Nighttime oxygen desaturation and symptoms of sleep-disordered breathing in long-stay nursing home residents

BACKGROUND: Sleep-disordered breathing (SDB) is common in older adults and has been implicated as a cause of decreased quality of life and even death. Sparse data exist on SDB in the nursing home setting. The authors evaluated SDB (using attended nocturnal pulse oximetry) in nursing home residents with daytime sleepiness and nighttime sleep disturbance. METHODS: Pulse oximetry was used to estimate the prevalence of nighttime oxygen desaturation in 109 long-stay nursing home residents (mean [standard deviation] age = 86.2 [9.2] years; 74% women). Pulse oximetry findings were compared to a structured observational measurement of symptoms of SDB, the Observational Sleep Assessment Instrument. Seventy-one participants had concurrent wrist actigraphy to estimate total sleep time during oximetry recording. RESULTS: Using the oxygen desaturation index (ODI; average number of oxygen desaturations 4% or more below the baseline level per hour), the authors found that 40% of the residents had abnormal ODI (ODI more than 5, which is suggestive of SDB). Of all observational variables assessed, only loud breathing during sleep was significantly correlated with ODI (r =.284; p =.003). When ODI was adjusted for estimated total sleep time, higher adjusted ODI was associated with higher body mass index (kg/m(2)). CONCLUSIONS: Abnormal ODI is common in nursing home residents. Observed loud breathing at night and high body mass index may suggest that further assessment of SDB is indicated. Future research should determine the importance of SDB and abnormal nocturnal oxygen desaturation on functioning and quality of life in nursing home residents.     

Prevalence of snoring and sleep-disordered breathing in a student population

INTRODUCTION: The prevalence of snoring and sleep-disordered breathing (SDB) in young adults in Southeast Asian countries is unknown. We aim to determine the symptoms and prevalence of SDB in a university student population using a questionnaire survey followed by home sleep monitoring. METHODS: The Sleep and Health Questionnaire (a modified version of the Specialized Centers of Research Sleep Questionnaire, translated into Chinese) was distributed to all first-year students (1,306 male and 1,757 female) enrolled in the Chinese University of Hong Kong. Subsequently, those students who returned the questionnaires were randomly chosen to undergo portable home sleep monitoring using the MESAM IV device (Madaus Medizin-Elektronik; Freiburg, Germany). RESULTS: A total of 1,910 replies were obtained from 3,063 questionnaires sent by mail (response rate, 62.4%). The female to male ratio was 1.8:1, with mean age of 19.4 years (SD, 1.3 years) and mean body mass index (BMI) of 20.0 (SD, 2.5). Overall, 25.7% of subjects reported snoring; 10.7% and 42.1% reported impaired performance ability and daytime sleepiness, respectively. Of the 88 subjects who underwent overnight sleep monitoring, 66 subjects (75%) were snorers and 8 subjects (9%) snored > 10% of the night. Male subjects had a higher BMI (p < 0.001) and tended to snore more often than female subjects (p = 0.06). Subjects with an oxygen desaturation index (ODI) > or = 3 had a BMI > 22 (p < 0.05). On sleep study, nine subjects (10.2%) and two subjects (2.3%) had a respiratory disturbance index (RDI) > or = 3 and an RDI > or = 5, respectively, associated with self-reported sleepiness, giving a minimum estimated prevalence of SDB as 0.1% (RDI > or = 5) in the study population. There was no correlation between recorded snoring with either RDI or self-reported sleepiness. Questionnaire responses, neck circumference, and alcohol consumption did not predict the occurrence of SDB. CONCLUSION: Snoring was prevalent, while SDB was uncommon in this student population. However, snoring and self-reported symptoms by questionnaire were poor predictors for SDB. Male gender showed a trend as an independent predictor for snoring, but not for SDB.     

