Sleep disordered breathing and depression among U.S. adults: National Health and Nutrition Examination Survey, 2005-2008

Ethical and Policy Implications of Racial and Ethnic Healthcare Disparities in Sleep Health

Despite efforts in recent years, including in policy and research, to address health disparities in the United States, many of those disparities continue to fester in marginalized racial/ethnic populations. Understanding sleep health disparities is critical in understanding the health and wellness of these groups. Using obstructive sleep apnea (OSA) in Black populations as a focus, this paper presents the role of race and ethnicity in the clinical understanding of sleep health-related issues by medical practitioners and the implications of the lack of clear policies or best practices to guide medical practitioners' attempts to meet sleep-related needs of marginalized racial/ethnic populations. Furthermore, the knowledge gap may be further complicated by the poor understanding and integration of existing evidence with the many, complex, sleep-associated co-morbidities. Policymaking in this area ought to be based on the ethical implications of disparate sleep-related health outcomes by race and ethnicity. So, we conclude by offering recommendations for developing ethically sound policies for addressing sleep problems in marginalized racial and ethnic populations.

Obstructive Sleep Apnea and Acute Lower Respiratory Tract Infections: A Narrative Literature Review

Both obstructive sleep apnea (OSA) and acute lower respiratory tract infections (LRTIs) are important global health issues. The pathophysiological links between OSA and LRTIs include altered immune responses due to chronic intermittent hypoxia and sleep fragmentation, increased aspiration risk, and a high burden of comorbidities. In this narrative review, we evaluated the current evidence on the association between OSA and the incidence and outcomes of acute LRTIs in adults, specifically community-acquired pneumonia and viral pneumonia caused by influenza and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Studies have demonstrated that OSA patients are more likely to develop bacterial pneumonia and exhibit a higher risk of invasive pneumococcal disease. The risk intensifies with the severity of OSA, influencing hospitalization rates and the need for intensive care. OSA is also associated with an increased risk of contracting influenza and suffering more severe disease, potentially necessitating hospitalization. Similarly, OSA contributes to increased COVID-19 disease severity, reflected by higher rates of hospitalization, longer hospital stays, and a higher incidence of acute respiratory failure. The effect of OSA on mortality rates from these infections is, however, somewhat ambiguous. Finally, we explored antibiotic therapy for OSA patients with LRTIs, addressing care settings, empirical regimens, risks, and pharmacokinetic considerations. Given the substantial burden of OSA and its significant interplay with acute LRTIs, enhanced screening, targeted vaccinations, and optimized management strategies for OSA patients should be prioritized.

Implications of depressive mood in OSAHS patients: insights from event-related potential

BACKGROUND

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a chronic breathing disorder characterized by recurrent upper airway obstruction during sleep. Although previous studies have shown a link between OSAHS and depressive mood, the neurobiological mechanisms underlying mood disorders in OSAHS patients remain poorly understood. This study aims to investigate the emotion processing mechanism in OSAHS patients with depressive mood using event-related potentials (ERPs).

METHODS

Seventy-four OSAHS patients were divided into the depressive mood and non-depressive mood groups according to their Self-rating Depression Scale (SDS) scores. Patients underwent overnight polysomnography and completed various cognitive and emotional questionnaires. The patients were shown facial images displaying positive, neutral, and negative emotions and tasked to identify the emotion category, while their visual evoked potential was simultaneously recorded.

RESULTS

The two groups did not differ significantly in age, BMI, and years of education, but showed significant differences in their slow wave sleep ratio (P = 0.039), ESS (P = 0.006), MMSE (P < 0.001), and MOCA scores (P = 0.043). No significant difference was found in accuracy and response time on emotional face recognition between the two groups. N170 latency in the depressive group was significantly longer than the non-depressive group (P = 0.014 and 0.007) at the bilateral parieto-occipital lobe, while no significant difference in N170 amplitude was found. No significant difference in P300 amplitude or latency between the two groups. Furthermore, N170 amplitude at PO7 was positively correlated with the arousal index and negatively with MOCA scores (both P < 0.01).

CONCLUSION

OSAHS patients with depressive mood exhibit increased N170 latency and impaired facial emotion recognition ability. Special attention towards the depressive mood among OSAHS patients is warranted for its implications for patient care.

The prevalence of obstructive sleep apnea in Japanese asthma patients

BACKGROUND

Obstructive sleep apnea (OSA) occurs more commonly in asthma patients than in the general population because these conditions share some comorbidities. In Japan, the prevalence of OSA in the general population is reported to be approximately 20%; however, few reports have described the prevalence of OSA in asthma patients. Furthermore, the characteristics of Japanese patients with OSA and asthma are not clear.

METHODS

Adult asthma patients were recruited from the outpatient departments of our institution between August 31, 2017, and March 31, 2019. In all included patients, the presence and severity of OSA were evaluated by the Epworth Sleepiness Scale (ESS) and a home sleep test (HST) using portable polysomnography (PSG). The rate of coexisting OSA in asthma patients and the characteristics of those patients according to the severity of OSA were investigated.

RESULTS

Fifty-three patients were included. OSA was detected in 36 (67.9%) patients (mild, n = 15; moderate, n = 14; and severe, n = 7). Patients with OSA had significantly higher body mass index, Brinkman index, apnea-hypopnea index (AHI), and 3% oxygen desaturation index (ODI) values in comparison to those without OSA, while the percentage of the predicted value of forced vital capacity (%FVC) and lowest SpO2 levels were significantly lower. As the severity of OSA increased, age, brain natriuretic peptide level, AHI, and 3%ODI increased, and in contrast, FVC, %FVC, forced expiratory volume in one second (FEV1), percentage of the predicted value of FEV1 (%FEV1), Epworth Sleepiness Scale (ESS), 3%ODI, and lowest SpO2 levels decreased. In particular, the fact that the ESS value was inversely correlated with the severity of OSA in our patients was different from the general characteristics of OSA. Moreover, the AHI value was negatively correlated with FVC, %FVC, FEV1, and %FEV1. BMI was the only independent factor for the presence of OSA, and for asthma severity (FEV1, % of predicted), there was a weak correlation with smoking history.

CONCLUSIONS

This is the first report to investigate the prevalence of OSA in Japanese asthma patients, using an HST. This study suggests that an HST should be performed in addition to the sleep interview for asthma patients with refractory disease, a low pulmonary function, advanced age, and high BMI because the more severe the OSA, the lower the ESS value may be.

Bi-level VNS therapy with different therapy modes at night and daytime improves seizures and quality of life in a patient with drug-resistant epilepsy

Induction or aggravation of sleep apnea is a known side effect of vagus nerve stimulation (VNS). We report the case of a 44 year old male with drug-resistant epilepsy and depression who did not experience any seizure reduction after 1 year of VNS but a worsening of depression and daytime sleepiness. After confirming VNS-associated sleep apnea we started the first bi-level VNS therapy with standard VNS settings during daytime and reduced settings during nighttime. Anti-seizure medication remained unchanged. Within 12 months his seizure frequency was reduced by 90 % and his depression improved, permitting a cessation of his antidepressant medication. The observations made in this case have contributed to the manufacturer of VNS developing new generator models that can automatically provide bi-level VNS.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sleep and Women's Mental Health

Women have increased risks for both sleep disturbances and disorders and for mental health issues throughout their lives, starting in adolescence. Women have a higher prevalence of insomnia disorder and restless legs syndrome (RLS) versus men, and obstructive sleep apnea (OSA) is more likely as women age. Hormonal transitions are important to consider in women's sleep. For women, insomnia, OSA, and RLS are predictive of depression, and insomnia and sleep-disordered breathing are predictive of Alzheimer disease. These findings underscore the importance of assessment, treatment, and future research examining sleep and mental health in women, given their unique and increased vulnerability.

Alterations of Limbic Structure Volumes in Patients with Obstructive Sleep Apnea

OBJECTIVES

We investigated the change in limbic structure volumes and intrinsic limbic network in patients with obstructive sleep apnea (OSA) compared to healthy controls.

