Showing papers in "Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine in 2007"

Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine.

Abstract: Based on a review of literature and consensus, the Portable Monitoring Task Force of the American Academy of Sleep Medicine (AASM) makes the following recommendations: unattended portable monitoring (PM) for the diagnosis of obstructive sleep apnea (OSA) should be performed only in conjunction with a comprehensive sleep evaluation. Clinical sleep evaluations using PM must be supervised by a practitioner with board certification in sleep medicine or an individual who fulfills the eligibility criteria for the sleep medicine certification examination. PM may be used as an alternative to polysomnography (PSG) for the diagnosis of OSA in patients with a high pretest probability of moderate to severe OSA. PM is not appropriate for the diagnosis of OSA in patients with significant comorbid medical conditions that may degrade the accuracy of PM. PM is not appropriate for the diagnostic evaluation of patients suspected of having comorbid sleep disorders. PM is not appropriate for general screening of asymptomatic populations. PM may be indicated for the diagnosis of OSA in patients for whom in-laboratory PSG is not possible by virtue of immobility, safety, or critical illness. PM may also be indicated to monitor the response to non-CPAP treatments for sleep apnea. At a minimum, PM must record airflow, respiratory effort, and blood oxygenation. The airflow, effort, and oximetric biosensors conventionally used for in-laboratory PSG should be used in PM. The Task Force recommends that PM testing be performed under the auspices of an AASM-accredited comprehensive sleep medicine program with written policies and procedures. An experienced sleep technologist/technician must apply the sensors or directly educate patients in sensor application. The PM device must allow for display of raw data with the capability of manual scoring or editing of automated scoring by a qualified sleep technician/technologist. A board certified sleep specialist, or an individual who fulfills the eligibility criteria for the sleep medicine certification examination, must review the raw data from PM using scoring criteria consistent with current published AASM standards. Under the conditions specified above, PM may be used for unattended studies in the patient's home. A follow-up visit to review test results should be performed for all patients undergoing PM. Negative or technically inadequate PM tests in patients with a high pretest probability of moderate to severe OSA should prompt in-laboratory polysomnography. Citation: Collop NA; Anderson WM; Boehlecke B; Claman D; Goldberg R; Gottlieb DJ; Hudgel D; Sateia M; Schwab R. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. J Clin Sleep Med 2007;3(7):737–747.

Insomnia: Definition, Prevalence, Etiology, and Consequences

Abstract: Estimates of the prevalence of insomnia depend on the criteria used to define insomnia and more importantly the population studied. A general consensus has developed from population-based studies that approximately 30% of a variety of adult samples drawn from different countries report one or more of the symptoms of insomnia: difficulty initiating sleep, difficulty maintaining sleep, waking up too early, and in some cases, nonrestorative or poor quality of sleep.2 Conclusions from the NIH State-of-the-Science Conference held in June 2005 indicate that the addition of a diagnostic requirement that includes perceived daytime impairment or distress as a function of the insomnia symptoms results in approximately 10% prevalence of insomnia.3 Finally, the application of more stringent diagnostic criteria, such as the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV),4 which includes the additional requirements that insomnia symptoms persist for at least 1 month and do not exclusively occur in the presence of another sleep disorder, mental disorder, or the direct physiological effects of a substance or medical condition, yields current prevalence estimates of approximately 6%.5 Several well-identified risk factors for insomnia were reported by the State-of-the-Science Conference in June 2005.3 Age and gender are the most clearly identified demographic risk factors, with an increased prevalence in women and older adults. While the cause of this increased risk in the elderly is not well defined, it may be due to the partial decline in functionality of sleep control systems that may contribute to insomnia in this older population. Importantly, the presence of comorbid medical conditions is also a significant contributor to the increased prevalence of insomnia in the elderly. Additionally, in women, insomnia is more prevalent with both the onset of menses and menopause.6 Comorbid medical disorders,7 psychiatric disorders,8 and working night or rotating shifts9 all represent significant risks for insomnia. It is important to recognize that these factors do not independently cause insomnia, but rather they are precipitants of insomnia in individuals predisposed to this disorder. In fact, chronic illnesses are a significant risk for insomnia. It is estimated that the majority of people with insomnia (approximately 75%-90%) have an increased risk for comorbid medical disorders,7 such as conditions causing hypoxemia and dyspnea, gastroesophageal reflux disease, pain conditions, and neurodegenerative diseases. Importantly, a variety of primary sleep disorders as well as circadian rhythm disorders are frequently comorbid with and often lead to insomnia. Among the primary sleep disorders, restless legs synDEFINITION OF INSOMNIA

