Placebo-controlled comparison of prazosin and cognitive-behavioral treatments for sleep disturbances in US Military Veterans

ObjectivePharmacological and cognitive-behavioral treatments targeting insomnia and nightmares have been shown to be effective in the treatment of military veterans with sleep complaints comorbid with symptoms of stress-related disorders, including Post-Traumatic Stress Disorder (PTSD), but the two approaches have not been directly compared. This randomized controlled trial compared the effects of prazosin vs. a behavioral sleep intervention (BSI), targeting nightmares and insomnia against a placebo pill control condition on sleep and daytime symptoms.MethodsFifty United States military veterans (mean age 40.9 years, SD = 13.2 years) with chronic sleep disturbances were randomized to prazosin (n = 18), BSI (n = 17), or placebo (n = 15). Each intervention lasted 8 weeks. Participants completed self-report measures of insomnia severity, sleep quality, and sleep disturbances. All kept a sleep diary throughout the intervention period. Polysomnographic studies were conducted pre- and post-intervention.ResultsBoth active treatment groups showed greater reductions in insomnia severity and daytime PTSD symptom severity. Sleep improvements were found in 61.9% of those who completed the active treatments and 25% of those randomized to placebo.ConclusionBSI and prazosin were both associated with significant sleep improvements and reductions in daytime PTSD symptoms in this sample of military veterans. Sleep-focused treatments may enhance the benefits of first-line PTSD treatments.     

Associations of nonrestorative sleep with insomnia, depression, and daytime function

Study objectivesNonrestorative sleep (NRS) complaints are common but associations with insomnia, daytime function or depressive symptoms are not well-established. This study aims to (1) describe insomnia related symptoms and sleep quality in those with NRS compared to those with no NRS; (2) identify the independent associations between NRS, insomnia severity, and depression; and (3) identify the association between NRS and daytime function independent of insomnia severity and depression.DesignCross sectional survey of enrollees at a health plan in the Midwestern United States.MeasurementRespondents were surveyed about the presence and frequency of NRS complaints, depression, insomnia severity and related symptoms. Multivariate regression was used to examine the study’s three research aims.ParticipantsStudy sample consisted of 541 subjects with NRS and 717 who reported never experiencing any NRS symptoms.ResultsWe found a statistically significant interaction between NRS and total sleep duration such that the association between sleep duration and sleep quality was attenuated in those with NRS compared to those without NRS (b = ?0.26, SE = 0.07, p < 0.0001). In multivariate analysis, subthreshold, moderate and severe insomnia were associated with NRS (OR [95%CI] = 5.93 [4.24–8.31], 9.22 [6.15–13.83] and 6.10 [3.34–11.14], respectively). NRS was independently associated with daytime physical function, cognitive function and emotional function OR [95%CI] = 2.21 [1.59–3.08], 1.90 [1.37–2.64] and 1.71 [1.23–2.36], respectively.ConclusionNRS is a complex concept that should be further defined and studied in the larger context of sleep quality, other insomnia related symptoms, daytime function and depression.     

Diagnostic and Statistical Manual criteria for insomnia related impairment in daytime functioning: polysomnographic correlates in older adults

ObjectiveDiagnosis of insomnia disorder by the Diagnostic and Statistical Manual (DSM)-IV, and as proposed by the DSM-V, includes criteria for impairment in occupational- or social functioning due to sleep complaints. This study evaluated the clinical and polysomnographic correlates of impairment in daytime functioning in older adults with insomnia.MethodsIn older adults with DSM-IV chronic insomnia (n = 68), clinical and demographic information, and measures of health functioning, medical co-morbidity, and polysomnographic sleep were obtained. Four questions that evaluated difficulties or distress in occupational- or social functioning related to sleep complaints were used to code DSM threshold criteria for impairment in daytime functioning. Stepwise regression was used to identify predictors of impairment in daytime functioning.ResultsImpairment in daytime functioning was significantly associated with younger age (p < 0.05), and the amount of wake time after sleep onset as assessed by polysomnography (p < 0.001), controlling for health functioning and minority racial status.ConclusionsAmount of wake time after sleep onset uniquely contributes to criteria symptoms of impairment in daytime functioning among older adults with insomnia. Treatments that target sleep maintenance have the potential to improve social and occupational functioning in older adults with sleep complaints.     