METHODS

We enrolled 26 patients with OSA and 30 healthy controls. They underwent three-dimensional T1-weighted magnetic resonance imaging (MRI) on a 3 T MRI scanner. The limbic structures were analyzed volumetrically using the FreeSurfer program. We examined the intrinsic limbic network using the Brain Analysis with Graph Theory program and compared the groups' limbic structure volumes and intrinsic limbic network.

RESULTS

There were significant differences in specific limbic structure volumes between the groups. The volumes in the right amygdala, right hippocampus, right hypothalamus, right nucleus accumbens, left amygdala, left basal forebrain, left hippocampus, left hypothalamus, and left nucleus accumbens in patients with OSA were lower than those in healthy controls (right amygdala, 0.102 vs. 0.113%, p = 0.004; right hippocampus, 0.253 vs. 0.281%, p = 0.002; right hypothalamus, 0.028 vs. 0.032%, p = 0.002; right nucleus accumbens, 0.021 vs. 0.024%, p = 0.019; left amygdala, 0.089 vs. 0.098%, p = 0.007; left basal forebrain, 0.020 vs. 0.022%, p = 0.027; left hippocampus, 0.245 vs. 0.265%, p = 0.021; left hypothalamus, 0.028 vs. 0.031%, p = 0.016; left nucleus accumbens, 0.023 vs. 0.027%, p = 0.002). However, there were no significant differences in network measures between the groups.

CONCLUSION

We demonstrate that the volumes of several limbic structures in patients with OSA are significantly lower than those in healthy controls. However, there are no alterations to the intrinsic limbic network. These findings suggest that OSA is one of the risk factors for cognitive impairments.

Investigating associations between social determinants, self-efficacy measurement of sleep apnea and CPAP adherence: the SEMSA study

Study objectives

The prospective Self-Efficacy Measure for Sleep Apnea study (SEMSAS) is investigating thresholds for health literacy, self-efficacy and precariousness at obstructive sleep apnea (OSA) diagnosis to predict CPAP adherence. This paper describes the study protocol and presents baseline data from the ongoing study.

Methods

Eligible individuals had confirmed OSA and were referred to a homecare provider for continuous positive airway pressure (CPAP) therapy initiation. Data on patient characteristics and comorbidities were collected, along with baseline evaluations of self-efficacy [15-item Self-Efficacy Measure for Sleep Apnea tool (SEMSA-15)], precariousness [Deprivation in Primary Care Questionnaire (DipCareQ)], and health literacy (Health Literacy Questionnaire). CPAP adherence over 12 months of follow-up will be determined using remote monitoring of CPAP device data. The primary objective is to define an optimal SEMSA-15 score threshold to predict CPAP adherence at 3- and 12-month follow-up.

Results

Enrollment of 302 participants (71% male, median age 55 years, median body mass index 31.6 kg/m²) is complete. Low self-efficacy (SEMSA-15 score ≤ 2.78) was found in 93/302 participants (31%), and 38 (12.6%) reported precariousness (DipCareQ score > 1); precariousness did not differ significantly between individuals with a SEMSA-15 score ≤ 2.78 versus >2.78. Health literacy was generally good, but was significantly lower in individuals with versus without precariousness, and with low versus high self-efficacy.

Conclusion

SEMSAS is the first study using multidimensional baseline assessment of self-efficacy, health literacy and precariousness, plus other characteristics, to determine future adherence to CPAP, including CPAP adherence trajectories. Collection of follow-up data is underway.

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.

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.

Diurnal symptoms of sleepiness and dysfunction predict future suicidal ideation in a French cohort of outpatients (FACE-DR) with treatment resistant depression: A 1-year prospective study about sleep markers

BACKGROUND

Patients suffering from treatment-resistant depression (TRD) are at risk of suicide. Sleep and circadian rhythm alterations are widely recognized as core symptoms of major depressive disorder and are associated with suicidal ideation. Thus, sleep and circadian rhythm alterations may be targeted to prevent suicide.

METHODS

Patients were recruited from a prospective cohort of the French network of TRD expert centers. Mood, sleep and circadian rhythms were assessed at baseline; suicidal risk was assessed both at baseline and during a one-year follow-up with standardized subjective questionnaires.

RESULTS

Excessive daytime sleepiness (adjusted odds ratio aOR = 1.7(1-3.3), p = 0.04) and daytime dysfunction (aOR = 1.81(1.16-2.81), p = 0.0085) increased the risk of suicidal thoughts over the one-year follow-up period in patients with TRD after adjustment on age, gender, depression, trauma, anxiety, impulsivity, current daily tobacco smoking and body mass index. Hypnotics intake is associated with a reduced risk of suicidal ideation at one-year follow-up after the same adjustments (OR = 0.73(0.56-0.95), p = 0.019). Other associations between sleep quality or circadian rhythms and suicidal ideations at either baseline or one year did not remain significant in multivariate analyses after the same adjustments.

LIMITATIONS

Sleep assessments were based on self-reported questionnaires rather than objective measures.

CONCLUSIONS

Daytime sleepiness and dysfunction are predictors of suicidal ideations, whereas hypnotics intake is associated with a reduced risk of suicidal ideations. Diurnal symptoms of sleep disturbances are therefore red flags to target for preventing suicide in depressed patients, and hypnotics seem efficient in preventing suicide for patients with TRD.

Prevalence, treatment and determinants of obstructive sleep apnoea and its symptoms in a population-based French cohort

Background

Obstructive sleep apnoea (OSA) is associated with increased morbidity and mortality. Although the disorder has been well studied in selected high-risk populations, few data exist on its prevalence in the general population. We aimed to assess the prevalence and determinants of OSA in France.

Methods

Data from participants of the French population-based CONSTANCES cohort aged 18-69 years at inclusion and being treated for sleep apnoea or screened for OSA in 2017 using the Berlin Questionnaire were analysed. Weighted analyses were performed to provide recent and representative results in the general population.

Results

Among 20 151 participants, the prevalence of treated sleep apnoea was 3.5% (95% CI 3.0-3.9%). The prevalence of untreated subjects with a positive Berlin Questionnaire was 18.1% (95% CI 17.3-19.2%) for a total weighted prevalence of treated sleep apnoea or high risk of OSA of 20.9% (95% CI 20.0-21.9%). Regarding prevalence of OSA symptoms, it was 37.2% (95% CI 36.1-38.3%) for severe snoring and 14.6% (95% CI 13.8-15.5%) for hypersomnolence. In multivariable logistic regression analysis, male sex, age, previous cardiovascular events, smoking, low educational level, low physical activity and depressive symptoms were associated with having either treated sleep apnoea or a positive Berlin Questionnaire.

Conclusion

In this large French population-based cohort, one in five participants had a high likelihood of OSA, whereas only 3.5% were treated for the disorder, suggesting major underdiagnosis in the general population. OSA diagnosis should be considered more often in people with risk factors such as depressive symptoms as well as unhealthy behaviours and socioeconomic conditions.

Insomnia and treatment-resistant depression

Depression and sleep disturbance are related closely with bidirectional relationship. The heterogenic diagnostic criteria of major depressive disorder composed by the myriad combination of symptoms including sleep disturbance. Insomnia is an identifiable risk factor for depression and the treatment of insomnia might be able to prevent subsequent major depressive episodes which draws psychiatrists' attention to the interface of psychiatry and sleep medicine field. It is important to identify occult sleep disturbance in patients with treatment-resistant depression to improve treatment outcome. New tools to objectively measure sleep at home environment represent a great march in clinical care and research modalities but need further validation before they can be applying widespread at sleep and depression intersection. Careful evaluation and measurement of the phenotype and nature of sleep disturbance will continue to advance understanding of the biological bases of psychiatric disorders and the connections with sleep.

Automated deep neural network analysis of lateral cephalogram data can aid in detecting obstructive sleep apnea

STUDY OBJECTIVES

Information on obstructive sleep apnea (OSA) is often latently detected in diagnostic tests conducted for other purposes, providing opportunities for maximizing value. This study aimed to develop a convolutional neural network (CNN) to identify the risk of OSA using lateral cephalograms.

