Predictors of Suicidal Ideation in People with Epilepsy Living in Korea

Background and Purpose

The risk of suicide or suicide attempts is reported higher in people with epilepsy (PWE) than in the general population. Although epileptic, psychiatric, and psychosocial factors are known risk factors for suicide or suicide attempt, no studies have evaluated the predictors of the severity of suicidal ideation-which is a warning sign for suicide attempts-in PWE. Therefore, we measured the severity of suicidal ideation and its risk factors.

Methods

Consecutive PWE who were medicated with antiepileptic drugs (AEDs) and attended epilepsy clinic were included in the study. The subjects completed self-reported questionnaires, which included the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Symptom Checklist-90-Revised (SCL-90-R), and Scale for Suicide Ideation-Beck (SSI-Beck). We compared the patients'' demographic and clinical variables, and BDI, BAI, and SCL-90-R scores with their SSI-Beck score, and used our findings to determine the predictors for suicidal ideation.

Results

In total, 257 PWE were enrolled in the study. SSI-Beck scores correlated strongly with several seizure-related variables, duration of education, IQ, BDI and BAI scores, and nine domains of the SCL-90-R questionnaire. However, the strongest predictor for suicidal ideation was BDI score (β=0.41, p<0.001), followed by several SCL-90-R domains, such as obsessive-compulsive (β=-0.39, p<0.001), depression (β=0.38, p<0.001), hostility (β=0.22, p=0.002), paranoid ideation (β=0.17, p=0.01), and IQ (β=-0.10, p=0.017). These variables explained 59% of the variance in the SSI-Beck score. The seizure-related variables that influenced the BDI score were seizure frequency, duration of education, MRI abnormality, and number of AEDs. However, these variables explained only 18% of the variance in the BDI score.

Conclusions

Major risk factors for suicidal ideation in PWE were depressive and psychiatric symptoms rather than seizure-related variables. Therefore, clinicians should focus on screening for depression and other psychiatric problems and treat them appropriately in order to reduce suicidal behavior in PWE. Since seizure-related variables also exhibited a minor role in determining depressive symptoms, stronger seizure-related risk factors for depression should be sought, such as seizure severity or psychosocial factors, to minimize suicidal behavior.     

Effect of CPAP treatment on residual depressive symptoms in patients with major depression and coexisting sleep apnea: Contribution of daytime sleepiness to residual depressive symptoms

BackgroundAlthough extensive studies have indicated a relationship between obstructive sleep apnea (OSA) and depressive symptoms, the effect of continuous positive airway pressure (CPAP) treatment on residual depressive symptoms in patients with both major depressive disorder (MDD) and coexisting OSA has not been examined.MethodsSeventeen patients with continued MDD despite pharmacotherapy such as antidepressants and/or benzodiazepines, who also had comorbid OSA, were required to complete the Beck Depression Inventory (BDI), Hamilton Rating Scale for Depression (HRSD), and Epworth sleepiness scale (ESS) at the commencement of the study and then again after 2 months of CPAP treatment.ResultsBDI and HRSD scores decreased from 19.7 to 10.8 and 16.7 to 8.0 after 2 months of CPAP treatment (both p < 0.01). We also found significant correlations among the improvement rates in BDI, HRSD and ESS scores (R = 0.86 and 0.75, both p < 0.01). The mixed effect model demonstrated a significant ESS effect on BDI and HRSD.ConclusionsThe results suggest that MDD patients with residual depressive symptoms despite pharmacotherapy who also have symptoms of suspected OSA, such as loud snoring, obesity, and daytime sleepiness, should be evaluated for sleep apnea by polysomnography and treated with an appropriate treatment such as CPAP. CPAP treatment may result in a significant improvement of residual depressive symptoms due to the improvement of daytime sleepiness in these patients.     

