What Works for One May Not Work for Another: A New Warning for Modafinil.

Narcolepsy is a clinical syndrome of hypothalamic disorder characterized by several sleep-wake disorders. The most common features include daytime sleepiness associated with hallucinations (hypnagogic and hypnopompic hallucinations) at the transition time of sleep-wake time, cataplexy or sudden loss of muscle tone, and sleep paralysis. We present a case of a patient affected with both narcolepsy and postural orthostatic tachycardia syndrome (POTS). POTS is a rare disorder characterized by orthostatic intolerance and abnormal autonomic response while sustaining an upright posture. In this case report, we highlight the impact of POTS on the choice of pharmacotherapy for narcolepsy.

Average volume-assured pressure support for patients with obstructive sleep apnea with failed CPAP titration.

Objectives: Obstructive sleep apnea (OSA) is a common disease, often treated using continuous positive airway pressure (CPAP) therapy. In many cases, patients fail a CPAP titration study due to inadequate control of the apnea-hypopnea index (AHI, events/hour) or due to treatment-emergent central sleep apnea (TE-CSA). We report our experience using a mode of non-invasive ventilation for alternative treatment of these patients. Material and Methods: We reviewed records of adults who had OSA with AHI≥15 diagnosed on polysomnography (PSG) with failed CPAP titration and in whom titrations with average volume-assured pressure support (AVAPS) with auto-titrating expiratory positive airway pressure were performed. Results: Forty-five patients, age 57.9±13.1 y, 26 males, body mass index (BMI) 40.2±8.7kg/m2. Reasons for CPAP titration failure included: TE-CSA (25, 55.6%) and inadequate control of AHI at maximum CPAP of 20cm H2O (20, 44.4%). Changes noted from baseline PSG to AVAPS titration: AHI: 65.3±29.3 decreased to 22.3±16.1 (p<0.001). Median time SpO2 ≤88%: 63.7 to 6.9min (p<0.001). In 16 patients the AHI was reduced to <15 and in 16 additional patients the AHI was reduced to <30. Improvement in AHI was not related to gender, age, or opioid use, but was correlated with BMI: ∆AHI=12.2 - (1.4 * BMI); p=0.05. AVAPS resulted in improved sleep architecture: median N3 sleep increased: 1.4% to 19.6% total sleep time (TST) (p<0.001), and median R sleep increased: 6.4% to 13.6% TST (p<0.01). Discussion: For patients with OSA for whom CPAP titration failed, titration with AVAPS may be an effective treatment.

Use of average volume-assured pressure support as a therapeutic option in patients with central sleep apnea syndrome.

PURPOSE: Central sleep apnea (CSA) syndrome commonly occurs with other medical conditions such as congestive heart failure, opiate use, and brainstem disorders. Various treatment modalities have been used with varied effectiveness in an attempt to improve ventilation and reduce the apnea-hypopnea index (AHI) in patients with CSA. This study evaluated whether or not a bilevel positive airway pressure mode of noninvasive ventilation, average volume-assured pressure support (AVAPS) is effective in treating CSA. METHODS: This was a retrospective review of patients with CSA who underwent AVAPS titration studies at our institution. We included patients with CSA with apnea-hypopnea index (events/hour) (AHI) ≥ 15, and examined the effectiveness of AVAPS in reducing AHI, improving oxygenation parameters, and improving sleep architecture. RESULTS: There were 12 patients, with mean age 62.8 ± 11.5 years, body mass index (BMI) 33.5 ± 4.7 kg/m2, 8 men, and Epworth Sleepiness Scale 9.3 ± 4.9. Five patients had CSA attributed to opiate use, 4 patients had CSA with Cheyne-Stokes respiration, and 3 patients had primary CSA. The only significant change from baseline PSG was AHI reduction with AVAPS: 63.3 ± 19.1 to 30.5 ± 30.3 (p < 0.003). In 5 patients (42%), AHI was reduced to < 15 with AVAPS use. Improvement in AHI was not related to gender, BMI, opiate use, or age. Defining response to therapy as AHI reduced to < 15, we found that lack of hypertension was the only significant predictor of response (p = 0.045). No significant changes in sleep architecture between the two studies were found. CONCLUSION: AVAPS is an effective mode of treating CSA in a significant proportion of patients. More studies are needed to confirm these findings and determine what factors are associated with response to therapy.