METHODS

The lateral cephalograms of 5,648 individuals (mean age, 49.0 ± 15.8 years; men, 62.3%) with or without OSA were collected and divided into training, validation, and internal test datasets in a 5:2:3 ratio. A separate external test dataset (n = 378) was used. A densely connected CNN was trained to diagnose OSA using a cephalogram. Model performance was evaluated using the area under the receiver operating characteristic curve (AUROC). Gradient-weighted class activation mapping (Grad-CAM) was used to evaluate the region of focus, and the relationships between the model outputs, anthropometric characteristics, and OSA severity were evaluated.

RESULTS

The AUROC of the model for the presence of OSA was 0.82 (95% confidence interval, 0.80-0.84) and 0.73 (95% confidence interval, 0.65-0.81) in the internal and external test datasets, respectively. Grad-CAM demonstrated that the model focused on the area of the tongue base and oropharynx in the cephalogram. Sigmoid output values were positively correlated with OSA severity, body mass index, and neck and waist circumference.

CONCLUSIONS

Deep learning may help develop a model that classifies OSA using a cephalogram, which may be clinically useful in the appropriate context. The definition of ground truth was the main limitation of this study.

CITATION

Jeong H-G, Kim T, Hong JE, et al. Automated deep neural network analysis of lateral cephalogram data can aid in detecting obstructive sleep apnea. J Clin Sleep Med. 2023;19(2):327-337.

Machine learning approaches for predicting sleep arousal response based on heart rate variability, oxygen saturation, and body profiles

Objective

Obstructive sleep apnea is a global health concern, and several tools have been developed to screen its severity. However, most tools focus on respiratory events instead of sleep arousal, which can also affect sleep efficiency. This study employed easy-to-measure parameters-namely heart rate variability, oxygen saturation, and body profiles-to predict arousal occurrence.

Methods

Body profiles and polysomnography recordings were collected from 659 patients. Continuous heart rate variability and oximetry measurements were performed and then labeled based on the presence of sleep arousal. The dataset, comprising five body profiles, mean heart rate, six heart rate variability, and five oximetry variables, was then split into 80% training/validation and 20% testing datasets. Eight machine learning approaches were employed. The model with the highest accuracy, area under the receiver operating characteristic curve, and area under the precision recall curve values in the training/validation dataset was applied to the testing dataset and to determine feature importance.

Results

InceptionTime, which exhibited superior performance in predicting sleep arousal in the training dataset, was used to classify the testing dataset and explore feature importance. In the testing dataset, InceptionTime achieved an accuracy of 76.21%, an area under the receiver operating characteristic curve of 84.33%, and an area under the precision recall curve of 86.28%. The standard deviations of time intervals between successive normal heartbeats and the square roots of the means of the squares of successive differences between normal heartbeats were predominant predictors of arousal occurrence.

Conclusions

The established models can be considered for screening sleep arousal occurrence or integrated in wearable devices for home-based sleep examination.

The Role of Sleep in Cognitive Function: The Value of a Good Night's Rest

As a universal, evolutionarily conserved phenomenon, sleep serves many roles, with an integral role in memory. This interplay has been examined in a variety of research. The purpose of this article will be to review the literature of sleep, aging, cognition, and the impact of two common clinical conditions (obstructive sleep apnea and insomnia) on cognitive impairment. This article will review data from meta-analyses, population studies, smaller cohort studies, neuropsychological studies, imaging, and bench data. Considerations are given to the current data trends and their limitations. This paper will explore the impact of sleep on cognitive impairment. Finally, we will conclude with integrating the separate mechanisms towards more generalized common pathways: disruption of sleep quality and reduction in sleep quantity lead to excessive neuronal activity without sufficient time for homeostasis. Sleep apnea and chronic insomnia can lead to oxidative stress and neuronal damage. These changes predispose and culminate in the development of cognitive impairment.

Shared decision making: A novel approach to personalized treatment in obstructive sleep apnea

Study objectives

i) To describe a novel approach of phenotyping by shared decision making (SDM) in obstructive sleep apnea (OSA) discharge consultations ii) to describe correlation between patient and observer based evaluations of SDM and iii) to describe treatment adherence.

Methods

Consecutive patients referred to the otorhinolaryngology department at Akershus University Hospital with suspected OSA between 2015 and 2016 participated. Patients with body mass index >30 were oversampled. Four male communication-trained doctors aged from 30 to 60 years participated. SDM was evaluated by modified content analysis and by the CollaboRATE self-report questionnaire and the “Observer OPTION (Young et al., 2008) [5]” rating scale. Positive airway pressure (PAP) treatment adherence and weight reduction was assessed by interview at six year follow-up.

Results

Eighteen consultations were video filmed. The content analysis revealed that the patient perspectives only briefly were explored. PAP was chosen by 17 of 18 patients. Median CollaboRATE questionnaire score was 29 (26, 30). Mean OPTION (Young et al., 2008) [5] score was 65.6 (SD 6.6, range 55–80). The correlation between SDM assessed by CollaboRATE self-report and by the “Observer OPTION (Young et al., 2008) [5]” rating scale was low (Pearson's r = 0.09). At follow up, 11 patients (64.7%) were PAP adherent and no one achieved 10% weight loss.

Conclusions

Despite a high degree of SDM compared to studies of non-OSA populations, the sub-optimal exploration of the patient perspective by communication-trained doctors precluded identification of patients willing to cope actively. SDM assessed by self-report and by a rating scale may represent two different constructs. PAP adherence was good.

•

Obstructive sleep apnea treatment adherence is a clinical challenge.

•

Little is known about the use of phenotyping by shared decision making in sleep research.

•

Phenotyping by shared decision making was found to occur, but the patient perspective was discussed to a small extent.

•

The CollaboRATE questionnaire is not optimal due to a ceiling effect for assessing shared decision making among patients with obstructive sleep apnea.

Evaluating symptoms and polysomnographic findings among male and female children with obesity with and without obstructive sleep apnea

OBJECTIVE

Limited data regarding sex-based differences in the presentation and phenotype of obstructive sleep apnea (OSA) exists among children with obesity. The study objectives were to compare reported symptoms and polysomnogram (PSG) findings between children with obesity 1) with and without OSA and 2) males and females with OSA.

PATIENTS/METHODS

This cross-sectional study included children with obesity, aged 8-18 years, with a diagnostic PSG between 2015 and 2021, referred for evaluating sleep-related breathing. Patient demographics, anthropometrics, and PSG data were recorded. Symptoms were evaluated using Epworth Sleepiness Scale and Pediatric Sleep Questionnaire. Pubertal staging was collected using Tanner Stage questionnaire. PSG parameters, symptoms and pubertal stage were compared between sexes with and without OSA.

RESULTS

Of 148 children, 61 (41%) had OSA. Within the OSA group, 41/62 (69%) were male (p = 0.002). Males with OSA reported higher Pediatric Sleep Questionnaire scores compared to males without OSA (0.38 ± 0.2 vs 0.23 ± 0.1; p = 0.002). Males with OSA reported more trouble breathing (p = 0.04) and mouth breathing (p = 0.008) compared to females with OSA. Females with OSA showed longer sleep onset latency (45.8 ± 40.6 min vs 22.4 ± 26.7; p = 0.02) and higher supine obstructive-apnea hypopnea index (32.9 ± 31.1 vs 20.4 ± 18.4 events/hour; p = 0.02) compared to males with OSA. A significant interaction was found between male sex and waist-to-height ratio (β = 15.34, R² = 0.18, p = 0.05).

CONCLUSIONS

Sex differences in symptoms and phenotype of OSA exist among children with obesity. Such information is beneficial for early diagnosis and management to mitigate adverse outcomes and comorbidities.

Relationship between lipids and sleep apnea: Mendelian randomization analysis

BACKGROUND

Lipids increase the risk of sleep apnea; however, the causality between them is still inconclusive.

AIM

To explore the causal relationship between serum lipids and sleep apnea using two-sample Mendelian randomization (MR) analysis.

