Obstructive sleep apnea and psychiatric disorders: a systematic review

The Complex Relationship between Neuromodulators, Circadian Rhythms, and Insomnia in Patients with Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) has been linked to disruptions in circadian rhythm and neurotrophin (NFT) signaling. This study explored the link between neuromodulators, chronotype, and insomnia in OSA. The participants (n = 166) underwent polysomnography (PSG) before being categorized into either the control or the OSA group. The following questionnaires were completed: Insomnia Severity Index (ISI), Epworth Sleepiness Scale, Chronotype Questionnaire (morningness-eveningness (ME), and subjective amplitude (AM). Blood samples were collected post-PSG for protein level assessment using ELISA kits for brain-derived neurotrophic factor (BDNF), proBDNF, glial-cell-line-derived neurotrophic factor, NFT3, and NFT4. Gene expression was analyzed utilizing qRT-PCR. No significant differences were found in neuromodulator levels between OSA patients and controls. The controls with insomnia exhibited elevated neuromodulator gene expression (p < 0.05). In the non-insomnia individuals, BDNF and NTF3 expression was increased in the OSA group compared to controls (p = 0.007 for both); there were no significant differences between the insomnia groups. The ISI scores positively correlated with all gene expressions in both groups, except for NTF4 in OSA (R = 0.127, p = 0.172). AM and ME were predicting factors for the ISI score and clinically significant insomnia (p < 0.05 for both groups). Compromised compensatory mechanisms in OSA may exacerbate insomnia. The correlation between chronotype and NFT expression highlights the role of circadian misalignments in sleep disruptions.

Are Depressive Symptoms in Obstructive Sleep Apnea Attributable to a Syndrome of Dysregulation of Rhythms and Hyperactivity (DYMERS)?

Background: Obstructive sleep apnea (OSA) is characterized by repeated airway obstructions during sleep, causing hypopnea, apnea, intermittent hypoxia, and sleep fragmentation. The severity of OSA is measured using the apnea-hypopnea index (AHI), with AHI ≥ 5 indicating OSA. This study aims to assess the frequency and type of depressive disorder characteristics of OSA patients and to evaluate the impact on quality of life, also considering the presence of hyperactivity. Methods: A case-control study using OSA patients referred to Cagliari's sleep disorder center. Controls were matched by age and sex from community databases. OSA diagnoses were made with AHI > 15. Depressive episodes were identified using BDI-SF, and H-QoL (Health related Quality of Life) was measured with the SF-12, focusing on item 10 for hyper-energy. Results: The clinical sample (n = 25) had a higher frequency of depressive episodes (36%) compared to controls (7% and 4%). Depressed OSA patients had worse H-QoL and higher hyper-energy scores, but the additional burden from depression was relatively low. Conclusions: The OSA sample has a higher frequency of depressive episodes compared to the general population. Depressive episodes in OSA patients are linked to higher scores on item 10 of the SF-12, indicating hyper-energy despite lower overall quality of life scores. While OSA significantly impacts quality of life, the additional burden from depression is less severe than in other chronic diseases. These findings suggest that depressive episodes in OSA may be related to rhythm dysregulation and hyperactivity (DYMERS).

The relationship between positive airway pressure tolerance and adherence: defining a new metric

STUDY OBJECTIVES

Positive airway pressure (PAP) therapy adherence rates range from 30% to 60%, yet adherent patients may still express dissatisfaction with treatment. The identification of factors affecting PAP tolerance could provide insight into its impact on adherence.

METHODS

Patients with obstructive sleep apnea presenting for first follow-up visit after newly initiating PAP therapy were given a 10-question PAP tolerance survey encompassing domains of psychosocial perception, practical issues, and side effects, utilizing 10-point visual analog scales. Relationships between adherence data, tolerance scores, and patient variables (demographics, sleep-related factors, comorbidities, usage data) were explored via 2-tailed t tests, multivariable regression analysis, and recursive partitioning regression trees with a significance level of P ≤ .05.

RESULTS

For 105 patients, tolerance scores were higher in patients considered adherent to therapy (P = .033), as were scores for individual survey questions addressing the ability to fall asleep (P = .013) and sleep through the night (P = .020). Depression positively (P = .006) and insomnia medication use negatively (P = .010) predicted tolerance score. Data-driven tolerance score cutoffs were identified to correlate with PAP adherence, with higher tolerance scores correlating with greater adherence rates.

CONCLUSIONS

PAP tolerance may play an important role in therapy adherence. Tolerance can be statistically defined and categorized based on prior adherence data. Its utility as a predictive tool in assessing future adherence is warranted.

CITATION

Tekumalla S, Plawecki A, Kaffenberger T, et al. The relationship between positive airway pressure tolerance and adherence: defining a new metric. J Clin Sleep Med. 2024;20(7):1033-1038.

Symptom content analysis of OSA questionnaires: time to identify and improve relevance of diversity of OSA symptoms?

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a heterogeneous condition covering many clinical phenotypes in terms of the diversity of symptoms. Patient-based OSA screening questionnaires used in routine practice contain significantly varying contents that can impact the reliability and validity of the screening. We investigated to what extent common patient-based OSA screening questionnaires differ or overlap in their item content by conducting a rigorous, methodical, and quantified content overlap analysis.

METHODS

We conducted an item content analysis of 11 OSA screening questionnaires validated in adult populations and characterized their overlap using a 4-step approach: (1) selection of OSA screening questionnaires, (2) item extraction and selection, (3) extraction of symptoms from items, and (4) assessment of content overlap with the Jaccard index (from 0, no overlap, to 1, full overlap).

RESULTS

We extracted 72 items that provided 25 distinct symptoms from 11 selected OSA questionnaires. The overlap between them was weak (mean Jaccard index: 0.224; ranging from 0.138 to 0.329). All questionnaires contained symptoms of the "OSA symptom" dimension (eg, snoring or witnessed apneas). The STOP-BANG (0.329) and the Berlin (0.280) questionnaires exhibited the highest overlap content. Ten symptoms (40%) were investigated in only 1 questionnaire.

CONCLUSIONS

The heterogeneity of content and the low overlap across these questionnaires reflect the challenges of screening OSA. The different OSA questionnaires potentially capture varying aspects of the disorder, with the risk of biased results in studies. Suggestions are made for better OSA screening and refinement of clinical OSA phenotypes.

CITATION

Gauld C, Baillieul S, Martin VP, et al. Symptom content analysis of OSA questionnaires: time to identify and improve relevance of diversity of OSA symptoms? J Clin Sleep Med. 2024;20(7):1105-1117.

Oral Health Implications of Obstructive Sleep Apnea: A Literature Review

BACKGROUND

Obstructive sleep apnea (OSA) is a prevalent sleep disorder characterized by repeated episodes of partial or complete obstruction of the upper airway during sleep. While the systemic implications of OSA are well documented, the dental consequences are less frequently discussed yet equally significant. This review aims to elucidate the oral health impacts of OSA, emphasizing the importance of interdisciplinary care.

METHODS

A comprehensive literature search was conducted across several databases to identify studies examining the relationship between OSA and various oral health parameters. The review included observational studies, clinical trials, and systematic reviews published in English up to January 2024.

RESULTS

OSA was significantly associated with heightened risks of bruxism, dry mouth, periodontal disease, temporomandibular joint disorders, palatal and dental changes, and alterations in taste sensation. Mouth breathing associated with OSA was a critical factor in exacerbating xerostomia and dental caries. Furthermore, the systemic inflammation induced by OSA appeared to correlate with the severity of periodontal disease. Patients using oral appliance therapy for OSA also showed notable changes in dental occlusion and required ongoing dental monitoring.

CONCLUSIONS

The findings underscore the bidirectional relationship between OSA and oral health, highlighting the need for dental professionals to be integral participants in the management of OSA. Early dental evaluation and intervention can contribute to the overall health and quality of life of individuals with OSA. The review advocates for the development of clinical guidelines to facilitate the early identification and management of OSA-related oral health issues within dental practice and encourages a collaborative approach to patient care.

Same sleep disorder but different sleep patterns: individual differences in sleep health and depressive symptomatology in veterans with obstructive sleep apnea

PURPOSE

Poor sleep health, a composite measure of key sleep characteristics, may relate to increased depressive symptoms among individuals treated for obstructive sleep apnea. The current investigation examined the association between sleep health and depressive symptomatology.

METHODS

In a pilot sample of 13 symptomatic OSA military Veterans with adequate CPAP adherence (mean age = 54.8, 76.9% male, 100% White), empirically validated cutoffs were applied to actigraphy-derived sleep variables: duration, efficiency, timing, and regularity.