QT interval variability index and QT interval duration during different sleep stages in patients with obstructive sleep apnea

ObjectivesThe aim of the study was to investigate the impact of obstructive sleep apnea (OSA) on the QT interval variability and duration in patients during different sleep stages.MethodsPolysomnographic recordings of 28 (13 male, 15 female) patients with OSA and 30 (15 male, 15 female) patients without OSA were analyzed. The QT interval variability index (QTVI) and the corrected QT interval (QTc) analyses were performed using two awake, 3–4 non-rapid eye movement (NREM) and three rapid eye movement (REM) sleep episodes (each 300 s). The Bazett formula, linear, and parabolic heart rate correction formulas with two separate α values were used.ResultsQTVI was statistically higher in OSA than in non-OSA patients for males while awake (awake −0.7 ± 0.3 vs −1.2 ± 0.2, p = 0.001; NREM ‒0.9 ± 0.4 vs −1.1 ± 0.3, p = 0.110; REM ‒1.1 ± 0.3 vs −1.3 ± 0.2, p = 0.667) and for females in all wake–sleep stages (awake −0.3 ± 0.7 vs −0.9 ± 0.5, p = 0.001; NREM ‒0.3 ± 0.5 vs −0.8 ± 0.4, p = 0.002; REM −0.3 ± 0.5 vs −1.0 ± 0.4, p < 0.001). QTVI was significantly higher during awake compared to sleep stages in OSA males (p < 0.05); no difference between wake–sleep stages was found in females (p > 0.05). Significant gender differences in QTVI existed in OSA patients during sleep (p < 0.05) but not while awake. No significant differences in QTc between patients groups were observed.ConclusionsOSA is associated with increased QT variability. REM sleep per se does not increase QTVI. In OSA patients, QTVI might be a more useful measure to detect ventricular repolarization abnormality than measures of QTc.     

Total durations of respiratory events are modulated within REM and NREM sleep by sleeping position and obesity in OSA patients

BackgroundSupine sleeping position and obesity are well-known risk factors for obstructive sleep apnea (OSA) and modulate the risk for OSA-related daytime symptoms. Although respiratory event durations are associated with OSA-related severe health consequences, it is unclear how sleeping position, obesity, and daytime sleepiness are associated with respiratory event durations during REM and NREM sleep. We hypothesize that irrespective of the apnea-hypopnea index (AHI), respiratory event durations differ significantly between various OSA subgroups during REM and NREM sleep.MethodsOne night in-lab polysomnographic recordings were retrospectively analyzed from 1910 untreated suspected OSA patients. 599 patients (AHI ≥ 5) were included in study and divided into subgroups based on positional dependency, BMI, and daytime sleepiness (Epworth Sleepiness Scale and Multiple Sleep Latency Test). Differences in total hypopnea time (THT), total apnea time (TAT), and total apnea-hypopnea time (TAHT) within REM and NREM sleep between the subgroups were evaluated.ResultsDuring REM sleep, positional OSA patients had lower THT (OR = 0.952, p < 0.001) and TAHT (OR = 0.943, p < 0.001) than their non-positional counterparts. Compared to normal-weight patients (BMI < 25 kg/m²), obese patients (BMI ≥ 30 kg/m²) had lower THT, TAT, and TAHT (ORs = 0.942–0.971, p ≤ 0.009) during NREM sleep but higher THT (OR = 1.057, p = 0.001) and TAHT (OR = 1.052, p = 0.001) during REM sleep. No significant differences were observed in THT, TAT, and TAHT between patients with and without daytime sleepiness.ConclusionRegardless of the AHI, respiratory event durations vary significantly between OSA sub-groups during REM and NREM sleep. Therefore, to personalize OSA severity estimation the diagnosis should be tailored based on patient's demographics, clinical phenotype, and PSG characteristics.     

The effects of brain wave vibration on oxidative stress response and psychological symptoms

ObjectiveBrain Wave Vibration (BWV) training is a simple healing practice, a kind of Mind Body Training. This study was designed to investigate the psycho-endocrine differences between BMV practitioners and naïve controls.MethodsThe experimental group included 54 individuals who had participated in BWV. The control group included 58 subjects who had not participated in formal BWV. Levels of plasma NO, reactive oxygen species (ROS), and superoxide dismutase (SOD) were measured, and the modified form of the Stress Response Inventory (SRI-MF), the Positive Affect and Negative Affect Scale (PANAS), the Beck Depression Inventory (BDI), and the Beck Anxiety Inventory (BAI) were administered.ResultsThe BWV group demonstrated significantly higher plasma NO levels (p=0.003), and levels of ROS and SOD did not differ between the two groups. The BWV group showed lower scores in BDI (p=0.009), BAI (p=0.009) and stress level (p<0.001) and higher scores on positive affect (p=0.023) compared with the control group. NO levels were associated with increased positive affect (p = 0.024) only in BWV subjects.ConclusionBWV may increase NO, a relaxation-related factor, possibly by improving emotional state.     

