Limits of the Epworth Sleepiness Scale in older adults

Purpose

Excessive daytime sleepiness (EDS) in older adults is associated with obstructive sleep apnea, falls, reduced quality of life, and mortality. The Epworth Sleepiness Scale (ESS) is widely used to assess sleepiness. However, EDS assessment with the ESS may not be accurate in older adults. We aimed to (1) describe the responsiveness of nondemented older subjects to the ESS and (2) compare the self-report ESS scores to those of close relatives (CR) proxy and identify factors influencing any discrepancies between them.

Methods

This is a cross-sectional observational study including 104 independently living nondemented older subjects with daytime sleepiness complaints and 104 nondemented CRs. Cognitive tests (Mini-Mental State Examination) and the ESS were completed separately by subjects and CRs to assess the subject’s daytime sleepiness.

Results

Almost 60 % of subjects and CRs were not able to answer at least one question on the ESS. Despite the fact that all subjects complained of EDS, only 24 % of them had an abnormal ESS score (>10). Subjects rated their sleepiness lower (7.10?±?4.31) than their CR proxy did (9.70?±?5.14) (p?<?0.0001). In multivariate analysis, an increase in age and a decrease in cognitive status of the subjects appeared related to the difference in ESS between subject and CR.

Conclusions

The majority of older adults were not able to answer all of the ESS items. The ESS may underestimate sleepiness severity in older subjects. Despite EDS complaints in all subjects, only one quarter of them had a pathological ESS score.     

Negative association between self-reported jaw symptoms and apnea–hypopnea index in patients with symptoms of obstructive sleep apnea syndrome: a pilot study

Objectives

Prior to oral appliance therapy for snoring and obstructive sleep apnea syndrome (OSAS), patients are screened for jaw symptoms (e.g., pain). However, the presence of jaw symptoms in a large spectrum of OSAS patients remains unknown. This study aimed to assess the distribution of subjective jaw symptoms in patients with symptoms of OSAS.

Methods

Five hundred and eleven consecutive patients (66 female, 445 male; mean age 49.6?±?12.6 years) with clinical symptoms of OSAS were enrolled for cardiorespiratory evaluation. Self-administered questionnaires were used to assess jaw symptoms, tooth grinding and clenching during sleep, morning oral dryness, morning heartburn sensation, and pain in the neck and back.

Results

The mean apnea–hypopnea (AHI) index was 32.5?±?30.6 per hour of sleep. Nineteen percent of patients (n?=?96) reported at least one jaw symptom. The presence of jaw symptoms was more frequently reported by patients with AHI less than 15 (25 %) than those with AHI of 15 and more (15 %, p?=?0.012). In the crude analyses, jaw symptoms were associated with tooth grinding, tooth clenching, morning oral dryness, morning heartburn sensation, and neck/back pain. Multiple logistic regression analysis confirmed that jaw symptoms were associated with AHI less than 15 (odds ratio (OR) 1.99, p?=?0.009), tooth clenching (OR 1.79, p?=?0.006), morning oral dryness (OR 2.17, p?=?0.02), and neck/back pain (OR 1.99, p?=?0.005).

Conclusions

Jaw symptoms can be found in 19 % of patients with symptoms of OSAS and are more frequently reported in patients with lower AHI, a patient population for whom oral appliances are often prescribed.     

The prevalence and associated risk factors of sleep disorder-related symptoms in pregnant women in China

Purpose

The sleep disorder in pregnant women remains unfamiliar to perinatal care providers, resulting in lack of appropriate care. This study was designed to investigate the prevalence of sleep disorder-related symptoms in pregnant women and to identify the associated risk factors.

Methods

Married pregnant women were enrolled from their first trimester and followed up until delivery. Nonpregnant married healthy women were selected as controls. A survey questionnaire was administered to each of them.

