depression, 2.74 [95% CI, 1.80-4.17]; adjusted HR for anxiety, 1.64 [95% CI, 1.13-2.39]).

Conclusions and Relevance

This observational study using nationwide data suggests that OSA is associated with an increased incidence of affective disorder, such as depression and anxiety. Further studies appear to be needed to confirm our findings and, if validated, then studies are needed to explore the nature of the observed association, including potential causality, between OSA and affective symptoms.

Effect of the CPAP-SAVER Intervention on Adherence

Obstructive sleep apnea (OSA) is the most common form of sleep-disordered breathing. Continuous positive airway pressure (CPAP) is the treatment of choice, but adherence is poor, contributing to a myriad of comorbidities that increase health burden. The study purpose was to examine the effect of the CPAP-SAVER intervention on adherence among adults with newly diagnosed OSA. Sixty-six participants were randomly assigned to intervention or standard care groups. Data were analyzed using chi-square, t-tests, and correlations. At one month, there was no significant difference in adherence between groups; CPAP beliefs and attitude were significantly higher and attitude significantly increased for the intervention group. Focus on CPAP beliefs and attitude by practitioners may impact CPAP adherence. With further research and replication of this study in larger samples to determine generalizability, the CPAP-SAVER intervention may provide underpinnings for the eventual development of an OSA-CPAP adherence management protocol.

Obstructive Sleep Apnea and Quality of Life: Comparison of the SAQLI, FOSQ, and SF-36 Questionnaires

INTRODUCTION

The impact of sleep on quality of life (QoL) has been well documented; however, there is a great need for reliable QoL measures for persons with obstructive sleep apnea (OSA). We compared the QoL scores between the 36-Item Short Form of the Medical Outcomes Survey (SF-36), Calgary Sleep Apnea Quality of Life Index (SAQLI), and Functional Outcomes Sleep Questionnaire (FOSQ) in persons with OSA.

METHODS

A total of 884 participants from the Sleep Heart Health Study second examination, who completed the SF-36, FOSQ, and SAQLI, and in-home polysomnograms, were included. The apnea hypopnea index (AHI) at 4% desaturation was categorized as no OSA (<5 /hour), mild to moderate OSA (5-30 /hour) and severe OSA (>30 /hour). QoL scores for each questionnaire were determined and compared by OSA severity category and by gender.

RESULTS

Participants were 47.6% male, 49.2% (n=435) had no OSA, 43.2% (n=382) had mild to moderate OSA, and 7.6% (n=67) had severe OSA. Participants with severe OSA were significantly older (mean age = 63.7 years, p <.0001), had higher BMI (mean = 34.3 kg/m², p <.0001) and had lower SF-36 Physical Component scores (PCS) (45.1) than participants with no OSA (48.5) or those with mild to moderate OSA (46.5, p= .006). When analyzed according to gender, no significant differences were found in males for QoL by OSA severity categories. However, females with severe OSA had significantly lower mean scores for the SAQLI (5.4, p= .006), FOSQ (10.9, p= .02), and SF-36 PCS (37.7, p<.0001) compared to females with no OSA (6.0, 11.5, 44.6) and those with mild to moderate OSA (5.9, 11.4, 48, respectively). Females with severe OSA also had significantly higher mean BMI (41.8 kg/m²,) than females with no OSA (26.5 kg/m²) or females with mild to moderate OSA (30.6 kg/m², p<.0001). The SF-36 PCS and Mental Component Scores (MCS) were correlated with the FOSQ and SAQLI (r=.37 PCS vs FOSQ; r=.31 MCS vs FOSQ; r=.42 PCS vs SAQLI; r=.52 MCS vs SAQLI; and r=.66 FOSQ vs SAQLI, p<.001 for all correlations). Linear regression analyses, adjusting for potential confounders, indicated that the impact of OSA severity on QoL is largely explained by the presence of daytime sleepiness.

CONCLUSION

The impact of OSA on QoL differs between genders with a larger effect on females and is largely explained by the presence of daytime sleepiness. Correlations among QoL instruments are not high and various instruments may assess different aspects of QoL.

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.

Anxiety and its relationship to quality of life independent of depression in patients with obstructive sleep apnea

OBJECTIVES

The relationship between anxiety and obstructive sleep apnea (OSA) has not been well studied. We evaluated the factors associated with anxiety and whether anxiety is related to quality of life (QoL) independently of depression in OSA patients.