The visual scoring of sleep in adults

Abstract: The 1968 Rechtschaffen and Kales (R & K) sleep scoring man- ual was published 15 years after REM sleep was discovered. Advances in the ensuing 28 years warranted a re-look at visual scoring of sleep stages. This paper describes the work of the AASM Visual Scoring Task Force, including methodology, a literature review and the rationale behind the new rules. Reliability studies of R & K scoring were reviewed; reliabil- ity was low for stage one and moderate for slow wave sleep. Evidence indicated that K complexes and slow waves are expressed maximal fron- tally, spindles centrally and alpha rhythm over the occipital region. Three derivations of EEG, two of electro-oculography, and one of chin EMG were recommended. Scoring by 30-second epochs was retained. New terminology for sleep stages was proposed. Attenuation of alpha rhythm was determined to be the most valid electrophysiological marker of sleep onset. Alternative measures were proposed for non-alpha generating subjects. K complexes associated with arousals were determined to be insufficient alone to define the new stage N2. No evidence was found to justify dividing slow wave sleep into two stages. No reasons were found to alter the current slow wave amplitude criteria at any age. The phenomena of REM sleep were defined. The rules for defining onset and termination of REM sleep periods were simplified. Movement time was eliminated and major body movements defined. Studies are needed to test the reliability of the new rules. Future advances in technology may require modification of these rules with time.

Chronic Opioid Use is a Risk Factor for the Development of Central Sleep Apnea and Ataxic Breathing

Abstract: Background:Chronic opioid therapy for pain management has increased dramatically without adequate study of potential deleterious effects on breathing during sleep.Methods:A retrospective cohort stu...

Validation of the ApneaLink for the screening of sleep apnea: a novel and simple single-channel recording device.

Abstract: Sleep apnea is a common disorder that affects more than 20 million adult Americans.1 It is associated with poor sleep quality, excessive daytime sleepiness,2 and decreased quality of life.3 Sleep apnea has been shown to have an increased prevalence in, or association with, morbid conditions such as heart failure,4,5 hypertension,6,7 cardiovascular disease,8,9 cerebrovascular disease,10 and insulin resistance.11,12 Studies have also demonstrated that sleep apnea is associated with increased rates of traffic accidents13 and has been identified as a major public health concern.14 Although effective treatment for sleep apnea is available, referral for diagnosis and treatment of sleep apnea may be difficult in some settings due to limited access to or availability of sleep specialists and sleep laboratories for diagnostic evaluation.15 In areas in which access is not an issue, some patients may be unwilling to undergo a sleep-laboratory study, even when recommended by their physician. Current estimates reveal that 93% of women and 82% of men with moderate to severe sleep apnea remain undiagnosed.16 Given the prevalence of the disorder in the general population, and the increased prevalence in populations with certain comorbid conditions, screening studies for sleep apnea may play an important role. Although full polysomnography (PSG) is the standard diagnostic test for sleep apnea,17 the use of a screening device may allow physicians to screen for sleep apnea in a variety of settings, such as patients' homes, hospitals, or extended-care facilities, allowing more effective triaging for sleep center diagnostic testing. A number of devices are now commercially available to screen patients for sleep apnea outside the traditional sleep-laboratory setting. These devices include single-channel and multi-channel recorders; however, there are limited data available regarding their efficacy as screening or diagnostic tools for sleep apnea, compared with PSG.18, 19 The aim of this study was to examine the accuracy of the apnea-hypopnea index (AHI) provided by the ApneaLink™ (ResMed Corporation, Poway, Calif), a single-channel recording device, against that obtained during simultaneous PSG, and to validate the ApneaLink device as a screening tool for sleep apnea in clinical practice.

