The joint contribution of insomnia and obstructive sleep apnoea on sickness absence

Comorbid Insomnia and Sleep Apnea: Challenges and Treatments

Insomnia and obstructive sleep apnea (OSA) are 2 of the most prevalent sleep disorders and frequently co-occur. Therapy can be challenging as treatment of 1 disease may worsen the other. Cognitive behavioral therapy for insomnia is the first-line treatment for insomnia and has been shown to improve compliance with positive airway pressure therapy. Other alternatives to OSA treatment may have higher acceptance in those with comorbid insomnia and sleep apnea (COMISA), such as mandibular advancement devices or emerging pharmacotherapies. Surgery, particularly hypoglossal nerve stimulation, appears to be well tolerated and may improve insomnia in those with COMISA. Otolaryngologists must be cognizant of the common presentation of COMISA in patients seeking surgical treatment and utilize a multidisciplinary approach to the treatment of these complex patients.

Content Comparison of Quality-of-Life Instruments Used in Economic Evaluations of Sleep Disorder Interventions: A Systematic Review

BACKGROUND

Assessment of quality of life (QoL) in people living with sleep disorders using questionnaires is necessary to compare intervention benefits. Knowledge of the content and concepts covered by specific QoL instruments is essential to determine which instruments are best suited for conducting economic evaluations of sleep-related interventions.

OBJECTIVES

This review aims to identify the QoL instruments that have been applied in economic evaluations of sleep disorder interventions and compare their conceptual overlap and content coverage using the framework of the International Classification of Functioning, Disability and Health (ICF).

METHODS

A systematic review of full economic evaluations in sleep published in peer-reviewed journals from conception to 30 May, 2023 was conducted. MEDLINE, PsychInfo, ProQuest, Cochrane, Scopus, CINAHL, Web of Science and Emcare were searched for eligible studies. Studies incorporating either generic or sleep-specific QoL instruments as the primary or secondary measures of effectiveness within a full economic evaluation were included. Quality appraisal against the JBI Critical Appraisal Checklist for Economic Evaluations and EURONHEED checklists and mapping of QoL items to ICF categories were performed by two reviewers, with a third helping settle any potential differences.

RESULTS

Sixteen instruments were identified as having been used in sleep health economic evaluations. The EQ-5D-3L, Epworth Sleepiness Scale, and Insomnia Severity Index were the most widely used, but the latter two are predominantly diagnostic tools and not specifically designed to guide economic evaluations. Other instruments with broader ICF content coverage have been least used, and these include the Sleep Apnea Quality of Life Index, Functional Outcomes of Sleep Questionnaire, 15 Dimensions, Short-Form 6 Dimensions, 12-item Short Form Survey, 36-item Short Form Survey and the GRID Hamilton Rating Scale for Depression.

CONCLUSIONS

This study provides an overview of current QoL instruments used in economic evaluations of sleep with respect to their content coverage. A combination of generic and sleep-specific instruments with broader ICF content coverage is recommended for such evaluations.

Comorbid Insomnia and Sleep Apnea: Challenges and Treatments

Insomnia and obstructive sleep apnea (OSA) are 2 of the most prevalent sleep disorders and frequently co-occur. Cognitive behavioral therapy for insomnia is the first line treatment for insomnia and has been shown to improve compliance with positive airway pressure therapy. Other alternatives to OSA treatment may have higher acceptance in those with comorbid insomnia and sleep apnea (COMISA). Surgery, particularly hypoglossal nerve stimulation, appears to be well tolerated and may improve insomnia in those with COMISA. Otolaryngologists must be cognizant of the common presentation of COMISA in patients seeking surgical treatment and utilize a multidisciplinary approach.

The effect of cognitive behavioural therapy for insomnia in people with comorbid insomnia and sleep apnoea: A systematic review and meta-analysis

Comorbid insomnia and sleep apnoea (COMISA) is a highly prevalent and debilitating sleep disorder. Cognitive behavioural therapy for insomnia (CBTi) may be an appropriate treatment for COMISA; however, no previous study has systematically reviewed and meta-analysed literature reporting on the effect of CBTi in people with COMISA. A systematic literature search was conducted across PsychINFO and PubMed (n = 295). In all, 27 full-text records were independently reviewed by at least two authors. Forward- and backward-chain referencing, and hand-searches were used to identify additional studies. Authors of potentially eligible studies were contacted to provide COMISA subgroup data. In total, 21 studies, including 14 independent samples of 1040 participants with COMISA were included. Downs and Black quality assessments were performed. A meta-analysis including nine primary studies measuring the Insomnia Severity Index indicated that CBTi is associated with a large improvement in insomnia severity (Hedges' g = -0.89, 95% confidence interval [CI] -1.35, -0.43). Subgroup meta-analyses indicated that CBTi is effective in samples with untreated obstructive sleep apnoea (OSA) (five studies, Hedges' g = -1.19, 95% CI -1.77, -0.61) and treated OSA (four studies, Hedges' g = -0.55, 95% CI -0.75, -0.35). Publication bias was evaluated by examining the Funnel plot (Egger's regression p = 0.78). Implementation programmes are required to embed COMISA management pathways in sleep clinics worldwide that currently specialise in the management of OSA alone. Future research should investigate and refine CBTi interventions in people with COMISA, including identifying the most effective CBTi components, adaptations, and developing personalised management approaches for this highly prevalent and debilitating condition.

Predicting the Risk of Sleep Disorders Using a Machine Learning-Based Simple Questionnaire: Development and Validation Study

BACKGROUND

Sleep disorders, such as obstructive sleep apnea (OSA), comorbid insomnia and sleep apnea (COMISA), and insomnia are common and can have serious health consequences. However, accurately diagnosing these conditions can be challenging as a result of the underrecognition of these diseases, the time-intensive nature of sleep monitoring necessary for a proper diagnosis, and patients' hesitancy to undergo demanding and costly overnight polysomnography tests.

OBJECTIVE

We aim to develop a machine learning algorithm that can accurately predict the risk of OSA, COMISA, and insomnia with a simple set of questions, without the need for a polysomnography test.

METHODS

We applied extreme gradient boosting to the data from 2 medical centers (n=4257 from Samsung Medical Center and n=365 from Ewha Womans University Medical Center Seoul Hospital). Features were selected based on feature importance calculated by the Shapley additive explanations (SHAP) method. We applied extreme gradient boosting using selected features to develop a simple questionnaire predicting sleep disorders (SLEEPS). The accuracy of the algorithm was evaluated using the area under the receiver operating characteristics curve.

RESULTS

In total, 9 features were selected to construct SLEEPS. SLEEPS showed high accuracy, with an area under the receiver operating characteristics curve of greater than 0.897 for all 3 sleep disorders, and consistent performance across both sets of data. We found that the distinction between COMISA and OSA was critical for accurate prediction. A publicly accessible website was created based on the algorithm that provides predictions for the risk of the 3 sleep disorders and shows how the risk changes with changes in weight or age.

CONCLUSIONS

SLEEPS has the potential to improve the diagnosis and treatment of sleep disorders by providing more accessibility and convenience. The creation of a publicly accessible website based on the algorithm provides a user-friendly tool for assessing the risk of OSA, COMISA, and insomnia.