RESULTS

Participants with zero optimal sleep scores had significantly higher depressive scores (M = 19.0, SD = 3.0) than participants with 1 or 2 (M = 9.8. SD = 4.3, p = .016) and 3 or more optimal sleep scores (M = 11.3, SD = 4.9, p = .038).

CONCLUSIONS

These preliminary findings suggest that better sleep health was associated with lower depressive symptomatology. Future work should replicate these preliminary findings in a larger sample.

Age-Related Changes in Sleep and Its Implications for Cognitive Decline in Aging Persons With Schizophrenia: A Critical Review

BACKGROUND AND HYPOTHESIS

Cognitive impairment is a core feature of schizophrenia that worsens with aging and interferes with quality of life. Recent work identifies sleep as an actionable target to alleviate cognitive deficits. Cardinal non-rapid eye movement (NREM) sleep oscillations such as sleep spindles and slow oscillations are critical for cognition. People living with schizophrenia (PLWS) and their first-degree relatives have a specific reduction in sleep spindles and an abnormality in their temporal coordination with slow oscillations that predict impaired memory consolidation. While NREM oscillatory activity is reduced in typical aging, it is not known how further disruption in these oscillations contributes to cognitive decline in older PLWS. Another understudied risk factor for cognitive deficits among older PLWS is obstructive sleep apnea (OSA) which may contribute to cognitive decline.

STUDY DESIGN

We conducted a narrative review to examine the published literature on aging, OSA, and NREM sleep oscillations in PLWS.

STUDY RESULTS

Spindles are propagated via thalamocortical feedback loops, and this circuitry shows abnormal hyperconnectivity in schizophrenia as revealed by structural and functional MRI studies. While the risk and severity of OSA increase with age, older PLWS are particularly vulnerable to OSA-related cognitive deficits because OSA is often underdiagnosed and undertreated, and OSA adds further damage to the circuitry that generates NREM sleep oscillations.

CONCLUSIONS

We highlight the critical need to study NREM sleep in older PWLS and propose that identifying and treating OSA in older PLWS will provide an avenue to potentially mitigate and prevent cognitive decline.

Association between sleep apnoea and risk of cognitive impairment and Alzheimer's disease: a meta-analysis of cohort-based studies

PURPOSE

To provide updated evidence on the association of obstructive sleep apnoea (OSA)/sleep-disordered breathing (SDB) with risk of all-cause cognitive impairment/dementia and Alzheimer's disease (AD).

METHODS

A systematic literature search was done in PubMed, EMBASE and Scopus databases for cohort studies (retrospective or prospective) that documented the association of SDB/OSA with the risk of cognitive impairment or all-cause dementia or AD. Only studies that were published in the year 2000 and onwards were included. The random-effects model was used for all the analyses and effect sizes were reported as hazards ratio (HR) with 95% confidence intervals.

RESULTS

Of 15 studies were included in the meta-analysis, SDB/OSA was diagnosed with at-home polysomnography in six studies, while five studies relied on self-report or questionnaires. In the remaining studies, International Classification of Diseases (ICD) codes determined the diagnosis of SDB. The overall pooled analysis showed that patients with SDB/OSA had higher risk of cognitive impairment and/or all-cause dementia (HR 1.52, 95% CI: 1.32, 1.74), when compared to patients without SDB/OSA. However, when studies with diagnosis of SDB based on polysomnography were pooled together, the strength of association for all-cause cognitive impairment was weaker (HR 1.32, 95% CI: 1.00, 1.74).

CONCLUSION

Findings suggest a possible association of SDB/OSA with risk of all-cause cognitive impairment and/or dementia. However, careful interpretation is warranted as the majority of the studies did not rely on objective assessment based on polysomnography.

Economic evaluation of telemonitoring as a follow-up approach for patients with obstructive sleep apnea syndrome starting treatment with continuous positive airway pressure

Telemonitoring of obstructive sleep apnea patients is increasingly being adopted though its cost-effectiveness evidence base is scanty. This study investigated whether telemonitoring is a cost-effective strategy compared with the standard follow-up in patients with obstructive sleep apnea who are starting continuous positive airway pressure treatment. In total, 167 obstructive sleep apnea patients were randomised into telemonitoring (n = 79) or standard follow-up (n = 88), initiated continuous positive airway pressure treatment, and were followed up for 6 months. The frequencies of healthcare contacts, related costs (in USD 2021 prices), treatment effect and compliance were compared between the follow-up approaches using generalised linear models. The cost effectiveness analysis was conducted from a healthcare perspective and the results presented as cost per avoided extra clinic visit. Additionally, patient satisfaction between the two approaches was explored. The analysis showed no baseline differences. At follow-up, there was no significant difference in treatment compliance, and the mean residual apnea-hypoapnea index. There was no difference in total visits, adjusted incidence rate ratio 0.87 (0.72-1.06). Participants in the telemonitoring arm made eight times more telephone visits, 8.10 (5.04-13.84), and about 73% fewer physical healthcare visits 0.27 (0.20-0.36). This translated into significantly lower total costs for the telemonitoring approach compared with standard follow-up, -192 USD (-346 to -41). The form of follow-up seemed to have no impact on the extent of patient satisfaction. These results demonstrate the telemonitoring of patients with obstructive sleep apnea initiating continuous positive airway pressure treatment as a cost saving strategy and can be argued as a potential worthy investment.

Obstructive sleep apnea and mental disorders: a bidirectional mendelian randomization study

BACKGROUND

Previous studies have reported associations between obstructive sleep apnea (OSA) and several mental disorders. However, further research is required to determine whether these associations are causal. Therefore, we evaluated the bidirectional causality between the genetic liability for OSA and nine mental disorders by using Mendelian randomization (MR).

METHOD

We performed two-sample bidirectional MR of genetic variants for OSA and nine mental disorders. Summary statistics on OSA and the nine mental disorders were extracted from the FinnGen study and the Psychiatric Genomics Consortium. The primary analytical approach for estimating causal effects was the inverse-variance weighted (IVW), with the weighted median and MR Egger as complementary methods. The MR Egger intercept test, Cochran's Q test, Rucker's Q test, and the MR pleiotropy residual sum and outlier (MR-PRESSO) test were used for sensitivity analyses.

RESULT

MR analyses showed that genetic liability for major depressive disorder (MDD) was associated with an increased risk of OSA (odds ratio [OR] per unit increase in the risk of MDD, 1.29; 95% CI, 1.11-1.49; P < 0.001). In addition, genetic liability for OSA may be associated with an increased risk of attention-deficit/hyperactivity disorder (ADHD) (OR = 1.26; 95% CI, 1.02-1.56; p = 0.032). There was no evidence that OSA is associated with other mental disorders.

CONCLUSION

Our study indicated that genetic liability for MDD is associated with an increased risk of OSA without a bidirectional relationship. Additionally, there was suggestive evidence that genetic liability for OSA may have a causal effect on ADHD. These findings have implications for prevention and intervention strategies targeting OSA and ADHD. Further research is needed to investigate the biological mechanisms underlying our findings and the relationship between OSA and other mental disorders.

Polysomnographic features of insomnia occurring in major depressive disorder, generalized anxiety disorder and bipolar mania: Comparison with primary insomnia and association with metabolic indicators

BACKGROUND

Insomnia is very common in psychiatric disorders, but the polysomnographic (PSG) characteristics of insomnia in various psychiatric disorders are still not agreed upon. This study aimed to investigate the characteristics of PSG and its relationship with metabolic indicators in insomnia patients with affective disorders and primary insomnia (PI) patients.

METHODS

A total of 38 patients with PI, 44 major depressive disorder patients with insomnia (DI), 49 generalized anxiety disorder patients with insomnia (GI), and 19 bipolar mania patients with insomnia (BI) were included. PSG was used to detect sleep problems in subjects, and biochemical indicators were also collected.

RESULTS

The results of this study found that subjects with BI were lower on REM sleep latency (RL), awakenings number (AN), number of microarousals (NM), and apnea-hypopnea index (AHI) than those with DI and GI, and lower on RL and AN than those with PI. Subjects with PI had lower NM and AHI than those with DI and GI. Patients with DI had a higher RL than those with GI. All results passed Bonferroni correction (p < 0.00078). No differences in biochemical indices were found among the four groups of subjects. Also, AHI was found to be positively correlated with free triiodothyronine (FT3) and fasting blood glucose in subjects.

CONCLUSION

This study suggests that various psychiatric disorders may have their characteristics in terms of PSG parameters, which prompted us to focus on the PSG characteristics of these disorders when assessing them, as well as to focus on their biochemical indicators.

The OSA patient journey: pathways for diagnosis and treatment among commercially insured individuals in the United States

STUDY OBJECTIVES

The aims of this study were to characterize obstructive sleep apnea (OSA) care pathways among commercially insured individuals in the United States and to investigate between-groups differences in population, care delivery, and economic aspects.