Results

We successfully performed a survey to 1,993 pregnant women and 598 nonpregnant women. The overall prevalence of sleep disorder-related symptoms in pregnant women was significantly higher than the controls (56.1 vs. 29.9 %, P?<?0.05). There was higher prevalence of snoring (30.2 %), observed sleep apnea (1.1 %), mouth breathing (23.7 %), nocturnal arousal (46.5 %), insomnia (35.1 %), and daytime sleepiness (52.6 %) in pregnant women. There were no significant differences of the prevalence of bruxism (7.0 vs. 6.7 %), sleep talking (8.1 vs. 7.2 %), and sleep walking (0.4 vs. 0.2 %) between the two groups (P?>?0.05). Nocturnal sleep time (8.0?±?1.3 h) was less in the third trimester compared with the nonpregnant women (8.2?±?1.1 h) (P?<?0.05). Smoking (OR?=?3.39), drinking (OR?=?2.40), allergic rhinitis/asthma (OR?=?1.71), an obvious difference in neck circumference (OR?=?1.11), and waistline (OR?=?1.07) changes between the first and third trimesters were the risk factors for sleep disorder-related problems.

Conclusions

There is a high prevalence of sleep disorder-related symptoms in pregnant women. Our data may provide a baseline for prevention and treatment of sleep disturbances in pregnant women.     

Clinical and polysomnographic differences between OSAH patients with/without excessive daytime sleepiness

Purpose

The purpose of this study is to describe the clinical and polysomnographic differences found in patients diagnosed with obstructive sleep apnea–hypopnea (OSAH), with or without excessive daytime sleepiness (EDS) measured by the Epworth Sleepiness Scale (ESS).

Methods

A physical examination, ESS, and polysomnography were applied to all the participants, considering an ESS score of >10 to indicate EDS and an ESS score of ≥16 to indicate severe EDS. Univariate (chi-squared or Student’s t test) and multivariate (multiple logistic regression) analysis approaches were used. A value of p?<?.05 was considered statistically significant.

Results

The study covered 151 OSAH patients, including 129 (85 %) male patients, 66 (44 %) with EDS and 23 (21 %) with severe EDS. In the univariate analysis of demographic and polysomnographic variables, a comparison between patients without and with EDS showed that the latter had a larger neck circumference, maximum O₂ desaturation, and increased sleep time at <90 % O₂ saturation, with significant statistical differences. In the multivariate analysis, this statistical significance disappears. A comparison between patients without EDS and with severe EDS did not reveal differences in demographic or polysomnographic variables.

Conclusions

Patients with OSAH and ESD showed more hypoxemia, but we did not find significant differences between OSAH patients with or without EDS.     

Factors associated with excessive daytime sleepiness in patients with severe obstructive sleep apnea

Purpose

Although excessive daytime sleepiness (EDS) is one of the key symptoms of obstructive sleep apnea (OSA), associations between OSA and EDS have been inconsistent, even in patients with severe OSA. To that end, our goal was to investigate factors associated with EDS based on the Epworth Sleepiness Scale (ESS) score in a large clinical population with severe OSA (apnea–hypopnea index ≥30).

Methods

This cross-sectional study included 1,126 consecutive adult patients referred for their first in-laboratory polysomnogram for suspicion of OSA. All patients completed a routine questionnaire including demographics, race, co-morbidities, sleep history, ESS, short-form quality of life questionnaire-12 (SF-12), the Center for Epidemiologic Studies Depression scale, and medications used. Severe OSA was diagnosed in 498 patients. After excluding patients taking narcotics, hypnotics, benzodiazepines, antidepressants, or those with diagnosis of depression, 355 patients remained in the final analytic cohort. Patients were divided into quartiles based on the ESS and comparisons were made between the lowest quartile (ESS?≤?6; n?=?105) and highest quartile (ESS?≥?13; n?=?97).

Results

Compared to the ESS?≤?6 group, patients in the ESS?≥?13 group had a significantly higher 3 % oxygen desaturation index and a significantly lower oxygen saturation nadir during sleep (p?<?0.05). Moreover, patients with severe OSA in the highest quartile of ESS had higher depressive symptomatology.

Conclusions

In patients with severe OSA, intermittent hypoxemia and depressive symptoms are important contributing factors to EDS.     

Risk for obstructive sleep apnea in obese, nondiabetic adults varies with insulin resistance status

Purpose

Obstructive sleep apnea (OSA) is an increasingly common sleep disorder, especially among obese adults. Early identification of adults at risk for OSA would be of substantial benefit; however, the magnitude of the obesity epidemic requires that screening be performed judiciously. The study’s aim was to utilize questionnaires that assess OSA risk and symptoms to test the hypothesis that the most insulin-resistant subset of obese individuals is at highest risk for OSA.