Neurocognitive functioning in comorbid insomnia and sleep apnea patients is better after positive airway pressure therapy, but worse after cognitive behavioral therapy for insomnia: exploratory analysis of cognitive outcomes from the Multidisciplinary Approach to the Treatment of Insomnia and Comorbid Sleep Apnea study

STUDY OBJECTIVES

Neurocognitive impairments in comorbid insomnia and sleep apnea (COMISA) are not well documented. We explored neurocognitive functioning and treatment effects in individuals with COMISA as an ancillary study to a randomized clinical trial.

METHODS

Participants with COMISA (n = 45; 51.1% female; mean age = 52.07 ± 13.29 years), from a 3-arm randomized clinical trial combining cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure (PAP) concurrently (CBT-I+PAP) or sequentially, completed neurocognitive testing at baseline, and post-treatment. Using Bayesian linear mixed models, we estimated effects of CBT-I, PAP, or CBT-I+PAP, compared to baseline, and CBT-I+PAP compared to PAP on 12 metrics across five cognitive domains.

RESULTS

This COMISA sample had worse neurocognitive performance at baseline than reported for insomnia, sleep apnea, and controls in the literature, though short-term memory and psychomotor speed performance appears intact. When comparing PAP to baseline, performance on all measures was better after treatment. Performance after CBT-I was worse compared to baseline, and only performance in attention/vigilance, executive functioning via Stroop interference and verbal memory was better with moderate-high effect sizes and moderate probability of superiority (61-83). Comparisons of CBT-I+PAP to baseline generated results similar to PAP and comparing CBT-I+PAP to PAP revealed superior performance in only attention/vigilance via psychomotor vigilance task lapses and verbal memory for PAP.

CONCLUSIONS

Treatment combinations involving CBT-I were associated with poorer neurocognitive performance. These potentially temporary effects may stem from sleep restriction, a component of CBT-I often accompanied by initially reduced total sleep time. Future studies should examine long-term effects of individual and combined COMISA treatment pathways to inform treatment recommendations.

CLINICAL TRIAL

This was an ancillary study from a clinical trial (Multidisciplinary Approach to the Treatment of Insomnia and Comorbid Sleep Apnea (MATRICS), which was preregistered at www.clinicaltrials.gov (NCT01785303)).

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Protective Effect of Fair and Supportive Leadership against Burnout in Police Employees

Background

This study investigated the association between fair and supportive leadership and symptoms of burnout and insomnia in police employees. Burnout and insomnia can have negative consequences for health, performance, and safety among employees in the police profession, and risk and protective factors should be thoroughly investigated.

Methods

Data were collected in a police district in Norway through questionnaires administered in October 2018 and May 2019. The sample consisted of 206 police employees (52% males), with an average age of 42 years and 16 years of experience in the police occupation.

Results

The results showed that a high degree of fair and supportive leadership was associated with lower levels of burnout and insomnia six months later. Fair and supportive leadership explained a greater amount of variance in burnout compared to insomnia. This finding indicates that fair and supportive leadership is a more important buffer factor against burnout than it is against insomnia. Stress was positively associated with burnout and insomnia, whereas quantitative job demands had no significant association with the concepts.

Conclusion

Fair and supportive leadership can help protect employees from adverse consequences of stress and contribute to improved occupational health, whereas a low degree of support and fair treatment from leaders can both represent a stressor by itself and contribute to poorer coping of stressful events at work. The important role of leadership should be incorporated in measures aimed at preventing and reducing burnout and sleep problems.

Stepped care management of insomnia co-occurring with sleep apnea: the AIR study protocol

BACKGROUND

Obstructive sleep apnea (OSA) and insomnia are commonly co-occurring conditions that amplify morbidity and complicates the management of affected patients. Unfortunately, previous research provides limited guidance as to what constitutes the best and most practical management approach for this comorbid patient group. Some preliminary studies show that when cognitive behavioral insomnia therapy (CBT-I) is combined with standard OSA therapies for these patients, outcomes are improved. However, the dearth of trained providers capable of delivering CBT-I has long served as a pragmatic barrier to the widespread use of this therapy in clinical practice. The emergence of sophisticated online CBT-I (OCBT-I) programs could improve access, showing promising reductions in insomnia severity. Given its putative scalability and apparent efficacy, some have argued OCBT-I should represent a 1st-stage intervention in a broader stepped care model that allocates more intensive and less assessable therapist-delivered CBT-I (TCBT-I) only to those who show an inadequate response to lower intensity OCBT-I. However, the efficacy of OCBT-I as a 1st-stage therapy within a broader stepped care management strategy for insomnia comorbid with OSA has yet to be tested with comorbid OSA/insomnia patients.

METHODS/DESIGN

This dual-site randomized clinical trial will use a Sequential Multiple Assignment Randomized Trial (SMART) design to test a stepped care model relative to standard positive airway pressure (PAP) therapy and determine if (1) augmentation of PAP therapy with OCBT-I improves short-term outcomes of comorbid OSA/insomnia and (2) providing a higher intensity 2nd-stage CBT-I to patients who show sub-optimal short-term outcomes with OCBT-I+PAP improves short and longer-term outcomes. After completing baseline assessment, the comorbid OSA/insomnia patients enrolled will be randomized to a 1st-stage therapy that includes usual care PAP + OCBT-I or UC (usual care PAP + sleep hygiene education). Insomnia will be reassessed after 8 weeks. OCBT-I recipients who meet "remission" criteria (defined as an Insomnia Severity Index score < 10) will continue PAP but will not be offered any additional insomnia intervention and will complete study outcome measures again after an additional 8 weeks and at 3 and 6 month follow-ups. OCBT-I recipients classified as "unremitted" after 8 weeks of treatment will be re-randomized to a 2nd-stage treatment consisting of continued, extended access to OCBT-I or a switch to TCBT-I. Those receiving the 2nd-stage intervention as well as the UC group will be reassessed after another 8 weeks and at 3- and 6-month follow-up time points. The primary outcome will be insomnia remission. Secondary outcomes will include subjective and objective sleep data, including sleep time, sleep efficiency, fatigue ratings, PAP adherence, sleepiness ratings, sleep/wake functioning ratings, and objective daytime alertness.

DISCUSSION

This study will provide new information about optimal interventions for patients with comorbid OSA and insomnia to inform future clinical decision-making processes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03109210 , registered on April 12, 2017, prospectively registered.

Impact of Sleep Deprivation on Job Performance of Working Mothers: Mediating Effect of Workplace Deviance

The current study takes its philosophical roots from organizational behavior and psychology domains to investigate the impact of sleep deprivation on the job performance of mothers working in primary, secondary, and higher education institutions (HEIs) of Pakistan. It also examines the mediating role of workplace deviance in the relationship between sleep deprivation and the job performance of working mothers. The authors followed the non-probability convenience sampling technique to study the relationship between sleep deprivation, workplace deviance, and job performance. The structural analyses indicated that sleep deprivation has a significant negative impact on the job performance of working mothers and sleep-deprived individuals often tend to perform poorly at the workplace. Such workers are also more likely to engage in workplace deviant behaviors. Moreover, workplace deviance is also found to act as a mediating variable in the relationship between sleep deprivation and job performance. The present research bridges the literature gap on the rarely investigated factors, namely sleep deprivation and workplace deviance, and provide a detailed understanding of how these factors can influence the performance of working mothers, specifically in Pakistan.