Long-term outcomes and predictors of chronic insomnia: a prospective study in Hong Kong Chinese adults

ObjectivesWe aimed to determine the longitudinal course and outcome of chronic insomnia in a five-year prospective study in Hong Kong Chinese adults.MethodsTwo thousand three hundred and sixteen middle-aged adults (53.3% females, 46.3 ± 5.1 years old at follow-up) were recruited at baseline and follow-up. Participants were divided into three groups: non-insomnia, insomnia symptoms, and insomnia syndrome (insomnia symptoms plus daytime symptoms). Upper airway inflammatory diseases, mental problems, and medical problems were additionally assessed at follow up.ResultsThe incidence of insomnia (symptoms and syndrome) was 5.9%. The persistence rate of insomnia syndrome was 42.7% for insomnia syndrome and 28.2% for insomnia symptoms. New incidence of insomnia was associated with younger age, unemployment, and daytime symptoms, while persistence of insomnia was associated with female sex, lower education level, and daytime symptoms at the baseline (p < 0.05). Baseline insomnia syndrome was significantly associated with upper airway inflammatory diseases (including asthma and laryngopharyngitis; adjusted OR = 1.97–17.9), mental problems, and medical conditions (including arthritis, psychiatric disorders, chronic pain, and gastroesophageal reflux disease; AOR = 2.29–3.77), whereas baseline insomnia symptoms were associated with poor mental health (AOR = 2.43), psychiatric disorders (AOR = 2.39), and chronic pain (AOR = 2.95).ConclusionsChronic insomnia is a common problem with considerable persistence and incidence rates among middle-aged Chinese adults. Insomnia syndrome has a higher persistence rate with more mental and medical comorbidities when compared with insomnia symptoms without daytime consequences.     

A randomized clinical trial of valerian fails to improve self-reported, polysomnographic, and actigraphic sleep in older women with insomnia

ObjectiveTo test the effects of nightly valerian (Valeriana officinalis) extract to improve sleep of older women with insomnia.MethodsParticipants in this phase 2 randomized, double-blind, crossover controlled trial were 16 older women (mean age = 69.4 ± 8.1 years) with insomnia. Participants took 300 mg of concentrated valerian extract or placebo 30 min before bedtime for 2 weeks. Sleep was assessed in the laboratory by self-report and polysomnography (PSG) at baseline and again at the beginning and end of each treatment phase (total of nine nights in the laboratory) and at home by daily sleep logs and actigraphy.ResultsThere were no statistically significant differences between valerian and placebo after a single dose or after 2 weeks of nightly dosing on any measure of sleep latency, wake after sleep onset (WASO), sleep efficiency, and self-rated sleep quality. In comparing each treatment to baseline in separate comparisons, WASO significantly increased (+17.7 ± 25.6 min, p = .02) after 2 weeks of nightly valerian, but not after placebo (+6.8 ± 26.4 min, NS). Side effects were minor and did not differ significantly between valerian and placebo.ConclusionValerian did not improve sleep in this sample of older women with insomnia. Findings from this study add to the scientific evidence that does not support use of valerian in the clinical management of insomnia.     