METHODS

We identified adults with OSA using a large, national administrative claims database (January 1, 2016-February 28, 2020). Inclusion criteria included a diagnostic sleep test on or within ≤ 12 months of OSA diagnosis (index date) and 12 months of continuous enrollment before and after the index date. Exclusion criteria included prior OSA treatment or central sleep apnea. OSA care pathways were identified using sleep testing health care procedural health care common procedure coding system/current procedural terminology codes then selected for analysis if they were experienced by ≥ 3% of the population and assessed for baseline demographic/clinical characteristics that were also used for model adjustment. Primary outcome was positive airway pressure initiation rate; secondary outcomes were time from first sleep test to initiation of positive airway pressure, sleep test costs, and health care resource utilization. Associations between pathway type and time to treatment initiation were assessed using generalized linear models.

RESULTS

Of 86,827 adults with OSA, 92.1% received care in 1 of 5 care pathways that met criteria: home sleep apnea testing (HSAT; 30.8%), polysomnography (PSG; 23.6%), PSG-Titration (19.8%), Split-night (14.8%), and HSAT-Titration (3.2%). Pathways had significantly different demographic and clinical characteristics. HSAT-Titration had the highest positive airway pressure initiation rate (84.6%) and PSG the lowest (34.4%). After adjustments, time to treatment initiation was significantly associated with pathway (P < .0001); Split-night had shortest duration (median, 28 days), followed by HSAT (36), PSG (37), PSG-Titration (58), and HSAT-Titration (75). HSAT had the lowest sleep test costs and health care resource utilization.

CONCLUSIONS

Distinct OSA care pathways exist and are associated with differences in population, care delivery, and economic aspects.

CITATION

Wickwire EM, Zhang X, Munson SH, et al. The OSA patient journey: pathways for diagnosis and treatment among commercially insured individuals in the United States. J Clin Sleep Med. 2024;20(4):505-514.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

Assessing the causal relationship between psychiatric disorders and obstructive sleep apnea: a bidirectional Mendelian randomization

Background

Extensive observational evidence suggests an association between psychiatric disorders (PDs) and obstructive sleep apnea (OSA), but their causal relationship remains unexplored. The objective of this study was to examine the causal relationship between PDs and OSA.

Methods

Mendelian randomization (MR) analysis was conducted with summary genetic data from the FinnGen and Psychiatric Genomics Consortium (PGC). Inverse-variance weighted (IVW), MR-Egger, weighted median, and weighted mode methods were employed to ascertain causal influence. Sensitivity analysis employing various methodologies assessed the robustness of the findings. Furthermore, multivariable Mendelian randomization (MVMR) was used to clarify if the exposures independently caused OSA.

Results

MR analysis showed that genetically determined major depressive disorder (MDD) increased the risk of OSA (IVW odds ratio [OR]: 1.377, 95% confidence interval [CI]: 1.242-1.526, P = 1.05×10-9). Sensitivity analysis showed no evidence of pleiotropy and heterogeneity. In MVMR, the significant association persisted after adjusting for BMI, smoking, and alcohol consumption. No conclusive evidence indicated the causal impact of other psychological characteristics on OSA. In the reverse MR analyses, there was no causal effect of OSA on PDs.

Conclusion

This study suggests a causal effect of MDD on OSA risk. Further research is needed to confirm these findings and understand how MDD contributes to OSA development, potentially aiding in reducing OSA incidence.

A Narrative Review of Self-Reported Scales to Evaluate Depression and Anxiety Symptoms in Adult Obstructive Sleep Apnea Patients

Background and Objectives: Obstructive sleep apnea (OSA) is a prevalent chronic condition that has been associated with mental disorders like depression and anxiety. This study intends to provide a practical overview of the most relevant self-reported and self-rating scales that assess depression and anxiety in OSA patients. Materials and Methods: A search for articles was performed using PubMed, Google Scholar, and Semantic Scholar using a combination of words for obstructive sleep apnea, depression, anxiety, and scales. The tools were ordered by type (screening and rating) and arranged chronologically according to the year of publication. Results: Three scales were identified for assessing depression, which were the Center for Epidemiologic Studies Depression Scale (CES-D), the Hospital Anxiety and Depression Scale (HADS-D), and the Patient Health Questionnaire-9 (PHQ-9). For rating depression, two scales were discussed: the Zung Self-Rating Depression Scale (SDS) and the Beck Depression Inventory (BDI), which has three versions (the BDI, the BDI-II, and the Fast Screen (BDI-FS)). For assessing anxiety, the Generalized Anxiety Disorder-7 (GAD-7) scale was identified. Two scales were reviewed for rating anxiety: the State-Trait Anxiety Inventory (STAI) and the Beck Anxiety Inventory (BAI). Each scale is accompanied by a brief description of its practicality and psychometric qualities and an analysis of its strengths and limitations. Conclusions: The findings of this review will contribute to the understanding of the importance of assessing mental health comorbidities in the context of OSA, ultimately guiding clinical practice and future research in this area.

Assessing the causal associations of sleep apnea with mental health and socioeconomic status: a bidirectional two-sample Mendelian randomization

OBJECTIVE

Traditional observational research has suggested a connection between socioeconomic position, mental health, and sleep apnea (SA), but the specifics of this connection are still unclear. Using the Mendelian randomization approach, we intended to evaluate the potential causal link between mental health, socioeconomic status, and SA.

METHODS

Our research employed summary statistics data from large-scale genome-wide association studies (GWAS) on mental health, socioeconomic status, and SA. In the main study, the connection between mental health, socioeconomic status, and SA was examined using the inverse variance weighted approach. In addition, as a supplement, we also used other Mendelian randomization methods, including MR Egger, weighted median, simple mode, and weighted mode.

RESULTS

The primary analysis showed that educational attainment, including longer years of schooling, college or university degree, and higher intelligence was associated with a lower risk of SA (OR = 0.750, 95%CI = 0.653-0.862; OR = 0.558, 95%CI = 0.423-0.735; OR = 0.871, 95%CI = 0.760-0.999, respectively), while social deprivation was associated with a higher risk of SA (OR = 1.821, 95%CI = 1.075-3.085). And the income was not associated with the risk of sleep apnea (OR = 0.877, 95%CI = 0.682-1.129). In mental health exposure, major depressive disorder was associated with a higher risk of sleep apnea (OR = 1.196, 95%CI = 1.015-1.409), while attention-deficit hyperactivity disorder, bipolar disorder, and schizophrenia were not associated with the risk of sleep apnea (OR = 1.064, 95%CI = 0.958-1.181; OR = 1.030, 95%CI = 0.942-1.127; OR = 0.990, 95%CI = 0.957-1.025, respectively). Reverse MR analysis failed to find a causal effect from SA on mental health and socioeconomic status.

CONCLUSIONS

This MR investigation offers proof of a possible causal relationship between SA, socioeconomic level, and mental health.

Factors associated with treatment adherence to mandibular advancement devices: a scoping review

PURPOSE

Obstructive sleep apnea (OSA) is frequently treated with continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs). For various reasons, both treatment options are often affected by low adherence. While factors associated with low CPAP adherence are described in the literature extensively, less is known about adherence to MAD therapy. This scoping review aimed to synthesize the body of literature on the factors associated with adherence to MAD treatment.

METHODS

A systematic literature search was conducted using bibliographic databases PubMed, Embase.com , Web of Science, and the Cochrane Library (Wiley) to identify relevant studies that described factors associated with adherence to MAD in the treatment of OSA or snoring combined with OSA in adults.

RESULTS

The literature search yielded a total of 694 references. Forty studies were found eligible for inclusion. The literature showed that factors with a possible negative influence on the adherence to MAD treatment are personality aspects; failing effectiveness of MAD; side effects during MAD therapy; using a thermoplastic MAD; dental treatments during MAD therapy; and a poor first experience with the MAD with inadequate guidance by professionals. Factors that may have a positive effect on MAD adherence include effectiveness of therapy, custom-made MAD, good communication skills of the practitioner, early recognition of side effects, stepwise titration of the MAD, and positive first experience with MAD.

CONCLUSIONS

The knowledge of factors associated with MAD adherence can be used to provide further insight into individual adherence to OSA treatments.

Effect of Prosthetic Rehabilitation on Airway Space in Edentulous Patients with Obstructive Sleep Apnea- a Preliminary Observational Study

Statement of the Problem

The common causes of obstructive sleep apnea (OSA) are identified as anatomic and/or functional abnormality in the oral cavity, oropharynx, velopharynx, and hypopharynx leading to compromised airway space and increased collapsibility.