The association of co-morbid insomnia and sleep apnea with prevalent cardiovascular disease and incident cardiovascular events

Insomnia and obstructive sleep apnea commonly co-occur (co-morbid insomnia and sleep apnea), and their co-occurrence has been associated with worse cardiometabolic and mental health. However, it remains unknown if people with co-morbid insomnia and sleep apnea are at a heightened risk of incident cardiovascular events. This study used longitudinal data from the Sleep Heart Health Study (N = 5803) to investigate potential associations between co-morbid insomnia and sleep apnea and cardiovascular disease prevalence at baseline and cardiovascular event incidence over ~11 years follow-up. Insomnia was defined as self-reported difficulties initiating and/or maintaining sleep AND daytime impairment. Obstructive sleep apnea was defined as an apnea-hypopnea index ≥ 15 events per hr sleep. Co-morbid insomnia and sleep apnea was defined if both conditions were present. Data from 4160 participants were used for this analysis. The prevalence of no insomnia/obstructive sleep apnea, insomnia only, obstructive sleep apnea only and co-morbid insomnia and sleep apnea was 53.2%, 3.1%, 39.9% and 1.9%, respectively. Co-morbid insomnia and sleep apnea was associated with a 75% (odd ratios [95% confidence interval]; 1.75 [1.14, 2.67]) increase in likelihood of having cardiovascular disease at baseline after adjusting for pre-specified confounders. In the unadjusted model, co-morbid insomnia and sleep apnea was associated with a twofold increase (hazard ratio, 95% confidence interval: 2.00 [1.33, 2.99]) in risk of cardiovascular event incidence. However, after adjusting for pre-specified covariates, co-morbid insomnia and sleep apnea was not significantly associated with incident cardiovascular events (hazard ratio 1.38 [0.92, 2.07]). Comparable findings were obtained when an alternative definition of insomnia (difficulties initiating and/or maintaining sleep without daytime impairment) was used.

Associations between burnout symptoms and sleep among workers during the COVID-19 pandemic

Background

Methods

Results

Conclusion

Understanding the unmet needs in insomnia treatment: a systematic literature review of real-world evidence

STUDY OBJECTIVE

The objective of this study was to define and characterize the unmet needs in the pharmacological management of insomnia.

METHODS

A systematic literature review was conducted to identify relevant literature reporting real-world evidence in insomnia, published from January 2009 to April 2020. Pharmacological treatments - both prescription (benzodiazepines, 'Z-drugs' and suvorexant) and off-label (antidepressants, antipsychotics, and antihistamines) - were considered.

RESULTS

Overall, 108 publications describing the humanistic (n = 59) and economic burden (n = 20) of insomnia, off-label treatment patterns (n = 28) and factors influencing treatment adherence or persistence (n = 8) were identified. A high prevalence of comorbid conditions was reported in patients with insomnia resulting in significantly lower health-related QoL compared to those with insomnia or a comorbidity alone. Current treatment options were associated with adverse events, including reduced sleep quality and next-day somnolence. An increased risk of accidents/injuries was also associated with insomnia and its treatment. Furthermore, safety concerns and perceived lack of efficacy for approved treatments have led to frequent off-label prescribing, despite a lack of clinical evidence of risk/benefit ratios. Safety concerns associated with benzodiazepines include risk of dependence, leading to prolonged treatment persistence and exacerbated adverse events, making them unsuitable for use in patients with chronic insomnia. Finally, the substantial economic burden of insomnia was evident, with reduced work productivity demonstrated in patients with insomnia compared to the general population.

CONCLUSIONS

This review highlights a clear unmet need for insomnia therapies that improve sleep quality without resulting in next-day impairment and/or dependence.

Co-morbid insomnia and obstructive sleep apnoea is associated with all-cause mortality

STUDY OBJECTIVES

Increased mortality has been reported in people with insomnia and in those with obstructive sleep apnoea (OSA). However, these conditions commonly co-occur and the combined effect of co-morbid insomnia and sleep apnoea (COMISA) on mortality risk is unknown. This study used Sleep Heart Health Study (SHHS) data to assess associations between COMISA and all-cause mortality risk.

METHODS

Insomnia was defined as difficulties falling asleep, maintaining sleep, and/or early morning awakenings from sleep ≥16 times a month and daytime impairment. OSA was defined as an apnoea-hypopnoea index ≥15 events/h sleep. COMISA was defined if both conditions were present. Multivariable adjusted Cox proportional hazard models were used to determine the association between COMISA and all-cause mortality (n=1210) over 15 years of follow-up.

RESULTS

5236 participants were included. 2708 (52%) did not have insomnia/OSA (control), 170 (3%) had insomnia-alone, 2221 (42%) had OSA-alone, and 137 (3%) had COMISA. COMISA participants had a higher prevalence of hypertension (ORs [95%CI]; 2.00 [1.39, 2.90]) and cardiovascular disease compared to controls (1.70 [1.11, 2.61]). Insomnia-alone and OSA-alone were associated with higher risk of hypertension but not cardiovascular disease compared to controls. Compared to controls, COMISA was associated with a 47% (HR, 95% CI; 1.47 (1.06, 2.07)) increased risk of mortality. The association between COMISA and mortality was consistent across multiple definitions of OSA and insomnia.

CONCLUSIONS

Co-morbid insomnia and sleep apnoea was associated with higher rates of hypertension and cardiovascular disease at baseline, and an increased risk of all-cause mortality compared to no insomnia/OSA.

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

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

Bi-directional relationships between co-morbid insomnia and sleep apnea (COMISA)

Insomnia and obstructive sleep apnea (OSA) commonly co-occur. Approximately 30-50% of patients with OSA report clinically significant insomnia symptoms, and 30-40% of patients with chronic insomnia fulfil diagnostic criteria for OSA. Compared to either insomnia or OSA alone, co-morbid insomnia and sleep apnea (COMISA) is associated with greater morbidity for patients, complex diagnostic decisions for clinicians, and reduced response to otherwise effective treatment approaches. Potential bi-directional causal relationships between the mechanisms and manifestations of insomnia and OSA could play an integral role in the development and management of COMISA. A greater understanding of these relationships is required to guide personalized diagnostic and treatment approaches for COMISA. This review summarizes the available evidence of bi-directional relationships between COMISA, including epidemiological research, case studies, single-arm treatment studies, randomized controlled treatment trials, and objective sleep study data. This evidence is integrated into a conceptual model of COMISA to help refine the understanding of potential bi-directional causal relationships between the two disorders. This theoretical framework is essential to help guide future research, improve diagnostic tools, determine novel therapeutic targets, and guide tailored sequenced and multi-faceted treatment approaches for this common, complex, and debilitating condition.

Sleep Apnea and Insomnia: Emerging Evidence for Effective Clinical Management

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

Randomized controlled trial of an integrated approach to treating insomnia and improving the use of positive airway pressure therapy in veterans with comorbid insomnia disorder and obstructive sleep apnea

STUDY OBJECTIVES

Cognitive behavioral therapy for insomnia (CBTI) for comorbid insomnia and obstructive sleep apnea (OSA) has had mixed results. We integrated CBTI with a positive airway pressure (PAP) adherence program and tested effects on sleep and PAP use.