Sleep disordered breathing in the elderly

Sleep disordered breathing (SDB), i.e., obstructive, central or mixed sleep apneas, has been recognized as a common occurrence in the elderly. Aging is per se associated with a decrease in the quality of sleep; SDB may further disrupt the sleep architecture in older subjects. The prevalence of obstructive sleep apnea (OSA) increases with aging; available studies report prevalence rates of 11-62%. Furthermore, OSA has been associated with increased mortality in older adults. Central apneas and periodic breathing occur with increased frequency either in subjects with neurological disorders such as infarction, tumor, sequelae of infection, diffuse encephalopathies, or in chronic heart failure. Patients with cerebrovascular disease (stroke, or transient ischemic attacks) have a markedly high prevalence of SDB, mainly OSA. In these patients, SDB is associated with a poorer functional prognosis at 3 and 12 months after the acute event, and a higher mortality. The clinical impact of SDB on cognitive function appears to be modest in patients without dementia, although there is a moderate increase in daytime sleepiness. In Alzheimer's disease (AD) however, SDB occurs more frequently than in non-demented older subjects, and its severity is correlated with the degree of cognitive impairment. The hypothesis of a causal relationship between AD and SDB remains a subject of controversy. The possibility of SDB should be considered in the elderly in the differential diagnosis of "reversible dementias", increased daytime sleepiness, or unexplained right-sided heart failure.     

Prevalence of snoring and sleep-disordered breathing in a group of commercial bus drivers in Hong Kong

Objectives: To assess the prevalence of sleep‐­disordered breathing (SDB) and its associated symptoms in a group of commercial bus drivers in Hong Kong. Methods: Two hundred and sixteen of 410 bus drivers from three different shifts were interviewed with the Sleep & Health Questionnaire (SHQ) and the Epworth sleepiness scale (ESS) at a Hong Kong bus depot. Seventeen subjects from each shift were then randomly selected for at‐home sleep study using the Mesam IV device (Madaus Medizin?Elektronik, Freiburg, Germany). Results: There were 207 men and nine women (mean age 42.4 ± 7.5 years; body mass index (BMI) 25.4 ± 4.5 kg/m²; ESS 5.3 ± 4.2). From the SHQ it was discovered that: (i) daytime sleepiness was reported by 87 subjects (40%), (ii) snoring ≥ 3 times per week was reported by 80 subjects (37%), (iii) witnessed apnoea was reported by 17 subjects (7.9%) and (iv) 29 subjects (13.4%) reported having fallen asleep during driving. Among the 51 subjects who underwent the at‐home sleep study: (i) 31 subjects (61%) had respiratory disturbance index (RDI) ≥ 5 per hour of sleep, (ii) 21 subjects (41%) had RDI ≥ 10 per hour of sleep, (iii) 12 subjects (24%) had RDI ≥ 15 per hour of sleep and (iv) 35 subjects (68.6%) snored objectively ≥ 10% of the night. Ten subjects (20%) had RDI ≥ 5 and sleepiness at work, while five subjects (9.8%) had RDI ≥ 5 and ESS > 10. No significant differences were noted in the SHQ responses, ESS, objective snoring or RDI among the three groups. Multiple regression analysis showed that BMI and witnessed apnoea were the only positive independent predictors of RDI. Conclusions: This study showed a high prevalence of objective snoring and SDB in a group of commercial bus drivers. Neither self‐reported sleepiness nor the ESS could identify subjects with SDB. (Intern Med J 2002; 32: 149?157)     

Continuous positive airway pressure reduces subjective daytime sleepiness in patients with mild to moderate Alzheimer's disease with sleep disordered breathing