The effect of opioids on sleep architecture.

Abstract: STUDY OBJECTIVES The effect of opioid medications on sleep architecture has been demonstrated in patients with comorbid pain or opioid addiction. This study examined whether commonly used opioid medications have an adverse effect on sleep architecture in healthy adults. METHODS Forty-two healthy subjects were examined with polysomnography after a bedtime dose of placebo, sustained-release morphine sulfate (15 mg), or methadone (5 mg) on each of 3 different nights in a double-blind multiple crossover study in a sleep laboratory in the General Clinical Research Center at an academic medical center. RESULTS Both opioid drugs significantly reduced deep sleep and increased stage 2 sleep (both p < .01); neither had an effect on sleep efficiency, wake after sleep onset, or total sleep time. CONCLUSIONS Single doses of oral opioid medications can significantly affect sleep architecture in healthy adults, and observed reductions in slow-wave sleep following opioid administration may have important implications for the pathogenesis of opioid-use related fatigue.

Phasic or Transient? Comment on the Terminology of the AASM Manual for the Scoring of Sleep and Associated Events

Abstract: In the recently published American Academy of Sleep Medicine (AASM) scoring manual for sleep stages,1 the term phasic was replaced throughout by transient. Recommendations for changes in terminology should be made with great care, especially when terminology is a core topic, as indicated by the subtitle of the AASM manual, “Rules, Terminology, and Technical Specifications.” The decision by the Visual Task Force was substantiated in an accompanying paper.2 The recommendation was based on the following reasoning, “Dictionary definitions of phase do not include short-lived transient activity and the term is used in physics for a particular appearance or state in a regularly cycle of changes.”2p129 This argument is misleading, since the term phasic in the context of rapid eye movement (REM) sleep was derived from physiology not physics. Physiologists discriminate between phasic and tonic muscle fibers according to the discharge pattern (see, e.g.3). This also becomes clear by the following quotation from Hobson and Scheibel.4 “Orlovsky (1970) has shown that, complementing these slowly conducting systems, fast reticulospinal fibers are activated in phase with mainly the flexors of one of the limbs in each step and Shimamura and Kuruge (1977) have demonstrated that the reticulospinal neurons thought to be part of the spinal-bulbar-spinal reflex are also phasically activated. Phasic rhythmic activity may also be recorded in vestibulo-spinal and rubrospinal pathways during locomotion (Orlovsky, 1972a,b).”4p62 In his book Neuronal Substrates of Sleep and Epilepsy, Steriade devoted a whole chapter to phasic events.5p187–98

Sleep Disorders in Chronic Traumatic Brain Injury

Abstract: Traumatic brain injury occurs in 100–400 per 100,000 people per year in North America and Europe. The common causes are road traffic accidents, falls, assaults, sport injuries, and domestic accidents. Males are more often affected than women. The most common age group which suffers from traumatic brain injury is 15–35 years. It is the most frequent cause of death between ages 1–15.1 Sleep related problems secondary to chronic TBI have been described anecdotally or in case-report format since 1941. 2–10 Some commonly reported disorders include hypersomnia, narcolepsy, delayed sleep phase, insomnia, fatigue, alteration of sleepwake schedule, and movement disorders. Sleep disorders are a common finding after the acute phase of TBI. They result in daytime somnolence which in turn may lead to poor daytime performance, altered sleep-wake schedule, heightened anxiety, and poor individual sense of well being, insomnia, and depression. Only recently have the attempts have been made to investigate this relationship more systematically in chronic TBI11–14 The most critical study is that of Guilleminault et al who concluded that impaired daytime functioning and somnolence is present in 98% of all patients with TBI, and sleep disordered breathing is a common finding.4 Pain caused by associated cervical whiplash may be an important contributing factor. Sleep related abnormalities are more prevalent in more severely head-injured patients, such as those in coma for >24 hours, those with skull fractures, or those requiring neurosurgical intervention. Kauffman et al14 reached similar conclusions in adolescents with minor head injury and found that sleep disturbances may be long-term. This study was undertaken to extend these systematic observations in the evolving knowledge of sleep disorders in TBI survivors, as the sleep disorders make an impact on the rehabilitation of these patients15,16 and can exacerbate other symptoms such as pain, cognitive deficits, fatigue, and irritability. 16