METHODS

125 veterans (mean age 63.2, 96% men, 39% non-Hispanic white, 26% black/African American, 18% Hispanic/Latino) with comorbid insomnia and newly-diagnosed OSA (apnea-hypopnea index ≥ 15) were randomized to 5-weekly sessions integrating CBTI with a PAP adherence program provided by a "sleep coach" (with behavioral sleep medicine supervision), or 5-weekly sleep education control sessions. Participants and assessment staff were blinded to group assignment. Outcomes (baseline, 3 and 6 months) included Pittsburgh Sleep Quality Index (PSQI), 7-day sleep diary (sleep onset latency [SOL-D], wake after sleep onset [WASO-D], sleep efficiency [SE-D]), 7-day actigraphy (SE-A), and objective PAP use (hours/night and nights ≥ 4 h). Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10) were also collected.

RESULTS

Compared to controls, intervention participants showed greater improvement (baseline to 3 and 6 months, respectively) in PSQI (-3.2 and -1.7), SOL-D (-16.2 and -15.5 minutes), SE-D (10.5% and 8.5%), SE-A (4.4% and 2.6%) and more 90-day PAP use (1.3 and 0.9 more hours/night, 17.4 and 11.3 more nights PAP ≥ 4 h). 90-day PAP use at 3 months was 3.2 and 1.9 h/night in intervention versus controls. Intervention participants also had greater improvements in ISI, ESS, and FOSQ-10 (all p < 0.05).

CONCLUSIONS

An intervention integrating CBTI with a PAP adherence program delivered by a supervised sleep coach improved sleep and PAP use in adults with comorbid insomnia and OSA.

TRIAL REGISTRATION

ClinicalTrials.govStudy name: Novel Treatment of Comorbid Insomnia and Sleep Apnea in Older VeteransURL: https://clinicaltrials.gov/ct2/results?cond=&term=NCT02027558&cntry=&state=&city=&dist=Registration: NCT02027558.

Prevalence and associations of co-morbid insomnia and sleep apnoea in an Australian population-based sample

INTRODUCTION

Insomnia and obstructive sleep apnoea (OSA) are the two most prevalent sleep disorders, and frequently co-occur (COMISA) in sleep clinic samples. However, few studies have investigated the prevalence or associations of COMISA in the general population.

METHODS

We used population-based online survey data from 2044 Australian adults. The prevalence and associations of insomnia, OSA and COMISA were investigated according to symptom-level, and disorder-level definitions. Insomnia was defined according to chronic difficulties initiating and/or maintaining sleep (DIMS; symptom-level), and ICSD-3 chronic insomnia disorder (disorder-level). OSA was defined according to self-reported frequent obstructive events, snoring or doctor-diagnosed OSA (symptom-level), and doctor-diagnosed OSA (disorder-level). COMISA was defined if both conditions were met (for symptom-level, and disorder-level threshold). Associations with other conditions, and general health were investigated with Poisson regression analyses.

RESULTS

Chronic insomnia occurred more frequently among participants with doctor-diagnosed OSA (22.3%), compared to those without (14.3%, p = 0.010). Doctor-diagnosed OSA was more common among participants with chronic insomnia (10.2%) compared to those without (6.2%; p = 0.010). DIMS also occurred more frequently among participants with OSA symptoms (66.6%), compared to those without (47.2%; p < 0.001). Participants with symptom-level COMISA reported increased co-morbid conditions, and worse general health compared to participants with symptoms of insomnia-alone, OSA-alone, or neither insomnia/OSA.

CONCLUSIONS

COMISA at symptom and disorder level were common and associated with increased medical and psychiatric co-morbidity, as well as poor general health. More investigation is required to understand bi-directional associations underpinning the high co-morbidity, and improve diagnostic and treatment approaches for COMISA to reduce associated morbidity.

Associations of Sleep and Health Functioning with Premature Exit from Work: A Cohort Study with a Methodological Emphasis

Sleep and functioning are associated with a risk of early workforce exit. However, patterns of change in sleep and functioning through time have not been investigated using person-oriented approaches to show what features of sleep and functioning are associated with an early exit. We examined the pattern of interactions between sleep and health functioning characterizing homogenous subgroups of employees and their associations with premature work exit. An additional aim was to provide a tutorial providing detailed description on how to apply these models, compared to traditional variable based risk factors. We analyzed data from 5148 midlife employees of the City of Helsinki, Finland, surveyed over three phases (2000–02, 2007, and 2012). Using repeated measures latent class analyses (RMLCA) we classified people into groups based on their trajectories in sleep and functioning. We identified four longitudinal groups: (1) Stable good sleep and functioning (reference), (2) Persistent sleep problems and good or moderate functioning, (3) Poor functioning with good sleep, and (4) Problematic sleep and health functioning. Compared to group 1, elevated risk was found in all classes with group 4 being the worst. In conclusion, focusing on person-orientated patterns of interactions between sleep and functioning helped produce qualitatively different and quantitatively stronger predictions than using conventional risk factor methodology. Thus, longitudinal person-oriented approaches may be a more powerful method for quantifying the role of sleep and health functioning as risks for premature exit from work.

Association between obstructive sleep apnea and multiple involuntary job loss history among recently unemployed adults

BACKGROUND

Obstructive sleep apnea (OSA) has been associated with negative occupational outcomes including absenteeism and poor work productivity. This analysis explored whether the severity of OSA was associated with multiple involuntary job loss history among recently unemployed adults.

METHODS

This is a cross-sectional analysis of data from the screening visit of the Assessing Daily Activity Patterns Through Occupational Transitions study. Information was collected from 261 participants who recently involuntarily lost their jobs. Data included demographics, employment, medical history, and results from a limited channel home sleep apnea test. The respiratory event index was categorized as <5 events per hour (no-OSA), 5 to <15 (mild OSA), and ≥15 (moderate to severe OSA). Logistic regression and propensity score matching were used to identify factors associated with multiple involuntary job loss.

RESULTS

A total of 44.8% of participants reported multiple involuntary job loss. Those with mild OSA had 1.85 (95%CI: 1.04, 3.28) increased odds of reporting multiple involuntary job loss as compared to participants with no OSA in the unadjusted model; while participants with moderate-to-severe OSA had 2.71 (95%CI: 1.33, 5.70) increased odds. After adjusting for age, sex, ethnicity, beginning work between 7 and 9 AM, job type, and, compensation type, the odds of involuntary job loss among participants with moderate-severe OSA were 2.46 (95%CI: 1.13, 5.52) as compared to having no OSA.

CONCLUSIONS

In a sample of recently unemployed adults, having OSA significantly increased the odds of reporting previous involuntary job losses. This study suggests OSA could be a risk factor for job loss.

A randomized controlled trial of CBT-I and PAP for obstructive sleep apnea and comorbid insomnia: main outcomes from the MATRICS study

STUDY OBJECTIVES

To investigate treatment models using cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure (PAP) for people with obstructive sleep apnea (OSA) and comorbid insomnia.

METHODS

121 adults with OSA and comorbid insomnia were randomized to receive CBT-I followed by PAP, CBT-I concurrent with PAP, or PAP only. PAP was delivered following standard clinical procedures for in-lab titration and home setup and CBT-I was delivered in four individual sessions. The primary outcome measure was PAP adherence across the first 90 days, with regular PAP use (≥4 h on ≥70% of nights during a 30-day period) serving as the clinical endpoint. The secondary outcome measures were the Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI) with good sleeper (PSQI <5), remission (ISI <8), and response (ISI reduction from baseline >7) serving as the clinical endpoints.