OBJECTIVES: Studies have reported that 33% to 70% of patients with Alzheimer's disease (AD) have sleep-disordered breathing (SDB). Continuous positive airway pressure (CPAP) treatment has been shown to reduce daytime sleepiness and improve health-related quality of life in nondemented older people with SDB. The effect of therapeutic CPAP treatment on daytime sleepiness in patients with mild-moderate AD with SDB was assessed. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Patients' home and the University of California San Diego, General Clinical Research Center, J. Christian Gillin Laboratory of Sleep and Chronobiology. PARTICIPANTS: Thirty-nine community-dwelling elderly patients with mild-moderate probable AD with SDB. INTERVENTION: Patients were randomly assigned to receive 6 weeks of therapeutic CPAP or 3 weeks of sham CPAP followed by 3 weeks of therapeutic CPAP. MEASUREMENTS: Epworth Sleepiness Scale (ESS) was administered at baseline, 3 weeks, and 6 weeks. Changes in daytime sleepiness in subjects who received optimal therapeutic CPAP were compared with changes in the sham CPAP group. RESULTS: Within the therapeutic CPAP group, ESS scores were reduced from 8.89 during baseline to 6.56 after 3 weeks of treatment (P=.04) and to 5.53 after 6 weeks of treatment (P=.004). In the sham CPAP group, there was no significant difference after 3 weeks of sham CPAP but a significant decrease from 7.68 to 6.47 (P=.01) after 3 weeks of therapeutic CPAP. CONCLUSION: These data provide evidence of the effectiveness of CPAP in reducing subjective daytime sleepiness in patients with AD with SDB.     

The effect of race and sleep-disordered breathing on nocturnal BP "dipping": analysis in an older population

STUDY OBJECTIVES: BP normally drops (or "dips") by approximately 10% at nighttime; however, in a number of illnesses there is an increased amount of "nondipping" of nocturnal BP. This study examined whether nondipping in older African Americans and older white subjects is related to the presence of sleep-disordered breathing (SDB) and hypertension. DESIGN: Prospective study with a convenience sample. SETTING: All data were collected in the subjects' homes. PARTICIPANTS: Seventy self-defined African Americans with complaints of snoring or excessive daytime sleepiness, and 70 age-matched and gender-matched white subjects. Measurements and results: Sleep was recorded for 2 nights, with 1 night of oximetry. BP was recorded on a separate 24-h period. African Americans had higher dipping ratios than white subjects even after accounting for covariates such as respiratory disturbance index (RDI), oxygen desaturation index (ODI), body mass index, and average 24-h mean arterial pressure (p = 0.025). Higher values of RDI (R(2) = 0.0686, p = 0.021) and ODI (R(2) = 0.042, p < 0.03) were correlated with higher dipping ratios in both African Americans and white subjects. However, there was a three-way interaction such that higher RDIs were correlated primarily with nondipping in African Americans receiving antihypertensive medication (R(2) = 0.0373, p = 0.022). CONCLUSIONS: These results demonstrated that African Americans tend to be "nondippers," while white subjects tended to be "dippers." This nondipping was not a result of weight, gender, or of having SDB. The analyses also confirmed that, in both races, the dipping ratio was greatest in those with SDB and hypertension. The third hypothesis, that RDI would be greatest in the nondipping hypertensive subjects, was true only for the African Americans.     

Relation of measures of sleep-disordered breathing to neuropsychological functioning

Sleep-disordered breathing (SDB) has been associated with neuropsychological (NP) deficits. The extent to which such effects are attributable to unmeasured confounders or selection biases, or are manifest across a range of SDB is unclear. The relationship of SDB with a broad range of NP functions was examined in 100 volunteers with a spectrum of SDB and without underlying comorbidity. Factor analysis suggested that the NP tests could be summarized as four constructs: declarative memory, signal discrimination, working memory, and set shifting. These factors plus vigilance were dependent variables. Independent variables were age, the respiratory disturbance index (RDI), a sleepiness score, the arousal index, and sleep-associated hypoxemia. Factors "declarative memory" (measuring 25% of the common variance, alpha = 0.95), "signal discrimination" (10% variance, alpha = 0.70), and "working memory" (9% variance, alpha = 0.52) were each significantly, linearly predicted by hypoxemia and/or the RDI, with no evidence for significant threshold effects. SDB measures accounted for 4-6% of the variance in NP constructs. In contrast, sleepiness best predicted vigilance. Thus, adverse exposures (hypoxemia or RDI) during sleep may negatively influence NP functions in a dose-response relationship, and, other than vigilance, these effects may not be directly attributable to sleepiness.     