Psychometric properties of the Pre-Sleep Arousal Scale in a large community sample

ObjectiveThe purpose was to examine the psychometric properties of the Pre-Sleep Arousal Scale.MethodsFrom a randomly selected sample of the general population (N = 5000), 2327 participants completed a survey on nighttime symptoms, daytime symptoms, health outcomes, and psychological processes. The study sample consisted of 1890 participants who did not fulfill criteria for a sleep disorder other than insomnia.ResultsFindings indicated that the PSAS did not produce an adequate factorial solution. When three problematic items were removed, the solution, accounting for 48.5% of the variance, improved (PSAS-13). One subscale, cognitive arousal (α = .88), consisted of five items (37.1%), and one subscale, somatic arousal (α = .72), of eight items (11.4%). The two factors were significantly inter-correlated (ρ = .51) and associated with the PSAS-13 (ρ = .91, ρ = .80). Among those with insomnia, a shortened PSAS (PSAS-14) was established, which consisted of a cognitive and a somatic subscale (48.6% of the variance). The PSAS-13 and the two subscales showed discriminant validity between three sleep groups (normal sleep, poor sleep, and insomnia disorder) (R² = .24–.34). The PSAS-13 and the subscales demonstrated convergent validity with measures on sleep-related worry, sleep-related beliefs, anxiety, and depression. The PSAS-13 and the two subscales were significantly correlated with sleep parameters and daytime impairment.ConclusionThough acceptable psychometric properties were established for the PSAS, the cognitive subscale's focus upon general pre-sleep arousal and the relatively low variance accounted for calls for further work on and a possible re-conceptualization of the PSAS.     

Clinical significance of night-to-night sleep variability in insomnia

ObjectivesTo evaluate the clinical relevance of night-to-night variability of sleep schedules and insomnia symptoms.MethodsThe sample consisted of 455 patients (193 men, mean age = 48) seeking treatment for insomnia in a sleep medicine clinic. All participants received group cognitive behavioral therapy for insomnia (CBTI). Variability in sleep parameters was assessed using sleep diary data. Two composite scores were computed, a behavioral schedule composite score (BCS) and insomnia symptom composite score (ICS). The Insomnia Severity Index, the Beck Depression Inventory, and the Morningness–Eveningness Composite Scale were administered at baseline and post-treatment.ResultsResults revealed that greater BCS scores were significantly associated with younger age, eveningness chronotype, and greater depression severity (p < 0.001). Both depression severity and eveningness chronotype independently predicted variability in sleep schedules (p < 0.001). Finally, CBTI resulted in reduced sleep variability for all sleep diary variables except bedtime. Post-treatment symptom reductions in depression severity were greater among those with high versus low baseline BCS scores (p < 0.001).ConclusionsResults suggest that variability in sleep schedules predict reduction in insomnia and depressive severity following group CBTI. Schedule variability may be particularly important to assess and address among patients with high depression symptoms and those with the evening chronotype.     

Sleep disordered breathing in an elderly community-living population: Relationship to cardiac function, insomnia symptoms and daytime sleepiness

ObjectiveTo describe the prevalence of sleep disordered breathing (SDB) and its relationship to systolic function, different insomnia symptoms as well as excessive daytime sleepiness (EDS) in elderly community-living people. This has not been investigated previously.MethodThree hundred thirty-one subjects (71–87 years) healthy enough to be independently living in their own homes underwent echocardiographic examinations and sleep respiratory recordings. Questionnaires were used to evaluate insomnia symptoms and EDS.ResultsMild SDB (AHI 5–15) was found in 32%. Moderate SDB (AHI 15–30) occurred in 16%, and 7% had severe SDB (AHI > 30). Median AHI was significantly higher (p < 0.001) in those with mildly impaired systolic function (AHI 11.7) and moderately impaired systolic function (AHI 10.9) compared to those with normal systolic function (AHI 5.0). Impaired systolic function was associated with central sleep apnea (CSA) but not with obstructive sleep apnea. Concerning insomnia symptoms and EDS, only difficulties in initiating sleep correlated significantly (p < 0.05) with AHI.ConclusionSDB is common among the elderly. CSA may be related to impaired systolic function/heart failure. However, detection of SDB in this population may be problematic since insomnia symptoms and EDS correlated poorly with SDB.     