CPAP adherence is associated with reduced inpatient utilization among older adult Medicare beneficiaries with pre-existing cardiovascular disease.

STUDY OBJECTIVES: To examine the impact of adherence to continuous positive airway pressure (CPAP) therapy on health care utilization among a nationally representative and sample of older adults with multiple morbidities and pre-existing cardiovascular disease and subsequently diagnosed with obstructive sleep apnea in the United States. METHODS: Our data source was a random 5% sample of Medicare administrative claims data. All participants (n = 1,921) were of age ≥ 65 years, diagnosed with cardiovascular disease and obstructive sleep apnea, and subsequently began treatment with CPAP between 2009-2013. Based on the number of CPAP machine charges, individuals were categorized as low, partial, or high adherers (ie, < 4, 4-12, and > 12 CPAP charges, respectively). The impact of CPAP adherence status on health care utilization was assessed across multiple points of service, including outpatient encounters, inpatient stays, emergency department visits, and prescription fills over 24 months following CPAP initiation. RESULTS: Significant differences in demographic and comorbid disease characteristics were observed between low adherers (n = 377), partial adherers (n = 236), and high adherers (n = 1,308). After adjusting for covariates and relative to low adherers, high adherers demonstrated reduced inpatient visits (hazard ratio 0.75; 95% confidence interval 0.57, 0.97). CONCLUSIONS: In this nationally representative sample of older Medicare beneficiaries with multiple morbidities and relative to low adherers, high adherers demonstrated reduced inpatient utilization. CITATION: Wickwire EM, Bailey MD, Somers VK, et al. CPAP adherence is associated with reduced inpatient utilization among older adult Medicare beneficiaries with pre-existing cardiovascular disease. J Clin Sleep Med. 2022;18(1):39-45.

Correction: What Works for One May Not Work for Another: A New Warning for Modafinil.

[This corrects the article DOI: 10.7759/cureus.27287.].

Enhancing motor learning in people with stroke via memory reactivation during sleep.

PURPOSE: Investigate the use of repetitive delivery of task-related auditory cues, known as targeted memory reactivation (TMR), throughout a 1-hour daytime nap to enhance motor learning in individuals with chronic stroke. RESEARCH METHOD: Participants with a history of stroke at least 6 months prior were recruited to perform a novel overhand throwing task to randomly appearing target locations using the nonparetic upper extremity immediately before and after a 1-hour daytime nap. Half of the participants received TMR during the nap. RESULTS: Participants who received TMR demonstrated a greater overall reduction in absolute and variable spatial errors relative to the NoTMR control group. Both groups demonstrated similar generalization of skill to 2 untrained variants of the trained task, but not to a novel untrained task. CONCLUSIONS: This study suggests that TMR may enhance motor learning after stroke. Future studies should investigate whether TMR can lead to improvements of the paretic upper extremity during clinically based rehabilitation interventions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Improving sleep medicine education among health professions trainees.

STUDY OBJECTIVES: Despite increasing recognition of its importance, sleep medicine education remains limited during medical training. We sought to assess the baseline knowledge of a group of health professions trainees and to determine whether an educational sleep medicine "boot camp" led to improvement in sleep medicine knowledge. METHODS: Participants attended a 2-day introduction to sleep medicine course designed for new sleep medicine fellows in July 2017 and 2018. Participants completed 2 validated sleep knowledge questionnaires (The Assessment of Sleep Knowledge in Medical Education and The Dartmouth Sleep Knowledge and Attitude Survey) prior to and at the conclusion of the course. RESULTS: A total of 21 health professions trainees including 14 sleep medicine fellows completed both presurveys and postsurveys. Baseline Assessment of Sleep Knowledge in Medical Education Survey score was 21.4 ± 3.4 out of 30 (71.4% ± 11.4%) and baseline Dartmouth Sleep Knowledge and Attitude Survey score was 16.1 ± 2.4 out of 24 (67.3% ± 9.9%). There was no difference in baseline scores between sleep medicine fellows and other health professions trainees. There was a statistically significant improvement in the Assessment of Sleep Knowledge in Medical Education Survey (2.9 ± 2.1 points, P = .004) and Dartmouth Sleep Knowledge and Attitude Survey (2.5 ± 3.0 points, P = .001) scores among all participants after the course, without a difference in degree of improvement among sleep medicine fellows compared to other health professions trainees. CONCLUSIONS: Our findings suggest that baseline sleep medicine knowledge is higher than previously reported among health professions trainees. An educational sleep medicine boot camp improved knowledge even in a group of learners with high baseline knowledge and interest in sleep medicine, including new sleep medicine fellows. CITATION: Wappel SR, Scharf SM, Cohen L, et al. Improving sleep medicine education among health profession trainees. J Clin Sleep Med. 2021;17(12):2461-2466.