Different scoring rules for respiratory event-related leg movements: effects on the prevalence of periodic limb movements during sleep and their association with depressive symptoms in patients with obstructive sleep apnea

BackgroundWe compared the prevalence of periodic leg movements during sleep (PLMS) according to two different scoring rules of the American Academy of Sleep Medicine (AASM) 2012 and World Association of Sleep Medicine (WASM) 2016 and determined their association with depressed mood in patients with obstructive sleep apnea (OSA).MethodsPLMS, defined as a periodic leg movements index of >15, were diagnosed on a diagnostic and continuous positive airway pressure (CPAP) titration polysomnography using the AASM 2012 and WASM 2016 rules. The Beck Depression Inventory (BDI) and Epworth Sleepiness Scale (ESS) were used, and multiple regression analyses were performed.ResultsAmong 160 OSA patients, the proportion with PLMS scored by the WASM 2016 criteria was significantly higher than that scored by the AASM 2012 criteria in a diagnostic study (20.6% vs. 16.3%, respectively; P = 0.016) but not in CPAP titration study and only in patients with severe OSA. In adjusted models, PLMS were positively associated with BDI scores and a BDI of ≥10 on both diagnostic and CPAP titration studies when scored by the WASM 2016. By contrast, when scored by the AASM 2012, PLMS were associated with BDI scores (but not BDI of ≥10) only in a CPAP titration study.ConclusionsThere are significant differences in the prevalence of PLMS and their association with depressed mood depending on the scoring rules in patients with OSA. The current AASM scoring criteria underestimate the prevalence of PLMS, and PLMS are more likely associated with depressed mood according to the WASM scoring criteria.     

Moderate-to-severe obstructive sleep apnea is associated with subclinical myocardial injury and impaired hemodynamics in pulmonary hypertension patients

BackgroundThe clinical significance of obstructive sleep apnea (OSA) in pulmonary hypertension (PH) patients remains unclear. We investigated the hemodynamics and serum troponin T concentrations associated with OSA in PH patients.MethodsCross-sectional study was performed on data from 97 clinically stable PH patients. Using overnight sleep study, we evaluated apnea–hypopnea index (AHI) and divided patients into two groups: none-to-mild OSA (AHI < 15/h, N = 81) and moderate-to-severe OSA (AHI ≥ 15/h, N = 16). Clinical, hemodynamic, and laboratory data were compared with OSA severity.ResultsModerate-to-severe OSA patients had higher pulmonary vascular resistance (PVR; 6.5 [5.7–12.9] vs 4.4 [2.9–6.4] Wood units, p = 0.001) and mean pulmonary artery pressure (mPAP; 37 [30–49] vs 30 [22–37] mmHg, p = 0.045), and a lower cardiac index (2.2 [1.6–2.6] vs 2.8 [2.3–3.5] L/min/m², p = 0.001) than those without. There was no association between plasma B-type natriuretic peptide (BNP) or serum C-reactive protein levels and OSA. However, high-sensitivity troponin T (hs-TnT) level was significantly higher in moderate-to-severe OSA patients (13 [8–18] vs 6 [4–10] ng/L, p <0.001). The hs-TnT level positively correlated with the plasma BNP level, mPAP, PVR, AHI, obstructive apnea index, and 6-min walking distance. After adjustment for age, estimated glomerular filtration rate, hypertension, smoking, and plasma BNP level, moderate-to-severe OSA was an independent factor for determining the plasma level of log hs-TnT level (β = 0.419, 95% confidence interval 0.119–0.718, p = 0.007).ConclusionsModerate-to-severe OSA is associated with impaired hemodynamics and subclinical myocardial damage in PH patients. Thus, OSA-related myocardial injury may play a role in hemodynamic destabilization with its associated poor prognosis.     