Prevalence of insomnia and sleep characteristics in the general population of Spain

ObjectiveThe goals of this study were to estimate the prevalence of insomnia symptomatology and diagnoses in the Spanish general population and to determine if certain sleep parameters were related to specific insomnia symptoms.MethodsThis is a cross-sectional telephone survey performed in the general population of Spain using a representative sample of 4065 individuals aged 15 years or older. The participation rate was 87.5%. Interviews were conducted using the Sleep-EVAL system. The questions were related to sociodemographic characteristics, sleep–wake schedule, events occurring during sleep, insomnia symptoms, daytime consequences and DSM-IV diagnoses of sleep disorders.ResultsOverall, 20.8% (95% C.I. 19.6–22.1%) of the sample reported at least one insomnia symptom occurring at least three nights/week. The prevalence was higher in women than in men (23.9% vs. 17.6%) and increased with age. Difficulty maintaining sleep at least three nights/week was the most prevalent symptom. DSM-IV insomnia disorder diagnoses were found in 6.4% (95% C.I. 5.6–7.1%) of the sample. Delayed bedtime and wake-up time, irregular bedtime hours and hypnagogic hallucinations were the most frequent in participants who had difficulty initiating sleep. Perception of light and “too short” sleep were the most frequent in participants who had early morning awakenings. Participants who had a non-restorative sleep were more likely to extend sleep on days off than other insomnia participants. Medical consultations in the previous year were more frequent in insomnia participants compared to participants without insomnia. One-fifth of insomnia participants were using sleep-promoting medication.ConclusionsInsomnia is frequent in Spain, affecting up to one in five individuals. Results show that insomnia is multidimensional and needs to be assessed as such.     

The relationship between psychotic-like experiences and sleep disturbances in adolescents

ObjectiveWe investigated the relationships between sleep disturbances and psychotic-like experiences (PLEs) among adolescents.MethodsA total of 8530 students (grades 7–11) were recruited in the Republic of Korea, and 7172 students who completed all of the relevant questionnaires participated in the current study. The survey included the Eppendorf Schizophrenia Inventory (ESI), the Youth Psychosis At Risk Questionnaire (Y-PARQ), the Beck Depression Inventory (BDI), the Epworth Sleepiness Scale and questionnaires about sleep disturbances (insomnia, cataplexy and snoring).ResultsSubjects with insomnia, excessive daytime somnolence (EDS), or probable cataplexy had higher ESI and Y-PARQ scores after controlling for age, sex and BDI scores (all p < 0.001). Insomnia (OR = 4.40), EDS (OR = 3.84) and probable cataplexy (OR = 2.97) predicted clinical high risk of psychosis. Insomnia, EDS and probable cataplexy remained as significant predictors of clinical high risk for psychosis, even after controlling for depressive symptoms or when analyses were confined to non-depressive adolescents.ConclusionsInsomnia and EDS were found to predict PLEs in adolescents, independent of depression. Our findings suggest that adolescents complaining of insomnia or sleepiness may require further assessment regarding potential risk of psychosis.     

Snoring men with daytime sleepiness drive more than others: A population-based study

ObjectiveTo investigate whether subjects with daytime sleepiness who snore or report witnessed sleep apneas drive more than others.MethodsQuestions on snoring, witnessed sleep apnea, excessive daytime sleepiness and driving distance per year were included in the Northern Sweden component of the WHO, MONICA study. Invited were 10756 subjects aged 25–79 years, randomly selected from the population register.ResultsThere were 7905 (73%) subjects, 3858 men and 4047 women who responded to the questionnaire and attended a visit for a physical examination. Habitually snoring men with daytime sleepiness drove a mean of 22566 (95% CI 18550–26582) km a year, which was significantly more than non-snoring men without excessive daytime sleepiness who drove 17751 (95% CI 17076–18427) km a year, p = 0.02, after adjustments for age, body mass index, smoking and physical activity. Men reporting witnessed sleep apnea and excessive daytime sleepiness also drove more than their counterparts in adjusted analysis, p = 0.01. Women reporting daytime sleepiness and witnessed apnea tended to drive more, while snoring women with daytime sleepiness did not.ConclusionsMen suffering from excessive daytime sleepiness who snore habitually or report witnessed sleep apneas drive significantly more than others.     