CPAP adherence is associated with reduced risk for stroke among older adult Medicare beneficiaries with obstructive sleep apnea.

STUDY OBJECTIVES: To examine the impact of adherence to continuous positive airway pressure (CPAP) therapy on risk of stroke among a nationally representative sample of older adults with obstructive sleep apnea. METHODS: We performed a retrospective cohort study among Medicare beneficiaries aged ≥ 65 years who were newly diagnosed with obstructive sleep apnea and had initiated CPAP (2009-2013). Monthly indicators of CPAP adherence included charges for machines, masks, or supplies and were summed over a 25-month follow-up to create a CPAP adherence variable. Stroke was modeled as a function of CPAP adherence using generalized estimating equations. RESULTS: We found that 5,757 beneficiaries met the inclusion criteria and were included in the final sample. Of these, 407 (7%) experienced stroke. After adjusting for demographic and clinical characteristics, CPAP adherence was associated with a reduced risk of stroke (hazard ratio, 0.98; 95% confidence interval, 0.96-0.99) over 25 months, indicating a 2% reduction in risk of stroke for each month of CPAP adherence. When sensitivity analyses were performed to stratify results by time since the first CPAP charge, the protective effect remained significant for the 12- and 6-month but not the 3-month outcome models. CONCLUSIONS: In this national analysis of older adult Medicare beneficiaries with obstructive sleep apnea, CPAP adherence was associated with significantly reduced risk of stroke.

Diagnosed or prescribed only? A national analysis of initial evaluation and management of insomnia among older adult Medicare beneficiaries.

Study Objectives: To describe initial insomnia-related encounters among a national sample of Medicare beneficiaries, and to identify older adults at risk for potentially inappropriate prescription insomnia medication usage. Methods: Our data source was a random 5% sample of Medicare administrative claims data (2006-2013). Insomnia was operationalized as International Classification of Disease, Ninth Revision, Clinical Modification diagnostic codes. Insomnia medications included FDA-approved insomnia-related medication classes and drugs. Logistic regression was employed to identify predictors of being "prescribed only" (i.e., being prescribed an insomnia medication without a corresponding insomnia diagnosis). Results: A total of N = 60 362 beneficiaries received either an insomnia diagnosis or a prescription for an insomnia medication as their first sleep-related encounter during the study period. Of these, 55.1% (n = 33 245) were prescribed only, whereas 44.9% (n = 27 117) received a concurrent insomnia diagnosis. In a fully adjusted regression model, younger age (odds ratio (OR) 0.98; 95% confidence interval (CI) 0.98, 0.99), male sex (OR 1.15; 95% CI 1.11, 1.20), and several comorbid conditions (i.e., dementia [OR 1.21; 95% CI 1.15, 1.27] and anemia [OR 1.17; 95% CI 1.13, 1.22]) were positively associated with being prescribed only. Conversely, black individuals (OR 0.83; 95% CI 0.78, 0.89) and those of "other" race (OR 0.89; 95% CI 0.84, 0.94) were less likely to be prescribed only. Individuals who received care from a board-certified sleep medicine provider (BCSMP) were less likely to be prescribed only (OR 0.27; 95% CI 0.16, 0.46). Conclusions: Fewer than half of Medicare beneficiaries prescribed insomnia medications ever received a formal sleep-related diagnosis.

CPAP adherence reduces cardiovascular risk among older adults with obstructive sleep apnea.