METHODS

Single nucleotide polymorphism (SNP) data related to serum lipids were obtained from the Global Lipids Genetics Consortium study, which included 188578 individuals of European ancestry. Additionally, sleep apnea-related SNP data were collected from the United Kingdom Biobank study, which comprised 463005 individuals of European ancestry. Two-sample MR analysis was performed to assess the causality between serum lipids and sleep apnea based on the above public data.

RESULTS

Genetically predicted low-density lipoprotein (odds ratio [OR] = 0.99, 95% confidence interval [CI] = 0.99 to 1.00; P = 0.58), high-density lipoprotein (OR = 0.99, 95%CI = 0.99 to 1.00; P = 0.91), triglyceride (OR = 1.00, 95%CI = 0.99 to 1.00; P = 0.92), and total cholesterol (OR = 0.99, 95%CI = 0.99 to 1.00; P = 0.33) were causally unrelated to sleep apnea.

CONCLUSION

Our MR analysis suggests that genetically predicted serum lipids are not risk factors of sleep apnea.

Computational assessment of upper airway muscular activity in obstructive sleep apnea - In vitro validation

Neuromuscular control of the upper airway contributes to obstructive sleep apnea (OSA). An accurate, non-invasive method to assess neuromuscular function is needed to improve surgical treatment outcomes. Currently, surgical approaches for OSA are based on airway anatomy and are often not curative. When the airway surface moves, the power transferred between air in the airway lumen and the structures of the upper airway may be a measure of airway neuromuscular activity. The aim of this study was to validate power transfer as a measure of externally applied forces, representing neuromuscular activity, through cine computed tomography (CT) imaging and computational fluid dynamics (CFD) analysis in a 3D-printed airway model. A hollow elastic airway model was manufactured. An insufflation/exsufflation device generated airflow within the model lumen. The model was contained in an airtight chamber that could be positively or negatively pressurized to represent muscular forces. These forces were systematically applied to dilate and collapse the model. Cine CT imaging captured airway wall movement during respiratory cycles with and without externally applied forces. Power transfer was calculated from the product of wall movement and internal aerodynamic pressure forces using CFD simulations. Cross-correlation peaks between power transfer and changes in externally applied pressure during exhalation and inhalation were -0.79 and 0.95, respectively. Power transfer calculated via cine CT imaging and CFD was an accurate surrogate measure of externally applied forces representing airway muscular activity. In the future, power transfer may be used in clinical practice to phenotype patients with OSA and select personalized therapies.

Prevalence of depression and anxiety in obstructive sleep apnea

INTRODUCTION

Organic comorbidities of obstructive sleep apnea (OSA) have been widely studied. However, psychiatric disorders, especially depression and anxiety, have not attracted so much attention.

AIM

The primary aim was to determine the prevalence and the predictive factors of depression and anxiety in OSA patients. The secondary aim was to investigate the association between OSA severity and these psychiatric disorders.

METHODS

A cross-sectional study including untreated OSA patients without mental illness history was conducted. Patients were administered the Hospital Anxiety (HADS-A) and Depression Scale (HADS-D). Depression and anxiety were diagnosed for HAD-D and HAD-A scores ≥ 8.

RESULTS

Eighty patients were included (mean age: 54.83 ± 13.12 yr; female: 52 (65%); mean Body mass index (BMI) :34.7±6.14 kg/m2). The prevalence of depression and anxiety was 35 % and 43.8% of patients respectively. Both depressive and anxious OSA patients had more libido disorder ( p=0.011, p=0.0007 ;respectively), anhedonia (p= 10-4, p= 10-4respectively ) and suicidal ideas(p= 0.002 ,p=0.019 respectively). Moreover, depressed OSA patients had lower socio-economic condition (p= 0.019), more coronary artery diseases (CAD) (p=0.019) and less cognitive disorder (p= 0.005). The HADS-D (r=0,095; p=0,404) and the HADS-A (r=0,212; p=0,059) were not correlated with the Apnea/Hyponea Index. The determinants of depressive and anxious mood were female-sex (p= 0.035, p=0.004 respectively) and libido disorder (p=0.040, p=0.02 respectively). Anhedonia (p=10-4) and CAD (p=0.010) were also identified as a predictive factors of depression.

CONCLUSIONS

In our study, the high prevalence of depression and axiety in apneic patients demonstrates the importance of the psychiatric component in the management of this disease. A collaboration between pneumologists and psychiatrists is necessary in order to improve the quality of life of these patients.

Self-reported sleep and exercise patterns in patients admitted with suicidal attempts: a cross-sectional comparative study

BACKGROUND

There is evidence that sleep disturbances and exercise are risk factors for suicide attempts; however, whether sleep disturbances are independently associated with suicide attempts is debatable. We compared the sleep and exercise patterns of individuals who attempted suicide to those of the general population and investigated whether sleep disturbances were independently associated with suicide attempts.

METHODS

Over a year, individuals presented to the emergency department at Hamad General Hospital and Mental Health Services in Doha with suicide attempts (n = 127) filled out questionnaires on sleep and exercise, demographics, and clinical measures. A control group (n = 126) from two primary care centers filled out the same questionnaires during the same period.

RESULTS

Subjects in the suicide group were significantly younger, single, had a lower level of education, and showed considerably more early insomnia, daytime tiredness, interrupted sleep, and no regular exercise. The most common diagnoses seen with suicidality were adjustment disorder and major depression, and the most common method used to attempt suicide was an overdose. After multiple regression analysis, being Arab, belonging to the category "other nationalities," unemployment, and early insomnia were significantly associated with an increased risk of suicide attempts.

CONCLUSION

This is the first comparative study on suicide in the Arabian Gulf. Individuals in Qatar with acute stress, depressive symptoms, sleep disturbances, and lack of exercise are at increased risk of attempting suicide. Thus, clinicians need to routinely screen for sleep and physical activity because of their significant contribution to physical and mental well-being.

Sex differences in the effectiveness and affecting factors to adherence of continuous positive airway pressure therapy

Although sex differences in clinical backgrounds of patients with obstructive sleep apnea (OSA) are well known, studies of sex differences about the influencing factors on adherence to continuous positive airway pressure (CPAP) are very sparse. Our aim was to investigate the effects of CPAP use affecting therapeutic adherence in sex differences. We retrospectively assessed demographic data, clinical characteristics, OSA-related symptoms, and effects and adherence of CPAP use in 348 patients (264 males, median age 58 years) who continued CPAP for at least 1 year. Poor adherence was defined as CPAP dropout within 1 year after starting CPAP or the average cumulative CPAP use less than four hours/night. We also studied the predictors or influencing factors of CPAP adherence by multivariate logistic regression analyses. Age was higher and the severity of OSA was lower in female patients. Although the adherence level itself was not significantly different between both sexes, influencing factors were different. OSA severity, such as apnea-hypopnea index and sleepiness, and many effects from CPAP use (respiratory difficulty, difficult adaptation to CPAP use, improved awakening, reduced nocturia, and easy adaptation to CPAP) influenced adherence only in men. Common factors of poor adherence in both sexes were lower age, insomnia by CPAP use, and improved daytime sleepiness. No other specific factors predicted poor adherence in women. We found that there were sex differences in influencing factors on CPAP adherence not only in clinical characteristics of OSA, but also in effectiveness and side effects of CPAP use.

Association of long-term exposure to PM2.5 with hypertension and diabetes among the middle-aged and elderly people in Chinese mainland: a spatial study

Background

Epidemiological evidence has shown an association between long-term exposure to fine particulate matter (PM_2.5) and hypertension and diabetes, but few studies have considered the spatial properties of the samples. This study aimed to investigate the long-term effect of PM_2.5 exposure on hypertension and diabetes among middle-aged and elderly people in China based on a spatial study.

Methods

We conducted a national cross-sectional study of the most recently launched wave 4 2018 data of the China Health and Retirement Longitudinal Study (CHARLS) to calculate the prevalence of hypertension and diabetes. The exposure data of annual average PM_2.5 concentrations were estimated combined with satellite observations, chemical transport modeling, and ground-based monitoring. A shared component model (SCM) was used to explore the association of PM_2.5 with hypertension and diabetes, in which these two diseases borrowed information on spatial variations from each other. Then, we evaluated the effect variations in PM_2.5 in different periods and smoking status on changes in outcomes.

