As part of the National Institute of Mental Health Epidemiologic Catchment Area study, 7954 respondents were questioned at baseline and 1 year later about sleep complaints and psychiatric symptoms using the Diagnostic Interview Schedule. Of this community sample, 10.2% and 3.2% noted insomnia and hypersomnia, respectively, at the first interview. Forty percent of those with insomnia and 46.5% of those with hypersomnia had a psychiatric disorder compared with 16.4% of those with no sleep complaints. The risk of developing new major depression was much higher in those who had insomnia at both interviews compared with those without insomnia (odds ratio, 39.8; 95% confidence interval, 19.8 to 80.0). The risk of developing new major depression was much less for those who had insomnia that had resolved by the second visit (odds ratio, 1.6; 95% confidence interval, 0.5 to 5.3). Further research is needed to determine if early recognition and treatment of sleep disturbances can prevent future psychiatric disorders.

Epidemiologic study of sleep disturbances and psychiatric disorders : an opportunity for prevention

10 Winthrop-University Hospital, Mineola, NY Background: Obstructive sleep apnea (OSA) is a common chronic disorder that often requires lifelong care. Available practice param- eters provide evidence-based recommendations for addressing as- pects of care. Objective: This guideline is designed to assist primary care provid- ers as well as sleep medicine specialists, surgeons, and dentists who care for patients with OSA by providing a comprehensive strategy for the evaluation, management and long-term care of adult patients with OSA. Methods: The Adult OSA Task Force of the American Academy of Sleep Medicine (AASM) was assembled to produce a clinical guideline from a review of existing practice parameters and available literature. All existing evidence-based AASM practice parameters relevant to the evaluation and management of OSA in adults were incorporated into this guideline. For areas not covered by the practice parameters, the task force performed a literature review and made consensus recom- mendations using a modified nominal group technique. recommendations: Questions regarding OSA should be incorpo- rated into routine health evaluations. Suspicion of OSA should trigger a comprehensive sleep evaluation. The diagnostic strategy includes a sleep-oriented history and physical examination, objective testing, and education of the patient. The presence or absence and severity of OSA must be determined before initiating treatment in order to identify those patients at risk of developing the complications of sleep apnea, guide selection of appropriate treatment, and to provide a baseline to establish the effectiveness of subsequent treatment. Once the diag- nosis is established, the patient should be included in deciding an ap- propriate treatment strategy that may include positive airway pressure devices, oral appliances, behavioral treatments, surgery, and/or ad- junctive treatments. OSA should be approached as a chronic disease requiring long-term, multidisciplinary management. For each treat- ment option, appropriate outcome measures and long-term follow-up are described.

Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine

Background Obstructive sleep apnea (OSA) is a common chronic disorder that often requires lifelong care. Available practice parameters provide evidence-based recommendations for addressing aspects of care. Objective This guideline is designed to assist primary care providers as well as sleep medicine specialists, surgeons, and dentists who care for patients with OSA by providing a comprehensive strategy for the evaluation, management and long-term care of adult patients with OSA. Methods The Adult OSA Task Force of the American Academy of Sleep Medicine (AASM) was assembled to produce a clinical guideline from a review of existing practice parameters and available literature. All existing evidence-based AASM practice parameters relevant to the evaluation and management of OSA in adults were incorporated into this guideline. For areas not covered by the practice parameters, the task force performed a literature review and made consensus recommendations using a modified nominal group technique. Recommendations Questions regarding OSA should be incorporated into routine health evaluations. Suspicion of OSA should trigger a comprehensive sleep evaluation. The diagnostic strategy includes a sleep-oriented history and physical examination, objective testing, and education of the patient. The presence or absence and severity of OSA must be determined before initiating treatment in order to identify those patients at risk of developing the complications of sleep apnea, guide selection of appropriate treatment, and to provide a baseline to establish the effectiveness of subsequent treatment. Once the diagnosis is established, the patient should be included in deciding an appropriate treatment strategy that may include positive airway pressure devices, oral appliances, behavioral treatments, surgery, and/or adjunctive treatments. OSA should be approached as a chronic disease requiring long-term, multidisciplinary management. For each treatment option, appropriate outcome measures and long-term follow-up are described.

Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults.

Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing.

Our understanding of the nature and consequences of upper-airway obstruction in adults during sleep has evolved considerably over the past two decades. Sleep apnea — defined as repeated episodes of obstructive apnea and hypopnea during sleep, together with daytime sleepiness or altered cardiopulmonary function — is common.1 Epidemiologic studies estimate that the condition affects 2 to 4 percent of middle-aged adults.2 Only a small portion of the cases in this group of adults have been diagnosed; this is related to insufficient awareness of sleep apnea among physicians and the public at large.3 Definitions The manifestations of upper-airway closure during sleep . . .

