Outcomes Data for Continuous Positive Airway Pressure Treatment: What Do We Really Know?

Obstructive sleep apnea is one of the most common chronic respiratory illnesses, causing daytime sleepiness and cognitive and cardiovascular morbidity. The most successful treatment has been with positive airway pressure (continuous positive airway pressure or bilevel positive airway pressure). It has been surprisingly difficult to demonstrate improvement in these outcomes with continuous positive airway pressure treatment. This may be because of difficulty quantifying the illness, and heterogeneity in pathophysiology and clinical presentations. This article reviews what has been proven about clinical outcomes, and what is likely if not completely proven.

Normal and Abnormal Sleep in the Elderly.

Sleep-related complaints are so common in older adults that it may be difficult to distinguish whether the complaint is a consequence of normal aging or a disease process. The elderly are more likely to have common medical problems that affect sleep, and the most common sleep problems, including sleep apnea and insomnia, are more prevalent in this demographic. This article briefly describes normal sleep in general, the clinical assessment of sleep complaints, and expected changes with aging, with an overview of the epidemiology of insomnia and sleep apnea in this age group.

Obstructive Sleep Apnea: Treatment with Positive Airway Pressure.

As in other adults, continuous positive airway pressure treatment for obstructive sleep apnea should be the mainstay of treatment. Benefits include improvements in sleepiness and quality of life, as well as improvements in hypertension control, arrhythmias, cardiovascular risk, and mortality. This article discusses issues in prescribing this treatment, including those related specifically to elderly individuals.

Sleep in the Elderly: Unanswered Questions.

Sleep normally changes with aging, with implications for healthy elderly individuals as well as for those with disease states. Less slow wave sleep (deep sleep) is expected, along with more awakenings, and a tendency toward earlier sleep times. Rapid eye movement sleep behavior disorder is seen primarily in elderly individuals, and it often represents the earliest sign of a chronic and progressive neurologic disease. Complaints of difficulty initiating and maintaining sleep (insomnia) become more common with aging. Irregular breathing with sleep also becomes more common, with an increased Apnea Hypopnea Index that may not always be clinically important.

Association Between Eyelid Laxity and Obstructive Sleep Apnea.

Importance: While much has been reported on the relationship between floppy eyelid syndrome and obstructive sleep apnea (OSA), the diagnostic criteria of floppy eyelid syndrome are often subjective and vague. Objective: To evaluate the association between OSA and quantitative markers of eyelid laxity or secondary ocular surface disease in a sleep clinic population. Design, Setting, and Participants: This investigation was a cross-sectional observational study at the Center for Sleep Medicine at Icahn School of Medicine at Mount Sinai. Participants were individuals referred for overnight polysomnography from March 1 to August 30, 2015. Main Outcomes and Measures: Eyelid laxity and ocular surface disease were assessed on bedside ophthalmologic examination. The presence and severity of OSA were determined from polysomnography results. Initial correlation between OSA and ocular surface and eyelid markers was calculated through bivariate linear regression analysis, and the association between ocular symptoms was obtained through bivariate ordered logistic regression. Analysis was repeated adjusting for known associations between OSA and sex, age, body mass index, and medical comorbidities through multivariable analysis. Results: In total, 201 individuals (402 eyes) were enrolled in the study. Their mean (SD) age was 53.2 (13.5) years, 43.3% (n = 87) were female, 56.7% (n = 114) were of white race/ethnicity, 26.9% (n = 54) were black/African American, 4.0% (n = 8) were Asian, 8.0% (n = 16) were multiracial or other, and 4.5% (n = 9) were of unknown race/ethnicity, with 21.9% (n = 44) of all individuals self-identifying as Hispanic and 75.1% (n = 151) self-identifying as non-Hispanic. After adjustment, no association was observed between OSA severity and an eyelid laxity score (regression coefficient, 0.85; 95% CI, -0.33 to 0.62; P = .40) or an ocular surface score (regression coefficient, 1.09; 95% CI, -0.32 to 0.29; P = .93). Through subset analysis, male sex was associated with a higher ocular surface score, while older age and diabetes were associated with a higher eyelid laxity score. Only one patient (0.5%) exhibited findings of floppy eyelid syndrome. Conclusions and Relevance: Among individuals referred for overnight polysomnography, quantitative markers of eyelid laxity were not associated with the presence or severity of OSA. Subset analysis suggests that prior studies may have been limited by confounding variables or the technique of identifying eyelid laxity.