Results

The prevalence of hypertension and diabetes was 44.27% and 18.44%, respectively, among 19,529 participants. The annual average PM_2.5 concentration in 31 provinces ranged from 4.4 μg/m³ to 51.3 μg/m³ with an average of 27.86 μg/m³ in 2018. Spatial auto-correlations of the prevalence of hypertension and diabetes and PM_2.5 concentrations were seen (Moran’s I = 0.336, p = 0.01; Moran’s I = 0.288, p = 0.03; Moran’s I = 0.490, p = 0.01). An interquartile range (IQR: 16.2 μg/m³) increase in PM_2.5 concentrations was significantly associated with a higher prevalence of hypertension and diabetes with odds ratios (ORs) of 1.070 [95% credible interval (95% CrI): 1.034, 1.108] and 1.149 (95% CrI: 1.100, 1.200), respectively. Notably, the effect of PM_2.5 on both hypertension and diabetes was relatively stronger among non-smokers than smokers.

Conclusion

Our nationwide study demonstrated that long-term exposure to PM_2.5 might increase the risk of hypertension and diabetes, and could provide guidance to public policymakers to prevent and control hypertension and diabetes according to the spatial distribution patterns of the above effects in China.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12984-6.

Obstructive Sleep Apnea: Another Condition to Screen for in Women with Infertility

Women with obstructive sleep apnea (OSA) are at increased risk of poor pregnancy outcomes such as fetal growth restriction, hypertensive disorders of pregnancy, and gestational diabetes mellitus. Given this increased risk, we aimed to study the screening prevalence of OSA in women seeking fertility treatment. We performed a cross sectional study of patients presenting to a university-affiliated fertility clinic between March-April 2021. Patients were asked to complete OSA screening (STOP-BANG), anxiety screening (GAD-7), and depression screening (PHQ-2) questionnaires. 107 women completed the surveys. Mean age was 35.1 years and mean body mass index (BMI) was 25.7 kg/m2. Nine (8.4%) women screened positive for OSA using the STOP-BANG screening tool. Women who screened positive for OSA were more likely to be older (37.8 years vs. 34.7 years, p = 0.02) and have a higher BMI (42.6 kg/m2 vs. 27.4 kg/m2, p < 0.001). Women who screened positive for OSA were also more likely to screen positive for mild-severe depressive symptoms (22.2% vs. 3.1%, p = 0.006) and mild-severe anxiety (66.7% vs. 21.4%, p = 0.003) symptoms. 24.3% of the population had polycystic ovary syndrome (PCOS). Women with PCOS were more likely to screen positive for OSA (19.2% vs. 4.9%; p = 0.04). Despite this being a low-risk population of young women seeking fertility evaluation or treatment, 8% screened positive for OSA. Given the association between OSA and adverse pregnancy outcomes, our results underline the need to screen women seeking fertility treatment.

The relationships between obstructive sleep apnea and psychiatric disorders: a narrative review

Introduction: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Its prevalence tends to increase worldwide. Untreated sleep apnea is associated with a higher risk of metabolic diseases, cardiovascular diseases, stroke, road accidents, and death, but also it is suggested that it increases the risk of mental disorders.

Method: The literature review was based on a search of articles on Medline, Pubmed, and Google Scholar from 2003 to 2021 using the keywords: obstructive sleep apnea; mental disorders; cognitive functions; affective disorders; depression; bipolar disorder; schizophrenia; psychotic disorders. The analysis included original studies, meta-analysis, and review articles.

Discussion: The result obtained from researches published so far does not allow for drawing unequivocal conclusions. There is a lot of bias present in study protocols and inclusion/exclusion criteria. Nonetheless, it seems that some disorders have a better proven correlation with OSA. Cognitive impairment, depression, and anxiety disorders are linked to OSA not only in terms of the overlapping of symptoms but also of a causal relationship. Psychotic disorders and bipolar disorders connections with OSA are confirmed, but they are not yet well understood. All correlations are found to be possibly bidirectional.

Conclusion: 1. Multiple lines of evidence increasingly point towards a bidirectional connection between OSA and mental disorders, and the cause and effect relationship between these two groups of disorders requires further research.

2. Due to reports of an increased risk of OSA with antipsychotic drugs, caution should be exercised when initiating therapy with this type of drug in patients with known risk factors for it.

3. Screening for OSA in psychiatric patients should be introduced as OSA can increase cognitive impairment, affective, and psychotic symptoms.

Spatial analysis of the effects of PM2.5 on hypertension among the middle-aged and elderly people in China

Hypertension is currently one of the most common chronic diseases with high global prevalence associated with a huge social and economic burden. In recent years, air pollution has become a focus of research, especially the effects of PM2.5 on hypertension. However, few studies have considered the spatial properties of the sample; thus, the results might be unreliable. Based on the China Health and Retirement Longitudinal Study (CHARLS) and the Environmental Status Bulletin for each province in China, we used the extended shared component model (SCM) to fit the spatial variation of hypertension risk and to reveal the impact of PM2.5 on hypertension in males and females. Our results revealed that the crude prevalence of hypertension for the whole population in China was 32.74% in 2015, with the prevalence in men experiencing slightly higher than that in women (32.92% vs. 32.58%). We found that the distribution of hypertension prevalence exhibited obvious spatial aggregation for the whole population in China (Moran's I = 0.39, P = 0.001), with similar results in both men (Moran's I = 0.18, P = 0.027) and women (Moran's I = 0.52, P = 0.001). Furthermore, the smoothed results obtained using the SCM indicated that some eastern and central provinces had relatively higher hypertension risk, while the risk in southeastern provinces was much lower. The risk was also relatively lower in most western provinces, except for some northwestern regions. Notably, our results showed that PM2.5 was a risk factor for hypertension, and the impact of PM2.5 on women was slightly greater than that on men, with odds ratios (OR) of 1.063 (1.041, 1.086) and 1.048 (1.025, 1.071), respectively. Our findings suggest the existence of distinct spatial differences in the prevalence of hypertension and small sex-related differences in the risk of hypertension in China.

The role of circadian rhythms in Obstructive Sleep Apnea symptoms and novel targets for treatment

Obstructive Sleep Apnea (OSA) is a common disorder that is associated with disability, premature mortality and lost quality of life. Excessive daytime sleepiness and depressive symptoms confer a great portion of the disability and lost quality of life associated with the disorder. While showing robust rates of response and symptoms resolutions, current treatments aimed at correcting the respiratory disturbances are not universally successful and a non-negligible proportion of patients who are correctly using available therapies do not experience symptomatic relief, suggesting that mechanisms beyond the respiratory disturbances may be involved in the pathogenesis of symptoms. A growing body of literature concerning animal and human models suggests that the sleep and respiratory disturbances commonly seen in OSA, namely sleep fragmentation, partial sleep deprivation, intermittent hypoxia, can promote shifts in circadian rhythms ultimately leading to misalignment between sleep-wake rhythms and the internal clock, as well as desynchrony amongst peripheral clocks and peripheral and central clock. This manuscript reviews the current evidence in support of a circadian disturbance underlying OSA symptomatology and proposes new applications for existing chronotherapeutic interventions with the potential for improving symptoms and quality of life for those patients that do not find symptomatic relief with currently available treatments.

Relationship between the Spectral Power Density of Sleep Electroencephalography and Psychiatric Symptoms in Patients with Breathing-related Sleep Disorder

Objective

Patients with breathing-related sleep disorder (BRSD) often complain of psychiatric symptoms such as depression in addition to snoring, excessive sleepiness, and disturbed sleep. However, the relationship between psychiatric symptoms and severity of sleep apnea in BRSD is controversial. We conducted this study to investigate the relationship between psychiatric symptoms and sleep electroencephalography (EEG) findings in BRSD patients using spectral analysis.