Associations of symptoms of sleep apnea with cardiovascular disease, cognitive impairment, and mortality among older Japanese-American men.

OBJECTIVES: To examine the association between symptoms of sleep apnea and prevalent cardiovascular disease, cognitive impairment, and subsequent 3-year mortality. DESIGN: A longitudinal study. SETTING: Participants lived in the community on Oahu, Hawaii. PARTICIPANTS: A total of 2905 older Japanese-American men participating in the fourth examination of the Honolulu Heart Program cohort study from 1991-1993, which is the baseline for the Honolulu-Asia Aging Study of dementia. MEASUREMENTS: Self-reported snoring, daytime sleepiness, and breathing pauses; diagnosed cardiovascular disease and dementia; cognitive functioning and vital status approximately 3 years later. RESULTS: More than 12% of the participants reported that they often or always snored loudly, and 8% reported being sleepy most of the day. Fewer than 2% reported that they stop breathing when sleeping, and this was found more frequently among habitual snorers (7%, P < .001) and those sleepy during the day (5%, P < .001). The prevalence of habitual snoring declined in the older age groups, was higher among those with greater Body Mass Index scores, and was not associated with the reporting of daytime sleepiness, diagnosis of heart disease, stroke, dementia, or cognitive impairment. Daytime sleepiness was more prevalent at older ages and was associated with a higher prevalence of heart disease and with cognitive impairment and dementia, chronic obstructive pulmonary disease, and diabetes. Self-reported apnea was associated only with a history of pneumonia. Three-year mortality was not associated with these symptoms after adjusting for prevalent heart disease and cognitive impairment. CONCLUSION: Symptoms of sleep apnea are reported less frequently in older Japanese-American men. Excessive daytime sleepiness is associated with poor cognition and dementia, but whether it also is an indicator for sleep apnea in this age group remains unclear. Epidemiologic studies of sleep apnea in older adults will require polysomnography to determine accurately the correlates and consequences of this condition.     

Sleep disordered breathing and cognitive function in a retirement village population.

Sleep disordered breathing (SDB) may be associated with cognitive dysfunction in non-demented elderly people. A random sample of 96 retirement village residents were given both neuropsychological assessment and overnight sleep monitoring with a portable microprocessor based system (Vitalog PMS-8). Respiratory disturbance index (RDI) was calculated as the number of apnoeas and hypopnoeas per hour of sleep. RDI was not associated with 'memory', 'verbal', and 'motor' factors identified from the analysis of cognitive tests, but was associated with the 'cerebral efficiency' factor (R2 = 0.21, p less than 0.0001). Seventy-three subjects had repeat neuropsychological tests, median time to follow-up being 17 months. Baseline RDI did not predict changes in scores on the two factors identified from the second analysis. We conclude that mild to moderate disturbance of breathing during sleep is not associated with cognitive dysfunction in non-demented subjects.     

The impact of ageing and sex on the association between sleepiness and sleep disordered breathing

The aim of our study was to investigate age-related changes in sleepiness symptoms associated with sleep disordered breathing (SDB). Wisconsin Sleep Cohort participants were assessed using polysomnography, the Epworth Sleepiness Scale (ESS) and the multiple sleep latency test (MSLT). SDB was defined as an apnoea/hypopnoea index ≥15 events·h(-1), and sleepiness as ESS ≥10 and MSLT ≤5 min. Odds ratios were calculated using generalised estimating equations associating sleepiness with SDB, and conditional logistic regression examining changes in longitudinal sleepiness status (ESS only). Models were a priori stratified by sex. ESS was measured in 1,281 participants and MSLT in 998 at multiple time-points (ESS n=3,695; MSLT n=1,846). Significant interactions were found between SDB and age in males, but not females. The odds ratios modelled for sleepiness in a 40-yr-old male with SDB were significant compared to a male without SDB (ESS 2.1 and MSLT 2.9); however, these associations were not significant at 60 yrs of age. The within-subject odds ratio for sleepiness was also significant at 40 yrs of age (OR 3.4), but not at 60 yrs of age. The age-related reductions in the association between sleepiness and SDB may have clinical implications for the diagnosis and treatment of SDB in older people as sleepiness is often used as a therapeutic target.     