STUDY OBJECTIVES: To examine (1) the impact of adherence to continuous positive airway pressure (CPAP) therapy on risk for cardiovascular (CVD) events among a nationally representative sample of older adults with obstructive sleep apnea (OSA), and (2) the heterogeneity of this effect across subgroups defined by race, sex, and socioeconomic status. METHODS: We conducted a retrospective cohort study among Medicare beneficiaries aged ≥ 65 years with OSA (2009-2013). Monthly indicators of CPAP adherence (charges for machines, masks, or supplies) were summed over 25 months to create a CPAP adherence variable. New CVD events (ischemic heart disease, cardiac and peripheral procedures) were modeled as a function of CPAP adherence using generalized estimating equations. Heterogeneity of the effect of CPAP on new CVD events was evaluated based on race, sex, and socioeconomic status. RESULTS: Among 5024 beneficiaries diagnosed with OSA who initiated CPAP, 1678 (33%) demonstrated new CVD events. Following adjustment for demographic and clinical characteristics, CPAP adherence was associated with reduced risk of new CVD events (hazard ratio 0.95; 95% confidence interval 0.94, 0.96) over 25 months. When analyses were stratified by time since the first CPAP charge, the protective effect remained significant for the 12- and 6-month, but not 3-month, outcome models. No significant differences were observed in the protective effect of CPAP based on race, sex, or socioeconomic status. CONCLUSIONS: In this national study of older adult Medicare beneficiaries with OSA, CPAP adherence was associated with greatly reduced risk for CVD events. This risk reduction was consistent across race, sex, and socioeconomic subgroups.

Which older adults receive sleep medicine specialty care? Predictors of being seen by a board-certified sleep medicine provider.

STUDY OBJECTIVES: The aim of this study was to characterize older adult Medicare beneficiaries seen by board-certified sleep medicine providers (BCSMPs) and identify predictors of being seen by a BCSMP. METHODS: Our data source was a random 5% sample of Medicare administrative claims data (2006-2013). BCSMPs were identified using a cross-matching procedure based on national provider identifiers available within the Medicare database and assigned based on the first sleep disorder diagnosis received. Sleep disorders (insomnia, sleep-related breathing disorders, hypersomnias, circadian rhythm sleep-wake disorders, parasomnias, and restless legs syndrome) were operationalized as International Classification of Disease, Ninth Revision, Clinical Modification diagnostic codes. The number of sleep disorders per beneficiary was computed and compared between BCSMPs and nonspecialists. Logistic regression was used to identify medical and demographic predictors of being seen by a BCSMP. RESULTS: A total of 57,209 beneficiaries received one or more sleep disorder diagnoses during the study period. Of these, 1,279 (2.2%) were initially diagnosed by a BCSMP. Relative to individuals seen by nonspecialists, beneficiaries treated by a BCSMP were more likely to have two or more sleep disorders (9.0% vs 24.1%, P < .001). The most common diagnosis assigned by BCSMPs was obstructive sleep apnea (70.4% of patients seen by BCSMPs were diagnosed with obstructive sleep apnea). The most common diagnosis assigned by nonspecialists was insomnia (48.2% of patients seen by nonspecialists were diagnosed with insomnia). In a fully adjusted regression model, male sex (odds ratio [OR] 1.53; 95% confidence interval [CI] 1.36, 1.72), asthma (OR 1.50; 95% CI 1.30, 1.73), and heart failure (OR 1.24; 95% CI 1.10, 1.41) were positively associated with being treated by a BCSMP. Conversely, depression (OR 0.85, 95% CI 0.73, 1.00), anxiety (OR 0.69, 95% CI .59, .82), Alzheimer and related dementias (OR 0.80, 95% CI .65, .99), and anemia (OR .88, 95% CI .78, .99) were associated with a reduced likelihood of being seen by a BCSMP. CONCLUSIONS: Relative to older adults seen by nonspecialists, those seen by BCSMPs are more medically but less psychiatrically complex and are diagnosed with a greater number of sleep disorders. These results suggest the possibility that medically complex patients are referred for specialty care, whereas psychiatrically complex patients might be seen at the nonspecialist level. Further, these results demonstrate the value of board certification in sleep medicine in caring for complex sleep patients.

Lower socioeconomic status and co-morbid conditions are associated with reduced continuous positive airway pressure adherence among older adult medicare beneficiaries with obstructive sleep apnea.