Methods

All participants underwent polysomnography and evaluation using Symptom Checklist-90-Revised (SCL-90-R) scale. We analyzed the absolute spectral power density values of standard EEG frequency bands in the participants (n = 169) with BRSD during the non-rapid eye movement (NREM) sleep period. We performed correlation analysis between the domain scores of SCL-90-R scale and the absolute values of the EEG frequency bands.

Results

Significant positive correlation was observed between the absolute spectral power density values in the slow oscillation band and the degree of paranoid ideation (r = 0.226, p = 0.028) and depression (r = 0.216, p = 0.044) in SCL-90-R. The multiple linear regression model showed that higher paranoid ideation domain score (B = 0.007, p = 0.020), younger age (B = −0.011, p < 0.001), and female sex (B = 0.213, p = 0.004) were associated with higher slow oscillation power during NREM sleep.

Conclusion

The results of the present study suggested a relationship between sleep EEG and psychiatric symptoms in patients with BRSD. This relationship needs to be validated with further studies.

Sleep-Disordered Breathing Is Associated With Impaired Odor Identification in Older U.S. Adults

BACKGROUND

Sleep-disordered breathing (SDB) is a common, underdiagnosed condition in older adults with major health consequences, including disrupted central nervous system functioning. Whether SDB may affect sensory function is unclear. We sought to address this question by comparing 2 forms of olfactory testing which measure peripheral and central olfactory processing.

METHODS

We assessed SDB (survey-reported snoring frequency, nighttime apneic events, or diagnosis of sleep apnea) in the National Social Life, Health, and Aging Project, a nationally representative sample of older U.S. adults. Odor sensitivity (peripheral) and odor identification (central) were assessed with validated instruments. Logistic regression was used to test the relationship between SDB and olfaction, accounting for relevant covariates, including demographics, cognition, and comorbidity.

RESULTS

Twenty-nine percent of older U.S. adults reported symptoms of SDB (apneic events or nightly snoring). Of these, only 32% had been diagnosed with sleep apnea. Older adults with SDB (those who reported symptoms or have been diagnosed with sleep apnea) were significantly more likely to have impaired odor identification (odds ratio 2.13, 95% confidence interval 1.19-3.83, p = .012) in analyses that accounted for age, gender, race/ethnicity, education, cognition, comorbidities (including depression), and body mass index. Presence of SDB was not associated with impaired odor sensitivity (odds ratio 1.03, 95% confidence interval 0.75-1.43, p = .84).

CONCLUSION

SDB is highly prevalent but underdiagnosed in older U.S. adults and is associated with impaired odor identification but not odor sensitivity. These data support the concept that SDB affects pathways in the central nervous system which involve chemosensory processing.

Snoring and depression symptoms in pregnant women

OBJECTIVE

Pregnant patients are vulnerable to both depression and sleep-disordered breathing, and both convey risks for maternal and fetal outcomes. Previous research has indicated that sleep-disordered breathing is associated with depression, but further information related to the risk of depression based on timing of onset of snoring is needed.

DESIGN

When presenting to clinic for their initial prenatal visit, pregnant patients completed a packet of questionnaires, which included measures related to depression (Edinburgh Postnatal Depression Scale) and snoring. Habitual snoring was defined as snoring 3 or more nights per week.

RESULTS

In total, 1367 women were included and 34.1% reported habitual snoring, either chronic (24.4%) or pregnancy-onset (9.8%), with increased frequency of pregnancy-onset habitual snoring in later stages of pregnancy. Unadjusted analyses suggested increased odds of depressive symptoms in chronic and pregnancy-onset habitual snoring groups relative to nonsnorers (odds ratio [OR]: 2.01, 95% confidence interval [CI]: 1.39, 2.92, P < .01; OR: 2.50, 95% CI: 1.54, 4.07, P < .01, respectively). These findings were maintained after adjusting for maternal age, marital status, gestational age, and parity (chronic habitual snoring OR: 1.69, 95% CI: 1.14, 2.53, P < .01; pregnancy-onset habitual snoring OR: 2.79, 95% CI: 1.35, 5.78, P < .01).

CONCLUSIONS

Maternal snoring may be a risk factor for prenatal depressive symptoms. Pregnancy-onset habitual snoring confers additional risk for depression compared to not snoring during pregnancy.

Salivary biomarkers associated with obstructive sleep apnea: a systematic review

Introduction: This study aimed to define and characterize current literature describing salivary biomarker changes with the goal of improving diagnosis and treatment outcomes for sleep apnea.Area Covered: A search of six databases yielded 401 peer-reviewed articles published through October 2019 corresponded to 221 unique references following deduplication. Twenty studies were selected. The sample size ranged from 17 to 99. The samples were mostly whole saliva and selected glandular areas.Expert Opinion: Most targeted studies focused on the level of salivary cortisol and ɑ-amylase. One study used RNA transcriptome analysis of 96 genes. Only two explored novel targets using mass spectrometry. ɑ-amylase, myeloperoxidase, and IL-6 were among those biomarkers found associated with OSA. Cytokeratin, CystatinB, calgranulin A, and alpha-2-HS-glycoprotein are upregulated in OSA patients based on non-targeting mass spectrometry. Salivary cortisol and ɑ-amylase and others appeared to be associated with severity of OSA and OSA treatment. There were inconsistencies in saliva collection and processing protocols. More studies are needed in exploring novel biomarkers to examine if these biomarkers are capable of diagnosing and monitoring OSA through proteomics or transcriptomics. Salivary biomarkers have a potential to be a noninvasive measure for the disease diagnosis and treatment outcome monitoring for sleep apnea.

Comparing the effects of supplemental oxygen therapy and continuous positive airway pressure on patients with obstructive sleep apnea: a meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVE

Obstructive sleep apnea (OSA) is associated with hypertension, psychological impairment, neurocognitive dysfunction, and poor quality of sleep. Continuous positive airway pressure (CPAP) has been confirmed to effectively improve OSA, while the effects of supplemental oxygen therapy on OSA have still remained controversial. This meta-analysis aimed to compare the effects of supplemental oxygen therapy and CPAP on patients with OSA.

METHODS

PubMed, Cochrane library, EMBASE, and Web of Science databases were systematically searched from inception until April 2020. Randomized controlled trials (RCTs) that compared the effects of supplemental oxygen therapy and CPAP on patients with OSA were selected without language restriction.

RESULTS

In this meta-analysis, 8 RCTs that involved 887 patients were found eligible for further analyses. Pooled data showed that there was no significant difference in improving nocturnal oxygen saturation (SpO₂) level (95% confidence interval (CI) = - 1.17 to 1.53) or symptoms of depression (95%CI = - 0.69 to 1.19) between supplemental oxygen therapy and CPAP. Supplemental oxygen therapy was found less effective in reducing apnea-hypopnea index (AHI), time of SpO₂ < 90%, blood pressure, and improving quality of sleep compared with CPAP. A subgroup analysis based on flow rate of oxygen indicated that the effects of supplemental oxygen therapy on blood pressure significantly differed. Furthermore, an improvement in overall time of SpO₂ < 90% was correlated to duration of supplemental oxygen therapy.

CONCLUSIONS

CPAP is clinically effective for the treatment of patients with OSA. However, supplemental oxygen therapy can be cautiously used for improving nocturnal hypoxia and symptoms of depression when CPAP is not acceptable or not tolerated. Supplemental oxygen therapy is a promising option to alleviate partial disorders of OSA. Further studies need to focus on flow rate of oxygen and duration of supplemental oxygen therapy.

Psychological disturbances and their association with sleep disturbances in patients admitted for cardiovascular diseases

BACKGROUND

Depression and anxiety are common mental health problems that are strongly associated with sleep disturbances, according to community-based researches. However, this association has not been investigated among patients admitted for cardiovascular diseases (CVDs). We examined the prevalence of depression and anxiety in inpatients with various CVDs and their association with sleep disturbances.

MATERIALS AND METHODS

This cross-sectional study included 1294 patients hospitalized for CVDs in a Japanese university hospital were evaluated for their mental status using the Hospital Anxiety and Depression Scale (HADS), for sleep-disordered breathing (SDB) using pulse oximetry, and for sleep quality using the Pittsburgh Sleep Quality Index (PSQI).