Sleep-disordered breathing and cognition in older women

OBJECTIVES: To investigate the association between objectively measured sleep‐disordered breathing (SDB) and cognitive impairment in community‐dwelling older women and to determine whether the apolipoprotein E (APOE) ?4 allele modifies this association. DESIGN: Cross‐sectional. SETTING: Participants' homes and two sites of the Study of Osteoporotic Fractures (SOF). PARTICIPANTS: Four hundred forty‐eight women with a mean age±standard deviation (SD) of 82.8±3.4. MEASUREMENTS: Participants completed the Mini‐Mental State Examination (MMSE), Trail Making Test Part B (Trails B), and polysomnography (PSG). SDB indices were the apnea–hypopnea index (AHI), the central apnea index (CAI), and oxygen saturation (SaO₂) nadir less than 80%. APOE ?4 was determined for a subset of 242 women. Cognitive impairment was defined as 1.5 SDs or more from the sample mean on either cognitive test (MMSE or Trails B). RESULTS: All SDB indices were associated with cognitive impairment according to the MMSE (AHI (per SD, odds ratio (OR)=1.4, 95% confidence interval (CI)=1.03–1.9), AHI of ≥30 (OR=3.4, 95% CI=1.4–8.1), SaO₂ nadir <80% (OR=2.7, 95% CI=1.1–6.6), and CAI (per SD, OR=1.4, 95% CI=1.1–1.7)). Weaker, nonsignificant associations emerged between SDB and Trails B. In women who completed genotyping, each SD increase in AHI was associated with 70% greater odds of cognitive impairment according to the MMSE (OR=1.7, 95% CI=1.2–2.6). Women with the ?4 allele had a nearly five times greater odds of impairment (per SD, OR=4.6, 95% CI‐1.0–20.7); the association was smaller and nonsignificant in women without the ?4 allele (per SD, OR=1.5, 95% CI‐0.9–2.4; P for interaction=.08). CONCLUSION: SDB is an important risk factor for cognitive impairment in older women, especially those with the APOE ?4 allele. Mechanisms linking these disorders need to be identified.     

Sleep disordered breathing in primary care medicine

Primary care medicine plays a key role in the delivery of health care. Sleep disorders medicine is a new specialty and standard medical school curricula do not contain any or only very little training in sleep medicine. Unrecognized and therefore untreated sleep disorders account for a large loss of human life and socio-economic damage. Recognition of sleep disorders, in particular sleep-disordered breathing at the primary care level is thus a major element in health care delivery. The objective of this study was to assess the occurrence of the risk of sleep-disordered breathing (SDB) in a large primary care population. 852 primary care patients received a validated questionnaire which contained items based on signs and symptoms of SDB, periodic limb movement disorder (PLMD), and insomnia. A polygraphically validated algorithm was used to identify patients with a high suspicion of having sleep disordered breathing. Based on this algorithm 20% of the study participants had a high risk for SDB, 18.5% of PLMD and 25% of insomnia. Most commonly daytime sleepiness and fatigue was associated in patients with a positive likelihood of SDB, PLMD, and insomnia. Fifty percent of all primary care patients reported to snore while 31% of snorers reported to snore every night. SDB was twice as common in men than in women and associated with a significantly higher body mass index. A popular validated scale to assess the degree of daytime sleepiness, the Epworth sleepiness scale, was not always useful to document the degree of daytime sleepiness. We conclude that SDB, PLMD, and insomnia are very frequent sleep disorders in primary care patients yielding the need to include assessment of these sleep disorders in the medical history of primary care physicians.     