Purpose

This study was conducted to evaluate the effect of implant-supported mandibular complete denture in improving the airway space among completely edentulous patients with OSA and compare it with conventional complete denture.

Materials and Method

In this observational study, completely edentulous individuals were screened with snoring, tiredness, observed apnea, high blood pressure, body mass index, age, neck circumference, and gender (STOP-Bang) questionnaire to evaluate the incidence of OSA. Ten mild-moderate patients were included as study participants. Lateral cephalograms (L1) made at the edentulous state was considered baseline. They were rehabilitated with complete denture prosthesis. One week after denture insertion, two implants were placed in the edentulous mandibular arch. Delayed loading protocol was followed. Lateral cephalogram (L2) was made 6 months after complete denture insertion and 6 months after implant-supported prosthesis (L3). Cephalometric tracings were used to evaluate change in upper airway space (UAS), middle airway space (MAS), and lower airway space (LAS). Repeated measures ANOVA was used to evaluate statistical significance in the airway measurements made at the three intervals. Post hoc Tukey HSD and Bonferroni test were used to assess if the differences obtained were truly significant.

Results

Statistical analysis revealed significant differences in UAS, MAS and LAS between L1, L2 and L3 (p< 0.05). Post hoc Tukey HSD indicated that UAS increased significantly at all three intervals followed by LAS and MAS respectively (α=.05). Post hoc Bon-ferroni test indicated that implant-supported mandibular complete dentures had a significant improvement in airway space when compared to conventional complete dentures (α=.05).

Conclusion

Implant-supported mandibular complete denture could be effective in edentulous patients with mild-moderate OSA.

The effect of obstructive sleep apnea severity on PTSD symptoms during the course of esketamine treatment: a retrospective clinical study

STUDY OBJECTIVES

Intranasal administration of esketamine is Food and Drug Administration-approved for treatment-resistant depression. In a recent retrospective case series, we show that it has promise in reducing symptoms of posttraumatic stress disorder (PTSD) as well. Untreated obstructive sleep apnea (OSA) is prevalent among veterans with PTSD and has been shown to interfere with other PTSD treatments. In the current study, we examined whether OSA impacts esketamine's effectiveness in reducing symptoms of PTSD or depression.

METHODS

Participants were 60 veterans with a diagnosis of major depressive disorder and PTSD who received intranasal esketamine treatment at the San Diego Veterans Affairs (VA) Medical Center. We used growth-curve modeling to examine changes in depression and PTSD symptoms following esketamine treatments and, in the subset of individuals screened for OSA (n = 24, all prescribed positive airway pressure therapy), examined the impacts of OSA severity on these trajectories.

RESULTS

We first showed that both PTSD and depressive symptoms significantly decreased over the course of esketamine treatment. In the subset of veterans screened for OSA, individuals with lower OSA severity reported the greatest reduction in PTSD symptoms, while veterans with the most severe OSA reported the least reduction in PTSD symptoms. Depression response was not affected by severity of OSA in this analysis.

CONCLUSIONS

Veterans with PTSD and depression tend to benefit from esketamine treatment, but OSA may interfere with esketamine effectiveness. Comorbid OSA should be assessed for and treated to maximize esketamine's benefits in PTSD.

CITATION

Titone MK, Hunt C, Bismark A, et al. The effect of obstructive sleep apnea severity on PTSD symptoms during the course of esketamine treatment: a retrospective clinical study. J Clin Sleep Med. 2023;19(12):2043-2051.

Sleep-wake disorders in veterans with opioid use disorder: Prevalence and comorbidities

OBJECTIVE

To determine the prevalence of sleep-wake disorders among veterans with opioid use disorder (OUD) and the demographic characteristics, medical comorbidities, and outpatient medications in this group.

METHODS

US veterans seeking care in the VA Connecticut Healthcare System between January 1, 2000, and December 31, 2021 with a diagnosis of OUD (N = 5937) were analyzed retrospectively for sleep-wake disorders (N = 1447). That group was analyzed for demographic characteristics, comorbidities, and medications.

RESULTS

Of those with OUD, 24.4% had a diagnosis of any sleep-wake disorder. The most common was obstructive sleep apnea (73.7%). Major depressive disorder (68.6%) and hypertension (67.1%) were the most common comorbid conditions. Commonly prescribed medications included antidepressants (91%) and benzodiazepines (62%).

CONCLUSIONS

Veterans with OUD frequently suffer from sleep-wake disorders. Comorbid medical and psychiatric conditions and the detrimental effects of specific medication classes should be considered in this patient population to create more effective prevention and treatment strategies.

CPAP adherence after ambulatory and in-hospital management in patients aged 65 years and older

OBJECTIVES

The aims of this study are to evaluate the early adherence to CPAP treatment in patients aged 65 years and older and to compare ambulatory (ACPAP) and in-hospital (HCPAP) management in starting CPAP treatment.

METHODS

Adherence to CPAP therapy at 3 months was retrospectively studied in patients on whom CPAP therapy was initiated between 1 January 2020 and 31 December 2021. Patients in the ACPAP group were selected based on the current Belgian reimbursement criteria (OAHI ≥30/h and few comorbidities).

RESULTS

146 patients were studied (median OAHI 43.35/h [32.02; 57.40]; median age 69 [67.0; 73.0]): 116 (79.5%) patients in the HCPAP and 30 (20.5%) in the ACPAP group. Based on an adherence threshold of average CPAP use of ≥ 4 hours per day, 120 (82%) patients were adherent to the treatment; 94 (81%) patients in the HCPAP and 26 (86.7%) in the ACPAP group. The median CPAP use for the total population was 6.4 h/day [4.89; 7.34], reaching 6.3 h/d [4.79; 7.15] for the HCPAP group and 6.8 h/d [6.21; 8.06] for the ACPAP group (p = 0.019). Insomnia was a significant risk factor for non-adherence (OR 5.16 [1.64; 16.08], p = 0.0043) but the ACPAP method was not (OR 0.66 [0.18; 1.91], p = 0.4748).

CONCLUSION

Early CPAP adherence in patients ≥ 65 years old was good in terms of average use per day and proportion of adherent patients. ACPAP method was not a risk factor for lower CPAP adherence in patients presenting severe OSAS (OAHI ≥30/h) and few comorbidities.

Effects of CPAP and Mandibular Advancement Devices on depressive symptoms in patients with obstructive sleep apnea: a meta-analysis of randomized controlled trials

PURPOSE

Studies show that patients with obstructive sleep apnea (OSA) are more likely than the general population to have psychological disorders such as depression. However, it is less clear how OSA treatment affects this association. This meta-analysis aimed to assess whether or not continuous positive airway pressure (CPAP) and mandibular advancement devices (MADs) reduce depression symptoms in patients with OSA.

METHODS

We searched Pubmed, Embase, Web of Science, and Cochrane Library from creating the databases until November 2022. Our analysis included RCTs that examined CPAP and MAD treatment effectiveness for depression in patients with OSA.

RESULTS

We identified 17 CPAP studies comprising 1,931 patients for inclusion in the meta-analysis. The results of the meta-analysis using a fixed effects model found that CPAP improved depressed mood in patients with OSA relative to controls (SMD = 0.27;95% CI:0.18,0.36), with small heterogeneity among trials (I2 = 8.1% < 50%, P = 0.359). We performed subgroup analyses on three factors: the length of trial follow-up, patient adherence data, and depression assessment scales. The meta-analysis also identified six MAD studies involving 315 patients. According to this analysis, there was no heterogeneity between studies (I2 = 0%, P = 0.748). MADs did not significantly improve depression symptoms compared to controls, indicating a combined effect of SMD = 0.07 (95% CI: - 0.15,0.29), P > 0.05.

CONCLUSION

The present findings confirm that CPAP may improve depressive symptoms in patients with OSA. However, the review results suggest that MADs have no significant effect on depressive symptoms in patients with OSA, a finding that is different from the results of previous meta-analyses.