STUDY OBJECTIVES: To examine rates of adherence to continuous positive airway pressure (CPAP) therapy among a representative sample of older adult Medicare beneficiaries with obstructive sleep apnea (OSA), and to identify demographic and health-related factors associated with CPAP adherence. METHODS: Using a 5% sample of Medicare claims data, we utilized Medicare policy and CPAP machine charges as a proxy for CPAP adherence. A cumulative logit model was used to identify demographic, medical, and psychiatric predictors of CPAP adherence status. RESULTS: Of beneficiaries who initiated CPAP (n = 3,229), 74.9% (n = 2,417) met the so-called "90-day Medicare adherence criteria," but only 58.8% of these individuals (n = 1,420) continued to use CPAP throughout the entire 13-month rent-to-own period. Anxiety, anemia, fibromyalgia, traumatic brain injury, and lower socioeconomic status (SES) were all associated with reduced CPAP adherence. CONCLUSIONS: These results provide the first national estimates of CPAP adherence among older adult Medicare beneficiaries in the United States. In addition, findings highlight the salience of medical and psychiatric comorbidity, as well as SES, as important markers of CPAP adherence among older adults in the United States. Future studies should seek to evaluate interventions to improve CPAP adherence among older adults of lower SES.

Survival benefit of lung transplantation compared with medical management and pulmonary rehabilitation for patients with end-stage COPD.

BACKGROUND: COPD patients account for a large proportion of lung transplants; lung transplantation survival benefit for COPD patients is not well established. METHODS: We identified 4521 COPD patients in the United Network for Organ Sharing (UNOS) dataset transplanted from May 2005 to August 2016, and 604 patients assigned to receive pulmonary rehabilitation and medical management in the National Emphysema Treatment Trial (NETT). After trimming the populations for NETT eligibility criteria and data completeness, 1337 UNOS and 596 NETT patients remained. Kaplan-Meier estimates of transplant-free survival from transplantation for UNOS, and NETT randomisation, were compared between propensity score-matched UNOS (n=401) and NETT (n=262) patients. RESULTS: In propensity-matched analyses, transplanted patients had better survival compared to medically managed patients in NETT (p=0.003). Stratifying on 6 min walk distance (6 MWD) and FEV1, UNOS patients with 6 MWD <1000 ft (∼300 m) or FEV1 <20% of predicted had better survival than NETT counterparts (median survival 5.0 years UNOS versus 3.4 years NETT; log-rank p<0.0001), while UNOS patients with 6 MWD ≥1000 ft (∼300 m) and FEV1 ≥20% had similar survival to NETT counterparts (median survival, 5.4 years UNOS versus 4.9 years NETT; log-rank p=0.73), interaction p=0.01. CONCLUSIONS: Overall survival is better for matched lung transplant patients compared with medical management alone. Patients who derive maximum benefit are those with 6 MWD <1000 ft (∼300 m) or FEV1 <20% of predicted, compared with pulmonary rehabilitation and medical management.

Sensorimotor performance is improved by targeted memory reactivation during a daytime nap in healthy older adults.

Sensorimotor consolidation occurs during sleep. However, the benefit of sleep-based consolidation decreases with age due to decreased sleep quality and quantity. This study aimed to enhance sensorimotor performance through repetitive delivery of task-based auditory cues during sleep, known as targeted memory reactivation (TMR). Healthy older adults performed a non-dominant arm throwing task before and after a 1 h nap. While napping, half of participants received TMR throughout the hour. Participants who received TMR during sleep demonstrated a greater overall change in throwing accuracy from the start of the first to the end of the second throwing task session. However, there was no generalization of throwing accuracy to variants of the task or to a novel dart throwing task. Findings support the use of TMR during sleep to enhance task-specific sensorimotor performance in healthy older adults despite age-related decreases in sleep quality and quantity. Future research is needed to evaluate the effects of TMR on rehabilitation protocols.

Practice patterns of board-certified sleep medicine providers: a national analysis among older adult Medicare beneficiaries.

STUDY OBJECTIVES: To examine the proportion of Medicare beneficiaries with sleep disorders who were evaluated by board-certified sleep medicine providers (BCSMPs). METHODS: Using a random 5% sample of Medicare administrative claims data (2007-2011), BCSMPs were identified by employing a novel cross-matching approach based on National Provider Identifiers available within the Medicare database. Sleep disorders were included based partially on the International Classification of Sleep Disorders, Third Edition (insomnia, sleep-related breathing disorders, hypersomnias, circadian rhythm sleep-wake disorders, parasomnias, and restless legs syndrome), and operationalized as International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes. The proportion of beneficiaries with each disorder who were seen by BCSMPs and nonspecialists was computed. RESULTS: Among older adult Medicare beneficiaries with sleep disorders, the most common sleep disorder was insomnia (n = 65,033), and the least common sleep disorder was narcolepsy (n = 784). Individuals with central sleep apnea (n = 1,561) were most likely to be treated by a BCSMP (63.9% of beneficiaries with central sleep apnea), and individuals diagnosed with insomnia were least likely to be treated by a BCSMP (16.4% of beneficiaries with insomnia). Most BCSMPs treated beneficiaries with obstructive sleep apnea (84.9% of BCSMPs) and insomnia (75.8% of BCSMPs). CONCLUSIONS: BCSMPs are involved in the care of a substantial proportion of Medicare beneficiaries with sleep disorders.