METHODS

Data were collected from adults with newly diagnosed, untreated OSA. The State-Trait Anxiety Inventory-State Scale (STAI-S), the Beck Depression Inventory (BDI), the Epworth Sleepiness Scale (ESS), and the Short Form 36 Health survey (SF-36) were used. Anxiety and depression were defined as high levels of anxiety symptoms (STAI-S score≥40) and depressive symptoms (BDI≥10), respectively. Associations between anxiety and OSA were analyzed using multiple linear regression analysis.

RESULTS

Of 655 OSA subjects included, the prevalence of anxiety and depression was 48.4% and 46.4%, respectively. The scores of STAI-S had strong correlations with BDI (r=0.676, p<0.001). Female sex (p<0.05), excessive daytime sleepiness (ESS≥10) (p<0.05), and a lower educational level (p<0.05) were identified as independent factors for predicting the presence of anxiety in OSA patients. The severity of OSA measured by the apnea-hypopnea index or respiratory distress index was not related to comorbid anxiety. In linear regression analysis, both anxiety (ß=-10.196, p<0.001) and depression (ß=-16.317, p<0.001) were independently associated with lower SF-36 scores in OSA patients.

CONCLUSIONS

The presence of anxiety can be predicted by female sex, daytime sleepiness, and a lower educational level. Both anxiety and depression were independently associated with a lower QoL in OSA patients.

The efficacy of a brief motivational enhancement education program on CPAP adherence in OSA: a randomized controlled trial

BACKGROUND

Poor adherence to CPAP treatment in OSA adversely affects the effectiveness of this therapy. This randomized controlled trial (RCT) examined the efficacy of a brief motivational enhancement education program in improving adherence to CPAP treatment in subjects with OSA.

METHODS

Subjects with newly diagnosed OSA were recruited into this RCT. The control group received usual advice on the importance of CPAP therapy and its care. The intervention group received usual care plus a brief motivational enhancement education program directed at enhancing the subjects' knowledge, motivation, and self-efficacy to use CPAP through the use of a 25-min video, a 20-min patient-centered interview, and a 10-min telephone follow-up. Self-reported daytime sleepiness adherence-related cognitions and quality of life were assessed at 1 month and 3 months. CPAP usage data were downloaded at the completion of this 3-month study.

RESULTS

One hundred subjects with OSA (mean ± SD, age 52 ± 10 years; Epworth Sleepiness Scales [ESS], 9 ± 5; median [interquartile range] apnea-hypopnea index, 29 [20, 53] events/h) prescribed CPAP treatment were recruited. The intervention group had better CPAP use (higher daily CPAP usage by 2 h/d [Cohen d = 1.33, P < .001], a fourfold increase in the number using CPAP for ≥ 70% of days with ≥ 4 h/d [P < .001]), and greater improvements in daytime sleepiness (ESS) by 2.2 units (P = .001) and treatment self-efficacy by 0.2 units (P = .012) compared with the control group.

CONCLUSIONS

Subjects with OSA who received motivational enhancement education in addition to usual care were more likely to show better adherence to CPAP treatment, with greater improvements in treatment self-efficacy and daytime sleepiness.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT01173406; URL: www.clinicaltrials.gov.

The effect of long-term life dissatisfaction on health-related quality of life among general population subjects

The aim of this population-based study (n = 329) was to explore how long-term life dissatisfaction (LS burden) and concurrent life dissatisfaction are associated with the concurrent health-related quality of life (HRQL) (RAND-36), and how long-term life dissatisfaction predicts HRQL in the general population. The sum of the life satisfaction scores in 1998, 1999, 2001 (LS burden) and the concurrent life satisfaction score (LS) in 2005 were used to categorize the study participants into satisfied, intermediate and dissatisfied groups. Differences in RAND-36 dimensions in 2005 were investigated with respect to the LS burden and concurrent life dissatisfaction. The predictive power of the LS burden for HRQL dimensions was assessed with logistic regression models. Both a high LS burden and concurrent life dissatisfaction were strongly associated with HRQL and were risk factors for poor HRQL, regardless of its dimensions. The LS burden predicted all of the RAND-36 dimensions, except for physical functioning. Screening of life dissatisfaction can be used to identify service users whose HRQL should be further investigated. Assessment of HRQL provides information on the domains and factors that require mental health nursing intervention. This knowledge could assist mental health nurses in both the alleviation of disease consequences and promotion of well-being of service users.