RESULTS

Patient characteristics were as below: mean age, 63.9±14.7 years; 25.7% female. Overall, 18.9% had depression (HADS-depression≥8) and 17.1% had anxiety (HADS-anxiety≥8). The presence of depression was associated with female sex, older age, higher plasma brain natriuretic peptide level, lower estimated glomerular filtration rate, and the prevalence of heart failure. Overall, 46.5% patients were categorized as having a poor sleep quality (PSQI>5), and 28.5% patients had SDB (3% oxygen desaturation index>15). Although depression and anxiety were not associated with SDB, they were independently associated with poor sleep quality (OR = 3.09, 95% CI 2.19-4.36; OR = 3.93, 95% CI 2.71-5.69, respectively).

CONCLUSIONS

Depression and anxiety were not uncommon in patients with CVDs. Poor sleep quality could be an important risk factor linked to psychological disturbances.

Machine and Deep Learning in Molecular and Genetic Aspects of Sleep Research

Epidemiological sleep research strives to identify the interactions and causal mechanisms by which sleep affects human health, and to design intervention strategies for improving sleep throughout the lifespan. These goals can be advanced by further focusing on the environmental and genetic etiology of sleep disorders, and by development of risk stratification algorithms, to identify people who are at risk or are affected by, sleep disorders. These studies rely on comprehensive sleep-related data which often contains complex multi-dimensional physiological and molecular measurements across multiple timepoints. Thus, sleep research is well-suited for the application of computational approaches that can handle high-dimensional data. Here, we survey recent advances in machine and deep learning together with the availability of large human cohort studies with sleep data that can jointly drive the next breakthroughs in the sleep-research field. We describe sleep-related data types and datasets, and present some of the tasks in the field that can be targets for algorithmic approaches, as well as the challenges and opportunities in pursuing them.

Effect of continuous positive airway pressure on symptoms of anxiety and depression in patients with obstructive sleep apnea

Purpose

The objective was to assess the effect of continuous positive airway pressure (CPAP) on symptoms of anxiety and depression in patients with obstructive sleep apnea (OSA). We hypothesized a decrease in symptoms at follow-up, but that improvement relied on CPAP adherence.

Methods

The sample comprised 468 patients (mean age 55.5 years (SD = 12.0), 72% men) with OSA who received CPAP at a Norwegian hospital. OSA was diagnosed according to standard respiratory polygraphy. Mean baseline respiratory event index (REI) was 28.4 (SD = 20.6). Symptoms of anxiety and depression were assessed prior to CPAP treatment and at follow-up after a median of 20 weeks, range 6–52 weeks, with the Hospital Anxiety and Depression Scale (HADS). Patients were classified as CPAP adherent (≥ 4 h per night) or non-adherent (< 4 h per night).

Results

There was a significant decrease in anxiety scores from baseline (mean = 5.16, SD = 3.94) to follow-up (mean = 4.76, SD = 3.81), p < 0.001. Similarly, depression scores decreased from baseline (mean = 4.31, SD = 3.66) to follow-up (mean = 3.89, SD = 3.69), p < 0.001. Cohen’s d (0.19 and 0.18, respectively) indicated small effect sizes. The reduction in anxiety scores did not depend on CPAP adherence (no interaction effect F(1, 466) = 0.422, p = 0.516), whereas the reduction in depression scores were seen only in the CPAP adherent group (interaction effect F(1, 466) = 7.738, p = 0.006).

Conclusions

We found a decrease in symptoms of anxiety and depression from baseline to follow-up of CPAP treatment. The improvement in symptoms of depression was depending on CPAP adherence. This underlines the importance of adherence for optimal effect of CPAP treatment.

REM sleep loss-induced elevated noradrenaline could predispose an individual to psychosomatic disorders: a review focused on proposal for prediction, prevention, and personalized treatment

Historically and traditionally, it is known that sleep helps in maintaining healthy living. Its duration varies not only among individuals but also in the same individual depending on circumstances, suggesting it is a dynamic and personalized physiological process. It has been divided into rapid eye movement sleep (REMS) and non-REMS (NREMS). The former is unique that adult humans spend the least time in this stage, when although one is physically asleep, the brain behaves as if awake, the dream state. As NREMS is a pre-requisite for appearance of REMS, the latter can be considered a predictive readout of sleep quality and health. It plays a protective role against oxidative, stressful, and psychopathological insults. Several modern lifestyle activities compromise quality and quantity of sleep (including REMS) affecting fundamental physiological and psychopathosomatic processes in a personalized manner. REMS loss-induced elevated brain noradrenaline (NA) causes many associated symptoms, which are ameliorated by preventing NA action. Therefore, we propose that awareness about personalized sleep hygiene (including REMS) and maintaining optimum brain NA level should be of paramount significance for leading physical and mental well-being as well as healthy living. As sleep is a dynamic, multifactorial, homeostatically regulated process, for healthy living, we recommend addressing and treating sleep dysfunctions in a personalized manner by the health professionals, caregivers, family, and other supporting members in the society. We also recommend that maintaining sleep profile, optimum level of NA, and/or prevention of elevation of NA or its action in the brain must be seriously considered for ameliorating lifestyle and REMS disturbance-associated dysfunctions.

Severe obstructive sleep apnea in patients with chronic obstructive pulmonary disease is associated with an increased prevalence of mild cognitive impairment

BACKGROUND

Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) are associated with mild cognitive impairment (MCI). However, this association is unclear. This study aimed to assess the prevalence of MCI in patients with overlap syndrome, determine whether OSA increases the risk of MCI in patients with COPD, and investigate the potential mechanisms for this association.

METHODS

Participants with stable Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 2-4 COPD and complaints of snoring in 2016-2018 were enrolled in this cross-sectional observational study. All were free of asthma, acute left-sided congestive heart failure, unstable coronary heart disease, uncontrolled hypertension, diabetes, encephalitis, and epilepsy. They underwent pulmonary function tests and overnight polysomnography and completed the Montreal Cognitive Assessment (MoCA). MCI was defined by an MoCA score of <23, while OSA was defined by an apnea-hypopnea index (AHI) of ≥15 per hour. The association between MCI, demographics, and comorbidities was tested by logistic regression analysis with adjustment for confounders. Sleep-disordered breathing measures were investigated as potential mechanisms underlying this relationship.

RESULTS

MCI was significantly more common in patients with overlap syndrome than in those with COPD (40.6% [43/106] vs 24.6% [42/171]). After adjustment, severe OSA was an independent contributor to MCI (odds ratio, OR 2.27; 95% confidence interval, CI 1.12-4.62). Increased percent of night-time spent with oxygen saturation <90% (TSat₉₀) was associated with increased odds of MCI (odds ratio 4.75, 95% CI 2.73-11.13).

CONCLUSIONS

MCI is more prevalent in overlap syndrome than in COPD. OSA may contribute to MCI in COPD. The mechanism may involve TSat₉₀.

Depression during perimenopause: the role of the obstetrician-gynecologist

Depression in women is more common during perimenopause (the transition to menopause) than at other times in the life cycle. Symptoms of depression may be different in perimenopausal women compared to younger or older women, and are often dismissed as part of normal menopause. This is an expert narrative review. There are several evidence-based screening modalities which can be integrated into routine women's health visits, and can facilitate distinguishing between depression and normal perimenopausal symptoms. There is emerging evidence regarding the effect of hormonal changes on the development of perimenopausal depression and its optimal treatment, though critical research gaps remain. Obstetrician-gynecologists and other primary care providers play a vital role in the detection and management of depression in women. Providers caring for women during perimenopause have a unique opportunity to diagnose depression in their patients and identify appropriate treatment options.

Vasomotor symptoms in women over 60: results from the Data Registry on Experiences of Aging, Menopause, and Sexuality (DREAMS)

OBJECTIVE

Frequency of vasomotor symptoms (VMS) in older women and the contributing factors are largely undefined. We measured the frequency of moderate-to-severe vasomotor symptoms (msVMS) in women ≥60 years of age and examined their characteristics to determine factors that may associate with VMS in older women.