Older adult US Medicare beneficiaries with untreated obstructive sleep apnea are heavier users of health care than matched control patients.

STUDY OBJECTIVES: To examine the effect of untreated obstructive sleep apnea (OSA) on health care utilization (HCU) and costs among a nationally representative sample of Medicare beneficiaries. METHODS: Our data source was a random 5% sample of Medicare administrative claims data for years 2006-2013. OSA was operationalized as (1) receipt of one or more International Classification of Disease, Version 9, Clinical Modification diagnostic codes for OSA in combination with (2) initiation of OSA treatment with either continuous positive airway pressure or oral appliance (OA) therapy. First, HCU and costs were assessed during the 12 months prior to treatment initiation. Next, these HCU and costs were compared between beneficiaries with OSA and matched control patients without sleep-disordered breathing using generalized linear models. RESULTS: The final sample (n = 287,191) included 10,317 beneficiaries with OSA and 276,874 control patients. In fully adjusted models, during the year prior to OSA diagnosis and relative to matched control patients, beneficiaries with OSA demonstrated increased HCU and higher mean total annual costs ($19,566, 95% confidence interval [CI] $13,239, $25,894) as well as higher mean annual costs across all individual points of service. Inpatient care was associated with the highest incremental costs (ie, greater than control patients; $15,482, 95% CI $8,521, $22,443) and prescriptions were associated with the lowest incremental costs (ie, greater than control patients; $431, 95% CI $339, $522). CONCLUSIONS: In this randomly selected and nationally representative sample of Medicare beneficiaries and relative to matched control patients, individuals with untreated OSA demonstrated increased HCU and costs across all points of service.

Economic aspects of insomnia medication treatment among Medicare beneficiaries.

STUDY OBJECTIVES: To examine economic aspects of insomnia and insomnia medication treatment among a nationally representative sample of older adult Medicare beneficiaries. METHODS: Using a random 5% sample of Medicare administrative data (2006-2013), insomnia was defined using International Classification of Disease, Version 9, Clinical Modification diagnostic codes. Treatment was operationalized as one or more prescription fills for an US Food and Drug Administration (FDA)-approved insomnia medication following diagnosis, in previously untreated individuals. To evaluate the economic impact of insomnia treatment on healthcare utilization (HCU) and costs in the year following insomnia diagnosis, a difference-in-differences approach was implemented using generalized linear models. RESULTS: A total of 23 079 beneficiaries with insomnia (M age = 71.7 years) were included. Of these, 5154 (22%) received one or more fills for an FDA-approved insomnia medication following insomnia diagnosis. For both treated and untreated individuals, HCU and costs increased during the 12 months prior to diagnosis. Insomnia treatment was associated with significantly increased emergency department visits and prescription fills in the year following insomnia diagnosis. After accounting for pre-diagnosis differences between groups, no significant differences in pre- to post-diagnosis costs were observed between treated and untreated individuals. CONCLUSIONS: These results advance previous research into economics of insomnia disorder by evaluating the impact of medication treatment and highlighting important differences between treated and untreated individuals. Future studies should seek to understand why some individuals diagnosed with insomnia receive treatment but others do not, to identify clinically meaningful clusters of older adults with insomnia, and to explore the economic impact of insomnia and insomnia treatment among subgroups of individuals with insomnia, such as those with cardiovascular diseases, mood disorders, and neurodegenerative disease.

Use of targeted memory reactivation enhances skill performance during a nap and enhances declarative memory during wake in healthy young adults.

