The role of education in cognitive functions among middle-age and older patients with untreated obstructive sleep apnea.

OBJECTIVE: The goal of the current study was to examine the interaction between educational level and obstructive sleep apnea (OSA), one of the most under diagnosed sleep disorders, on cognitive functions such as verbal fluency, psychomotor vigilance, executive functions, visuospatial ability, and attention span. MATERIAL AND METHODS: One hundred and nine participants (47 controls and 62 untreated OSA patients) participated in the study and completed the Wisconsin Card Sorting Test, WAIS-III digit span and block design, semantic and phonemic fluency tests, and a psychomotor vigilance task. Subjective sleep and health measures were assessed. RESULTS: In semantic fluency and visuospatial ability tasks, patients with higher education performed better than patients with lower education and controls with lower education. This difference in moderation effects was not observed for vigilance, phonemic fluency, attention span, or executive functions although education was a significant predictor for all cognitive tasks. CONCLUSION: Higher education may have contributed to cognitive reserve in OSA patients (but not for controls) as reflected in better semantic fluency and visuospatial ability. This benefit of higher education contributing to larger cognitive reserve in patients with OSA helped buffer the deficits for some cognitive functions but not for others. This may indicate that this buffer is not limitless because when the cognitive demand gets higher the educational buffer no longer works.

Sleep-Related Leg Cramps: A Review and Suggestions for Future Research.

Various medications and behavioral treatments for sleep-related leg cramps have been tried, but the quality of the evidence is low. Quinine seems to be effective, but dangerous. ß-Agonists may be one of the more common causes of secondary leg cramps. Statins may not be implicated in leg cramps as much as has been believed. Potassium-sparing diuretics may have a higher incidence of sleep-related leg cramps than potassium-depleting diuretics. Plantar flexion of the feet may elicit most sleep-related leg cramps. More research into behavioral treatments is needed. A standardized sleep-related leg cramp questionnaire would be useful to expand research.

Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children.

Bedtime problems and frequent night wakings are highly prevalent in infants, toddlers, and preschoolers. Evidence suggests that sleep disruption and/or insufficient sleep have potential deleterious effects on children's cognitive development, regulation of affect, attention, health outcomes, and overall quality of life, as well as secondary effects on parental and family functioning. Furthermore, longitudinal studies have demonstrated that sleep problems first presenting in infancy may become chronic, persisting into the preschool and school-aged years. A solid body of literature now exists supporting the use of empirically-based behavioral management strategies to treat bedtime problems and night wakings in infants, toddlers, and preschoolers. The following practice parameters present recommendations for the use of behavioral (i.e., non-pharmacological) treatments of bedtime problems and night wakings in young children (aged 0 - 4. years 11 months). A companion review paper on which the recommendations are based was prepared by a taskforce appointed by the Standards of Practice Committee (SPC) of the American Academy of Sleep Medicine (AASM), and summarizes the peer-reviewed scientific literature on this topic. The authors of the review paper evaluated the evidence presented by the reviewed studies according to modified Sackett criteria. Using this information and a grading system described by Eddy (i.e., standard, guideline or option), the Standards of Practice Committee and Board of Directors of the American Academy of Sleep Medicine determined levels of treatment recommendation presented in the practice parameters below. These practice parameters provide 3 types of recommendations. First, recommendations are provided indicating that behavioral interventions are effective in the treatment of bedtime problems and night wakings in young children, producing reliable and significant clinical improvement in sleep parameters. Second, recommendations are made regarding specific behavioral therapies, including: (1) unmodified extinction, extinction with parental presence, and preventive parent education are all rated as individually effective therapies in the treatment of bedtime problems and night wakings (Standards), and (2) graduated extinction, bedtime fading/positive routines and scheduled awakenings are rated as individually effective therapies in the treatment of bedtime problems and night wakings but with less certainty (Guidelines). There was insufficient evidence to recommend standardized bedtime routines and positive reinforcement as single therapies. In addition, although behavioral therapies for bedtime problems and night wakings are often combined, there was insufficient evidence available to recommend one individual therapy over another or to recommend an individual therapy over a combination of therapies. Finally, recommendations are provided regarding the beneficial effects of behavioral treatments on secondary outcomes, including daytime functioning (child) and parental well-being.

Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep-related breathing disorders.

Positive airway pressure (PAP) devices are used to treat patients with sleep related breathing disorders (SRBD) including obstructive sleep apnea (OSA). Currently, PAP devices come in three forms: (1) continuous positive airway pressure (CPAP), (2) bilevel positive airway pressure (BPAP), and (3) automatic self-adjusting positive airway pressure (APAP). After a patient is diagnosed with OSA, the current standard of practice involves performing full, attended polysomnography during which positive pressure is adjusted to determine optimal pressure for maintaining airway patency. This titration is used to find a fixed single pressure for subsequent nightly usage. A task force of the Standards of Practice Committee of the American Academy of Sleep Medicine reviewed the available literature. Based on this review, the Standards of Practice Committee developed these practice parameters as a guideline for using CPAP and BPAP appropriately (an earlier review and practice parameters for APAP was published in 2002). Major conclusions and current recommendations are as follows: 1) A diagnosis of OSA must be established by an acceptable method. 2) CPAP is effective for treating OSA. 3) Full-night, attended studies performed in the laboratory are the preferred approach for titration to determine optimal pressure; however, split-night, diagnostic-titration studies are usually adequate. 4) CPAP usage should be monitored objectively to help assure utilization. 5) Initial CPAP follow-up is recommended during the first few weeks to establish utilization pattern and provide remediation if needed. 6) Longer-term follow-up is recommended yearly or as needed to address mask, machine, or usage problems. 7) Heated humidification and a systematic educational program are recommended to improve CPAP utilization. 8) Some functional outcomes such as subjective sleepiness improve with positive pressure treatment in patients with OSA. 9) CPAP and BPAP therapy are safe; side effects and adverse events are mainly minor and reversible. 10) BPAP may be useful in treating some forms of restrictive lung disease or hypoventilation syndromes associated with hypercapnia.

Sleep panic attacks: a micro-movement analysis.

Earlier work by our group and others has pointed to a role for movement during sleep in sleep-panic attacks. Specifically, our group has reported that panic disorder patients, as a group, appear to move more during sleep than age-matched controls, whereas the subgroup of panic disorder who "panic" during sleep move less on the nights they experience sleep-panic attacks than they do on nights without sleep-panic attacks. We studied the movement of sleep-panic patients in a more detailed fashion with more than one sleep movement index. Fourteen patients with sleep-panic attacks were compared with 14 waking panic patients, 13 social phobic patients, and 14 normal controls. Subjects from the other groups were age matched to the sleep-panic group. Their comparison study night corresponded to the night number of the sleep-panic attack. Sleep-panic patients did move less on panic nights than did the normal controls on the corresponding sleep-panic night according to two separate sleep movement indices. Although not statistically significant, sleep-panic patients also moved less on their panic night than did either of the other anxious groups on corresponding nights. Rechtshaffen and Kales' Movement Time (MT) measure appears to overestimate actual min of movement during sleep in all subjects. The movement noted in sleep-panic patients may have some role in the pathophysiology of sleep-panic attacks. A possible mechanism is explained.