Treatment of elderly primary insomnia patients with EVT 201 improves sleep initiation,sleep maintenance,and daytime sleepiness

ObjectiveTwo doses of EVT 201, a partial positive allosteric modulator of the GABA_A system, were evaluated in elderly primary insomnia patients with daytime sleepiness.Patients and methodsParticipants were 149 elderly patients with DSM-IV primary insomnia including evidence of daytime sleepiness (53 males, 96 females; mean age 71.3 yrs, range 65–86 yrs). A randomized, multicentre, double-blind, placebo-controlled, parallel-group design was used to assess the hypnotic efficacy of EVT 201 1.5 and 2.5 mg during seven consecutive nights. Polysomnography (PSG) was performed on nights 1, 6 and 7 of treatment. Daytime assessments on Day 8 included the multiple sleep latency test (MSLT), Rey Auditory Verbal Learning Test (RAVLT), Psychomotor Vigilance Task (PVT) and the Karolinska Sleepiness Scale (KSS). The primary endpoint was total sleep time (TST) and the key secondary endpoint was mean MSLT latency.ResultsCompared to placebo, EVT 201 1.5 and 2.5 mg increased TST (30.9, 56.4 min, respectively; p = 0.0001, p < 0.0001); reduced wake after sleep onset (WASO; ?15.2, ?36.1 min, respectively; p = 0.014, p < 0.0001); reduced latency to persistent sleep (LPS; ?15.9, ?19.9 min, respectively; p = 0.009, p = 0.001). The 2.5 mg dose also reduced WASO in hours 5–8 (?16.3 min, p = 0.001). Both doses also improved subjective sleep quality and usual subjective efficacy measures. A significantly longer mean MSLT latency was observed on Day 8 with both doses, compared to placebo (2 min increase; p = 0.03, both doses). The PVT, RAVLT, and POMS did not differ among treatment groups. No serious or unexpected treatment emergent adverse events were noted.ConclusionEVT 201 improved PSG measures of sleep onset and sleep maintenance and significantly reduced daytime physiological sleep tendency. These findings suggest that treatment of primary insomnia in older patients has the potential to improve daytime sleepiness as well as sleep.     

Efficacy and safety of doxepin 6 mg in a four-week outpatient trial of elderly adults with chronic primary insomnia

IntroductionThe efficacy and safety of doxepin (DXP), a histamine H₁ receptor antagonist, was evaluated in elderly adults with sleep maintenance insomnia.MethodsThis was a randomized, double-blind, placebo-controlled outpatient trial. Elderly adults meeting DSM-IV-TR criteria for primary insomnia were randomized to four weeks of nightly treatment with either DXP 6 mg (N = 130) or placebo (PBO; N = 124). Efficacy was assessed using patient self-report instruments and clinician ratings. Patient-reported endpoints included subjective total sleep time (sTST), subjective wake after sleep onset (sWASO), latency to sleep onset (LSO), sleep quality, and a Patient Global Impression scale (PGI). The primary endpoint was sTST at week 1.ResultsDXP 6 mg produced significantly more sTST and less sWASO at week 1 (both p-values <0.0001) than PBO. These significant improvements versus placebo were maintained at weeks 2–4 (all p-values <0.05). There were no significant differences in LSO for DXP 6 mg versus PBO. DXP 6 mg significantly improved sleep quality (weeks 1, 3, and 4, p < 0.05) and several outcome-related parameters, including several items on the PGI, the severity and improvement items of the Clinician Global Impression scale (CGI; weeks 1 and 2) and the Insomnia Severity Index (ISI; weeks 1–4), all versus PBO. There were no reports of anticholinergic effects (e.g., dry mouth) or memory impairment. The safety profile of DXP 6 mg was comparable to that of PBO.ConclusionsIn elderly adults with insomnia, DXP 6 mg produced significant improvements in sleep maintenance, sleep duration, and sleep quality endpoints that were sustained throughout the trial. These data suggest that DXP 6 mg is effective for treating sleep maintenance insomnia and is well-tolerated in elderly adults with chronic primary insomnia.     