Methods

Nondiabetic, overweight to obese volunteers underwent direct quantification of insulin sensitivity by measuring steady-state plasma glucose concentrations during the insulin suppression test. Insulin-sensitive and insulin-resistant individuals were administered the Berlin and STOP questionnaires to determine OSA risk status, and Epworth Sleepiness Scale (ESS) to evaluate daytime sleepiness. Fasting insulin and lipid/lipoprotein measurements were performed.

Results

Insulin-mediated glucose disposal differed threefold (p?<?0.001) between equally obese, insulin-resistant (n?=?22) and insulin-sensitive (n?=?14) individuals, associated with higher fasting insulin and triglyceride and lower high-density lipoprotein cholesterol (HDL-C) concentrations in insulin-resistant individuals. Fourteen (64 %) insulin-resistant as compared with 2 (14 %) insulin-sensitive individuals were found to be at high risk for OSA by both questionnaires (p?<?0.01). Whereas half of insulin-resistant individuals met the ESS criteria for excessive daytime sleepiness, only one insulin-sensitive individual did (p?=?0.011).

Conclusions

High risk for OSA and excessive daytime sleepiness is prevalent among the insulin-resistant subgroup of obese individuals. Surrogate estimates of insulin resistance based on fasting insulin, triglycerides, and/or HDL-C can be used to help identify those obese adults who would benefit most from OSA screening and referral for polysomnography.     

Prediction of obstructive sleep apnea syndrome in a large Greek population

Purpose

We aimed to evaluate the predictive value of anthropometric measurements and self-reported symptoms of obstructive sleep apnea syndrome (OSAS) in a large number of not yet diagnosed or treated patients. Commonly used clinical indices were used to derive a prediction formula that could identify patients at low and high risk for OSAS.

Methods

Two thousand six hundred ninety patients with suspected OSAS were enrolled. We obtained weight; height; neck, waist, and hip circumference; and a measure of subjective sleepiness (Epworth sleepiness scale??ESS) prior to diagnostic polysomnography. Excessive daytime sleepiness severity (EDS) was coded as follows: 0 for ESS????3 (normal), 1 for ESS score 4?C9 (normal to mild sleepiness), 2 for score 10?C16 (moderate to severe sleepiness), and 3 for score >16 (severe sleepiness). Multivariate linear and logistic regression analysis was used to identify independent predictors of apnea?Chypopnea index (AHI) and derive a prediction formula.

Results

Neck circumference (NC) in centimeters, body mass index (BMI) in kilograms per square meter, sleepiness as a code indicating EDS severity, and gender as a constant were significant predictors for AHI. The derived formula was: $ {\hbox{AHIpred}} = {\hbox{NC}} \times 0.{84} + {\hbox{EDS}} \times {7}.{78} + {\hbox{BMI}} \times 0.{91} - [{8}.{2} \times {\hbox{gender constant }}\left( {\hbox{1 or 2}} \right) + {37}] $ . The probability that this equation predicts AHI greater than 15 correctly was 78%.

Conclusions

Gender, BMI, NC, and sleepiness were significant clinical predictors of OSAS in Greek subjects. Such a prediction formula can play a role in prioritizing patients for PSG evaluation, diagnosis, and initiation of treatment.     

Mood disorders are highly prevalent in patients investigated with a multiple sleep latency test

Purpose

Excessive daytime sleepiness (EDS) is a debilitating symptom which occurs commonly in both primary sleep and mood disorders. The prevalence of mood disorders in patients with EDS, evaluated objectively with a mean sleep latency test (MSLT), has not been reported. We hypothesize that mood disorders are highly prevalent in patients being investigated for EDS. This study aims to report the prevalence of mood disorder in the MSLT population and investigate the association between mood disorder and objective and subjective scores of sleepiness.

Methods

A retrospective multicenter study of adults with a MSLT and Hospital Anxiety and Depression Score (HADS) identified over a 3-year period. The HADS is a validated questionnaire in detecting depression (HADS-D ≥ 8) and anxiety (HADS-A ≥ 11) in the sleep clinic population. Data collected included demographics, medical, and sleep study information. Mood disorder prevalence was compared to the general sleep clinic population. Correlation between measures of sleepiness and mood was performed.