Sex differences within symptom subtypes of mild obstructive sleep apnea

ObjectivesPrior studies have identified symptom subtypes of moderate to severe (AHI >15) obstructive sleep apnea (OSA). They have not yet been consistently examined in those with mild OSA (AHI 5–15 events/hour). This is important as women are more likely than men to present with mild OSA and may present with different OSA symptoms. The objectives of this study were to determine 1) symptom subtypes in mild OSA and 2) if there are sex differences in the distribution of subtypes.MethodsThe sample included men (n = 921) and women (n = 797) with mild OSA, aged 39–90 years, evaluated with a single night of in–home polysomnography as part of the Sleep Heart Health Study. Latent class analysis determined symptom subtypes. Testing for sex differences relative to OSA severity and symptom subtype used chi-squared test for independence. Bonferroni corrected z-tests compared column proportions.ResultsSymptom subtypes of mild OSA were not significantly different than those identified in prior studies of moderate-severe OSA (p > 0.05): minimally symptomatic (36.4%), disturbed sleep (11.6%), moderately sleepy (37%), and excessively sleepy (15%), p > 0.05. Sex differences within the symptom subtypes were significant [χ²(df = 3) = 30.04, p < 0.001, Cramer's V = 0.132]. Relative to men, women were more likely to be in the disturbed sleep subtype (p < 0.05), and the excessively sleepy subtype (p < 0.05) while less likely to be in the moderately sleep (<0.05) subtype. Women and men were equally represented in the minimal symptoms subtype (p > 0.05).ConclusionsResults suggest symptom reporting among individuals with mild OSA differs as a function of sex. These data have important clinical implications for screening men and women for OSA.     

The validity of self-rated psychotic symptoms in depressed inpatients

BackgroundSelf-ratings of psychotic experiences might be biased by depressive symptoms.MethodData from a large naturalistic multicentre trial on depressed inpatients (n = 488) who were assessed on a biweekly basis until discharge were analyzed. Self-rated psychotic symptoms as assessed with the 90-Item Symptom Checklist (SCL-90) were correlated with the SCL-90 total score, the SCL-90 depression score, the Beck Depression Inventory (BDI), the Hamilton Depression Rating Scale 21 item (HAMD-21) total score, the Montgomery Åsberg Depression Rating Scale (MADRS) total score and the clinician-rated paranoid-hallucinatory score of the Association for Methodology and Documentation in Psychiatry (AMDP) scale.ResultsAt discharge the SCL-90 psychosis score correlated highest with the SCL-90 depression score (0.78, P < 0.001) and with the BDI total score (0.64, P < 0.001). Moderate correlations were found for the MADRS (0.34, P < 0.001), HAMD (0.37, P < 0.001) and AMDP depression score (0.33, P < 0.001). Only a weak correlation was found between the SCL-90 psychosis score and the AMDP paranoid-hallucinatory syndrome score (0.15, P < 0.001). Linear regression showed that change in self-rated psychotic symptoms over the treatment course was best explained by a change in the SCL-90 depression score (P < 0.001). The change in clinician-rated AMDP paranoid-hallucinatory score had lesser influence (P = 0.02).ConclusionsIn depressed patients self-rated psychotic symptoms correlate poorly with clinician-rated psychotic symptoms. Caution is warranted when interpreting results from epidemiological surveys using self-rated psychotic symptom questionnaires as indicators of psychotic symptoms. Depressive symptoms which are highly prevalent in the general population might influence such self-ratings.     

Obstructive sleep apnoea in adult patients post-tonsillectomy

BackgroundThe impact of removing the upper airway lymphoid tissue and in particular, tonsillectomy, in adults with OSA has not been demonstrated in large populations.AimsTo compare the severity of OSA and the prevalence of cardiovascular, metabolic and respiratory co-morbidities between patients with OSA who had undergone previous tonsillectomy and those who had not.MethodsThe 19,711 participants in this study came from the European sleep apnea database (ESADA) which comprises data from unselected adult patients aged 18–80 years with a history of symptoms suggestive of OSA referred to sleep centers throughout Europe.ResultsThere were no differences between the two groups in terms of sex ratio and age (146 patients with previous tonsillectomy vs. 19565 patients without). Patients who had undergone tonsillectomy had a lower body mass index (29.3 ± 5.2 kg/m² vs 32.2 ± 6.6 kg/m², p < 0.001), lower subjective sleep latency (17.1 ± 17.8 min vs 25.5 ± 30.4 min, p = 0.001), lower ODI (15.7 ± 18.3 events/hour vs 30.7 ± 26.1 events/hour, p < 0.001), and SpO₂<90% time during sleep (21.8 ± 47.5 min vs 52.6 ± 80.8 min, p < 0.001). OSA patients with tonsillectomy had a lower prevalence of Type II diabetes mellitus (p = 0.001), hypertension (p < 0.001) and a higher prevalence of hyperlipidemia (p < 0.001) and were less likely to be commenced on CPAP (p < 0.001).ConclusionIn a large population of almost 20,000 OSA patients from across Europe, patients who had undergone tonsillectomy presented with less severe OSA at time of diagnosis, and had a lower prevalence of Type II diabetes mellitus and cardiovascular co-morbidities.     