Evaluation of the Continuous Positive Airway Pressure Effect on Neurotrophins' Gene Expression and Protein Levels

Neurotrophins (NT) might be associated with the pathophysiology of obstructive sleep apnea (OSA) due to concurrent intermittent hypoxia and sleep fragmentation. Such a relationship could have implications for the health and overall well-being of patients; however, the literature on this subject is sparse. This study investigated the alterations in the serum protein concentration and the mRNA expression of the brain-derived neurotrophic factor (BDNF), glial cell line-derived neurotrophic factor (GDNF), neurotrophin-3 (NTF3), and neurotrophin-4 (NTF4) proteins following a single night of continuous positive airway pressure (CPAP) therapy. This study group consisted of 30 patients with OSA. Venous blood was collected twice after a diagnostic polysomnography (PSG) and PSG with CPAP treatment. Gene expression was assessed with a quantitative real-time polymerase chain reaction. An enzyme-linked immunosorbent assay was used to determine the protein concentrations. After CPAP treatment, BDNF, proBDNF, GDNF, and NTF4 protein levels decreased (p = 0.002, p = 0.003, p = 0.047, and p = 0.009, respectively), while NTF3 increased (p = 0.001). Sleep latency was correlated with ΔPSG + CPAP/PSG gene expression for BDNF (R = 0.387, p = 0.038), NTF3 (R = 0.440, p = 0.019), and NTF4 (R = 0.424, p = 0.025). OSA severity parameters were not associated with protein levels or gene expressions. CPAP therapy could have an impact on the posttranscriptional stages of NT synthesis. The expression of different NTs appears to be connected with sleep architecture but not with OSA severity.

The additive value of continuous positive airway pressure treatment on psychological symptoms

OBJECTIVE

To screen psychological problems of patients with obstructive sleep apnea syndrome (OSAS) by utilizing the psychological symptom screening test Symptom Checklist-90-Revised (SCL-90-R) and to evaluate the effect of continuous positive airway pressure (CPAP) treatment.

METHODS

The SCL-90-R and Epworth Sleepiness Scale (ESS) test were applied to 66 patients with Apnea-Hypopnea Index (AHI ≥ 30/h) using CPAP device and 20 healthy individuals; the test results were compared.

RESULTS

The age of the patients ranged from 28 to 67 years, and the patient group comprised 54 males (81.8%) and 12 females (18.2%). The AHI scores ranged from 30.05 to 99.80, with a mean of 49.34 ± 21.40. Significant improvement was seen in 6 of the 11 SCL-90-R scores in CPAP-treated patients.

CONCLUSION

The authors conclude that the SCL-90-R test may be appropriate for evaluating the response to CPAP treatment in OSAS patients and monitoring the psychosocial effects of treatment.

Longitudinal risk factors for obstructive sleep apnea: A systematic review

Despite substantial disease burden, existing evidence on the risk factors for obstructive sleep apnea (OSA) have been derived primarily from cross-sectional studies without determining temporality. Therefore, we aimed to systematically synthesize the literature on longitudinal risk factors for sleep study-assessed OSA and questionnaire-assessed probable OSA from cohort studies in the general adult population settings. We systematically searched Embase and Medline (on OVID) databases. Eleven studies met the inclusion criteria. Meta-analyses were not conducted due to methodological heterogeneity of exposure and outcome measurements. There was consistent evidence that weight gain was associated with incident (n = 2) and greater severity (n = 2) of OSA. One study each observed an association of higher baseline body-mass index, male sex, asthma, a specific genetic polymorphism in rs12415421, and insulin resistance/hyperglycemia, with incident OSA. Long-term exposure to ambient air pollution (NO2, n = 1) was associated with OSA, and menopausal transitions (n = 1) with higher apnea-hypopnea index. There were no eligible studies on long-term smoking or alcohol use. In conclusion, approximately 10% increase in weight, especially in males, might alert clinicians to consider potential or worsening OSA. Large, well-designed longitudinal studies are needed to consolidate knowledge on other associations with OSA development, especially on potentially modifiable risk factors.

Effects of continuous positive airway pressure and mandibular advancement appliance therapy on sleep bruxism in adults with obstructive sleep apnea: a pilot study

STUDY OBJECTIVES

This study aimed to investigate the effects of continuous positive airway pressure (CPAP) and mandibular advancement appliance (MAA) therapy on rhythmic masticatory muscle activity (RMMA), a biomarker of sleep bruxism (SB), and to compare the effects of CPAP with MAA in adults with obstructive sleep apnea (OSA).

METHODS

This cohort study included individuals with OSA who received treatment with CPAP or MAA. Polysomnographic recordings with and without therapy were performed in each individual. Statistical analyses were performed with repeated measures ANOVA.

RESULTS

A total of 38 individuals with OSA were enrolled, 13 on CPAP and 25 with MAA, mean age 52.6 ± 10.6 years, 32 men, mean baseline apnea-hypopnea index (AHI) 26.5 ± 15.2 events/hour, mean RMMA index 3.5 ±events/hour. In the total group, the RMMA index decreased significantly with CPAP and MAA therapies (P < 0.05). The changes in the RMMA index with therapy did not differ significantly between CPAP and MAA (P > 0.05). The RMMA index decreased in 60% of the individuals with OSA, and the changes ranged widely, with a median of 52% and an interquartile range of 107%.

CONCLUSIONS

Both CPAP and MAA therapies significantly reduce SB in individuals with OSA. However, the interindividual differences in the effects of these therapies on SB are large.

CLINICAL TRIAL REGISTRATION

https://trialsearch.who.int (NL8516); April 08, 2020.

Pharmacological management of co-morbid obstructive sleep apnoea and insomnia

INTRODUCTION

Clinical presentation of both insomnia and obstructive sleep apnea (COMISA) is common. Approximately 30% of clinical cohorts with OSA have insomnia symptoms and vice versa. The underlying pathophysiology of COMISA is multifactorial. This poses a complex clinical challenge. Currently, there are no clinical guidelines or recommendations outside of continuous positive airway pressure (CPAP) therapy and cognitive behavioral therapy for insomnia (CBTi). Clinically translatable precision medicine approaches to characterize individual causes or endotypes may help optimize future pharmacological management of COMISA.

AREAS COVERED

This review article provides an up-to-date account of COMISA and its consequences, the underlying pathophysiology of sleep apnea, insomnia and COMISA, current treatment approaches and limitations, pharmacotherapy targets and future priorities.

EXPERT OPINION

There are multiple promising emerging therapies, but clinical trial data specifically in COMISA populations are lacking. This is a priority for future investigation to inform development of evidence-based guidelines. Pharmacotherapies, particularly for insomnia, do not target the underlying causes of the disorder thus, are indicated for short-term use only and should remain second line. Future multidisciplinary research should be directed toward the multifactorial nature of COMISA and the challenges of adapting COMISA treatment in clinical practice and overcoming the practical barriers that health-care providers and consumers encounter.

Oral appliance therapy for obstructive sleep apnea: a retrospective study in a psychiatric sleep clinic

OBJECTIVES

We evaluated the continuity and effectiveness of oral appliances (OAs) for treating obstructive sleep apnea (OSA) in a psychiatric sleep clinic, specifically focusing on mild cases and those with psychiatric comorbidity.

METHODS

We retrospectively examined the medical records of 106 OSA patients treated with OA. Survival analysis was performed to assess the discontinuation of OA use. Clinical Global Impression-Improvement (CGI-I) scale were obtained from medical records. The apnea-hypopnea index (AHI), measured by polysomnography (PSG), and Epworth Sleepiness Scale (ESS) were compared between diagnosis and after post-OA treatment if a second PSG for efficacy assessment was conducted.

RESULTS

Among all 106 patients, Kaplan-Meier analysis estimated a discontinuation rate of 16.8% at 1 year. This tended to be higher for OSA patients with psychiatric comorbidity (22.7%) than those without (11.6%), though it was not statistically significant (P=0.08). The overall rate of improvement in CGI-I scale was 37.7% and was significantly lower in OSA patients with psychiatric comorbidity (25.0%) than those without (48.3%). Among the 74 patients who underwent a second PSG, AHI and ESS were significantly lower after OA treatment for the entire group and subgroups of OSA severity at diagnosis and psychiatric comorbidity, except for ESS in the moderate OSA severity subgroup.

CONCLUSION

OA continuation was relatively good, and sleepiness was relieved by OA use, even in mild OSA patients and those with psychiatric comorbidity. However, the continuation and subjective improvement of symptoms were slightly lower in OSA patients with psychiatric comorbidity.

An exploratory study on the association between serotonin and sleep breathing disorders

This exploratory observational study aimed to evaluate whether the blood levels of serotonin and enzymes involved in serotonin synthesis are associated with sleep breathing parameters. A total of 105 patients were included in this study, who were subjected to single-night polysomnography with simultaneous audio-video recordings. Peripheral blood samples were collected to estimate the serum levels of serotonin, tryptophan hydroxylase 1 (TPH1), and aromatic l-amino acid decarboxylase (AADC). Results showed a negative correlation between blood serotonin levels, and oxygen desaturation index (ODI) (p = 0.027), central apnea (p = 0.044) and obstructive apnea (OA) (p = 0.032) scores. Blood TPH1 levels were negatively correlated with average (p = 0.003) and minimal saturation (p = 0.035) and positively correlated with apnea-hypopnea index (p = 0.010), OA (p = 0.049), and hypopnea index (p = 0.007) scores. A tendency to sleep-disordered breathing seemed to co-occur with lower blood serotonin and higher TPH1 levels.Clinical Trial Registration : www.ClinicalTrials.gov , identifier NCT04214561.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The risk of obstructive sleep apnea is highly correlated with depressive symptoms among the Korean adults population: results from the 2020 Korea National Health and Nutrition Examination Survey

OBJECTIVES

We aimed to examine the association between Obstructive Sleep Apnea (OSA) risk, health behaviors, and depressive symptoms in a representative Korean sample.