Sleep is an important component of motor memory consolidation and learning, providing a critical tool to enhance training and rehabilitation. Following initial skill acquisition, memory consolidation is largely a result of non-rapid eye movement sleep over either a full night or a nap. Targeted memory reactivation is one method used to enhance this critical process, which involves the pairing of an external cue with task performance at the time of initial motor skill acquisition, followed by replay of the same cue during sleep. Application of targeted memory reactivation during sleep leads to increased functional connectivity within task-related brain networks and improved behavioural performance in healthy young adults. We have previously used targeted memory reactivation throughout the first two slow-wave sleep cycles of a full night of sleep to enhance non-dominant arm throwing accuracy in healthy young adults. Here, we aimed to determine whether application of targeted memory reactivation throughout a 1-hr daytime nap was sufficient to enhance performance on the same non-dominant arm throwing task in healthy young adults. Participants were allocated to either nap or no nap, and within those groups half received targeted memory reactivation throughout a 1-hr between-session period, leading to four groups. Only participants who slept between sessions while receiving targeted memory reactivation enhanced their throwing accuracy upon beginning the second session. Future studies will aim to use this technique as an adjunct to traditional physical rehabilitation with individuals with neurologic diagnoses such as stroke.

Untreated insomnia increases all-cause health care utilization and costs among Medicare beneficiaries.

STUDY OBJECTIVES: To examine the impact of untreated insomnia on health care utilization (HCU) among a nationally representative sample of Medicare beneficiaries. METHODS: Our data source was a random 5% sample of Medicare administrative data for years 2006-2013. Insomnia was operationalized as the presence of at least one claim containing an insomnia-related diagnosis in any given year based on International Classification of Disease, Version 9, Clinical Modification codes or at least one prescription fill for an insomnia-related medication in Part D prescription drug files in each year. We compared HCU in the year prior to insomnia diagnosis to HCU among to non-sleep disordered controls during the same period. RESULTS: A total of 151 668 beneficiaries were found to have insomnia. Compared to controls (n = 333 038), beneficiaries with insomnia had higher rates of HCU across all point of service locations. Rates of HCU were highest for inpatient care (rate ratio [RR] 1.61; 95% confidence interval [CI] 1.59, 1.64) and lowest for prescription fills (RR 1.17; 95% CI 1.16, 1.17). Similarly, compared to controls, beneficiaries with insomnia demonstrated $63,607 (95% CI $60,532, $66,685) higher all-cause costs, which were driven primarily by inpatient care ($60,900; 95% CI $56,609, $65,191). Emergency department ($1,492; 95% CI $1,387, $1,596) and prescription costs ($486; 95% CI $454, $518) were also elevated among cases relative to controls. CONCLUSIONS: In this randomly selected and nationally representative sample of older Medicare beneficiaries and compared to non-sleep disordered controls, individuals with untreated insomnia demonstrated increased HCU and costs across all points of service.

The Impact of Treatments for OSA on Monetized Health Economic Outcomes: A Systematic Review.

OBJECTIVE: To review systematically the published literature regarding the impact of treatment for OSA on monetized health economic outcomes. METHODS: Customized structured searches were performed in PubMed, Embase (Embase.com), and the Cochrane Central Register of Controlled Trials (Wiley) databases. Reference lists of eligible studies were also analyzed. Titles and abstracts were examined, and articles were identified for full-text review. Studies that met inclusion criteria were evaluated in detail, and study characteristics were extracted using a standardized template. Quantitative characteristics of the studies were summarized, and a qualitative synthesis was performed. RESULTS: Literature searches identified 2,017 nonredundant abstracts, and 196 full-text articles were selected for review. Seventeen studies met inclusion criteria and were included in the final synthesis. Seven studies included formal cost-effectiveness or cost-utility analyses. Ten studies employed cohort designs, and four studies employed randomized controlled trial or quasi-experimental designs. Positive airway pressure was the most common treatment modality, but oral appliances and surgical approaches were also included. The most common health economic outcomes were health-care use (HCU) and quality-adjusted life years (QALYs). Follow-ups ranged from 6 weeks to 5 years. Overall, 15 of 18 comparisons found that treatment of OSA resulted in a positive economic impact. Treatment adherence and OSA severity were positively associated with cost-effectiveness. CONCLUSIONS: Although study methodologies varied widely, evidence consistently suggested that treatment of OSA was associated with favorable economic outcomes, including QALYs, within accepted ranges of cost-effectiveness, reduced HCU, and reduced monetized costs.