Management of Obstructive Sleep Apnea and Comorbid Insomnia: A Mixed-Methods Evaluation

The purpose of this study was to examine the process of care in an interdisciplinary sleep clinic for patients with obstructive sleep apnea (OSA) and comorbid insomnia. A mixed-methods approach was used to examine clinical and patient-centered measures for 34 patients who received positive-airway pressure for OSA or cognitive-behavior therapy for insomnia. The results revealed baseline-to-follow-up improvements on several self-reported sleep parameters and measures of daytime functioning. Qualitative analyses from patient interviews revealed three themes: conceptual distinctions about each sleep disorder, importance of treating both sleep disorders, and preferences with regard to the sequence of treatment. These findings indicate that patients with OSA and comorbid insomnia encounter unique challenges. A dimensional approach to assessment and treatment is proposed for future research.     

The Utility of Three Screening Questionnaires for Obstructive Sleep Apnea in a Sleep Clinic Setting

Purpose

The aim of this study was to determine the diagnostic value of three screening questionnaires in identifying Korean patients at high risk for obstructive sleep apnea (OSA) in a sleep clinic setting in Korea.

Materials and Methods

Data were collected from 592 adult patients with suspected OSA who visited a sleep center. All patients completed the Sleep Apnea of Sleep Disorder Questionnaire (SA-SDQ), the Berlin questionnaire, and the STOP-Bang questionnaire. Estimated OSA risk was compared to a diagnosis of OSA. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated for each questionnaire.

Results

The prevalence of OSA was 83.6% using an apnea-hypopnea index (AHI) ≥5/h and 58.4% for an AHI ≥15/h. The STOP-Bang questionnaire had a high sensitivity (97% for AHI ≥5/h, 98% for AHI ≥15/h), but the specificity was low (19% and 11%, respectively). In contrast, the sensitivity of the SA-SDQ was not high enough (68% for AHI ≥5/h, 74% for AHI ≥15/h) to be useful in a clinical setting, whereas the specificity was relatively good (66% and 61%, respectively). The sensitivity and specificity values of the Berlin questionnaire fell between those of the STOP-Bang questionnaire and the SA-SDQ.

Conclusion

The STOP-Bang questionnaire may be useful for screening OSA in a sleep clinic setting, but its specificity is lower than the acceptable level for this purpose. A new screening questionnaire with a high sensitivity and acceptable specificity is therefore needed in a sleep clinic setting.     

口腔矫治器在阻塞性睡眠呼吸暂停综合征治疗中的应用

目的:探讨口腔矫治器治疗阻塞性睡眠呼吸暂停综合征(OSAS)的临床疗效,为口腔正畸治疗OSAS提供理论依据.方法:采用矫治器治疗OSAS患者15例,将治疗前后多导睡眠监测所测的呼吸功能改变与治疗前X线头影值进行相关分析,比较疗效的差异.结果:15例OSAS患者呼吸暂停指数及最低血氧饱和度有明显改善.结论:口腔正畸治疗OSAS是一种新的、有效可行的方法.     

Logging on for Better Sleep: RCT of the Effectiveness of Online Treatment for Insomnia

Study Objectives:

Despite effective cognitive behavioral treatments for chronic insomnia, such treatments are underutilized.^1,2 This study evaluated the impact of a 5-week, online treatment for insomnia.

Design:

This was a randomized controlled trial with online treatment and waiting list control conditions.

Participants:

Participants were 118 adults with chronic insomnia.

Setting:

Participants received online treatment from their homes.

Intervention:

Online treatment consisted of psychoeducation, sleep hygiene, and stimulus control instruction, sleep restriction treatment, relaxation training, cognitive therapy, and help with medication tapering.

Measurements and Results:

From pre- to post-treatment, there was a 33% attrition rate, and attrition was related to referral status (i.e., drop-outs were more likely to have been referred for treatment rather than recruited from the community). Using a mixed model analysis of variance procedure (ANOVA), results showed that online treatment produced statistically significant improvements in the primary end points of sleep quality, insomnia severity, and daytime fatigue. Online treatment also produced significant changes in process variables of pre-sleep cognitive arousal and dysfunctional beliefs about sleep.

Conclusions:

Implications of these findings are that identification of who most benefits from online treatment is a worthy area of future study.

Citation:

Vincent N; Lewycky S. Logging on for better sleep: RCT of the effectiveness of online treatment for insomnia. SLEEP 2009;32(6):807-815.     