METHODS

Cross-sectional data from the 2020 Korea National Health and Nutrition Examination Survey (KNHANES) were analyzed. The sample included 4,352 adults aged 40 years and older. Multiple linear regression analysis was performed to examine the association between OSA risk, health behaviors, and depressive symptoms.

RESULTS

In total, 23.1% of the participants reported a high risk of OSA. Of the respondents, 39.8%, 19.0%, 27.2%, and 8.7% reported hypertension, snoring, tiredness, and observed apnea, respectively. The prevalence of moderate-severe depressive symptoms among adults with high-risk OSA was 7.5%. The significant associations between OSA risk and sex with PHQ-9 were shown in univariate linear regression. In the multiple linear regression analysis, the association between high risk of OSA and PHQ-9 showed in total (B = 1.58; P < 0.001), male (B = 1.21; P < 0.001), and female (B = 1.93; P < 0.001).

CONCLUSIONS

A high risk of OSA was associated with an increased prevalence of depressive symptoms. Monitoring the risk factors of depressive symptoms, including OSA, or unhealthy behaviors may decrease the mental health issues of middle-aged and older adults.

Obstructive sleep apnea related to mental health, health-related quality of life and multimorbidity: A nationwide survey of a representative sample in Republic of Korea

OBJECTIVES

This study assessed the effects of obstructive sleep apnea (OSA) on mental health, health-related quality of life (HRQoL), and multimorbidity in Korean adults.

METHODS

The study included 8030 participants from the Korea National Health and Nutrition Examination Survey Ⅷ (2019-2020). The risk of OSA was assessed using STOP-BANG questionnaire. Depression was measured using the Patient Health Questionnaire-9 (PHQ-9), and stress was measured using a questionnaire. HRQoL was determined by EuroQol 5-dimension (EQ-5D) and Health-related Quality of Life Instrument with 8 Items (HINT-8) scores. Multimorbidity was defined as the presence of 2 or more chronic diseases. A complex sample multivariate logistic regression analysis was conducted.

RESULTS

Participants with a high OSA risk were more likely to a have high PHQ-9 score (OR 4.31, 95% confidence interval [CI] 2.80-6.65), total depression (OR 4.07, 95% CI 2.67-6.19) stress (OR 2.33, 95% CI 1.85-2.95), lower EQ-5D (OR 2.88, 95% CI 2.00-4.15) and HINT-8 scores (OR 2.87, 95% CI 1.65-4.98), and multimorbidity (OR 2.62, 95% CI 2.01-3.41) than participants with low OSA risk. High OSA risk was significantly associated with all EQ-5D and HINT-8 items.

CONCLUSIONS

This study adds to the few population-based studies showing associations between mental health, HRQoL, and multimorbidity using nationwide data. OSA prevention might be helpful for good mental health, improving HRQoL, and comorbidity burdens. The results provide novel insights regarding the association between sleep apnea and multimorbidity.

Sleep Problems Associate With Multimorbidity: A Systematic Review and Meta-analysis

Objectives: To summarize the evidence on the association between sleep problems and multimorbidity. Methods: Six electronic databases (PubMed, Web of Science, Embase, China National Knowledge Infrastructure, VIP, and Wan fang) were searched to identify observational studies on the association between sleep problems and multimorbidity. A random-effects model was used to estimate the pooled odds ratios (ORs) and 95% confidence intervals for multimorbidity. Results: A total of 17 observational studies of 133,575 participants were included. Sleep problems included abnormal sleep duration, insomnia, snoring, poor sleep quality, obstructive sleep apnea (OSA) and restless legs syndrome (RLS). The pooled ORs (95% CIs) for multimorbidity were 1.49 (1.24-1.80) of short sleep duration, 1.21 (1.11-1.44) of long sleep duration and 2.53 (1.85-3.46) for insomnia. The association of other sleep problems with multimorbidity was narratively summarized due to limited number of comparable studies. Conclusion: Abnormal sleep duration and insomnia are associated with higher odds of multimorbidity, while the evidence on association of snoring, poor sleep quality, obstructive sleep apnea and restless legs syndrome with multimorbidity remains inconclusive. Interventions targeting sleep problems should be delivered for better management of multimorbidity.

FKBP5 genetic variants are associated with respiratory- and sleep-related parameters in Chinese patients with obstructive sleep apnea

Introduction

Obstructive sleep apnea (OSA) has been associated with psychiatric disorders, especially depression and posttraumatic stress disorder (PTSD). FKBP5 genetic variants have been previously reported to confer the risk of depression and PTSD. This study aimed to investigate the association of single nucleotide polymorphisms (SNPs) in the FKBP5 gene with OSA and OSA-related quantitative traits.

Methods

Four SNPs within the FKBP5 gene (rs1360780, rs3800373, rs9296158, rs9470080) were genotyped in 5773 participants with anthropometric and polysomnography data. Linear regression and logistic regression analyses were performed to evaluate the relationship between FKBP5 SNPs and OSA-related traits. Binary logistic regression was used to assess the effect of SNPs on OSA susceptibility. Interacting genes of SNPs were assessed based on the 3DSNP database, and expression quantitative trait loci (eQTL) analysis for SNPs was adopted to examine the correlation of SNPs with gene expression. Gene expression analyses in human brains were performed with the aid of Brain Atlas.

Results

In moderate-to-severe OSA patients, all four SNPs were positively associated with AHI_REM, and rs9296158 showed the strongest association (ß = 1.724, p = 0.001). Further stratified analyses showed that in men with moderate OSA, rs1360780, rs3800373 and rs9470080 were positively associated with wake time (p = 0.0267, p = 0.0254 and p = 0.0043, respectively). Rs1360780 and rs3800373 were 28 and 29.4%more likely to rate a higher ordered MAI category (OR (95% CI) = 1.280 (1.042 - 1.575), p = 0.019; OR (95% CI) = 1.294 (1.052 - 1.592), p = 0.015, respectively). Rs9296158 and rs9470080 increased the risk of low sleep efficiency by 25.7 and 28.1% (OR (95% CI) = 1.257 (1.003 - 1.575), p = 0.047; OR (95% CI) = 1.281 (1.026-1.6), p = 0.029, respectively). Integrated analysis of eQTL and gene expression patterns revealed that four SNPs may exert their effects by regulating FKBP5, TULP1, and ARMC12.

Conclusion

Single nucleotide polymorphisms in the FKBP5 gene were associated with sleep respiratory events in moderate-to-severe OSA patients during REM sleep and associated with sleep architecture variables in men with moderate OSA. FKBP5 variants may be a potential predisposing factor for sleep disorders, especially in REM sleep.

Impact of Complete Denture and Mandibular Advancement Device in the Management of Completely Edentulous Obstructive Sleep Apneic Individuals: A Systematic Review with Meta-Analysis

Statement of the Problem

Obstructive sleep apnea (OSA) is an underdiagnosed and potentially serious disorder that is accentuated by edentulism. The overclosure of the mandible and a potential upper airway collapse during sleep creates challenges in treating edentulous sleep apneic patients.

Purpose

To evaluate complete dentures and mandibular advancement devices as potential oral appliances in the management of sleep apnea in completely edentulous patients.

Materials and Method

The study design was a systematic review with meta-analysis. The search criteria complied with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines and the keywords in population, intervention, control, and outcomes (PICO) format was systematically searched for relevant research articles published till August 2021 in an electronic database (PubMed, Cochrane, Science Direct, Ovid). Randomized controlled trials and cohort studies were included that compared the effectiveness of oral appliances on apnea-hypopnea index (AHI), airway space, and quality of sleep in edentulous sleep apneic patients.

Results

1785 articles were derived from the initial search and based on inclusion criteria, 10 articles were systematically filtered for qualitative analysis and assessed for risk of bias using the Cochrane risk of bias tool and ROBINS-I tool. Out of the 10 articles, 5 articles were taken for quantitative analysis. The use of a mandibular advancement device (MAD) showed a decrease in AHI score, but the available data was heterogeneous to conduct a meta-analysis. The mean difference of AHI for the random effect model between the non-complete denture and complete denture wearers at sleep was -0.49[95% CI (-1.47,0.48)] events per hour, but the change was non-significant (p>.05).