Psychometric properties of the Parkinson's Disease Sleep Scale – Brazilian version

Parkinson's Disease Sleep Scale (PDSS) is a specific scale for the assessment of sleep disturbances in subjects with Parkinson's Disease (PD). This cross-sectional study set out to validate the PDSS in a Brazilian Portuguese Version (PDSS-BR). Ninety-five patients with PD participated in the study; their PD symptoms were evaluated by Unified Parkinson's Disease Rating Scale (UPDRS sections I–IV) and Hoehn and Yahr scale. Patients completed Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Beck Depression Inventory (BDI) and PDSS-BR. PDSS-BR internal consistency was satisfactory (Cronbach's α: 0.82; all PDSS-BR items were significantly and positively associated with total score). Test–retest reliability for total PDSS-BR score was 0.94. PDSS-BR score was highly correlated with sleep PSQI scale (r_s = ?0.63; p < 0.0001) and moderately with ESS (r_s = ?0.32; p < 0.001) and UPDRS sections I (r_s = ?0.38; p < 0.0001) and II (r_s = ?0.36; p < 0.0001) and BDI (r_s = ?0.55; p < 0.0001). Depressive symptoms, as determined by the BDI, were associated with significantly worse quality of nocturnal sleep, as measured by the PDSS-BR.The psychometric attributes of the PDSS-BR were satisfactory and consistent with those of previous studies. In summary, PDSS-BR can be useful for clinical and research purposes in Brazil.     

A randomized,controlled trial of positional therapy versus oral appliance therapy for position-dependent sleep apnea

ObjectiveTo compare the effectiveness of positional therapy (PT) with the sleep position trainer (SPT) to oral appliance therapy (OAT) in patients with mild-to-moderate positional obstructive sleep apnea (POSA).MethodsMulticenter, prospective, randomized, controlled trial. Patients with mild-to-moderate POSA (apnea-hypopnea index (AHI) ≥5 ≤ 30/hour sleep) were randomized for PT or OAT. Polysomnography was repeated after 3 months. Efficacy, adherence, mean disease alleviation (MDA), quality of life, dropouts and adverse events were evaluated.ResultsA total of 177 patients were screened for the study; 99 underwent randomization and 81 completed the study. Intention-to-treat (ITT) analysis of median [IQR] AHI showed a reduction in the PT group from 13.0 [9.7–18.5] to 7.0 [3.8–12.8], p < 0.001 and in the OAT group from 11.7 [9.0–16.2] to 9.1 [4.9–11.7], p < 0.001. Mean adherence (≥4 h/night, ≥5 days/week) was 89.3 ± 22.4% for SPT versus 81.3 ± 30.0% in OAT patients, p = 0.208.ConclusionsOral appliance therapy and positional therapy were equally effective in reducing the median AHI in patients with mild-to-moderate POSA. The results of this study have important implications for future OSA treatment guidelines and daily clinical practice.ClinicalTrials.gov numberNCT02045576.     