METHODS

A cross-sectional survey was completed using the Menopause Health Questionnaire from the Data Registry on Experiences of Aging, Menopause, and Sexuality. Data were collected from women presenting for menopause consultation to Mayo Clinic, Rochester, MN, from January 1, 2006 to October 7, 2014. We created a binary variable where women were classified as having msVMS bother if they reported "quite a bit" or "extremely" compared with women reporting "not at all" or "a little bit." Women with and without msVMS were evaluated by menopause type, self-rated heath, current tobacco, caffeine, and alcohol use, as well as pertinent medication use. Associations between participant characteristics and msVMS were evaluated using logistic regression and a multivariable model with age as a covariate. Interactions between participant characteristics and age were also assessed.

RESULTS

Of the 4,956 women presenting for menopause consultation, 921 (18%) were ≥60 years old. Of these, 379 (41.2%) reported msVMS bother. Women with msVMS were more likely to have a history of nonspontaneous menopause and report their health as fair, versus good or excellent. Women reporting current use of hormone therapy (HT) (21%) were less likely to report msVMS compared with those not taking HT (P < 0.001).

CONCLUSIONS

A substantial number of women seen in a specialty menopause clinic were over age 60 years and reported msVMS, highlighting that VMS may be disruptive in women over a decade past the natural age of menopause.

[Sleep quality and sexual functioning in healthy adults]

INTRODUCTION

There are not enough scientific investigations, especially with a normative population, that show the association between sleep quality and sexual functioning.

METHOD

945 healthy individuals, 62% female, 38% male, mean age 34.27 years (standard deviation=15.82), who completed a sociodemographic questionnaire, the Portuguese version of the Oviedo Sleep Questionnaire and the Portuguese version of the Massachusetts General Health Hospital-Sexual Functioning Questionnaire entered this study.

RESULTS

Moderate levels of subjective satisfaction with sleep and low levels of insomnia and hypersomnia were observed. However, women suffer more from these forms of sleep disorders. Subjective satisfaction with sleep quality is positively correlated with overall sexual functioning and all of its dimensions, and insomnia is negatively correlated with sexual functioning and all of its dimensions. From the linear regression analysis, the model of prediction of general sexual functioning was tested according to sleep quality variables, and a statistically significant model was obtained (p <0.001), with the variables in question explaining 7% of general sexual functioning, with β values ??for subjective satisfaction with sleep of 0.189 and for insomnia of -0.140.

DISCUSSION

Based on the results obtained, it is possible to demonstrate that the higher the quality of sleep, the greater the sexual functioning, and that it is negatively influenced mainly by insomnia.

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

Background

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

Case presentations

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

Conclusions

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

Sleep as a Therapeutic Target in the Aging Brain

Sleep is a behavioral phenomenon conserved among mammals and some invertebrates, yet the biological functions of sleep are still being elucidated. In humans, sleep time becomes shorter, more fragmented, and of poorer quality with advancing age. Epidemiologically, the development of age-related neurodegenerative diseases such as Alzheimer's and Parkinson's disease is associated with pronounced sleep disruption, whereas emerging mechanistic studies suggest that sleep disruption may be causally linked to neurodegenerative pathology, suggesting that sleep may represent a key therapeutic target in the prevention of these conditions. In this review, we discuss the physiology of sleep, the pathophysiology of neurodegenerative disease, and the current literature supporting the relationship between sleep, aging, and neurodegenerative disease.

Role of Obstructive Sleep Apnea in Cognitive Impairment

Obstructive sleep apnea (OSA) is a prevalent sleep related breathing disorder characterized by repetitive collapse of the upper airways leading to intermittent hypoxia and sleep disruption. Clinically relevant neurocognitive, metabolic and cardiovascular disease often occurs in OSA. Systemic hypertension, coronary artery disease, type 2 diabetes mellitus, cerebral vascular infarctions and atrial fibrillation are among the most often cited conditions with causal connections to OSA. Emerging science suggest that untreated and undertreated OSA increases the risk of developing cognitive impairment, including vascular dementia and neurodegenerative disorders, like Alzheimer’s disease. As with OSA, cardiovascular disease and type 2 diabetes mellitus, the incidence of dementia increases with age. Given our rapidly aging population, dementia prevalence will significantly increase. The aim of this treatise is to review current literature linking OSA to dementia and explore putative mechanisms by which OSA might facilitate the development and progression of dementia.

Effects of continuous positive airway pressure on depression and anxiety symptoms in patients with obstructive sleep apnoea: results from the sleep apnoea cardiovascular Endpoint randomised trial and meta-analysis

BACKGROUND

Whether continuous positive airway pressure (CPAP) treatment can improve depression or anxiety symptoms in obstructive sleep apnoea (OSA) patients remains uncertain.

METHODS

Secondary analysis of the Sleep Apnea Cardiovascular Endpoints (SAVE) trial, combined with a systematic review of randomised evidence. The SAVE secondary analyses involved 2410 patients with co-existing moderate-severe OSA and established cardiovascular disease randomly allocated to CPAP treatment plus usual care or usual care alone and followed up for 3·7 (SD 1·6) years. We evaluated the effect of CPAP treatment on depression and anxiety caseness (scores ≥ 8 on the Hospital Anxiety and Depression Scale depression and anxiety subscales [HADS-D and HADS-A]) for OSA patients.

FINDINGS

CPAP treatment was associated with reduced odds of depression caseness (adjusted odds ratio [OR] 0·80, 95% confidence interval [CI] 0·65-0·98, P = 0·031) compared to usual care in the SAVE trial and the treatment effect was greater in those with pre-existing depression symptoms. A systematic review of 20 randomised trials including 4255 participants confirmed a benefit of CPAP in reducing depression symptoms in OSA patients: the overall effect (standardised mean difference) was - 0·18 (95% CI - 0·24 to - 0·12). No effect of CPAP treatment on anxiety caseness was found both in patients of the SAVE study (adjusted OR 0·98, 95% CI 0·78-1·24, P = 0·89) and the systematic review.

INTERPRETATION

CPAP reduces depression symptoms in patients with co-existing OSA and CVD independently of improvements in sleepiness.

Comparison of Psychiatric Symptoms in Patients With Obstructive Sleep Apnea, Simple Snoring, and Normal Controls

OBJECTIVE

Patients with sleep-related breathing disorders are known to have more severe psychiatric symptoms than good sleepers. The aim of this study was to compare the psychiatric symptoms of participants with obstructive sleep apnea (OSA), those with simple snoring (SS), and normal controls (NC).

METHODS

A total of 386 participants (260 with OSA, 75 with SS, and 51 NC) completed self-report questionnaires including the Symptoms Checklist 90-Revised and underwent nocturnal polysomnography. The scores of nine primary symptom dimensions and three global distress indices of the Symptoms Checklist 90-Revised were compared among the three groups, adjusting for age, sex, and body mass index.

RESULTS

Participants with suspected OSA (OSA + SS) reported more severe psychiatric symptoms than the NC group. Compared with the participants with OSA, those with SS manifested more severe obsessive-compulsive (1.4 (1.0) versus 1.1 (0.7), p = .008) and depressive (1.2 (1.2) versus 0.8 (0.8), p = .031) symptoms and higher Global Severity Index (1.0 (0.9) versus 0.7 (0.6), p = .039) and Positive Symptom Distress Index (2.0 (0.8) versus 1.7 (0.6), p = .009). Only higher Pittsburgh Sleep Quality Index values predicted higher Global Severity Index (B = 0.11, p = .041) and Positive Symptom Distress Index (B = 0.46, p = .007) in suspected OSA participants.

CONCLUSIONS

This study found that individuals with suspected OSA experienced more severe psychiatric symptoms than NCs and that psychiatric symptoms were more severe in the SS group than in the OSA group. The psychiatric symptoms of suspected OSA patients were associated with subjective sleep quality rather than with the apnea-hypopnea index.