Should testing for obstructive sleep apnea be offered routinely to older family medicine patients? A prospective cohort study.

In our previous studies, we offered older family medicine patients testing for obstructive sleep apnea (OSA) and discovered that 80% of patients who accepted, were later diagnosed with unsuspected OSA. In the present study, we followed such patients for 3 years of usual treatment. The goals were to (1) observe whether wider testing for OSA would increase case recognition and treatment uptake; (2) identify symptom and health characteristics associated with diagnosis and treatment efficacy. 101 women and 75 men (>45 years) recruited from family medicine clinics completed questionnaires, polysomnography and consented to chart review (Time 1). Participants with OSA were offered treatment and follow-up with a sleep medicine specialist. All were re-evaluated after 3 years (Time 2). At Time 1, 93% of participants received a diagnosis of OSA. Of these, 53 initiated treatment (46 PAP therapy); at Time 2, 24 PAP users met criteria for adherence. PAP-adherent participants had worse OSA and worse reported symptoms at Time 1 than non-adherent participants. At Time 2, PAP-adherent participants improved on insomnia and daytime symptoms compared to non-adherent participants who showed no change. Adherent and non-adherent participants showed no difference in health indices at Time 1 and no change at three-year follow-up. Benefits of treatment included improvements in co-morbid insomnia and daytime functioning; however, offering wider testing for OSA to older, family medicine patients yielded a high rate of diagnosis but low treatment adoption and adherence. Therefore, a cost-effective strategy would identify and support those likely to adopt and adhere to treatment.

Impact of the COVID-19 pandemic on obstructive sleep apnea: recommendations for symptom management.

STUDY OBJECTIVES: In the context of the current COVID-19 pandemic situation, we address the following important questions: (1) How can patients be identified for possible OSA while sleep clinic testing is temporarily unavailable or limited? and (2) What measures can be suggested to improve sleep health until proper diagnosis and treatment become safe and available again? METHODS: As a proxy for home or in-laboratory testing, validation of a symptom-based measure of OSA risk is presented, based on an ongoing larger prospective study of 156 family medicine patients with OSA (88 women, 68 men; mean age, 57 years) and 60 control participants (36 women, 24 men; mean age, 54 years) recruited from the community. Participants completed the Sleep Symptom Checklist (SSC) and a range of other self-report measures; primary care patients also underwent a polysomnographic sleep study. RESULTS: Results showed that (1) individuals with OSA reported more symptoms on the SSC related to insomnia, daytime symptoms, sleep disorders, and psychological maladjustment than did the control group (all P < .001), and (2) their sleep-related symptoms were significantly more severe than those of the control patients. In addition, several polysomnographic indices in recently diagnosed untreated individuals with OSA were significantly correlated with SSC measured sleep disorder symptoms, and SSC scores significantly distinguished participants with OSA from control participants. CONCLUSIONS: Our findings suggest that family practitioners can effectively prescreen patients for possible OSA by inquiring about 5 items that form the SSC sleep disorders subscale. If OSA is suspected, then we can recommend a range of behavioral techniques to improve symptoms. The current pandemic causes us to reflect that the provisional targeting of symptoms and guidance regarding mitigation strategies while waiting for specialist care could serve patients well at any time.

Dream enactment behavior: review for the clinician.

NONE: Dream enactment behavior commonly occurs on occasion in normal children and adults. Disruptive and frequent dream enactment behavior may come to the attention of the clinician either as the primary reason for consultation or as a prominent characteristic of a patient with other sleep disorders. Questioning patients with chronic neurologic and psychiatric disorders may also reveal previously unrecognized behavior. In the absence of sleep pathology, process of dream enactment likely begins with active, often emotionally charged dream content that may occasionally break through the normal REM sleep motor suppressive activity. Disrupted sleep resulting from many possible causes, such as circadian disruption, sleep apnea, or medications, may also disrupt at least temporarily the motor-suppressive activity in REM sleep, allowing dream enactment to occur. Finally, pathological neurological damage in the context of degenerative, autoimmune, and infectious neurological disorders may lead to chronic recurrent and severe dream enactment behavior. Evaluating the context, frequency, and severity of dream enactment behavior is guided first and foremost by a structured approach to the sleep history. Physical exam and selected testing support the clinical diagnosis. Understanding the context and the likely cause is essential to effective therapy.