Sex Differences in Excessive Daytime Sleepiness Among Patients With Obstructive Sleep Apnea

Background and PurposeTo identify sex differences in daytime sleepiness associated with apnea severity and periodic limb movements during sleep (PLMS) in subjects with obstructive sleep apnea (OSA).MethodsThis study used the Epworth Sleepiness Scale (ESS), Beck Depression Inventory (BDI), and Sleep Hygiene Index (SHI) in logistic regression analyses with interaction terms. Severe OSA, excessive daytime sleepiness (EDS), and PLMS were defined as an apnea-hypopnea index of ≥30, an ESS score of ≥11, and a periodic limb movements index of >15, respectively.ResultsThe 1,624 subjects with OSA (males, 79.1%) comprised 45.3%, 38.2%, and 16.4% with severe OSA, EDS, and PLMS, respectively. Multiple logistic regression without interaction terms showed that sex, severe OSA, and PLMS were not significantly associated with EDS. However, significant interactions were noted between sex and severe OSA and PLMS in EDS in both crude and adjusted models (all p values<0.05). In the adjusted model, severe OSA was associated with EDS in males (p=0.009) but not in females. PLMS were more likely to be associated with EDS in females (p=0.013), whereas PLMS were less likely to be associated with EDS in males (p=0.041). The models were adjusted by the BDI score, SHI, and presence of medical comorbidities.ConclusionsThere are significant sex differences in subjective daytime sleepiness in subjects with severe OSA and PLMS. Severe OSA and PLMS may influence daytime sleepiness more in males and females, respectively.     

Psychopathologic correlates of adult sleepwalking

ObjectivesSleepwalking (SW) often has been associated with psychopathology, but the nature and magnitude of this relation remains unclear. The aim of our study was to investigate the presence of psychopathology in a large cohort of sleepwalkers and to determine if levels of psychopathology showed differential relations to specific characteristics of the disorder, including clinical history.MethodsOne-hundred and five sleepwalkers (39 men, 66 women; mean age, 32.4 ± 9.5 years) referred to our sleep disorders clinic for chronic SW underwent a comprehensive clinical investigation that included an overnight polysomnography (PSG) assessment in 90% of cases. All participants also completed a series of questionnaires, including the Beck Depression Inventory, Second Revision (BDI-II), the Beck Anxiety Inventory (BAI), and the Symptom Checklist 90-Revised (SCL-90-R).ResultsThe proportion of sleepwalkers who scored above the minimal clinical threshold on the BDI-II, BAI, and SCL-90-R was 27%, 40%, and 28%, respectively. Only 15% of sleepwalkers showed moderate to severe symptoms on the BDI-II and 19% on the BAI. Taken as a whole, these profiles are similar to those observed in the general adult population. The presence of psychopathology in sleepwalkers was associated with a negative family history for SW, a higher frequency of nightmares, and with potentially injurious behaviors enacted during somnambulistic episodes.ConclusionsA majority of adult sleepwalkers consulting for the disorder do not report clinically significant levels of depression or anxiety. Overall, sleepwalkers with and without psychopathology appear more similar than dissimilar.     

Seasonal effects on the continuous positive airway pressure adherence of patients with obstructive sleep apnea

ObjectiveThis study examined seasonal differences in continuous positive airway pressure (CPAP) therapy adherence among patients with obstructive sleep apnea (OSA).MethodsPatients aged ≥20 years with OSA who had used CPAP devices on the automatic setting for >12 consecutive months (n = 141) were included in this retrospective study from December 2015–2016. The information of CPAP use (pressure, hours of actual use) was extracted from database downloaded from patients’ CPAP devices. Patients were divided into adherent and non-adherent groups using the cutoff point of 70% CPAP use for ≥4 h daily over the 1-year study period. CPAP use data were averaged for each season.ResultsPatients in the adherent group were significantly older than those in the non-adherent group (p < 0.001). In the adherent group, the rate of ≥4 h daily CPAP use was significantly lower, the daily duration of CPAP use was significantly shorter, and the residual apnea–hypopnea index (AHI; events/hour) was significantly higher in summer than in other seasons (all p < 0.001). In the non-adherent group, the duration of daily CPAP use and the AHI differed significantly between winter and summer (p = 0.008 and p < 0.001, respectively).ConclusionsSeasonal changes were associated with the CPAP adherence of patients with OSA. The study findings suggest that there is possibility of increasing the duration of CPAP use by adjusting the bedroom environment in hot and humid seasons.     