Brain Activation Changes Before and After PAP Treatment in Obstructive Sleep Apnea

Study Objectives:

Obstructive sleep apnea syndrome (OSAS) is associated with cognitive and functional deficits, most of which are corrected after positive airway pressure (PAP) treatment. Previous studies investigating the neural underpinnings of OSAS failed to provide consistent results both on the cerebral substrates underlying cognitive deficits and on the effect of treatment on these anomalies. The aims of the study were a) to investigate whether never-treated OSA patients demonstrated differences in brain activation compared to healthy controls during a cognitive task; and b) to investigate whether any improvements in cognitive functioning found in OSA patients after treatment reflected a change in the underlying cerebral activity.

Design:

OSA patients and healthy controls underwent functional magnetic resonance imaging (fMRI) scanning. They were compared on performance and brain activation during a 2-back working-memory task. Patients were also re-evaluated after 3 months treatment with PAP. Cognitive functions were evaluated using neurocognitive tests. Sleepiness (ESS), mood (Beck Depression Inventory) and, quality-of-life (SF-36) were also assessed.

Setting:

The Sleep Disorders Center and CERMAC at the Vita-Salute San Raffaele University.

Patients or Participants:

17 OSA patients and 15 age- and education-matched healthy controls.

Interventions:

PAP treatment for 3 months.

Measurements and Results:

Compared to controls, never-treated OSA patients showed increased activations in the left frontal cortex, medial precuneus, and hippocampus, and decreased activations in the caudal pons. OSA patients showed decreases in activation with treatment in the left inferior frontal gyrus and anterior cingulate cortex, and bilaterally in the hippocampus. Most neurocognitive domains, impaired at baseline, showed significant improvement after treatment.

Conclusions:

OSA patients showed an overrecruitment of brain regions compared to controls, in the presence of the same level of performance on a working-memory task. Decreases of activation in prefrontal and hippocampal structures were observed after treatment in comparison to baseline. These findings may reflect a neural compensation mechanism in never-treated patients, which is reduced by effective treatment.

Citation:

Castronovo V; Canessa N; Ferini Strambi L; Aloia MS; Consonni M; Marelli S; Iadanza A; BruschiA; Falini A; Cappa SF. Brain activation changes before and after PAP treatment in obstructive sleep apnea. SLEEP 2009;32(9):1161-1172.     

Obstructive Sleep Apnea and Aldosterone

Background:

Obstructive sleep apnea (OSA) is a major risk factor for hypertension and has been associated with increased risk for cardiovascular morbidity. A dysregulated renin-angiotensin-aldosterone system may contribute to excess sodium retention and hypertension and may be activated in OSA. We tested the hypothesis that serum levels of aldosterone and plasma renin activity (PRA) are increased by apneic sleep in subjects without cardiovascular disease, compared to healthy control subjects.

Methods and Results:

Plasma aldosterone level was measured in 21 subjects with moderate to severe OSA and was compared to 19 closely matched healthy subjects. Plasma renin activity (PRA) was measured in 19 OSA patients and in 20 healthy controls. Aldosterone and PRA were measured before sleep (9pm), after 5 hrs of untreated OSA (2am) and in the morning after awakening (6am). There were no baseline (9pm) differences in serum aldosterone levels and PRA between the healthy controls and OSA patients (aldosterone: 55.2 ± 9 vs 56.0 ± 9 pg/mL; PRA: 0.99 ± 0.15 vs 1.15 ± 0.15 ng/mL/hr). Neither several hours of untreated severe OSA nor CPAP treatment affected aldosterone levels and PRA in OSA patients. Diurnal variation of both aldosterone and PRA was observed in both groups, in that morning renin and aldosterone levels were higher than those measured at night before sleep.

Conclusions:

Our study shows that patients with moderate to severe OSA without co-existing cardiovascular disease have plasma aldosterone and renin levels similar to healthy subjects. Neither untreated OSA nor CPAP treatment acutely affect plasma aldosterone or renin levels.

Citation:

Svatikova A; Olson LJ; Wolk R; Phillips BG; Adachi T; Schwartz GL; Somers VK. Obstructive sleep apnea and aldosterone. SLEEP 2009;32(12):1589-1592.     

Patient-Provider Communication With Older Adults About Sleep Apnea Diagnosis and Treatment

Patient–provider communication impacts adherence to therapy. We explored older adults’ communication with their providers, preferences for communication, and views on communication attributes and decision aid characteristics, by conducting four focus groups. Several participants reported they had received insufficient information about their sleep apnea diagnosis and treatment options. Most participants felt that it would be helpful to have treatment information tailored to their needs, including information on the negative impact of treatment on comfort and convenience and disclosure about common barriers to adherence. Participants provided desired characteristics for a decision aid, including their preferred delivery method, content, and format. These findings have implications for how to design useful decision aids for older adults with newly diagnosed sleep apnea.     