An Objective Measure of Drowsy Driving: Are We There Yet?

CITATION: Rizzo D, Baltzan M. An objective measure of drowsy driving: are we there yet? J Clin Sleep Med. 2019;15(9):1191-1192.

Determinants of policy decisions for non-commercial drivers with OSA: An integrative review.

Excessive daytime sleepiness and reduced cognitive functioning secondary to obstructive sleep apnea (OSA) have been identified as an important health-related risk in commercial transportation with, possibly, an increased chance of road accidents. This has resulted in a variety of policies and restrictions imposed on commercial drivers. Here we review current knowledge to assess whether available data are sufficient to guide policy decisions concerning restrictions for non-commercial drivers. The review shows that there is a lack of uniformity among different consensus conferences and guidelines as to how to deal with drivers with OSA. Clear guidelines are limited and few are evidence based. It is unclear which aspect of OSA is the most valid measure of severity (e.g., apnea-hypopnea index vs oxygen desaturation index). Traditionally, sleepiness has been invoked as a major risk factor for impaired driving. Recently, there also has been an awareness that daytime fatigue, as distinct from sleepiness, has an impact on driving behavior. However, the precise effect of fatigue on driving, as well as its role in the formulation of guidelines, remain to be evaluated. We conclude that there are at least two major difficulties for the driving recommendation process: a) there is no accurate metric quantifying severity of driving risk associated with OSA, and b) there are substantial individual differences among those with OSA, both experiential and behavioral. We present implications from this review for future research and policy formulation.

Sleep, chronic pain, and opioid risk for apnea.

Pain is an unwelcome sleep partner. Pain tends to erode sleep quality and alter the sleep restorative process in vulnerable patients. It can contribute to next-day sleepiness and fatigue, affecting cognitive function. Chronic pain and the use of opioid medications can also complicate the management of sleep disorders such as insomnia (difficulty falling and/or staying asleep) and sleep-disordered breathing (sleep apnea). Sleep problems can be related to various types of pain, including sleep headache (hypnic headache, cluster headache, migraine) and morning headache (transient tension type secondary to sleep apnea or to sleep bruxism or tooth grinding) as well as periodic limb movements (leg and arm dysesthesia with pain). Pain and sleep management strategies should be personalized to reflect the patient's history and ongoing complaints. Understanding the pain-sleep interaction requires assessments of: i) sleep quality, ii) potential contributions to fatigue, mood, and/or wake time functioning; iii) potential concomitant sleep-disordered breathing (SDB); and more importantly; iv) opioid use, as central apnea may occur in at-risk patients. Treatments include sleep hygiene advice, cognitive behavioral therapy, physical therapy, breathing devices (continuous positive airway pressure - CPAP, or oral appliance) and medications (sleep facilitators, e.g., zolpidem; or antidepressants, e.g., trazodone, duloxetine, or neuroleptics, e.g., pregabalin). In the presence of opioid-exacerbated SDB, if the dose cannot be reduced and normal breathing restored, servo-ventilation is a promising avenue that nevertheless requires close medical supervision.

Sleep in the Postpartum: Characteristics of First-Time, Healthy Mothers.