Epidemiological and clinical relevance of insomnia diagnosis algorithms according to the DSM-IV and the International Classification of Sleep Disorders (ICSD)

BackgroundAlthough the epidemiology of insomnia in the general population has received considerable attention in the past 20 years, few studies have investigated the prevalence of insomnia using operational definitions such as those set forth in the ICSD and DSM-IV, specifying what proportion of respondents satisfied the criteria to reach a diagnosis of insomnia disorder.MethodsThis is a cross-sectional study involving 25,579 individuals aged 15 years and over representative of the general population of France, the United Kingdom, Germany, Italy, Portugal, Spain and Finland. The participants were interviewed on sleep habits and disorders managed by the Sleep-EVAL expert system using DSM-IV and ICSD classifications.ResultsAt the complaint level, too short sleep (20.2%), light sleep (16.6%), and global sleep dissatisfaction (8.2%) were reported by 37% of the subjects. At the symptom level (difficulty initiating or maintaining sleep and non-restorative sleep at least 3 nights per week), 34.5% of the sample reported at least one of them. At the criterion level, (symptoms + daytime consequences), 9.8% of the total sample reported having them. At the diagnostic level, 6.6% satisfied the DSM-IV requirement for positive and differential diagnosis. However, many respondents failed to meet diagnostic criteria for duration, frequency and severity in the two classifications, suggesting that multidimensional measures are needed.ConclusionsA significant proportion of the population with sleep complaints do not fit into DSM-IV and ICSD classifications. Further efforts are needed to identify diagnostic criteria and dimensional measures that will lead to insomnia diagnoses and thus provide a more reliable, valid and clinically relevant classification.     

Prevalence of restless legs syndrome among adults in Iceland and Sweden: Lung function, comorbidity, ferritin, biomarkers and quality of life

ObjectiveThis study investigates the prevalence and the association between restless legs syndrome (RLS) and a large variety of health variables in two well-characterized random samples from the general population in Reykjavik, Iceland, and Uppsala, Sweden.MethodsUsing the national registries of inhabitants, a random sample from adults aged 40 and over living in Reykjavík, Iceland (n = 939), and Uppsala, Sweden (n = 998), were invited to participate in a study on the prevalence of COPD (response rate 81.1% and 62.2%). In addition, the participants were asked to answer the following questionnaires: International RLS Rating Scale, Short Form-12, the Epworth Sleepiness Scale, and questions about sleep, gastroeosophageal reflux, diabetes and hypertension, as well as pharmacological treatment. Interleukin-6 (IL-6), C-reactive protein (CRP) and ferritin were measured in serum.ResultsRLS was more commonly reported in Reykjavik (18.3%) than in Uppsala (11.5%). Icelandic women reported RLS almost twice as often as Swedish women (24.4 vs. 13.9% p = 0.001), but there was no difference in prevalence of RLS between Icelandic and Swedish men. RLS was strongly associated with sleep disturbances and excessive daytime sleepiness. Subjects with RLS were more likely to be ex- and current smokers than subjects without RLS (p < 0.001). Respiratory symptoms and airway obstruction were more prevalent among those reporting RLS and they also estimated their physical quality of life lower than those without RLS (p < 0.001). RLS was not associated with symptoms of the metabolic syndrome like hypertension, obesity, markers of systemic inflammation (IL-6 and CRP) or cardiovascular diseases. Ferritin levels were significantly lower in RLS participants (p = 0.0002), but not (p = 0.07) after adjustment for center, age, sex and smoking history.ConclusionRestless legs syndrome was twice as common among Icelandic women compared to Swedish women. No such difference was seen for men. RLS was strongly associated with smoking and respiratory symptoms, decreased lung function, sleep disturbances, excessive daytime sleepiness, and physical aspects of life quality. RLS was not associated with markers of the metabolic syndrome like hypertension, obesity, cardiovascular diseases or biomarkers of systemic inflammation.     