Results

Two hundred twenty patients were included with mean age 41.1 ± 15.7 years, mean body mass index 28.6 kg/m² of whom 30% had anxiety (HADS-A > 11) and 43% depression (HADS-D > 8). Mean results for the cohort are ESS 13.7, mean sleep latency 11.5 min, HADS-A 8.2, and HADS-D 7. There was no significant correlation between objective sleepiness, as measured by the mean sleep latency, and either HADS-A (?0.006, p = 0.93) or HADS-D score (0.002, p = 0.98). There was, however, a weak correlation between subjective sleepiness, as measured by the ESS, and the mean sleep latency (?0.25, p < 0.01), HADS-A (0.15, p = 0.03), and HADS-D (0.2, p = 0.004). There was no significant association between diagnosis of hypersomnia disorders and presence of anxiety (p = 0.71) or depression (p = 0.83).

Conclusions

Mood disorders are highly prevalent in the MSLT population. There was a weak correlation found between subjective measures of sleepiness and mood disorders, but not between objective measures of sleepiness and mood disorders. Routine screening for mood disorders in patients with hypersomnolence should be considered.

     

The evaluation of excessive daytime sleepiness in taxi drivers

Excessive daytime sleepiness (EDS) is a common but underrecognized and preventable cause of traffic accidents. It creates a problem of particular importance for professional drivers. We performed the Epworth Sleepiness Scale (ESS) and questionnaire related to their history of traffic accidents to 118 professional taxi drivers to determine the EDS and its effects on driving performance in taxi drivers. There were 58 (49.2%) subjects with loud snoring, 8 (5.9%) subjects with cardinal symptoms due to obstructive sleep apnea syndrome (OSAS) and 28 (23.7%) subjects with ESS > or =10 in the group of taxi drivers. Eighty (67.8%) drivers had been involved in a traffic accident. We found a significant relation between the number of traffic accident and EDS, witnessed apnea, cardinal symptom related to OSAS but not with snoring. The present data that sleepiness is a common symptom in taxi drivers and may be related to traffic accident.     

Personality profiles in patients with obstructive sleep apnea

Objective

The Minnesota Multiphasic Personality Inventory (MMPI) responses between snorers and obstructive sleep apnea (OSA) may be different. Thus, we compared the MMPI responses between snorers and OSA.

Design

A clinical-based cross-sectional survey.

Participants

This is a survey of 94 treatment-naive sleep-disordered breathing (SDB) subjects.

Method

Clinical information, body mass index (BMI), 36-item Short Form Health Survey, the Turkish version of the MMPI, Epworth sleepiness scale (ESS), fatigue scale, attention-deficit scale, and polysomnography were collected. All patients with OSA and snorers was accepted as individuals with SDB (AHI?>?0 events/h). The threshold of five apnea and hypopnea per hour of sleep was chosen to define both OSA and snorers. Disability profile is consisting of four or more MMPI clinical scale elevations.

Results

OSA patients compared to snorers have significantly higher absolute scores on hypochondriasis (Hs) (65.0?±?12.0 vs 58.4?±?7.9, p?=?0.01, respectively). OSA patients compared to snorers have significantly higher rate of clinical elevation on both psychopathic deviance (13.0 vs 0?%, p?=?0.03, respectively) and Hs (26.1 vs 3.3?%, p?=?0.01, respectively). People with disability profile has lower the quality of life, a higher score for inattention, a higher fatigue scores, and higher sleepiness scores. The quality of life and attention deficit and daytime sleepiness scores were associated with total MMPI absolute score in individuals with SDB in bivariate analyses.

Conclusion

Present study indicated that patients with OSAS compared to snorers displayed significantly more hyopchondriasis and psychopathic deviance personality characteristics. The daytime functions in individuals with sleep-disordered breathing may be influenced by the severity of psychopathology.     

Effects of surgically assisted rapid maxillary expansion on obstructive sleep apnea and daytime sleepiness

Purpose

The aim of the study was to evaluate the effects of surgically assisted rapid maxillary expansion (SARME) on obstructive sleep events and daytime sleepiness in adults with obstructive sleep apnea syndrome (OSAS).