The different clinical faces of obstructive sleep apnoea: a cluster analysis

Although commonly observed in clinical practice, the heterogeneity of obstructive sleep apnoea (OSA) clinical presentation has not been formally characterised. This study was the first to apply cluster analysis to identify subtypes of patients with OSA who experience distinct combinations of symptoms and comorbidities. An analysis of baseline data from the Icelandic Sleep Apnoea Cohort (822 patients with newly diagnosed moderate-to-severe OSA) was performed. Three distinct clusters were identified. They were classified as the "disturbed sleep group" (cluster 1), "minimally symptomatic group" (cluster 2) and "excessive daytime sleepiness group" (cluster 3), consisting of 32.7%, 24.7% and 42.6% of the entire cohort, respectively. The probabilities of having comorbid hypertension and cardiovascular disease were highest in cluster 2 but lowest in cluster 3. The clusters did not differ significantly in terms of sex, body mass index or apnoea-hypopnoea index. Patients with OSA have different patterns of clinical presentation, which need to be communicated to both the lay public and the professional community with the goal of facilitating care-seeking and early identification of OSA. Identifying distinct clinical profiles of OSA creates a foundation for offering more personalised therapies in the future.

OSA symptoms associated with and predictive of anxiety in middle-aged men: secondary analysis of NHANES data

OBJECT

This population-based study examined obstructive sleep apnea (OSA) symptoms predictive of anxiety in middle-aged men.

METHOD

Secondary analyses were conducted on the National Health and Nutrition Examination Survey (NHANES) 2007-2008 data using weighted samples and complex sample analysis techniques (unweighted N=1,217).

FINDINGS

Nonrefreshing sleep (χ(2)=69.333, p<0.001), excessive daytime sleepiness (χ(2)=47.766, p<0.001), and sleep fragmentation (χ(2)=30.692, p<0.001) were significantly associated with anxiety. Nonrefreshing sleep (OR 3.582, p<0.001) and awakenings due to apneic episodes (OR 2.047, p=0.001) were predictive of anxiety.

CONCLUSION

Comorbid anxiety and OSA symptoms are common and have implications for activities of daily living, social responsibilities, and quality of life. Screening for anxiety among men with OSA symptoms is recommended.

[Structural equation modeling on health-related quality of life in patients with obstructive sleep apnea]

PURPOSE

This study was done to test structural equation modeling of health-related quality of life (QOL) of men with obstructive sleep apnea in order to identify parameters affecting QOL and provide guidelines for interventions and strategies to improve QOL in these patients.

METHODS

Model construction was based on 'The conceptual model of patient outcome in health-related QOL' by Wilson and Cleary, using the variables; age, physiological factors, social support, cognitive appraisal, symptoms and QOL. Participants were 201 adult male patients recruited at a tertiary university hospital in Seoul. Data were collected via questionnaires, polysomnography, and clinical records.

RESULTS

Age and symptoms directly influenced QOL. Social support and cognitive appraisal about sleep did not have a direct influence on QOL, but indirectly affected it via symptoms. QOL was lower in patients who were younger and had more severe symptoms. Symptoms were more severe for patients with lower social support and more dysfunctional cognitive appraisal. When social support was lower, cognitive appraisal was more dysfunctional.

CONCLUSION

These results suggest it is necessary to not only manage symptoms, but also apply interventions to increase social support and cognitive appraisal about sleep in order to increase QOL in patients with obstructive sleep apnea.

Factors influencing daytime sleepiness in Chinese patients with obstructive sleep apnea

This study examined clinically significant physiological and psychological factors contributing to the complaint of daytime sleepiness in 108 Chinese patients with newly diagnosed obstructive sleep apnea (OSA). A higher degree of obesity and greater anxiety, in addition to a higher Apnea-Hypopnea Index, were associated with more daytime sleepiness. The results of this study suggest that the experience of daytime sleepiness goes beyond disturbed breathing caused by sleep apnea. The evaluation of a sleepy patient with OSA should include an assessment of obesity and emotional stress. Future studies in larger samples considering other important factors, such as comorbid insomnia and habitual sleep duration, are warranted to confirm this finding.