RESULTS

No significant differences were found between the concomitant treatment arms and PAP only on PAP adherence measures, including the percentage of participants who met the clinical endpoint. Compared to PAP alone, the concomitant treatment arms reported a significantly greater reduction from baseline on the ISI (p = .0009) and had a greater percentage of participants who were good sleepers (p = .044) and remitters (p = .008). No significant differences were found between the sequential and concurrent treatment models on any outcome measure.

CONCLUSIONS

The findings from this study indicate that combining CBT-I with PAP is superior to PAP alone on insomnia outcomes but does not significantly improve adherence to PAP.

The Short-Term Efficacy of an Unguided Internet-Based Cognitive-Behavioral Therapy for Insomnia: A Randomized Controlled Trial With a Six-Month Nonrandomized Follow-Up

OBJECTIVE

Insomnia is a major health problem, and the need for effective and accessible treatment is urgent. The aim of the current study was to evaluate the short-term efficacy of an unguided Internet-based cognitive-behavioral treatment program for insomnia (CBTi), called SHUTi (Sleep Healthy Using the Internet).

METHODS

This study used a parallel arm randomized controlled trial in Norway. Participants were randomly allocated to the SHUTi condition or a Web-based patient education condition. Both groups were assessed before and after the nine-week intervention period (online sleep diaries and questionnaires). The SHUTi participants were reassessed in a six-month nonrandomized follow-up. Primary outcome measures were the Insomnia Severity Index (ISI) and the Bergen Insomnia Scale (BIS).

RESULTS

A total of 181 participants were included in the study; SHUTi condition (n = 95), patient education condition (n = 86). Intention-to-treat mixed-model repeated-measures analysis revealed that the SHUTi group had better short-term outcomes compared with the patient education group on most sleep measures. The SHUTi group showed a significant decrease on the primary outcomes, the ISI (d_between = -1.77, 95% CI = -2.23, -1.31) and the BIS (d_between = -1.00, 95% CI = -1.32, -.68). Improvements were maintained among the completing SHUTi participants at the six-month nonrandomized follow-up. However, dropout attrition was high.

CONCLUSION

Unguided Internet-based CBTi produced significant short-term improvements in sleep in patients with chronic insomnia. This highlights the benefits of making Internet-delivered CBTi programs available as a standard first-line treatment option in public health services. Nevertheless, the rate of dropout attrition (participants not completing post-assessment) in this trial limits the generalizability of the findings.

International consensus (ICON) on the ENT role in diagnosis of obstructive sleep apnea syndrome

During the 2017 IFOS ENT World Congress, an international expert panel was asked to clarify the role of ENT in the diagnosis process of the obstructive sleep apnea syndrome (OSA) in adults around the world. OSA is a major public health issue throughout the world. OSA is a highly prevalent disease with heavy clinical, social and economical outcomes. This high prevalence raises serious difficulties of diagnosis accessibility if only somnologists are able to confirm OSA diagnosis. First of all, the panellists reviewed the impact of OSA. Secondly, they defined the ENT role stressing ENT legitimacy, professional expertise and academic and institutional tasks. They also defined when somnologists were necessary. For the international panel, the ENT is a major player in the OSA diagnosis process.

Insomnia and hypertension: A systematic review

Insomnia is a prevalent sleep disorder that is associated with a multitude of health consequences. Particularly, insomnia has been associated with cardiovascular disease and its precursors, such as hypertension and blood pressure (BP) non-dipping. The present systematic review aimed to summarize the evidence on the concurrent and prospective associations between insomnia and hypertension and/or BP. Using electronic search engines (PubMed, SCOPUS, PsycINFO), 5,618 articles published from January 1970 to December 2017 were identified, and 64 met the inclusion criteria (26 to 162,121 participants; age range: 18-100; 46.4% male). Insomnia was based on diagnostic or non-diagnostic criteria. Hypertension was based on self-or physician-reports, antihypertensive medication use, and/or measured BP. Findings indicate that when insomnia is frequent, chronic, and/or accompanied with short sleep duration or objective markers of arousal, there is a strong association with hypertension/BP. Based on limited studies, hypertension did not significantly predict future insomnia in middle-aged adults, but did in older adults. Based on a majority of case-control studies, no differences in BP were found between participants with and without insomnia. Further research is needed to identify putative pathophysiological mechanisms underlying the link between insomnia and hypertension. The impact of insomnia therapy on BP should also be further examined in the future.

Associations of Insomnia Symptoms With Blood Pressure and Resting Heart Rate: The HUNT Study in Norway

OBJECTIVE

Although elevated heart rate and blood pressure might represent biologically plausible links for the association of insomnia symptoms with increased risk of cardiovascular disease (CVD), few large studies have investigated the associations of insomnia symptoms with these factors. Our aim was to investigate the associations of self-reported insomnia symptoms with systolic and diastolic blood pressure and resting heart rate in a large population-based study.

PARTICIPANTS

Self-reported information on insomnia symptoms, including sleep initiation problems, frequent awakening and early awakenings during night, and measurements of resting heart rate and blood pressure were collected from a total of 50,806 men and women who participated in the third wave of the Nord-Trøndelag Health Study (HUNT-3) in 2006-2008.

METHODS

In multivariable analyses, we adjusted for sociodemographic factors, lifestyle factors, established CVD risk factors, and snoring or breathing pauses.

RESULTS

Compared to participants reporting none of the insomnia symptoms, those having all three insomnia symptoms several times a week had lower diastolic blood pressure (-0.80 [95% CI: -1.47 to -0.14] mmHg, p = 0.02), lower systolic blood (-1.69 [95% CI: -2.76 to -0.63) mmHg, p < 0.001), and higher resting heart rate (0.83 [95% CI: 0.11 to 1.55] beats/minute, p = 0.02).

CONCLUSIONS

We found a modest positive association of insomnia symptoms with resting heart rate, and a modest inverse association of insomnia with blood pressure. However, the actual differences were small, and likely of less clinical importance. Prospective studies are needed to establish whether the potential link between insomnia and CVD is mediated through changes in heart rate and/or blood pressure.

Overcoming insomnia: protocol for a large-scale randomised controlled trial of online cognitive behaviour therapy for insomnia compared with online patient education about sleep

INTRODUCTION

Insomnia is a major public health concern. While cognitive behaviour therapy for insomnia (CBT-I) is acknowledged as the best available intervention, there are unanswered questions about its wider dissemination, socioeconomic benefits and its impact on health resource utilisation. The aim of this randomised controlled trial (RCT) is to investigate the effectiveness of a fully automated online version of CBT-I compared with online patient education about sleep (PE). Outcome measures comprise changes in symptoms of insomnia, time off work due to sick leave as well as medication and health resource utilisation. Also, we will examine (i) putative mediators of the effects of CBT-I on insomnia severity and (ii) selected potential psycho-bio-social moderators of the effects of the interventions.