改良悬雍垂腭咽成形术治疗阻塞性睡眠呼吸暂停综合征

目的：探讨提高悬雍垂腭咽成形（UPPP）术的疗效及减少并发症的手术方法。方法：通过在UPPP术中对口咽及腭帆肌群肌肉起止点进行恰当转位,治疗阻塞性睡眠呼吸暂停综合征（OSAS）86例。结果：术后6月～1 a随访观察,进行PSG监测。根据杭州标准,治愈76例（88.4%）,显效10例（11.6%）。7例（8.2%）术后出现并发症,均于6个月自愈。结论：在UPPP术中对口咽及腭帆肌群进行肌肉起止点转位,可以实现在悬雍垂、软腭减容的同时,合理保护口咽及腭咽肌群,维持其自身理功能,提高疗效,减少并发症。     

Patient and Partner Experiences With Obstructive Sleep Apnea and CPAP Treatment: A Qualitative Analysis

Few studies have investigated factors associated with continuous positive airway pressure (CPAP) treatment for sleep apnea from the patients’ and their partners’ perspective. This qualitative research study explored patients’ and partners’ experiences of CPAP and facilitators and barriers to CPAP use, and elicited suggestions for a first-time CPAP user program. Data from 27 participants were collected via four sleep apnea patient and four partner focus groups. Qualitative content analysis identified five themes: knowledge of sleep apnea, effects of sleep apnea, effects of CPAP, barriers and facilitators of CPAP, and ideas for a new user support program. Patients and partners emphasized the importance of partner involvement in the early CPAP treatment period. These data suggest consideration of a couple-oriented approach to improving CPAP adherence.     

Obstructive Sleep Apnea: A Risk Factor for Work Disability

Study Objective:

To examine obstructive sleep apnea (OSA) as a risk factor for work disability.

Patients and Setting:

Consecutive patients referred to the University of California San Francisco Sleep Disorders Center with suspected OSA (n = 183).

Design:

All patients underwent overnight polysomnography after completing a written survey which assessed work disability due to sleep problems, occupational characteristics and excessive daytime sleepiness (EDS) defined as an Epworth Sleepiness Scale score > 10.

Results:

Among 150 currently employed patients, 83 had OSA on polysomnography (apnea-hypopnea index ≥ 5). Compared with patients in whom both OSA and EDS were absent, patients with the combination of OSA and EDS were at higher risk of both recent work disability (adjusted odds ratio [OR], 13.7; 95% confidence interval [CI], 3.9–48) and longer-term work duty modification (OR, 3.6; CI, 1.1–12). When either OSA or EDS were absent, the strength of the association with work disability was less than when both OSA and EDS were present. When OSA was examined without respect to EDS, patients with OSA were at increased risk of recent work disability relative to patients without OSA (OR 2.6; 95% CI 1.2–5.8), but the association of OSA with longer-term work duty modification did not meet standard criteria for statistical significance (OR = 2.0, 95% CI 0.8–5.0).

Conclusions:

The combination of OSA and EDS contributes to work disability, and OSA by itself contributes to recent work disability. These findings should highlight to employers and clinicians the importance of OSA in the workplace to encourage patients to be screened for OSA, particularly in situations of decreased productivity associated with EDS.

Citation:

Omachi TA; Claman DM; Blanc PD; Eisner MD. Obstructive sleep apnea: a risk factor for work disability. SLEEP 2009;32(6):791-798.     

Screening for Trauma-Related Sleep Disturbance in Women Admitted for Specialized Inpatient Treatment

Abstract

The authors designed a Sleep Disturbance Screening questionnaire to assist clinicians in disentangling trauma-related factors that contribute to sleep disturbance from other common factors, such as depression. They administered the questionnaire to 129 female psychiatric inpatients, most of whom were treated in a specialty program for trauma-related disorders. Confirmatory and exploratory factor analyses distinguished four sleep disturbance scales, two pertaining to sleep disturbance generally (Insomnia, Hypersomnia) and two pertaining to sleep-related fear (Intrusive, Phobic). Correlations of the sleep disturbance scales with the Childhood Trauma Questionnaire (Bernstein et al., 1994), Impact of Event Scale-Revised (Weiss & Marmar, 1997), Dissociative Experiences Scale (Bernstein & Putnam, 1986), Beck Depression Inventory (Beck & Steer, 1993), and selected scales of the Millon Clinical Multiaxial Inventory (MCMI-III; Millon, 1994) show evidence of convergent and discriminant validity for the Sleep Disturbance Screening. The findings point to the potential diagnostic value of screening for trauma-related sleep disturbance, with the Sleep Disturbance Screening providing a small set of key questions that may be used in psychometric form or incorporated into routine diagnostic clinical interviews.     