The effects of ramelteon in a first-night model of transient insomnia

ObjectiveTo evaluate the efficacy and safety of ramelteon, a highly selective MT₁/MT₂ melatonin receptor agonist, for the treatment of transient insomnia in adults.MethodsIn a randomized, double-blind, placebo-controlled, multi-center study, 289 adults naive to a sleep laboratory environment were randomized to receive a single nighttime dose of ramelteon 8 mg, 16 mg, or placebo. The primary variable was latency to persistent sleep measured by polysomnography. Additional objective and subjective sleep parameters as well as next-morning residual effects were assessed.ResultsRamelteon 8 mg treatment significantly reduced latency to persistent sleep compared with placebo (12.2 min vs. 19.7 min, P = 0.004). Total sleep time was significantly increased with both ramelteon 8 mg (436.8 min, P = 0.009) and ramelteon 16 mg (433.1 min, P = 0.043) compared with placebo (419.7 min). Ramelteon did not alter sleep architecture, and no significant next-morning residual effects were detected. The incidence of adverse events was similar for the ramelteon and placebo groups and most were considered mild or moderate.ConclusionRamelteon 8 mg significantly decreased latency to persistent sleep and increased total sleep time, with no significant next-morning psychomotor, memory, or cognitive effects in this first-night model of transient insomnia.     

Daytime sleepiness and polysomnography in obstructive sleep apnea patients

BackgroundExcessive daytime sleepiness (EDS) is the major complaint in subjects with obstructive sleep apnea syndrome (OSAS). However, EDS is not universally present in all patients with OSAS. The mechanisms explaining why some patients with OSAS complain of EDS whereas others do not are unknown.ObjectiveTo investigate polysomnographic determinants of excessive daytime sleepiness (EDS) in a large multicenter cohort of patients with obstructive sleep apnea (OSAS).MethodsAll consecutive patients with an apnea–hypopnea index greater than 5 h⁻¹ who were evaluated between 2003 and 2005. EDS was assessed using the Epworth Sleepiness Scale (ESS), and patients were considered to have EDS if the ESS was >10.ResultsA total of 1649 patients with EDS ((mean [±SD] Epworth 15 ± 3) and 1233 without EDS (Epworth 7 ± 3) were studied. Patients with EDS were slightly younger than patients without EDS (51 ± 12 vs 54 ± 13 years, p < 0.0001), had longer total sleep time (p < 0.007), shorter sleep latency (p < 0001), greater sleep efficiency (p < 0.0001) and less NREM sleep in stages 1 and 2 (p < 0.007) than those without EDS. Furthermore, patients with EDS had slightly higher AHI (p < 0.005) and arousal index (p < 0.001) and lower nadir oxygen saturation (p < 0.01).ConclusionsPatients with OSAS and EDS are characterized by longer sleep duration and increased slow wave sleep compared to those without EDS. Although patients with EDS showed a mild worsening of respiratory disturbance and sleep fragmentation, these results suggest that sleep apnea and sleep disruption are not the primary determinants of EDS in all of these patients.     

Characteristics of insomnia in a primary care setting: EQUINOX survey of 5293 insomniacs from 10 countries

ObjectiveTo describe the characteristics of insomnia in primary care physicians’ (PCPs’) practices in 10 countries and to understand how the difficulty of maintaining sleep (DMS) was or was not associated with other insomnia symptoms such as difficulty initiating sleep (DIS), early morning awakenings (EMA) or nonrestorative sleep (NRS) in PCPs patients with insomnia.MethodsInternational, noninterventional, cross-sectional, observational survey conducted in a primary care setting in subjects complaining of sleep disturbances in 10 countries. A questionnaire based on DSM-IV and ICSD criteria was administered.ResultsThirteen thousand one hundred twenty-four subjects were enrolled by 647 physicians; 5293 of them (32.6%) had insomnia and were surveyed. The population was predominantly female (63.9%) with a mean age of 47.8 ± 15.3 years; 39.9% of these patients have already been treated for sleep difficulties. Combination of all types of insomnia symptoms (DIS + DMS + EMA + NRS) was the most frequently reported combination (38.6% of the subjects), while the percentage of subjects presenting with only one type of insomnia symptom (DIS, DMS, EMA or NRS) was very low: 3%, 1.8%, 0.9% and 1.4% respectively. DMS was on average the most commonly reported insomnia symptom (80.2%). Multiple logistic regression showed that DMS, EMA and NRS symptoms were significantly linked with each other and also to other insomnia criteria (sleep satisfaction, sleep quality, sleep duration, number of hours of sleep, frequency of insomnia symptoms, wake up rested / unrested and non restorative sleep).ConclusionsPatients visiting PCPs with insomnia are likely to present with severe and poly-symptomatic insomnia.     