METHODS AND ANALYSIS

A parallel-group RCT will be conducted in a target sample of about 1500 adults recruited across Norway. Participants will complete an online screening and consent process. Those who meet eligibility criteria will be randomised to receive direct access to fully automated online CBT-I or to an online PE programme. The primary outcome is change in insomnia severity immediately postintervention; secondary outcomes are change in daytime functioning and other sleep measures postintervention and at 6-month and 24-month follow-up. Objective data from national registries will be obtained at two time points (1 year and 2 years post-treatment), allowing a mirror image study of preintervention and postintervention rates of sick leave, and of medication and healthcare utilisation by condition.

ETHICS AND DISSEMINATION

The study protocol was approved by the Regional Committee for Medical and Health Research Ethics in South East Norway (2015/134). Findings from the RCT will be disseminated in peer-reviewed publications and conference presentations. Exploratory analyses of potential mediators and moderators will be reported separately. User-friendly outputs will be disseminated to patient advocacy and other relevant organisations.

TRIAL REGISTRATION NUMBER

NCT02558647; Pre-results.

Comorbid Insomnia With Obstructive Sleep Apnea: Clinical Characteristics and Risk Factors

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) and chronic insomnia are two common sleep disorders and both are considered independent risk factors for heart disease. The aim of this study was to investigate the prevalence of comorbid insomnia with OSA and to compare its clinical characteristics with those of OSA without insomnia.

METHODS

Patients who visited two tertiary university hospital sleep centers were screened. Those with a diagnosis of OSA using polysomnography were divided into two groups based on their scores on the Korean version of the Insomnia Severity Index (ISI-K): OSA with insomnia (OSA+I) (ISI-K score ≥ 15) and OSA without insomnia (OSA-I) (ISI-K score < 15). Subjective symptoms were evaluated using sleep questionnaires including ISI-K. Demographic and clinical characteristics of OSA+I and OSA-I were compared.

RESULTS

Out of 476 patients with OSA, 139 (29.2%) had significant insomnia. Patients in the OSA+I group had a higher percentage of females (35.3% versus 19.6%, P < .001) and have higher rates of heart disease (19.4% versus 8.6%, P < .001). OSA+I group showed lower quality of life, lower quality of sleep, higher sleep propensity, and higher depression as measured by the Korean versions of the Short-Form 36-Item Health Survey, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, and Beck Depression Inventory, respectively. There were no significant differences in adherence to continuous positive airway pressure between the groups.

CONCLUSIONS

There is a high prevalence of comorbid insomnia with OSA (29.2%), consistent with previous findings in Western studies. Comorbid insomnia with OSA may constitute a cumulative risk factor for cardiovascular disease. These findings warrant further investigation into the mechanisms involved in its pathogenesis and devising more efficient treatments.

Change in Job Strain as a Predictor of Change in Insomnia Symptoms: Analyzing Observational Data as a Non-randomized Pseudo-Trial

Study objectives:

To examine whether change in job strain leads to change in insomnia symptoms.

Methods:

Among 24873 adults (82% women, mean age 44 years) who participated in a minimum of three consecutive study waves (2000–2012), job strain was assessed at the first and second wave and insomnia symptoms at all three waves. We analyzed observational data as a “pseudo-trial” including participants with no job strain in the first wave and no insomnia symptoms in the first and second wave (n = 7354) to examine whether the onset of job strain between the first and second waves predicted the onset of insomnia symptoms in the third wave. We used a corresponding approach, including those with job strain in the first wave and insomnia symptoms in the first and second wave (n = 2332), to examine whether the disappearance of job strain between the first two waves predicted remission of insomnia symptoms in the third wave.

Results:

The onset of job strain predicted the onset of subsequent insomnia symptoms after adjustment for sex, age, marital status, education, smoking, physical activity, alcohol consumption, body mass index, and comorbidities (odds ratio compared to no onset of job strain 1.32, 95% CI 1.16–1.51). The disappearance of job strain was associated with lower odds of repeated insomnia symptoms (odds ratio compared to no disappearance of job strain 0.78, 95% CI 0.65–0.94). Further adjustment for shift work or sleep apnea did not change these associations.

Conclusions:

These results suggest that job strain is a modifiable risk factor for insomnia symptoms.

Sickness absenteeism is associated with sleep problems independent of sleep disorders: results of the 2016 Sleep Health Foundation national survey

INTRODUCTION

Sleep disorders are associated with sickness absenteeism (SA), at significant economic cost. Correlates of absenteeism are less well described in nonclinical samples.

PARTICIPANTS AND METHODS

We determined the relationship between markers of inadequate sleep and SA in a sample of 551 working adults aged ≥18 years across Australia. We considered diagnosed obstructive sleep apnea (OSA) and insomnia symptoms, daytime symptoms, and sleepiness with respect to sickness absenteeism (missing ≥1 day of work in the past 28 days because of problems with physical or mental health).

RESULTS

Sickness absenteeism was reported by 27.0% of participants and was more frequent in younger participants, university graduates, and those experiencing financial stress. Sickness absenteeism was independently associated with insomnia (odds ratio [OR]=2.5, confidence interval [CI]=1.5-4.0], OSA (OR=9.8, CI=4.7-20.7), sleep aid use (OR=3.0, CI=1.9-4.7), and daytime symptoms (OR=3.0, CI=2.0-4.6) and inversely associated with perception of getting adequate sleep (OR=0.6, CI=0.4-0.9). Associations persisted in the population free of insomnia and/or OSA.

CONCLUSIONS

In adults without clinical sleep disorders, sleep behaviors are contributing to sickness absenteeism. An increased focus at an organizational level on improvement of sleep hygiene is important to reduce lost work performance.

Association of Amplitude and Stability of Circadian Rhythm, Sleep Quality, and Occupational Stress with Sickness Absence among a Gas Company Employees-A Cross Sectional Study from Iran

Background

The present study was carried out to assess the relationship between sickness absence and occupational stress, sleep quality, and amplitude and stability of circadian rhythm as well as to determine contributing factors of sickness absence.

Methods

This cross sectional study was conducted on 400 randomly selected employees of an Iranian gas company. The data were collected using Pittsburgh sleep quality index, Karolinska sleepiness scale, circadian type inventory, and Osipow occupational stress questionnaires.

Results

The mean age and job tenure of the participants were 33.18 ± 5.64 years and 6.06 ± 4.99 years, respectively. Also, the participants had been absent from work on average 2.16 days a year. According to the results, 209 participants had no absences, 129 participants had short-term absences, and 62 participants had long-term absences. The results showed a significant relationship between short-term absenteeism and amplitude of circadian rhythm [odds ratio (OR) = 6.13], sleep quality (OR = 14.46), sleepiness (OR = 2.08), role boundary (OR = 6.45), and responsibility (OR = 5.23). Long-term absenteeism was also significantly associated with amplitude of circadian rhythm (OR = 2.42), sleep quality (OR = 21.56), sleepiness (OR = 6.44), role overload (OR = 4.84), role boundary (OR = 4.27), and responsibility (OR = 3.72).

Conclusion

The results revealed that poor sleep quality, amplitude of circadian rhythm, and occupational stress were the contributing factors for sickness absence in the study population.

Trouble Sleeping Associated With Lower Work Performance and Greater Health Care Costs: Longitudinal Data From Kansas State Employee Wellness Program

OBJECTIVE

To examine the relationships between employees' trouble sleeping and absenteeism, work performance, and health care expenditures over a 2-year period.

METHODS

Utilizing the Kansas State employee wellness program (EWP) data set from 2008 to 2009, multinomial logistic regression analyses were conducted with trouble sleeping as the predictor and absenteeism, work performance, and health care costs as the outcomes.