基于谱分析的阻塞型睡眠呼吸暂停研究

目的本文研究发生阻塞型睡眠呼吸暂停时患者的心率功率谱及血压功率谱结构与正常睡眠的差异.方法采用AR模型估计心率及血压的功率谱,并提取低频分量与高频分量的比值(LF/HF)作为特征参数,考察发生阻塞型睡眠呼吸暂停时功率谱结构的变化.结果发生阻塞型睡眠呼吸暂停时LF/HF是正常睡眠时的2～5倍,表明患者在此时的交感神经活动增强,迷走神经活动减弱.     

Slow Wave Sleep Deficiency Insomnia: A Problem in Thermo-Downregulation at Sleep Onset

The following review article attempts to develop the argument that a regulated, rapid drop in rectal, core-body temperature following sleep onset is a necessary prerequisite to the presence of sustained slow wave sleep (NREM Stage 4). Based upon this premise, a theory1 is presented to suggest that the slow wave sleep deficiency so commonly associated with chronic, primary insomnia (Gaillard, 1976, 1978) is the result of a failure in the thermoregulatory system to show a regulated, rapid decrease in body temperature with sleep onset which persists for the first 1–2 hrs into the sleep period.     

Predictors of Interest in Psychological Treatment for Insomnia Among Older Primary Care Patients With Disturbed Sleep

In this study, we examined whether the common sense model of illness representation (CSMIR) could be successfully used to predict interest in cognitive-behavioral treatment for insomnia (CBT-I) among older primary care patients with disturbed sleep. The Sleep Impairment Index (C. M. Morin, 1993) was used to assess sleep disturbance and the constructs of the CSMIR in primary care patients ages 55 and older. Statistical analyses showed that the CSMIR constructs of consequences (perceived adverse consequences of sleep disturbance to functioning), causes (attributing one's insomnia to bad sleeping habits), and emotion (concern about one's sleep problem) predicted interest in CBT-I. These data provided encouraging support for the ability of the CSMIR to accurately predict patient interest in treatment for insomnia. Implications for assessment and treatment of insomnia in primary care are discussed.     

睡眠呼吸暂停综合征患者的睡眠分期算法研究

针对可穿戴睡眠监测缺乏有效的自动睡眠分期和睡眠质量评价方法这一问题,提出一种适用于睡眠呼吸暂停综合征患者的自动睡眠分期方法。通过心电图R-R间期序列,分别得到心率变异性、呼吸幅度变异性和呼吸率变异性信号。以此为基础,提取时域、频域及非线性特征共55个。利用门控循环单元网络,分别构建清醒-睡眠二分类、清醒-快速眼动-非快速眼动睡眠三分类、清醒-快速眼动-浅睡-慢波睡眠四分类、清醒-快速眼动-非快速眼动Ⅰ-Ⅱ-Ⅲ期五分类等共4个不同分类粒度的睡眠分期模型;采用损失函数类别加权方法,有效降低数据非平衡对分期结果的影响。验证数据来自SHRS数据库的274例患者。借助准确率、Cohen's Kappa系数和睡眠结构指标对该睡眠分期方法进行性能评价。结果表明4个分类器的准确率分别为85.06%、75.44%、63.80%、62.13%,Cohen's Kappa系数达到了0.54、0.49、0.41、0.41,睡眠结构分析评估与临床结果之间的差异无统计学意义。所提出的方法基本满足睡眠质量评估的需求,适用于可穿戴睡眠监测应用。     

阻塞性睡眠呼吸暂停的遗传学研究

阻塞性睡眠呼吸暂停（obstructive sleep apnea, OSA）的遗传学研究尚处在初期,但迄今研究提示OSA有很强的遗传背景,其发病存在着家族聚集性且与相关中间表型有关,如与颅面结构、体内脂肪分布和呼吸调控的异常等有关。目前认为OSA的发病很可能是多基因与环境因素交互作用的结果。对OSA的分子遗传学研究可帮助理解OSA的病因和发病机理,并能促进对OSA的基因诊断和预防。