Methods

Sixteen individuals (7 women/9 men) aged 40.2?±?10.2 (range, 24.4 to 62.2 years) with maxillary transverse deficiency and OSAS (respiratory disturbance index [RDI] greater than 5) confirmed with full-night polysomnography (PSG) underwent SARME to evaluate its efficiency for OSAS treatment.

Results

Several PSG parameters and the Epworth Sleepiness Scale (ESS) results were compared in selected individuals before and after they underwent SARME. An RDI reduction from 35.4?±?38.5 to 16.0?±?19.7 was found, corresponding to a mean decrease of 54.6 % (p?=?0.0013). A 56.2 % (33.23?±?39.5 to 14.5?±?19.4, p?=?0.001) decrease was found in the apnea-hypopnea index (AHI), in addition to decreases in the desaturation and microarousal rates, among other parameters. The ESS scores improved from 12.5?±?5.3 to 7.2?±?3.5 (p?<?0.001).

Conclusions

SARME promotes an improvement in OSAS symptoms; decreases the rates of respiratory disturbances; microarousal, and desaturation; and reduces daytime sleepiness.

     

Can we get more from the Epworth Sleepiness Scale (ESS) than just a single score?

Purpose

The Epworth Sleepiness Scale (ESS) is a widely used tool for measuring sleepiness. In addition to providing a single measure of sleepiness (a one-factor structure), the ESS also has the capacity to provide additional information about specific factors that facilitate sleep onset, including a person’s posture, activity and environment. These features of sleepiness are referred to as somnificity. This study evaluates and compares the fit of a one-factor structure (sleepiness) and three-factor structure (reflecting low, medium and high levels of somnificity) for the ESS.

Methods

All participants (a community sample N?=?356 and a clinical sample N?=?679) were administered the ESS. Confirmatory factor analysis was used to evaluate and compare the fit of one- and three-factor models of the ESS.

Results

In both samples, a three-factor structure (community sample adjusted X ²?=?2.95, root mean square error of approximation (RMSEA)?=?0.07, Comparative Fit Index (CFI)?=?0.95; clinical sample adjusted X ²?=?3.98, RMSEA?=?0.07, CFI?=?0.98) provided a level of model fit that was at least as good as the one-factor structure (community sample adjusted X ²?=?5.01, RMSEA?=?0.11, CFI?=?0.87; clinical sample adjusted X ²?=?8.87, RMSEA?=?0.11, CFI?=?0.92).

Conclusions

In addition to a single measure of sleepiness, the ESS can provide subscale scores which relate to three underlying levels of somnificity. These findings suggest that the ESS can be used to measure an individual’s overall sleep propensity as well as more specific measures of sleep propensity in low, moderate and high levels of situational somnificity.     

Subjective sleepiness and daytime functioning in bariatric patients with obstructive sleep apnea

Purpose

The purpose of this study was to evaluate associations between obstructive sleep apnea (OSA) severity and self-reported sleepiness and daytime functioning in patients considering bariatric surgery for treatment of obesity.

Methods

Using a retrospective cohort design, we identified 342 patients who had sleep evaluations prior to bariatric surgery. Our final sample included 269 patients (78.6 % of the original cohort, 239 females; mean age?=?42.0?±?9.5 years; body mass index?=?50.2?±?7.7 kg/m²) who had overnight polysomnography and completed the Epworth Sleepiness Scale (ESS) and the Functional Outcomes of Sleep Questionnaire (FOSQ). Patients' OSA was classified as none/mild (apnea–hypopnea index (AHI)?<?15, n?=?112), moderate (15?≤?AHI?<?30, n?=?77), or severe (AHI?≥?30, n?=?80). We calculated the proportion of unique variance (PUV) for the five FOSQ subscales. ANOVA was used to determine if ESS and FOSQ were associated with OSA severity. Unpaired t tests compared ESS and FOSQ scores in our sample with published data.