Assessment of sleep studies in myotonic dystrophy

Myotonic dystrophy (MD) is the commonest adult muscular dystrophy and is associated with respiratory muscle weakness. The role of screening sleep studies is unclear in MD. We prospectively evaluated polysomnography/overnight oximetry in a group of MD patients and related this to the daytime respiratory function in an attempt to evaluate the usefulness of screening sleep studies. Twenty-five patients with type I MD [15 males; mean age (SD) 40.0 (10.9) years] who had at least one symptom suggestive of nocturnal hypoventilation were included in the study. We performed spirometry, maximal inspiratory and expiratory mouth pressures, sniff nasal inspiratory pressure, arterial blood gases and polysomnography or overnight oximetry. Excessive tiredness and sleepiness were the most common presenting symptoms. Prevalence of sleep related breathing disorder (SRBD) was 36%. FVC was found to be normal in 33% of subjects with significant SRBD. Mouth pressures were reduced more than FVC, even in patients with normal overnight oxygen saturation. Of all the daytime measures, FVC correlated best with arterial carbon dioxide tension (r = -0.7). Sleep studies were useful to identify a small group of myotonic dystrophy patients (12%, three out of 25 in our series) with SRBD that would have been missed with routine daytime assessments. Targeted sleep monitoring in patients who are older, with multiple symptoms suggestive of SRBD, especially if they are overweight seems to be the best way to utilize the existing resources. Home unattended oximetry was well tolerated and offers a practical screening tool in this challenging patient group where excess daytime sleepiness is often due to causes other than SRBD.     

Metabolic disturbances in obesity versus sleep apnoea: the importance of visceral obesity and insulin resistance

Obstructive sleep apnoea (OSA) is a very prevalent disorder particularly amongst middle-aged, obese men, although its existence in women as well as in lean individuals is increasingly recognized. Despite the early recognition of the strong association between OSA and obesity, and OSA and cardiovascular problems, sleep apnoea has been treated as a 'local abnormality' of the respiratory track rather than as a 'systemic illness'. In 1997, we first reported that the pro-inflammatory cytokines interleukin (IL)-6 and tumour necrosis factor-alpha (TNF alpha) were elevated in patients with disorders of excessive daytime sleepiness (EDS) and proposed that these cytokines were mediators of daytime sleepiness. Also, we reported a positive correlation between IL-6 or TNF alpha plasma levels and the body mass index (BMI). In subsequent studies, we showed that IL-6, TNF alpha, leptin and insulin levels were elevated in sleep apnoea independently of obesity and that visceral fat, was the primary parameter linked with sleep apnoea. The association of OSA with insulin resistance and diabetes type 2 has been confirmed since then in several epidemiological and clinical studies. Furthermore, our findings that women with polycystic ovary syndrome (PCOS, a condition associated with hyperandrogenism and insulin resistance) were much more likely than controls to have sleep disordered breathing (SDB) and daytime sleepiness support the pathogenetic role of insulin resistance in OSA. Other findings that support the view that sleep apnoea and sleepiness may be manifestations of a serious metabolic disorder, namely the Metabolic or Visceral Obesity Syndrome, include: obesity without sleep apnoea is associated with daytime sleepiness; PCOS and diabetes type 2 are independently associated with EDS after controlling for SDB, obesity and age; and increased prevalence of sleep apnoea in postmenopausal women, with hormonal replacement therapy associated with a significantly reduced risk for OSA. In conclusion, accumulating evidence provides support to our model of the bi-directional, feedforward, pernicious association between sleep apnoea, sleepiness, inflammation and insulin resistance, all promoting atherosclerosis and cardiovascular disease.     

Symptom burden of sleep-disordered breathing in mild-to-moderate congestive heart failure patients.