Subjective and objective measures of sleep in children with attention-deficit/hyperactivity disorder

ObjectiveTo compare objective and subjective measures of sleep in children with attention-deficit/hyperactivity disorder (ADHD) and healthy control subjects.MethodsIncluded were 107 unmedicated children with ADHD and 46 healthy control subjects, all aged 6–14. Sleep–wake patterns were monitored with actigraphy for at least five consecutive days. Subjects and parents completed daily electronic diaries assessing sleep and daytime behavior.ResultsActigraphy data from 80 ADHD patients and 45 control subjects showed that, compared to the healthy control group, the ADHD group experienced shorter actual sleep time (defined as time in minutes [from sleep onset to final morning awakening] of all epochs scored as sleep [i.e., excluding total duration of all epochs scored as “wake”]) (489.39 vs. 460.30 min, p = .001), significantly fewer sleep interruptions (44.45 vs. 35.33, p < .001), but more total interrupted sleep time (44.49 vs. 56.70 min, p = .002). Child diaries indicated children with ADHD had significantly more daytime sleepiness and difficulty getting up and less refreshing sleep. Parent diaries indicated children with ADHD had significantly more behavioral difficulties than the control group.ConclusionsResults suggest children with ADHD have reduced sleep quantity and more disturbed sleep on actigraphic measures, reduced sleep quality on the self report, and more problematic behaviors on the parent report. Clinical interventions for children with ADHD who present with sleep problems should include screening for etiologic and exacerbating factors, institution of behavioral-management strategies, and consideration of pharmacologic treatment targeted toward evening ADHD symptoms.     

The discrepancy between actigraphic and sleep diary measures of sleep in adolescents

ObjectiveTo explore the discrepancy between sleep diary and actigraphic measures of sleep in adolescents and to ascertain whether these discrepancies may vary according to characteristics of the participant.MethodsParticipants were 385 adolescents aged 13–18 years (X = 15.6, standard deviation [SD] = 0.95; 60% male) from eight high schools in South Australia. Adolescents completed the School Sleep Habits Survey and Pediatric Daytime Sleepiness Scale during class time, followed by an 8-day sleep diary and wrist actigraphy. The Flinders Fatigue Scale was completed on the final day of the study. Parents completed a sleep, medical, education, and family history survey.ResultsActigraphic estimates of wake after sleep onset (WASO) were substantially greater than sleep diary estimates (74 min actigraphy vs. 7 min sleep diary) and actigraphic estimates of total sleep time were substantially less than sleep diary and parent report (6 h 51 min actigraphy vs. 8 h 16 min sleep diary vs. 8 h 51 parent report). Actigraphy displayed no significant relationship with daytime functioning and weak relationships with concomitantly recorded sleep diary variables. Sex and puberty-related differences in actigraphic scoring were found, with more WASO and less sleep scored in boys compared to girls and more WASO scored amongst pubertally-mature boys than boys of less advanced pubertal development.ConclusionsThere may be differences in the sleep of adolescents that result in less actigraphic total sleep scored than perceived, particularly in boys, possibly because of increased sleep motor activity in adolescents that actigraphic algorithms score as wake. This is a significant concern that requires further examination with polysomnography.