Results

The average AHI was 29.5?±?31.5 events per hour (range?=?0–175.8). The mean ESS score was 6.3?±?4.8, and the mean global FOSQ score was 100.3?±?18.2. PUVs for FOSQ subscales showed moderate-to-high unique contributions to FOSQ variance. ESS and global FOSQ score did not differ by AHI group. Only the FOSQ vigilance subscale differed by OSA severity with the severe group reporting more impairment than the moderate and none/mild groups. Our sample reported less sleepiness and daytime impairment than previously reported means in patients and controls.

Conclusions

Subjective sleepiness and functional impairment were not associated significantly with OSA severity in our sample of patients considering surgery for obesity. Further research is needed to understand individual differences in sleepiness in patients with OSA. If bariatric patients underreport symptoms, self-report measures are not an adequate substitute for objective assessment and clinical judgment when evaluating bariatric patients for OSA. Patients with severe obesity need evaluation for OSA even in the absence of subjective complaints.     

Epworth Sleepiness Scale scores and adverse pregnancy outcomes

Purpose

Snoring is associated with adverse pregnancy outcomes including gestational hypertensive disorders, gestational diabetes, and Cesarean deliveries. The purpose of this study was to assess whether excessive daytime sleepiness (EDS) assessed by Epworth Sleepiness Scale (ESS) increases the risk of these complications further.

Methods

Following institutional review board approval and informed consent, English-speaking women in the immediate postpartum period were systematically selected and recruited. Women answered a survey that included questions regarding symptoms of sleep-disordered breathing (SDB) using the multivariable apnea prediction index and excessive daytime sleepiness using ESS. Pregnancy and fetal outcomes were collected by review of medical records. Standard statistical analysis with multivariable logistic regression was performed. ESS was evaluated both as a continuous variable and with various cutoffs given that pregnant women are likely more sleepy at baseline than the general population.

Results

In patients who underwent planned Cesarean delivery, mean ESS was significantly higher than in those with uncomplicated vaginal delivery, even after adjusting for confounders (adjusted odds ratio (aOR), 1.08; 95 % CI, 1.01–1.15; p?=?0.02). There was no significant association between EDS (defined as ESS of >10) and gestational diabetes or gestational hypertensive disorders in snorers or non snorers. However, a significant association with gestational diabetes was found in patients with an ESS of >16 compared to those with an ESS of ≤16, even after multiple adjustments (aOR, 6.82; 95 % CI, 1.19–39.27), but the number of subjects in an ESS of >16 category was small.

Conclusions

There is an increased association between women with higher ESS and planned Cesarean delivery. Severe EDS was associated with gestational diabetes in pregnant women in a small sample size. Future studies in larger samples need to confirm the association of severe EDS and gestational diabetes and elucidate potential mechanisms of the links with adverse outcomes.     

Relation between traffic accidents and sleep apnea syndrome in truck drivers

Obstructive sleep apnea syndrome (OSAS) is a disorder that causes excessive daytime sleepiness. Falling asleep while driving most often occurs during driving on empty roads, long distance drives, and those drives requiring low motor activity, and causes traffic accidents. We aimed to investigate the frequency of OSAS in long distance truck drivers and to evaluate the relation between OSAS and traffic accidents. A questionnaire containing demographic features, health statuses, OSAS symptoms of truck drivers and information about their accidents was filled with face to face interview. Three hundred and sixteen, male, long distance truck drivers were accepted to the study. Of the major symptoms of OSAS, snoring in 52.8%, excessive daytime sleepiness in 25.6%, witnessed apnea in 9.8%, all three symptoms in 2.8% of the drivers was determined. Ninety four of 316 (29.7%) drivers stated that they had traffic accidents. Twenty eight (29.8%) of those accidents caused loss of life. Nineteen (20.2%) drivers with accidents stated that the cause of the accident was falling asleep while driving. Snoring was present in 78.9% of those who had accidents due to sleeping, whereas in 51.5% of those who had accidents with other causes. Neck circumference and years of driving were significantly higher in drivers with accidents than those without. Snoring was significantly higher in those with a neck circumference > or = 42 cm, body mass index > or = 30 and number of accidents > or = 2. As a conclusion, OSAS risk factors and symptoms are commonly present in truck drivers and increases the risk for traffic accidents.     

Effect of musculoskeletal pain on sleep architecture in patients with obstructive sleep apnea

Rationale

Obstructive sleep apnea and chronic musculoskeletal pain both affect sleep. Sleep architecture of patients suffering from both is largely unknown.