Conclusion

The complete dentures as an oral appliance had reduced apneic episodes in completely edentulous sleep apneic patients, but the effectiveness cannot be solely attributed to the prosthesis in the treatment of OSA. MAD showed greater improvement in reducing AHI, however, the level of evidence was inadequate to provide a conclusive statement.

[Current Status of and Progress in Research on Obstructive Sleep Apnea and Comorbid Depressive Disorders]

Obstructive sleep apnea (OSA) and depressive disorders are common diseases in adults and they share in common many clinical symptoms, including sleep disturbance, fatigue, lack of concentration and cognitive function impairment. OSA and depressive disorders also share some common pathophysiological changes, including increased activity of the hypothalamic-pituitary-adrenal (HPA) axis, chronic low-grade inflammation, oxidative stress, and changes in gut microbiota and neurotransmitters, which may contribute to the comorbidity of OSA and depressive disorders. In the case of comorbid OSA and depressive disorders, OSA and depressive disorders may affect and exacerbate each other, thereby increasing the severity of diseases, entailing greater risk of cardiovascular and metabolic diseases, and causing greater difficulty in treatment. Herein, we summarized the latest research findings on the epidemiology, possible mechanisms, harms, and treatment of comorbid OSA and depressive disorders. This review may help improve clinicians' understanding of the comorbidity of OSA and depression disorders, thereby promoting early screening, prompt diagnosis and treatment, and improved prognosis. Further studies are needed for better understanding of the effect of the comorbidity of OSA and depressive disorders and treatment on cardiometabolic diseases.

Comorbid Major Depressive Disorder and Obstructive Sleep Apnea

Introduction

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

Method

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

Conclusion

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

Do Sleep Disorders and Western Diet Influence Psoriasis? A Scoping Review

Western diet may trigger sleep disorders and vice versa, but their single and mutual effects on systemic inflammatory diseases (i.e., psoriasis) are far from being fully elucidated. At the same time, psoriatic patients display a great burden of sleep disorders and dysmetabolisms related to an unhealthy lifestyle (i.e., diet). These patients are also affected by a chronic disorder deeply modulated by environmental factors (i.e., sleep and diet) capable to influence drug-response and disease progression. Thus, we aimed to summarize the evidence in the literature that may highlight a potential link among psoriasis–diet–sleep in order to further promote a multidisciplinary approach to psoriatic patients in the scientific community.

Screening for obstructive sleep apnoea in patients with serious mental illness

OBJECTIVE

Patients with serious mental illness (SMI) are at increased risk of obstructive sleep apnoea (OSA). Despite this, OSA is frequently under-recognised in the psychiatric population. This study describes the results of OSA screening in SMI patients.

METHOD

Patients with SMI attending a metropolitan mental health clinic were screened for OSA using the OSA50, STOP-BANG Questionnaire (SBQ), Epworth Sleep Score (ESS) and the Pittsburgh Sleep Quality Index (PSQI). They were then offered diagnostic sleep testing via ResMed ApneaLink^TM and polysomnography.

RESULTS

Of the 65 patients recruited, 65% had a primary diagnosis of schizophrenia or schizoaffective disorder, 85% were on antipsychotic medications and the majority were obese. Approximately 50% of patients reported poor sleep quality via the PSQI, in contrast to 12% with elevated daytime sleepiness via the ESS. 46% of our cohort were at risk of OSA due to an elevated OSA50 or SBQ. Of the five patients who agreed to proceed to diagnostic sleep testing, three were diagnosed with OSA.

CONCLUSION

A high proportion of patients with psychiatric illness are at risk of sleep-disordered breathing. Sleep dissatisfaction is high. The low uptake of sleep investigation requires improved patient engagement to improve OSA diagnosis in this high-risk group.

Acute sleep interventions as an avenue for treatment of trauma-associated disorders

Scientific evidence that acute, posttrauma sleep disturbances (eg, nightmares and insomnia) can contribute significantly to the pathogenesis of trauma-induced disorders is compelling. Sleep disturbances precipitating from trauma are uniquely predictive of daytime posttrauma symptom occurrence and severity, as well as subsequent onset of mental health disorders, including post-traumatic stress disorder. Conversely, adequate sleep during the acute posttrauma period is associated with reduced likelihood of adverse mental health outcomes. These findings, which are broadly consistent with what is known about the role of sleep in the regulation of emotion, suggest that the acute posttrauma period constitutes a "window of opportunity" during which treatment of sleep disturbances may be especially effective for preventing or mitigating progression of aberrant psychophysiological processes. At this point, the weight of the scientific evidence supporting this possibility warrants initiation of clinical trials to confirm the benefits of targeted prophylactic sleep enhancement, and to establish treatment guidelines as appropriate.

CITATION

Swift KM, Thomas CL, Balkin TJ, Lowery-Gionta EG, Matson LM. Acute sleep interventions as an avenue for treatment of trauma-associated disorders. J Clin Sleep Med. 2022;18(9):2291-2312.

Risk of incident obstructive sleep apnoea in patients with type 1 diabetes: a population-based retrospective cohort study

AIMS/HYPOTHESIS

People with type 2 diabetes are at increased risk of developing obstructive sleep apnoea. However, it is not known whether people with type 1 diabetes are also at an increased risk of obstructive sleep apnoea. This study aimed to examine whether people with type 1 diabetes are at increased risk of incident obstructive sleep apnoea compared with a matched cohort without type 1 diabetes.

METHODS

We used a UK primary care database, The Health Improvement Network (THIN), to perform a retrospective cohort study between January 1995 and January 2018 comparing sleep apnoea incidence between patients with type 1 diabetes (exposed) and without type 1 diabetes (unexposed) (matched for age, sex, BMI and general practice). The outcome was incidence of obstructive sleep apnoea. Baseline covariates and characteristics were assessed at the start of the study based on the most recent value recorded prior to the index date. The Cox proportional hazards regression model was used to estimate unadjusted and adjusted hazard ratios, based on a complete-case analysis.

RESULTS

In total, 34,147 exposed and 129,500 matched unexposed patients were included. The median follow-up time was 5.43 years ((IQR 2.19-10.11), and the mean BMI was 25.82 kg/m2 (SD 4.33). The adjusted HR for incident obstructive sleep apnoea in patients with type 1 diabetes vs those without type 1 diabetes was 1.53 (95% CI 1.25, 1.86; p<0.001). Predictors of incident obstructive sleep apnoea in patients with type 1 diabetes were older age, male sex, obesity, being prescribed antihypertensive or lipid-lowering drugs, atrial fibrillation and depression.

CONCLUSIONS/INTERPRETATION

Individuals with type 1 diabetes are at increased risk of obstructive sleep apnoea compared with people without diabetes. Clinicians should suspect obstructive sleep apnoea in patients with type 1 diabetes if they are old, have obesity, are male, have atrial fibrillation or depression, or if they are taking lipid-lowering or antihypertensive drugs.

Widespread aberrant functional connectivity throughout the whole brain in obstructive sleep apnea

Objective

Obstructive sleep apnea (OSA) is a sleep-related breathing disorder with high prevalence and is associated with cognitive impairment. Previous neuroimaging studies have reported abnormal brain functional connectivity (FC) in patients with OSA that might contribute to their neurocognitive impairments. However, it is unclear whether patients with OSA have a characteristic pattern of FC changes that can serve as a neuroimaging biomarker for identifying OSA.

Methods

A total of 21 patients with OSA and 21 healthy controls (HCs) were included in this study and scanned using resting-state functional magnetic resonance imaging (fMRI). The automated anatomical labeling (AAL) atlas was used to divide the cerebrum into 90 regions, and FC between each pair of regions was calculated. Univariate analyses were then performed to detect abnormal FCs in patients with OSA compared with controls, and multivariate pattern analyses (MVPAs) were applied to classify between patients with OSA and controls.

Results

The univariate comparisons did not detect any significantly altered FC. However, the MVPA showed a successful classification between patients with OSA and controls with an accuracy of 83.33% (p = 0.0001). Furthermore, the selected FCs were associated with nearly all brain regions and widely distributed in the whole brain, both within and between, many resting-state functional networks. Among these selected FCs, 3 were significantly correlated with the apnea-hypopnea index (AHI) and 2 were significantly correlated with the percentage of time with the saturation of oxygen (SaO₂) below 90% of the total sleep time (%TST < 90%).

Conclusion

There existed widespread abnormal FCs in the whole brain in patients with OSA. This aberrant FC pattern has the potential to serve as a neurological biomarker of OSA, highlighting its importance for understanding the complex neural mechanism underlying OSA and its cognitive impairment.