Goals for the present study were to (a) describe the sleep of healthy new mothers over a 6-month postpartum period, (b) examine how sleep quality relates to daytime levels of fatigue and sleepiness, and (c) evaluate the relationship between mothers' and infants' sleep parameters. The sample consisted of 37 healthy, partnered, first-time mothers who had experienced full-term vaginal birth and had a healthy infant. We investigated infants' sleep parameters and mothers' sleep, mood, and daytime functioning 2 and 6 months postpartum. We found that at 2 months postpartum, mothers reported sleeping 6 hours at night and just under one hour during the day. Despite relatively frequent nocturnal awakenings, mothers experienced minimal insomnia, nonrefreshing sleep, anxiety, depression, daytime sleepiness, or fatigue at either 2 or 6 months. The most robust relationship between mothers' and infants' sleep was in the number of nocturnal sleep-wake episodes. Of note is that none of the infant sleep parameters was related to mothers' anxiety, depression, fatigue, sleepiness, or nonrefreshing sleep at either time period. Our results indicate that (1) selected low risk new mothers are resilient in terms of sleep quality, daytime functioning, and mood and (2) these are independent of their infants' sleep parameters.

The challenge of identifying family medicine patients with obstructive sleep apnea: addressing the question of gender inequality.

Purpose: The purpose of this study was to examine the sleep characteristics, metabolic syndrome disease and likelihood of obstructive sleep apnea in a sample of older, family medicine patients previously unsuspected for sleep apnea. Methods: A total of 295 participants, minimum age 45, 58.7% women, were recruited from two family medicine clinics. None previously had been referred for sleep apnea testing. All participants completed a sleep symptom questionnaire and were offered an overnight polysomnography study, regardless of questionnaire results. 171 followed through with the sleep laboratory component of the study. Health data regarding metabolic syndrome disease (hypertension, hyperlipidemia, diabetes and obesity) were gathered by chart review. Results: Overall, more women than men enrolled in the study and pursued laboratory testing. Of those who underwent polysomnography testing, 75% of the women and 85% of the men were diagnosed with sleep apnea based on an apnea/hypopnea index of 10 or greater. Women and men had similar polysomnography indices, the majority being in the moderate to severe ranges. In those with OSA diagnosis, gender differences in sleep symptom severity were not significant. Conclusions: We conclude that greater gender equality in sleep apnea rates can be achieved in family practice if sleep apnea assessments are widely offered to older patients.

Refreshing Sleep and Sleep Continuity Determine Perceived Sleep Quality.

Sleep quality is a construct often measured, employed as an outcome criterion for therapeutic success, but never defined. In two studies we examined appraised good and poor sleep quality in three groups: a control group, individuals with obstructive sleep apnea, and those with insomnia disorder. In Study 1 we used qualitative methodology to examine good and poor sleep quality in 121 individuals. In Study 2 we examined sleep quality in 171 individuals who had not participated in Study 1 and evaluated correlates and predictors of sleep quality. Across all six samples and both qualitative and quantitative methodologies, the daytime experience of feeling refreshed (nonrefreshed) in the morning and the nighttime experience of good (impaired) sleep continuity characterized perceived good and poor sleep. Our results clarify sleep quality as a construct and identify refreshing sleep and sleep continuity as potential clinical and research outcome measures.

Manifestations of Insomnia in Sleep Apnea: Implications for Screening and Treatment.

The aims of this study were to examine the presence, type, and severity of insomnia complaints in obstructive sleep apnea (OSA) patients and to assess the utility of the Sleep Symptom Checklist (SSC) for case identification in primary care. Participants were 88 OSA patients, 57 cognitive-behavioral therapy for insomnia (CBT-I) patients, and 14 healthy controls (Ctrl). Each completed a sleep questionnaire as well as the SSC, which includes insomnia, daytime functioning, psychological, and sleep disorder subscales. Results showed that OSA patients could be grouped according to 3 insomnia patterns: no insomnia (OSA), n = 21; insomnia (OSA-I), n = 30, with a subjective complaint and disrupted sleep; and noncomplaining poor sleepers (OSA-I-NC), n = 37. Comparisons among the OSA, CBT-I, and Ctrl groups demonstrate distinct profiles on the SSC subscales, indicating its potential utility for both case identification and treatment planning.