RESULTS

EWP participants (N = 11,698 in 2008; 5636 followed up in 2009) who had higher levels of sleep disturbance were more likely to be absent from work (all P < 0.0005), have lower work performance ratings (all P < 0.0005), and have higher health care costs (P < 0.0005). Longitudinally, more trouble sleeping was significantly related to negative changes in all outcomes.

CONCLUSIONS

Employees' trouble sleeping, even at a subclinical level, negatively impacts on work attendance, work performance, and health care costs.

Sleep and sickness absence: a nationally representative register-based follow-up study

STUDY OBJECTIVES

We aimed to examine various sleep measures as determinants of sickness absence while considering confounders.

DESIGN

Nationally representative Health 2000 Survey linked with sickness absence data from the Finnish Social Insurance Institution.

SETTING

Finland.

PARTICIPANTS

Working-aged women (n = 1,875) and men (n = 1,885).

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

Insomnia-related symptoms, early morning awakenings, being more tired during daytime than other people of same age, use of sleeping pills, excessive daytime sleepiness, probable sleep apnea (4 items about snoring/apnea), and reporting that sleep duration varies between different seasons were examined as determinants of sickness absence over a 7.2 year follow-up. Poisson and gamma regression models were fitted. After adjusting age, all examined sleep disturbances except excessive daytime sleepiness were associated with sickness absence among men (RRs 1.3-2.5). Among women, after adjusting for age, insomnia-related symptoms, early morning awakenings, being more tired than others, and use of sleeping pills were associated with sickness absence (RRs 1.4-1.8). After further adjustments for education, working conditions, health behaviors, and objectively measured mental and somatic health, the associations somewhat attenuated but mainly remained. The optimal sleep duration with the lowest risk of sickness absence was 7.6 hours for women and 7.8 hours for men. Although persistence of other health problems could affect the estimates, direct costs due to sickness absence could decrease by up to 28% if sleep disturbances could be fully addressed.

CONCLUSIONS

This study highlights the need for prevention of sleep disturbances and promotion of optimal sleep length to prevent sickness absence.

Sleep and body mass index in adolescence: results from a large population-based study of Norwegian adolescents aged 16 to 19 years

Background

The aim of this study was to examine the association between body mass index (BMI) and sleep duration, insomnia and symptoms of obstructive sleep apnea (OSA) in adolescents.

Methods

Data were taken from a large population based study of 9,875 Norwegian adolescents aged 16–19. BMI was calculated from the self-reported body weight and categorized according to recommended age and gender specific cut offs for underweight, overweight and obesity. Detailed sleep parameters (sleep duration, insomnia, and OSA symptoms) were reported separately for weekdays and weekends. Data were analyzed using Pearson’s chi-squared test and ANOVAs for simple categorical and continuous comparisons, and multinomial logistic regressions for analyses adjusting for known confounders.

Results

There was evidence for a curvilinear relationship between BMI and both sleep duration and insomnia for girls, whereas the relationship was linear for boys. Compared to the average weekday sleep duration among adolescents in the normal weight range (6 hrs 29 min), both underweight (5 hrs 48 min), overweight (6 hrs 13 min) and obese (5 hrs 57 min) adolescents had shorter sleep duration. OSA symptoms were linearly associated with BMI. Controlling for demographical factors as well as physical activity did not attenuate the associations. Additional adjustment for depression reduced the association between insomnia and obesity to a non-significant level. The evidence for a link between both underweight and overweight/obesity, and short sleep duration and OSA symptoms remained in the fully adjusted analyses. The associations were generally stronger for girls.

Conclusions

This is one of the first population-based studies to investigate the relationship between sleep and BMI in adolescents while simultaneously controlling for important confounding factors. These findings require further research to investigate the temporal association between weights and sleep problems.

Workplace accidents, absenteeism and productivity in patients with sleep apnea

INTRODUCTION

Obstructive sleep apnea-hypopnea syndrome (OSAHS) has health-related outcomes, but the impact of OSAHS on occupational health has been scarcely studied. The aim of this study was to evaluate the effect of OSAHS on workplace accidents, absenteeism and productivity.

METHOD

One hundred eighty-two OSAHS patients and 71 healthy subjects completed the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index and the Spanish IMPALA (Impact of Disease on Work Productivity) index and answered various questions on workplace accidents and sick leave. Participants were classified to an OSAHS group or a non-OSAHS group according to polysomnography results.

RESULTS

Patients with OSAHS had more sick leave lasting longer than 30days (16.6% vs. 7%, P=.049) and lower productivity (63.80% vs. 83.20%, P=.000) than subjects without OSAHS, although the rate of workplace accidents was similar in both groups (27.4% vs 25.4%; P>.050). None of the OSAHS-related variables was associated with workplace accidents. A diagnosis of OSAHS was related with absenteeism. Psychological distress and OSAHS were related with productivity.

CONCLUSIONS

OSAHS causes limitations in the working lives of patients and leads to a higher incidence of sick leave and lower productivity. A diagnosis of OSAHS was the variable with most influence on the working lives of patients.

Occupational health of patients with obstructive sleep apnea syndrome: a systematic review

PURPOSE

The aim of this systematic literature review was to assess the impact of obstructive sleep apnea syndrome (OSAS) on patients' occupational health.

METHODS

We selected 19 studies that dealt with issues related to job performance and productivity, absenteeism, and psychosocial health of patients with OSAS and assessed the risk of bias in their conclusions.

RESULTS

Although methodologically rigorous studies are needed to confirm these findings, the results obtained suggest the existence of multiple relationships between OSAS and work limitations of patients (i.e., difficulties maintaining attention, learning new tasks, or performing monotonous tasks). The studies reviewed reached more scientifically consistent conclusions about such patients' risk of taking more days of sick leave or having work disability, particularly if they reported excessive daytime sleepiness. Very few studies have explored the relationship between OSAS and psychosocial occupational health of patients. Thus, there is a need for research to clarify these aspects of occupational medicine.

CONCLUSIONS

OSAS has numerous effects on patients' occupational health, yet, in general, results should be confirmed by studies with sufficiently large samples in which OSAS is diagnosed with reliable methods and occupational variables are assessed with standardized and validated questionnaires.

Job stress, burnout, and job satisfaction in sleep apnea patients

OBJECTIVE

To assess job stress, burnout, and job satisfaction in patients with obstructive sleep apnea syndrome (OSAS).

METHODS

A total of 182 patients with OSAS and 71 healthy individuals completed the Job Content Questionnaire, the Maslach Burnout Inventory - General Survey, the Index of Job Satisfaction, the Epworth Sleepiness Scale, and the Pittsburgh Sleep Quality Index. All participants were assessed with full-night polysomnography.

RESULTS

Survey scores of patients diagnosed with OSAS only differed from those of the control group in the emotional exhaustion dimension (P = 0.015). According to a multivariate analysis, the apnea-hypopnea index (AHI) was only correlated with perceived support at work (β coefficient = 0.142; P = 0.048). Associations were found between subjective sleep quality, perceived support from coworkers, and supervisors (β = 0.157; P = 0.025), psychological demands (β = 0.226; P = 0.001), emotional exhaustion (β = 0,405; P = 0.000), and cynicism (β = 0.224; P = 0.002). The study also revealed associations between excessive daytime sleepiness and the burnout dimensions emotional exhaustion (β = 0.232; P = 0.000) and cynicism (β = 0.139; P = 0.048).