Association between respiratory events and nocturnal gastroesophageal reflux events in patients with coexisting obstructive sleep apnea and gastroesophageal reflux disease

BackgroundLiterature has addressed the increased prevalence of gastroesophageal reflux disease (GERD) in obstructive sleep apnea (OSA). Significant improvement of GERD has been found after OSA treatment. However, precise mechanisms underlying this correlation remain unclear. We examined the association between nocturnal gastroesophageal reflux (GER) and sleep events in patients with coexisting OSA and GERD.MethodsA case-crossover study among 12 patients with coexisting moderate–severe OSA and GERD was conducted. Participants underwent simultaneous polysomnography and esophageal impedance and pH monitoring. GER subtypes (ie, acid reflux, non-acid reflux) were defined as outcomes. Respective control time points were selected in all eligible control periods. Each sleep event was assessed individually. Estimated odds ratios (ORs) and 95% confidence intervals (CIs) were analyzed. A p-value of < 0.05 was considered significant.ResultsPatients were determined as moderate to severe OSA (respiratory disturbance index of 42.66 [±22.09]). There were a total of 50 GER episodes, 22 acid reflux and 28 non-acid reflux. Arousals and awakenings were significantly associated with subsequent GER events. The OR for GER following an arousal was 2.31 (95% CI 1.39–3.68; p < 0.001) and following an awakening was 3.71 (95% CI 1.81–7.63; p < 0.001). GER events were significantly less likely to occur after other respiratory events (OR 0.38 [95% CI 0.18–0.82]; p = 0.01). No sleep events followed GER events (p > 0.05).ConclusionsBoth awakening and arousal appear to precipitate any subtype of GER events in patients with coexisting GERD and moderate to severe OSA. However, GER events were significantly less likely to occur after other respiratory events and did not appear to cause sleep-related events.     

Dexmedetomidine-induced polysomnography as a diagnostic method in obstructive sleep apnea: a reliable alternative method?

BackgroundUnder-diagnosis of obstructive sleep apnea (OSA) is common because of the demanding and time-consuming nature of polysomnography (PSG). Herein, we assessed the utility of a short daytime dexmedetomidine-induced PSG for diagnosis of OSA in adults.MethodsThis was a single-center, prospective, diagnostic trial. We evaluated 86 patients using a full overnight PSG and a short diurnal drug-induced PSG (DIPSG). DIPSG was induced by continuous intravenous dexmedetomidine infusion. Sedation depth was monitored and maintained using the Narcotrend index (50–70). Diagnostic performance for DIPSG with different apnea-hypopnea index (AHI) cut-off values were calculated. Bland–Altman plots used for analysis. Sleep architecture and position were compared.ResultsWe studied 47 OSA patients and 39 healthy volunteers. Sensitivity and specificity for detection of OSA by DIPSG were 92% and 79%, respectively, for an AHI cut-off value of 5, 90% and 77%, respectively, for an AHI cut-off value of 15, and 95% and 85%, respectively, for an AHI cut-off value of 30. The DIPSG bias was −5 (−25; 15) for AHI and −3 (−13; 7) for minimal oxygen saturation. N2 sleep was increased (32.9% vs. 50.75%, respectively; p < 0.01) and REM sleep was decreased (21.35% vs. 1.24%, respectively; p < 0.01) during DIPSG. Twenty-eight (33%) participants had postural shifts during DIPSG. No significant adverse events were observed during DIPSG.ConclusionsDexmedetomidine-induced PSG had a good sensitivity and specificity, and can be used as a screening tool for diagnosis of OSA in adults.Chinese Clinical Trial RegistrationChiCTR1900024044.     

Associations between nocturnal continuous blood pressure fluctuations and the characteristics of oxygen desaturation in patients with obstructive sleep apnea: a pilot study