Do all individuals with sleep apnea suffer from daytime sleepiness? A preliminary investigation.

We derived descriptive characteristics related to habitual sleep duration and insomnia for individuals newly diagnosed with sleep apnea/hypopnea syndrome and evaluated how sleep apnea/hypopnea syndrome, insomnia, depression, and sleep duration relate to sleepiness and fatigue. In total, 100 participants were divided into three sleep groups: short (<7 hours), long (≥ 8 hours), and midrange (7-7.9 hours). Polysomnography, insomnia, sleepiness, fatigue, depression, and gender were assessed. Half of the participants were short sleepers. They were more likely to have insomnia than midrange or long sleepers and they were more likely to be sleepy than midrange or long sleepers, regardless of insomnia.

Fatigue: The forgotten symptom of sleep apnea.

OBJECTIVE: The present investigation was designed to explore the role and implications of both daytime sleepiness and fatigue in obstructive sleep apnea syndrome with respect to sleep, perceived health quality, and psychological functioning. METHODS: Our participants consisted of two groups: 124 older community volunteers who completed a polysomnographic sleep study and were diagnosed with sleep apnea, and 19 healthy controls. All participants completed self-report measures of sleepiness, fatigue, sleep quality, health quality, and psychological functioning. RESULTS: The apnea sample was divided according to clinically relevant cut-offs on sleepiness and fatigue. When those with mid-range scores were ruled out, the following groups remained: low sleepiness/low fatigue (LL, n=23), high sleepiness/high fatigue (HH, n=28), high sleepiness/low fatigue (HS, n=10) and low sleepiness/high fatigue (HF, n=13). The respiratory disturbance index did not differ significantly among these groups and only the two highly fatigued groups (HH and HF) experienced significantly lower average oxygen saturation than the control group. Analyses revealed that the HH group was significantly worse than the LL and control groups on most sleep, health quality, and psychological measures. On these same measures, the groups for whom fatigue was low (LL and HS), regardless of sleepiness, were similar to controls. CONCLUSION: When patients with sleep apnea are classified into different sleepiness/fatigue categories, the results show that high fatigue is associated with more severe dysfunction than high sleepiness. The current debate on whether to treat apnea patients with low sleepiness needs to consider the impact of fatigue.

Classifying medication use in clinical research.

BACKGROUND: Medication use data are usually collected in clinical research. Yet no standardized method for categorizing these exists, either for sample description or for the study of medication use as a variable. OBJECTIVE: The present investigation was designed to develop a simple, empirically based classification scheme for medication use categorization. METHOD: The authors used factor analysis to reduce the number of possible medication groupings. This permitted a pattern of medication usage to emerge that appeared to characterize specific clinical constellations. To illustrate the technique's potential, the authors applied this classification system to samples where sleep disorders are prominent: chronic fatigue syndrome and sleep apnea. RESULTS: The authors' classification approach resulted in 5 factors that appear to cohere in a logical fashion. These were labeled Cardiovascular or Metabolic Syndrome Medication, Symptom Relief Medication, Psychotropic Medication, Preventative Medication, and Hormonal Medication. CONCLUSIONS: The findings show that medication profile varies according to clinical sample. The medication profile for participants with sleep apnea reflects known comorbid conditions; the medication profile associated with chronic fatigue syndrome appears to reflect the common perception of this condition as a psychogenic disorder.

Impaired sleep in chronic fatigue syndrome: how is it best measured?

The goal was to examine comparative efficacy of polysomnography, actigraphy, and self-report in evaluating the sleep/wake experience of individuals with chronic fatigue syndrome (CFS). Sleep parameters were evaluated by the three measurement modalities for the same night in 49 participants with CFS. Psychological and daytime functioning were measured by self-report. Results indicate that: (a) objectively measured nocturnal sleep time effectively approximated subjective experience although nocturnal wakefulness did not; (b) total sleep time and sleep efficiency differentiated individuals with and without insomnia complaints; (c) daytime sleepiness, fatigue, and non-refreshing sleep were not reflected by the objective sleep-related measures (polysomnography and actigraphy).