Objectives

This study seeks to define the sleep architecture of patients with chronic musculoskeletal pain and obstructive sleep apnea.

Methods

Patients with obstructive sleep apnea diagnosed by sleep study during the past 3 years were included. Patients with clinical documentation of chronic musculoskeletal pain constituted cases, while others were classified as controls.

Measurements

Demographics, clinical factors affecting sleep, medications affecting sleep, Epworth sleepiness scores, and polysomnographic parameters; total sleep time, sleep efficiency, sleep stages, rapid eye movement (REM) sleep onset, apnea–hypopnea index, arousal index, and periodic leg movements were recorded.

Results

There were 393 subjects: 200 cases (obstructive sleep apnea and chronic musculoskeletal pain) and 193 controls (obstructive sleep apnea alone). There was significant difference in total sleep time (274.5?±?62.5 vs. 302.2?±?60.1 min, p?=?0.0001), sleep efficiency (73.54?±?15.8 vs. 78.76?±?14.3 %, p?=?0.0003), and REM sleep onset (148.18?±?80.5 vs. 124.8?±?70.9 min, p?=?0.006). Subgroup analysis within the obstructive sleep apnea with chronic musculoskeletal pain group revealed that subjects had better total sleep time and sleep efficiency if they were on REM sleep affecting medications (suppressants and stimulants). Those on REM sleep suppressants slept 25.7 min longer and had 6.4 % more efficient sleep than those not on REM suppressants (p?=?0.0034 and p?=?0.0037).

Conclusion

Patients with obstructive sleep apnea and chronic musculoskeletal pain sleep not only significantly less but also with inferior sleep quality. Their REM sleep is also less in duration and its onset is delayed. Despite low TST and SE, these patients may not exhibit sleepiness.     

Angiotensin-converting enzyme gene polymorphism in north Indian population with obstructive sleep apnea

Background

A deletion of 287-bp Alu repeat of angiotensin-converting enzyme (ACE) insertion/deletion (I/D) gene is associated with hypertension.

Purpose

The aim of this study is to determine the frequency of ACE (I/D) polymorphism in patients with obstructive sleep apnea (OSA).

Methods

Genotyping of ACE (I/D) gene polymorphism and estimation of serum angiotensin-converting enzyme (SACE) activity were done in 813 subjects who underwent polysomnography. Of these, 395 were apneics and 418 were non-apneics.

Results

The frequencies of II genotype (OR = 1.8, 95 % CI 1.26–2.60, p?=?0.001) and I allele (OR = 1.4, 95 % CI 1.13–1.69, p?=?0.001) of ACE gene were found to be significantly increased in patients with OSA as compared to patients without OSA. Frequency of II genotype was significantly decreased (OR = 0.46, 95 % CI 0.28–0.77, p?=?0.003) in OSA patients with hypertension. In contrast, the frequencies of ID (OR?=?1.80, 95 % CI 1.08–2.99, p?=?0.024) and DD genotypes (OR?=?2.15, 95 % CI 1.30–3.57, p?=?0.003) were significantly increased in this group. The activity of SACE was significantly decreased in the apneic group as compared to the non-apneic group (OR?=?0.99, 95 % CI 0.98–1.00, p?=?0.04).

Conclusions

The findings suggest that II genotype confers susceptibility towards development of OSA whereas DD genotype confers susceptibility towards hypertension irrespective of OSA.     

Actigraphic assessment of sleep in chronic obstructive pulmonary disease

Purpose

Previously, sleep in chronic obstructive pulmonary disease (COPD) has been objectively investigated only by lab-based polysomnography. The main purpose of this study was to evaluate sleep quality in COPD patients in their home environment using actigraphy. We also investigated the factors associated with sleep impairment and the relationship between objective and subjective sleep quality and daytime somnolence in these patients.

Methods

Twenty-six patients with moderate to very severe COPD and 15 controls were studied by actigraphy for at least 5 days. Subjective sleep quality was evaluated by the Pittsburgh Sleep Quality Index and daytime sleepiness by the Epworth Sleepiness Scale (ESS). Dyspnea was quantified by the modified Medical Research Council (MMRC) scale.