Impairment of executive functions due to sleep alterations: An integrative review on the use of P300

Objective

Cognitive impairment due to sleep deprivation (SD) is an important global health concern as part of the growing rates of sleep disorders and sleep deprivation worldwide. Amongst the affected cognitive processes, the effects of SD on the executive functions (EFs) show diverse methods and inconclusive or contradictory results, highlighting the importance of further research in this field. Considering this scenario, we evaluate one of the most used methods for objectively evaluating EFs on SD: the event-related potential (ERP) P300.

Methods

Our study provides a comprehensive review on the use of P300 for evaluating executive functions in sleep alterations on subjects of all ages, as well as an analysis on the efficiency of P300 as an assessment method for executive functions compared to traditional neurocognitive batteries. We review the benefits of P300 application for multiple sleep/wake alterations, whether evoked in laboratory or as part of pre-existing sleep disorders.

Results

We assess the diverse protocols used to elicit and complement P300, the most identified alterations in amplitude and latency, and suggest new lines of study that could benefit from P300 within the field.

Conclusion

We conclude that P300 is a valuable asset for evaluating executive dysfunction under sleep deprivation both as a standalone protocol and in conjunction with subjective methods, with consistently significant results in assessing executive dysfunction in a diversity of subjects and etiologies.

In-hospital survival paradox in patients with sleep apnea-A nation-wide nested case-control study

BACKGROUND

Sleep apnea (SA) is a prevalent disorder characterized by recurrent events of nocturnal apnea originating from obstructive and/or central mechanisms. SA disrupts normal sleep and can lead to a series of complications when left untreated. SA results in intermittent hypoxia which has an impact on the cardio- and cerebrovascular system. Hospitalized patients with SA typically have a greater burden of comorbidity, a longer length of hospital stay, but may show an improvement of in-hospital mortality compared to patients without diagnosed SA. The reason for this survival benefit is controversial and we aimed to clarify this protective effect in the light of predictive factors including SA-associated comorbidities using a nation-wide hospitalization database.

METHODS AND FINDINGS

Data were extracted from a nation-wide hospitalization database provided by the Swiss Federal Office for Statistics. Hospitalized patients with a SA co-diagnosis were extracted from the database together with a 1:1-matched control population without SA. Overall, 212'581 patients with SA were hospitalized in Switzerland between 2002 and 2018. Compared to the controls, SA cases had a longer median length of hospital stay (7 days; 95% CI: 3 to 15 vs. 4 days; 95% CI: 2 to 10) (p < 0.001) and a higher median number of comorbidities (8 comorbidities; IQR: 5 to 11 vs. 3 comorbidities; IQR: 1 to 6) (p < 0.001). The risk of in-hospital mortality was lower in the SA cases compared to the controls (OR: 0.73; 95% CI: 0.7 to 0.76; p < 0.001). SA was associated with a survival benefit in hospitalizations related to 28 of 47 conditions with the highest rate of in-hospital death. Sixty-three comorbidities were significantly over-represented in SA cases among which obesity, hypertension and anatomic nasal deviations were associated with a significant decrease of in-hospital mortality.

CONCLUSIONS

Compared to matched controls, SA was associated with significant and relevant inpatient survival benefit in a number of most deadly conditions. Within SA-patients, associated comorbidities mostly correlated with a poorer prognosis, whereas obesity and hypertension were associated with an improved in-hospital mortality.

Mental Health Conditions According to Stress and Sleep Disorders

The purpose of this study was to compare associations between stress and sleep disorders (insomnia, hypersomnia, and sleep apnea), identify potential modifying effects, and compare associations between stress and types of sleep disorders with selected mental health conditions. Analyses were based on 21,027 employees aged 18–64 years in 2020 who were insured by the Deseret Mutual Benefit Administrators (DMBA). The risk of stress (2.3%) was significantly greater in women, singles, and those with dependent children. The risk of a sleep disorder was 12.1% (2.1% for insomnia, 1.0% for hypersomnia, and 10.1% for sleep apnea). The risk of stress was significantly greater for those with a sleep disorder (136% overall, 179% for insomnia, and 102% for sleep apnea after adjusting for age, sex, marital status, dependent children, and sleep disorders). The risk of stress among those with sleep apnea was significantly greater for singles than for married individuals. Approximately 9.5% had anxiety, 8.5% had depression, 2.0% had ADHD, 0.6% had bipolar disorder, 0.4% had OCD, and 0.1% had schizophrenia. Each of these mental health conditions was significantly positively associated with stress and sleep disorders. Bipolar disorder and schizophrenia were more strongly associated with stress and sleep disorders than were the other mental health conditions. Insomnia was more strongly associated with anxiety, bipolar disorder, OCD, and schizophrenia than was sleep apnea.

Chronic Unexplained Vomiting: A Case Report on Psychogenic Vomiting

Psychogenic vomiting is defined as recurrent vomiting without any known discernible organic reasons, or functional vomiting occurring from psychological stress. The overall clinical presentation of psychogenic vomiting suggests a wide range of disability levels, such as stress disorders, mood changes, depression, sexual problems, personality disorders, learned responses, conversion disorders, and illness problems. Non-pharmacological treatment modalities are important as medication for psychogenic vomiting such as individual and group psychotherapy, supportive and behavioral therapy, and family and marital therapy. In this case report, a 25-year-old male with schizophrenia on medication presented to an outpatient clinic with the primary complaint of recurrent vomiting. After ruling out pathologic and physiologic causes of vomiting. It was classified as psychogenic vomiting.

The influence of nocturnal use of complete dentures on cardiorespiratory parameters of patients with obstructive sleep apnea: a systematic review and meta-analysis

OBJECTIVE

To assess whether wearing complete dentures during sleep influences the cardiorespiratory parameters of patients with obstructive sleep apnea (OSA).

MATERIALS AND METHODS

A systematic review was performed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to determine whether wearing complete dentures during sleep influences the cardiorespiratory parameters of patients with OSA. An electronic search was performed in four databases, PubMed/MEDLINE, Cochrane Library, Web of Science, and SCOPUS, and in the gray literature (TRIALS) until November 2021. This review included clinical trials, randomized clinical trials, and studies in which patients using conventional complete dentures were diagnosed with OSA using polysomnography and the cardiorespiratory parameters were measured using oximetry or polysomnography during sleep.

RESULTS

In total, 788 references were found in the database, and 12 articles were selected for full reading. Six articles were selected for qualitative and quantitative analyses after applying the inclusion and exclusion criteria and reading the full article. The meta-analysis showed that mean oxygen saturation (SpO₂) increased with the use of complete dentures (p = 0.001), but the other parameters showed no significant differences between those wearing and not wearing dentures during sleep.

CONCLUSIONS

The mean SpO₂ reduced in patients wearing complete dentures, but the other cardiorespiratory parameters evaluated were not affected.

CLINICAL RELEVANCE

This study indicates a possible influence of the use of complete dentures on the mean SpO₂ during sleep. The use of complete denture could aid other treatments in improving respiratory and sleep quality.

Incidence and risk factors of chronic opioid use after sleep apnea surgery

STUDY OBJECTIVES

To assess the incidence and risk factors of chronic opioid use after OSA surgery.

METHODS

Using IBM MarketScan research database, adults (>18) who underwent a variety of sleep surgery procedures between 2007 and 2015, were identified. Subjects with one year of insurance coverage before and after the surgical procedure were included. Additional anesthesia event(s) in the year following the procedure of interest, and those who filled an opioid prescription within the year prior to surgery (not naïve) were excluded. Outcomes included rates of persistent opioid use (additional opioid prescriptions filled 90-180 days postoperatively), prolonged use (additional opioid prescriptions filled 181-365 days postoperatively) and inappropriate use (>100 MME). Evaluated variables include demographics, surgical procedures, and comorbidities.

RESULTS

A total of 10,766 surgical procedures met inclusion criteria. There was a trend of increased rates of perioperative opioid prescription. After multivariable logistic regression analysis, perioperative opioid prescription and smoking were independent risk factors for inappropriate opioid use (OR= 31.51, p<0.001; OR= 1.41, p=0.016 respectively). Opioid prescription and hypertension were independent risk factors for persistent opioid use (OR=37.8, p<0.001, OR=1.38, p=0.008). Perioperative opioid prescription, previous opioid dependence diagnosis, smoking and male gender were associated with continuous prolonged opioid use (OR=73.1, 8.13, 1.95, 1.55, respectively; p<0.001, 0.020, 0.024, 0.032, respectively).

CONCLUSIONS

While efforts by different societies are being implemented to control the opioid crisis, we found that perioperative opioid prescription for airway surgery targeting OSA is an independent risk factor for persistent, prolonged, and inappropriate opioid use.