The symptom burden resulting from sleep-disordered breathing (SDB) in patients with mild-to-moderate congestive heart failure (CHF) is unclear. The current authors monitored 24-h activity levels and compared subjective and objective measures of daytime sleepiness in 39 CHF patients, New York Heart Association class 2-3, on optimal medication. A total of 22 patients were classified as SDB (apnoea/hypopnoea index (AHI) median (range) 22.3 (16.6-100) events.h-1), and 17 as no SDB (NoSDB; AHI 3.7 (0-12.3) events.h-1). SDB was defined as AHI>or=15 events.h-1. Patients were assessed by 24-h activity monitoring (actigraphy) for a period of up to 14 days, a single objective sleepiness test (Oxford Sleep Resistance test) and Epworth Sleepiness Scale. The duration of daytime activity was significantly shorter in the SDB group compared with the NoSDB group. The SDB group also had increased time in bed and poorer sleep quality, as shown by the fragmentation index. Objectively the SDB group when compared with the NoSDB group were significantly sleepier, subjectively the groups did not differ. The amount of napping was similar for both groups. Despite the lack of subjective symptoms of daytime sleepiness, congestive heart failure patients with sleep-disordered breathing were objectively sleepier during the day and had reduced daytime activity with longer periods in bed and poorer sleep quality when compared with those without sleep-disordered breathing.     

Polysomnographic and clinical correlates of behaviorally observed daytime sleep in nursing home residents

BACKGROUND: The causes of daytime sleepiness among nursing home residents have not been well recognized. This study examines clinical and polysomnographic factors that are associated with daytime sleepiness among nursing home residents. METHODS: One hundred seventy-four nursing home residents from eight nursing homes in Atlanta, Georgia, participated in the study. Demographic and clinical data were obtained from medical records and assessment of participants obtained by trained research staff. Daytime sleepiness was determined by behavioral sleep-wake observation performed every 15 minutes. Overnight polysomnography was performed in a subgroup of the sample. RESULTS: The mean +/- standard deviation age was 83.4 +/- 8.8 years, and 136 participants were women (78%). The mean percentage +/- standard deviation of behavioral observations with sleep (BOS%) was 19.5 +/- 13.3%. Participants who were able to ambulate independently had significantly lower BOS% (14.2 +/- 9.6 vs 21.2 +/- 6.0, p =.001). Mini-Mental State Examination score was negatively correlated with BOS% (rho = -.279, p =.001). Among 48 participants who had polysomnography, sleep latency, total sleep time, wake after sleep onset, and sleep efficiency were not associated with BOS%. There was a significant negative correlation between BOS% and percentage of time spent in rapid eye movement sleep (rho = -.367, p =.010). Linear regression analyses, with BOS% as the dependent variable, showed that percentage of time spent in rapid eye movement sleep was the only variable independently predicting BOS%. CONCLUSION: Absence of association between BOS% and nocturnal sleep suggests that the causes of daytime sleepiness and nocturnal sleep problems may not be related. This finding may have important implications for interventions that aim to reduce daytime sleepiness among nursing home residents.     

Self-Reported Daytime Sleepiness and Sleep-Disordered Breathing in Patients With Atrial Fibrillation: SNOozE-AF