Results

COPD patients showed increased sleep latency (p?=?0.003), mean activity (p?=?0.003), and wake after sleep onset (p?=?0.003) and reduced total sleep time (TST; p?=?0.024) and sleep efficiency (p?=?0.001), as compared to controls. In patients, severity of dyspnea was correlated with sleep activity (r?=?0.41; p?=?0.04) and TST (r?=??0.46; p?=?0.02) and multiple regression analysis showed that MMRC score was the best predictor of TST (p?=?0.02) and sleep efficiency (p?=?0.03). Actigraphy measures during daytime were not significantly different between patients and controls. Subjective sleep quality was poorer in patients than controls (p?=?0.043). ESS scores were not significantly different between the two groups. Actigraphy measures were not correlated with subjective sleep quality or daytime somnolence in both groups.

Conclusions

Nocturnal sleep is markedly impaired in stable COPD patients studied by actigraphy in their home environment and this impairment is related to severity of dyspnea.     

Excessive daytime sleepiness in late pregnancy may not always be normal: results from a cross-sectional study

Purpose

Many changes that normally occur during pregnancy disrupt sleep and may lead to excessive daytime sleepiness (EDS). However, given that pregnancy may also predispose to the development of sleep-disordered breathing (SDB), we sought to investigate whether EDS may be associated with snoring, gasping, or apneas, further suggesting SDB.

Methods

A cross-sectional survey of women in the immediate postpartum period was conducted. Participants answered questions from the multivariable apnea prediction index regarding snoring, gasping, and witnessed apneas in the last 3 months of pregnancy. Participants were also asked to answer Epworth Sleepiness Scale (ESS) questions, and a score 0–24 was calculated (>10 considered abnormal). Medical history and medication use were obtained both by history and review of the medical record.

Results

Out of 1,000 women recruited, 990 women answered the ESS questionnaire completely. Mean prepregnancy body mass index (BMI) was 26.1?±?6.2 with 21.7 % of the sample having a prepregnancy BMI ≥30. Mean ESS score was 7.1?±?3.9, and 1.7 % of the total sample scored 16 or greater. ESS increased significantly with age, BMI, and neck circumference. All three symptoms of SDB were associated with higher mean ESS scores. In a multiple linear regression analysis, loud snoring, gasping, and apneas were statistically significant independent predictors of mean ESS score.

Conclusions

EDS measured by ESS is a common finding in pregnancy. Snoring, gasping, and apneas appear to be independent predictors of mean ESS scores.     

Effects of Exercise Training on Sleep Apnea: A Meta-analysis

Background

Several studies have shown a favorable effect of supervised exercise training on obstructive sleep apnea (OSA). This meta-analysis was conducted to analyze the data from these studies on the severity of OSA (primary outcome) in adults. Secondary outcomes of interest included body mass index (BMI), sleep efficiency, daytime sleepiness and cardiorespiratory fitness.

Methods

Two independent reviewers searched PubMed and Embase (from inception to March 6, 2013) to identify studies on the effects of supervised exercise training in adults with OSA. Pre- and postexercise training data on our primary and secondary outcomes were extracted.

Results

A total of 5 studies with 6 cohorts that enrolled a total of 129 study participants met the inclusion criteria. The pooled estimate of mean pre- to postintervention (exercise) reduction in AHI was ?6.27 events/h (95 % confidence interval [CI] ?8.54 to ?3.99; p < 0.001). The pooled estimates of mean changes in BMI, sleep efficiency, Epworth sleepiness scale and VO₂ peak were ?1.37 (95 % CI ?2.81 to 0.07; p = 0.06), 5.75 % (95 % CI 2.47–9.03; p = 0.001), ?3.3 (95 % CI ?5.57 to ?1.02; p = 0.004), and 3.93 mL/kg/min (95 % CI 2.44–5.42; p < 0.001), respectively.

Conclusions

This meta-analysis shows a statistically significant effect of exercise in reducing the severity of sleep apnea in patients with OSA with minimal changes in body weight. Additionally, the significant effects of exercise on cardiorespiratory fitness, daytime sleepiness, and sleep efficiency indicate the potential value of exercise in the management of OSA.