Obstructive Sleep Apnea

We conducted an evidence-based review of literature regarding use of oral appliances (OAs) in the treatment of snoring and obstructive sleep apnea syndrome (OSA) from 1995 until the present. Our structured search revealed 141 articles for systematic scrutiny, of which 87 were suit- able for inclusion in the evidence base, including 15 Level I to II random- ized controlled trials and 5 of these trials with placebo-controlled treat- ment. The efficacy of OAs was established for controlling OSA in some but not all patients with success (defined as no more than 10 apneas or hypopneas per hour of sleep) achieved in an average of 52% of treated patients. Effects on sleepiness and quality of life were also demonstrated, but improvements in other neurocognitive outcomes were not consistent. The mechanism of OA therapy is related to opening of the upper airway as demonstrated by imaging and physiologic monitoring. Treatment ad- herence is variable with patients reporting using the appliance a median of 77% of nights at 1 year. Minor adverse effects were frequent whereas major adverse effects were uncommon. Minor tooth movement and small changes in the occlusion developed in some patients after prolonged use, but the long-term dental significance of this is uncertain. In comparison to continuous positive airway pressure (CPAP), OAs are less efficacious in reducing the apnea hypopnea index (AHI), but OAs appear to be used more (at least by self report), and in many studies were preferred over CPAP when the treatments were compared. OAs have also been com- pared favorably to surgical modification of the upper airway (uvulopalato- pharyngoplasty, UPPP). Comparisons between OAs of different designs have produced variable findings. The literature of OA therapy for OSA now provides better evidence for the efficacy of this treatment modality and considerable guidance regarding the frequency of adverse effects and the indications for use in comparison to CPAP and UPPP. Citation: Ferguson KA; Cartwright R; Rogers R et al. Oral Appliances for Snoring and Obstructive Sleep Apnea: A Review. SLEEP 2006;29(2): 244-262.

http://www.mysilentsleep.com/docs/Research-18.pdf

Oral appliances for snoring and obstructive sleep apnea: a review.

Thirty male patients evaluated sequentially for sleep apnea syndrome by all-night clinical polysomnography were compared for apnea plus hypopnea index (A + HI) during the time in the side versus time in the back sleep posture. For 24 subjects of this sample, who occupied both major body positions during the evaluation night, the apnea index was found to be twice as high during the time spent sleeping on their backs as it was when they slept in the side position. This difference is reliable and inversely related to obesity. Five patients meeting diagnostic criteria for sleep apnea on an all-night basis fell within normal limits while in the side sleep position. This suggests sleep position adjustment may be a viable treatment for some nonobese sleep apnea patients.

/pdf/effect-of-sleep-position-on-sleep-apnea-severity-4n2ilcxn8n.pdf

Effect of sleep position on sleep apnea severity.

This paper, which has been reviewed and approved by the Board of Directors of the American Sleep Disorders Association, provides the background for the Standards of Practice Committee's parameters for the practice of sleep medicine in North America. The 21 publications selected for this review describe 320 patients treated with oral appliances for snoring and obstructive sleep apnea. The appliances modify the upper airway by changing the posture of the mandible and tongue. Despite considerable variation in the design of these appliances, the clinical effects are remarkably consistent. Snoring is improved and often eliminated in almost all patients who use oral appliances. Obstructive sleep apnea improves in the majority of patients; the mean apnea-hypopnea index (AHI) in this group of patients was reduced from 47 to 19. Approximately half of treated patients achieved an AHI of < 10; however, as many as 40% of those treated were left with significantly elevated AHIs. Improvement in sleep quality and sleepiness reflects the effect on breathing. Limited follow-up data indicate that oral discomfort is a common but tolerable side effect, that dental and mandibular complications appear to be uncommon and that long-term compliance varies from 50% to 100% of patients. Comparison of the risk and benefit of oral appliance therapy with the other available treatments suggests that oral appliances present a useful alternative to continuous positive airway pressure (CPAP), especially for patients with simple snoring and patients with obstructive sleep apnea who cannot tolerate CPAP therapy.

/pdf/oral-appliances-for-the-treatment-of-snoring-and-obstructive-2vb2nmej8w.pdf

Rosalind D. Cartwright

Papers

Oral appliances for snoring and obstructive sleep apnea: a review.

Effect of sleep position on sleep apnea severity.

Oral appliances for the treatment of snoring and obstructive sleep apnea: a review.

Principles and Practice of Sleep Medicine, 3rd ed.

Alcohol and NREM parasomnias: evidence versus opinions in the international classification of sleep disorders, 3rd edition.