Sleep apnea and psychological functioning in chronic fatigue syndrome.

Objectives were to explore: (1) whether sleep apnea/hypopnea syndrome (SAHS) should be considered a chronic fatigue syndrome (CFS) comorbidity, rather than a diagnostic exclusion criterion; and (2) to compare sleep/wake/ psychopathology in individuals with CFS, controls and another illness. Participants (CFS, SAHS, controls) completed questionnaires and were evaluated for SAHS; 68 percent were subsequently diagnosed with SAHS. CFS participants with and without SAHS did not differ. Both clinical groups were less well adjusted than controls. We conclude that SAHS should not be an exclusion criterion for CFS and that psychological problems in CFS seem a consequence of coping with illness.

Sleep disorder symptoms are common and unspoken in Canadian general practice.

OBJECTIVE: Primary care patients were surveyed for what sleep disorder symptoms they discussed with their physicians. Their responses were compared with those of new Sleep clinic patients. The goal was to discover what symptom presentation leads to a successful referral to a sleep clinic. METHODS: We recruited two samples: 191 older Primary care patients and 138 Sleep clinic patients. Participants completed the Sleep Symptom Checklist (SSC). This consists of 21 symptoms in four domains: insomnia, sleep disorder, daytime symptoms and psychological distress. All respondents indicated which symptoms had been discussed with their physician in the past year. Primary care subjects were designated as Decliners (completed SSC, refused further evaluation), Dropouts [completed some evaluation steps, but not polysomnography (PSG)] and Completers (completed PSG). RESULTS: Primary care participants frequently had symptoms but relatively few had discussed them with their doctor. Sleep clinic participants discussed significantly more symptoms with their referring physician than did Primary care Dropouts or Decliners in all categories except psychological distress. Primary care Completers, 88.5% of whom were ultimately diagnosed with sleep apnoea/hypopnoea syndrome and/or periodic limb movement disorder, also discussed their sleep disorder symptoms less frequently than did Sleep clinic patients but tended to give more prominence to symptoms of insomnia and impaired daytime function. CONCLUSIONS: The findings suggest that Primary care patients often have symptoms they do not discuss, even when a primary sleep disorder exists. The brief SSC checklist, developed in our laboratory, has potential to improve the referral rates of older primary care patients who have sleep disorder.

A diagnostic symptom profile for sleep disorder in primary care patients.

OBJECTIVE: The aim of the present study was (1) to evaluate the extent and nature of sleep disorder-related symptoms in the older primary care patient population and (2) to differentiate a pattern of self-reported symptoms that identify patients who should be referred to the sleep clinic for further evaluation. METHOD: One hundred ninety-six older adults recruited from family practice centers were administered a brief symptom survey measure. All were invited to participate in an extensive self-report evaluation, consultation with a sleep medicine specialist, and an overnight polysomnographic study. RESULTS: A substantial number of older primary care patients report symptoms related directly or indirectly to physiological sleep disorder. Over 30% of total reported some insomnia, 40% daytime sleepiness, and 10% apnea. Those participants who agreed to pursue further aspects of the study protocol endorsed a higher number and greater severity of primary sleep disorder symptoms than those who declined to continue beyond the first phases. Participants who chose to pursue polysomnography (13% of total) had a very high rate (88.5) of diagnosed sleep disorder. CONCLUSION: This study suggests that an older patient, male or female, who both endorses medically unexplained daytime sleepiness, fatigue, or other sleep disorder related symptoms and agrees to further evaluation, including overnight polysomnography, is at substantial risk for physiologically based sleep disorder. In the future, a brief, validated measure, such as the Sleep Symptom Checklist used in this study, would be an important part of the diagnostic process.