BackgroundPatients with obstructive sleep apnea (OSA) frequently experience apnea-related oxygen desaturation events (ODE) accompanied by striking blood pressure (BP) fluctuations during sleep. We aimed to investigate the effects of characteristics of ODE on nocturnal BP fluctuations in OSA patients.Methods and resultsA total of 6199 ODE were obtained from 30 patients with who underwent overnight portable monitoring and beat-to-beat BP monitoring simultaneously. The associations between nocturnal BP parameters and the characteristics of ODE were studied. The mean value of systolic BP (SBP) monitored during ODE was higher than the non-hypoxia SBP value (122.0 ± 15.9 vs. 120.4 ± 15.1 mmHg, P = 0.001) and nighttime SBP value (122.0 ± 15.9 vs. 120.8 ± 15.0 mmHg, P = 0.002). SBP variability (SBPV) during ODE was higher than the values not during ODE (14.0 ± 2.8 vs. 13.2 ± 2.6 mmHg, P = 0.043) and nighttime SBPV (14.0 ± 2.8 vs. 12.9 ± 2.3 mmHg, P < 0.001). Hypoxia SBP index, defined as the percentage of SBP surge (△SBP) ≥10 mmHg to all △SBP during ODE, increased with greater respiratory event index (P = 0.01). Both the coefficient of variation for SBP values of an ODE (SBPV′) and event-related SBP elevation (△SBP′) increased with raised amplitude of ODE (P < 0.001 for SBPV′ and P < 0.001 for △SBP′). Similar results were observed when the duration of events was analyzed (P < 0.001 for SBPV′ and P < 0.001 for △SBP′).ConclusionBP related to ODE may be the main component of increased BP during sleep in OSA patients. In addition to the frequency of respiratory events, the amplitude and duration of ODE may have a role in nocturnal BP fluctuations in OSA patients.     

The relationship between weight change and daytime sleepiness: the Sleep Heart Health Study

ObjectiveThrough a causal framework, we aim to assess the association between weight change and daytime sleepiness, and the role of obstructive sleep apnoea (OSA) in this relationship.MethodsFrom the Sleep Heart Health Study, we selected individuals who were: (1) 40–64 years old, with (2) body mass index (BMI) ≥18.5 kg/m², (3) no history of stroke, treatment for OSA, and tracheostomy at baseline. We used multiple linear regression to assess the relationship between five-year weight change and daytime sleepiness (assessed through Epworth Sleepiness Scale (ESS)) at five years, adjusting for daytime sleepiness, demographics, diabetes, subjective sleep duration, sleep disturbance, smoking status, weight, and use of antidepressants and benzodiazepines at baseline, in those with complete data (N = 1468). We further assessed the potential mediating role of OSA in this relationship.ResultsAt baseline, the study participants were on average 55 years old, 46% males, with mean BMI 28 kg/m²; and 25% had ESS>10. ESS at five years worsened by 0.36 units (95% confidence interval (CI) 0.12–0.61, p = 0.004) with every 10-kg weight gain. When stratified by sex, this relationship was only found in women (0.55, 95% CI 0.25–0.86, p < 0.001; p-interaction = 0.02). Approximately one-fifth of the relationship between weight change and daytime sleepiness was mediated by severity of OSA at five years.ConclusionWeight gain has a detrimental effect on daytime sleepiness, mostly through pathways other than OSA. This study provides further evidence and understanding of the relationship between obesity and excessive daytime sleepiness.     

Predictors and patterns of insomnia symptoms in OSA before and after PAP therapy

ObjectiveIdentify factors that predict improvement versus persistence of insomnia symptoms following treatment of obstructive sleep apnea (OSA) with positive airway pressure (PAP) therapy.MethodsArchival data from 68 PAP-treated sleep apnea patients aged 25–83 were analyzed using nonparametric tests and stepwise regression to assess the relationships between insomnia symptoms, multiple OSA variables, and PAP use over time.ResultsPretreatment insomnia symptom severity (ISS; b = −0.72, p < 0.001), PAP average use (b = −0.01, p = 0.01) and respiratory disturbance index (RDI; b = −0.02, p = 0.03) predict change in insomnia following PAP therapy. Forty-five percent (24/53) of the subjects with moderate to severe insomnia at pretreatment reported no/mild symptoms after PAP therapy and were considered improved. Improved subjects had lower pretreatment ISS (p < 0.001), higher RDI (p = 0.01), and higher average PAP use (p < 0.035) than subjects with persistent insomnia. Number of medications and comorbidities were similar between improved and persistent groups. New onset of insomnia symptoms occurred in 13% (2/15) of the patients with no/mild pretreatment insomnia.ConclusionsAlthough ISS declines following PAP treatment, 55% of OSA patients have persistent moderate to severe symptoms despite treatment. More severe OSA is linked to higher likelihood of insomnia improvement and the effect of PAP therapy on insomnia may be mediated by OSA severity. Persistent insomnia is unrelated to medication use or comorbidities and may represent an independent, self-sustaining disorder requiring targeted intervention.