CONCLUSION

Objective parameters of OSAS such as the AHI seem to have limited influence on the psychosocial aspects of the occupational life of patients with OSAS. There is evidence of significant associations between the subjective symptoms of the disease, such as daytime sleepiness, subjective sleep quality, job stress, and burnout.

Prevalence and Correlates of Insomnia and Excessive Sleepiness in Adults with Obstructive Sleep Apnea Symptoms

This study investigated the prevalence and correlates of insomnia and excessive sleepiness in adults presenting symptoms of obstructive sleep apnea (OSA) in the general population. Randomly selected participants ( N = 1,502; 50.7% men, 49.3% women), ages 40 to 70 yr. ( M = 53.6, SD = 8.5) were interviewed over the telephone. Insomnia and excessive sleepiness (hypersomnia) were assessed with the Bergen Insomnia Scale and the Epworth Sleepiness Scale, respectively. OSA symptoms were identified by self- or spouse reports on snoring, breathing cessations during sleep, and being tired or sleepy. The prevalence of OSA was 6.2%. Among these participants with OSA, 57.6% reported insomnia and 30.1% reported excessive sleepiness. Furthermore, OSA symptoms were associated with self-reported obesity, hypertension, diabetes, and depression, but only in participants with comorbid insomnia or excessive sleepiness.

Cardiovascular and psychiatric morbidity in obstructive sleep apnea (OSA) with insomnia (sleep apnea plus) versus obstructive sleep apnea without insomnia: a case-control study from a Nationally Representative US sample

PURPOSE

To evaluate cardiovascular and psychiatric morbidity in patient visits with obstructive sleep apnea (OSA) with insomnia (OSA+Insomnia) versus OSA without insomnia (OSA-Insomnia) in a nationally representative US sample.

METHODS

A retrospective case-control study of epidemiologic databases (National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey) representing an estimated ± standard error (SE) 62,253,910 ± 5,274,747 (unweighted count=7234) patient visits with diagnosis of OSA from 1995-2010, was conducted. An estimated 3,994,104 ± 791,386 (unweighted count=658) were classified as OSA+Insomnia and an estimated 58,259,806 ± 4,849,800 (unweighted count=6576) as OSA-Insomnia. Logistic regression analysis was carried out using OSA+Insomnia versus OSA-Insomnia as the dependent variable, and age (>50 years versus ≤ 50 years), sex, race ('White' versus 'non-White'), essential hypertension, heart failure, ischemic heart disease, cardiac dysrhythmia, cerebrovascular disease, diabetes, obesity, hyperlipidemia, depressive, anxiety, and adjustment disorders (includes PTSD), hypersomnia and all medications used as independent variables. All comorbidities were physician diagnosed using the ICD9-CM.

RESULTS

Among patient visits with OSA, an estimated 6.4%± 0.9% also had insomnia. Logistic regression analysis revealed that the OSA+Insomnia group was significantly more likely to have essential hypertension (all ICD9-CM codes 401) (OR=1.83, 95% CI 1.27-2.65) and provisionally more likely to have cerebrovascular disease (ICD9-CM codes 430-438) (OR=6.58, 95% CI 1.66-26.08). The significant OR for cerebrovascular disease was considered provisional because the unweighted count was <30.

CONCLUSIONS

In a nationally representative sample, OSA+Insomnia was associated significantly more frequently with essential hypertension than OSA-Insomnia, a finding that has not been previously reported. In contrast to studies that have considered patient self-reports of psychological morbidity, the absence of a significant association with psychiatric disorders in our study may be indicative of the fact that we considered only physician-rated psychiatric syndromes meeting ICD9-CM criteria. Our findings among the OSA+Insomnia group are therefore most likely conservative.

Traditional and nontraditional cardiovascular risk factors in comorbid insomnia and sleep apnea

OBJECTIVES

Insomnia and sleep apnea frequently co-occur and are independently associated with an increased risk of cardiovascular disease, but little is known about cardiovascular disease risk among individuals with comorbid insomnia and sleep apnea. The current study examined traditional risk factors and a physiologic biomarker of cardiovascular risk in comorbid insomnia and sleep apnea.

DESIGN

Community-based participatory research study.

PARTICIPANTS

The sample comprised 795 participants without preexisting cardiovascular disease from the Heart Strategies Concentrating On Risk Evaluation (Heart SCORE) study.

MEASUREMENTS AND RESULTS

Participants were assessed for symptoms of insomnia and sleep apnea risk, as well as for presence of obesity, smoking, a sedentary lifestyle, hypertension, dyslipidemia, and diabetes. Baseline resting brachial artery diameter was measured by B-mode ultrasonography. A total of 138 participants (17.4%) met criteria for insomnia syndrome alone, 179 (22.5%) were at high risk for sleep apnea alone, 95 (11.9%) reported both insomnia syndrome and high sleep apnea risk, and 383 (48.2%) reported having neither insomnia nor sleep apnea symptoms Both high sleep apnea risk alone and comorbid insomnia and high sleep apnea risk groups had greater frequencies of obesity, sedentary lifestyle, hypertension, and three or more traditional cardiovascular risk factors and significantly larger brachial artery diameters than the insomnia alone group and those without insomnia or sleep apnea symptoms. No differences in traditional cardiovascular risk factors or brachial artery diameter were found between the high sleep apnea risk and comorbid groups.

CONCLUSIONS

These findings suggest that sleep apnea is a major contributor to cardiovascular risk and co-occurring insomnia does not appear to add to this risk.

Clinically diagnosed insomnia and risk of all-cause and diagnosis-specific sickness absence: A nationwide Swedish prospective cohort study

Aims: Insomnia is a large health problem. In some prior studies, positive associations between insomnia symptoms and sickness absence have been observed. There is, however, no previous nationwide cohort study of clinically diagnosed insomnia and risk of incident sickness absence. Methods: Prospective nationwide cohort study based on Swedish population-based registers including all 4,956,358 individuals registered as living in Sweden on 31 December 2004/2005, aged 17–64 years, not on disability pension, old-age pension or on-going sickness absence. Those having insomnia inpatient or outpatient care, defined as having at least one admission/specialist visit with a main or secondary diagnosis of disorders of initiating and maintaining sleep [insomnias] (ICD-10: G47.0) during 2000/2001–2005, were compared to those with no such care. All-cause and diagnosis-specific incident sickness absence were followed during 2006–2010. Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were estimated by Cox proportional hazards regression. Results: In models adjusted for prior sickness absence, socio-demographic factors and inpatient and specialized outpatient care, associations between insomnia and increased risks of all-cause sickness absence (IRR 1.18, 95% CI 1.04–1.35) and sickness absence due to mental diagnoses (IRR 1.75, 95% CI 1.36–2.25) were observed. After further adjustment for insomnia medications these associations disappeared. No associations between insomnia and risk of sickness absence due to cancer, circulatory or musculoskeletal diagnoses, or injuries, were observed. Conclusions: In this nationwide cohort study, we observed increased risks of all-cause sickness absence and sickness absence due to mental diagnoses after adjustment for several potential confounders that disappeared after further adjustment for insomnia medications.