Obstructive airway disease and obstructive sleep apnea: effect of pulmonary function.

This study sought to determine whether reduced pulmonary function in obstructive airway disease (OAD) is an independent risk factor for obstructive sleep apnea (OSA). This was a prospective observational study conducted at an outpatient pulmonary clinic. Adults with a known diagnosis of COPD/asthma were enrolled as OAD group. Family members without a history of COPD/asthma who accompanied these patients to the clinic were enrolled as a control group. The Berlin Questionnaire (BQ) was used to assess OSA risk in the OAD group and controls. Forced expiratory volume in 1 second (FEV(1) % predicted) was determined from spirometry. The subjects at high risk for OSA were referred for a full overnight polysomnogram (PSG). The prevalence of patients with a high risk of OSA was 55.2% in the OAD group, which was higher than in the controls (7.5%, p < 0.0001). OAD subjects had a higher body mass index (BMI) and larger neck circumference than controls (p < 0.01). There was no difference in FEV(1) % predicted between the OAD patients at high risk and low risk of OSA. On receiver operator curve (ROC) analysis, FEV(1) % predicted was not a significant predictor of high OSA risk. Using logistic regression, FEV(1) % predicted had no association with OSA risk. There was no correlation between FEV(1) % predicted and total apnea-hypopnea index (AHI), oxygen desaturation index, % time spent below oxygen saturation 90%, and mean oxygen saturation on multiple regression analysis. OSA appears to be common in patients with COPD or asthma in an urban outpatient pulmonary clinic. However, the high prevalence of OSA in OAD patients appears to be due to obesity, and reduced pulmonary function is not an independent risk factor for OSA.

Sleep in the intensive care unit.

Sleep is commonly disrupted in intensive care unit patients. The causes of this sleep disruption include the underlying medical illness itself, intensive care unit (ICU) environment, psychological stress, and effects of many medications and other treatments used to help those who are critically ill. The purpose of this review is to discuss the relevant literature in this regard, in order to improve the knowledge and recognition of this problem by health care providers. Also general and specific integrative steps to improving sleep of patients in the ICU is also described.

Disparities in obstructive sleep apnea and its management between a minority-serving institution and a voluntary hospital.

We assessed disparities in severity of obstructive sleep apnea (OSA) and associated comorbidities, as well as in provision of sleep medicine health care, between patients evaluated for OSA in a voluntary hospital (VH) primarily serving a middle-class population with health-care insurance and a city hospital-based minority-serving institution (MSI) largely treating lower income, uninsured, and indigent patients. A retrospective chart review of patients evaluated for OSA at the VH (n=200) and at the MSI (n=103) was performed. Despite similar age and apnea hypopnea index, MSI patients had a greater body mass index, higher daytime systemic blood pressure, more comorbid medical conditions, and a lower minimum sleep SaO2 than VH patients. Systemic hypertension, diabetes mellitus, asthma, and congestive heart failure were more prevalent in the MSI group. Forty-two percent of the MSI patients diagnosed with OSA failed to follow up for treatment compared with 7% in the VH group, p<0.001. Disparities in OSA-associated comorbid conditions, as well as in delivery of sleep medicine-related health care, were evident between the VH and MSI groups. These findings suggest that OSA may be an important factor contributing to socioeconomic-based differences in morbidity and mortality.

Smoking and sleep disorders.

Cigarette smoking is the most important cause of preventable disease, disability, and premature death in the United States. In addition to adverse effects on respiratory, cardiovascular, cerebrovascular, and other systems, accumulating evidence indicates that cigarette smoking may also increase morbidity by adversely affecting sleep. This article focuses on the effects of cigarette smoking, nicotine, and pharmacologic agents used for smoking cessation on neuronal systems regulating sleep and clinically apparent sleep disorders.

Sleep in the elderly. What is normal?

Sleep is a basic biologic function that changes with normal aging and in many pathologic states. Some of the changes with aging are so profound that it is difficult to separate normal aging from disease. The problem is made worse by the difficulty of recognizing many common sleep disorders. Complaints of poor sleep or daytime somnolence are common in all adults but are more prevalent in elderly individuals. This article addresses normal sleep and the changes expected with aging, and reviews the more common sleep diseases in the elderly population, such as insomnia, sleep-disordered breathing, periodic limb movements of sleep, and the rapid eye movement sleep-behavior disorder.