BackgroundAtrial fibrillation (AF) management guidelines recommend screening for symptoms of sleep-disordered breathing (SDB). We aimed to assess the role of self-reported daytime sleepiness in detection of patients with SDB and AF.MethodsA total of 442 consecutive ambulatory patients with AF who were considered candidates for rhythm control and underwent polysomnography comprised the study population. The utility of daytime sleepiness (quantified by the Epworth Sleepiness Scale [ESS]) to predict any (apnea-hypopnea index [AHI] ≥ 5), moderate-to-severe (AHI ≥ 15), and severe (AHI ≥ 30) SDB on polysomnography was tested.ResultsMean age was 60 ± 11 years and 69% patients were men. SDB was present in two-thirds of the population with 33% having moderate-to-severe SDB. Daytime sleepiness was low (median ESS = 8/24) and the ESS poorly predicted SDB, regardless of the degree of SDB tested (area under the curve: 0.48-0.56). Excessive daytime sleepiness (ESS ≥ 11) was present in 11.9% of the SDB population and had a negative predictive value of 43.1% and a positive predictive value of 67.5% to detect moderate-to-severe SDB. Male gender (odds ratio [OR]: 2.3, 95% confidence interval [CI]: 1.4-3.8, P = 0.001), obesity (OR: 3.5, 95% CI: 2.3-5.5, P < 0.001), diabetes (OR: 2.3, 95% CI: 1.2-4.4, P = 0.08), and stroke (OR: 4.6, 95% CI: 1.7-12.3, P = 0.002) were independently associated with an increased likelihood of moderate-to-severe SDB.ConclusionsIn an ambulatory AF population, SDB was common but most patients reported low daytime sleepiness levels. Clinical features, rather than daytime sleepiness, were predictive of patients with moderate-to-severe SDB. Lack of excessive daytime sleepiness should not preclude patients from being investigated for the potential presence of concomitant SDB.     

Daytime sleepiness is associated with 3-year incident dementia and cognitive decline in older Japanese-American men

OBJECTIVES: To assess the longitudinal association between sleep disturbances (insomnia and daytime sleepiness) and incidence of dementia and cognitive decline in older men. DESIGN: Community-based longitudinal cohort study. SETTING: The Honolulu-Asia Aging Study of dementia that is linked to the Honolulu Heart Program's fourth examination, conducted 1991-1993, and the 3-year follow-up fifth examination, conducted 1994-1996. PARTICIPANTS: Two thousand three hundred forty-six Japanese-American men age 71 to 93 years who screened negative for prevalent dementia at baseline and were screened again for dementia incidence in a 3-year follow-up examination. MEASUREMENTS: Baseline self-reports of trouble falling asleep or early morning awakening (insomnia) and being sleepy during the day (daytime sleepiness); Cognitive Abilities Screening Instrument (CASI) scores from baseline and followup; clinical diagnosis of incident dementia; and other baseline measures including age, years of education, body mass index, depressive symptoms, and history of hypertension, heart disease, diabetes mellitus, asthma, and use of benzodiazepines. RESULTS: After adjusting for age and other factors, persons reporting excessive daytime sleepiness at baseline (8%) were twice as likely to be diagnosed with incident dementia than were those not reporting daytime sleepiness (odds ratio (OR)=2.19, 95% confidence interval (CI)=1.37-3.50) and about 40% more likely to have >or=9 point drop in their CASI score between examinations (OR=1.44, 95% CI=1.01-2.08). In contrast, insomnia was not associated with cognitive decline or incidence of dementia. CONCLUSIONS: Daytime sleepiness in older adults may be an early indicator of decline in cognitive functioning and onset of dementia.     

Women with Sleep Apnea Have Lower Levels of Sex Hormones

Background: Low levels of sex hormones, especially progesterone, are suspected as a risk factor for sleep-disordered breathing (SDB). Objective: To test the hypothesis that serum levels of progesterone, estradiol, and 17-OH progesterone are lower in those women with clinically significant SDB. Design: Clinical cohort of convenience. Setting: University Hospital Sleep Laboratory. Methods: We investigated sleep and breathing parameters and serum levels of sex hormones in 53 consecutive women (ages 24 to 72 years) being evaluated for symptoms of daytime sleepiness. Analysis of hormonal status by specific radioimmunoassays and fluorescence immunoassays was done from blood samples taken after an overnight polysomnography. Results: Across the cohort, taking account of age and cycle time or postmenopausal status, those with an apnea-hypopnea index (AHI) greater than 10/hrs of sleep had significantly lower levels of 17-OH progesterone, progesterone, and estradiol than those with an AHI less than 10. Conclusion: We conclude that reductions in female sex hormones are associated with an increased probability of SDB in women with daytime sleepiness.