Do Insomnia Complaints Cause Hypertension or Cardiovascular Disease

Abstract: Insomnia is estimated to affect as many as one third of Americans. Although the prevalence of insomnia depends on how it is defined and diagnosed, it is easily the most commonly reported sleep problem.1,2 Insomnia is more prevalent in women than in men at all ages.1–6 Other reported risks for insomnia include aging,4,5 medical illness,4,5,7,8 sleep apnea,9 depression, psychiatric illness,3,6 and some lifestyle factors.10, 11 Insomnia is associated with reduced quality of life and may precede depression.3 A recent cross-sectional analysis12 found that insomnia was strongly associated with impaired quality of life and poor physical and mental health, but, as the authors noted, “the cross-sectional nature of the survey does not permit conclusions as to directions of cause and effect.…” Indeed, insomnia has not clearly been shown to be causally associated with adverse outcomes. In fact, Kripke et al found a reduced mortality rate for those individuals complaining of sleeping difficulty after 6 years of follow-up.13 We have previously reported that neither insomnia complaints nor the use of hypnotics was associated with increased mortality at 6.3 years of follow-up.14 On the other hand, both long sleep and short sleep are associated with increased morbidity and mortality in population-based studies.13,15,16 Recent work with population-based studies has demonstrated an increased risk of cardiovascular disease with short (and long) sleep duration.17–20 It is possible that insomnia complaints may not directly lead to death, but that they may predispose to factors that increase mortality risk. Efforts to establish the prevalence, outcomes, and efficacy of treatment of insomnia have been hampered by the imprecision in its diagnosis. There are several characterizations of insomnia in the literature: difficulty falling asleep; difficulty staying asleep, early morning awakening, and nonrestorative sleep. The DSM-III-R21 and DSM IV22 classifications and the International Classification of Sleep Disorders, 2nd edition23 include varying criteria for insomnia. The DSM IV criteria include complaints of sleep problems 3 times a week for a month but also daytime consequences. Few epidemiologic studies include information about daytime consequences or the frequency or severity of insomnia symptoms. The recently published Research Diagnostic Criteria for Insomnia Disorder include sleep complaints, nonrestorative sleep, and daytime impairment in the definition but do not have duration, severity, or frequency criteria.24 The recent National Institutes of Health Consensus Conference on Insomnia concluded, “Insomnia may be defined as complaints of disturbed sleep in the presence of adequate opportunity and circumstance for sleep. The disturbance may consist of one or more of three features: (1) difficulty in initiating sleep; (2) difficulty in maintaining sleep; or (3) waking up too early. A fourth characteristic, nonrestorative or poor-quality sleep, has frequently been included in the definition, although there is controversy as to whether individuals with this complaint share similar pathophysiologic mechanisms with the others.”25 Another significant problem with studies of the impact of insomnia is that sleep complaints frequently coexist in individuals with medical and psychologic problems that could be the actual or primary cause of adverse associations of insomnia. In fact, the National Institutes of Health consensus conference noted, “Insomnia usually appears in the presence of at least one other disorder. Particularly common comorbidities are major depression, generalized anxiety, substance abuse, attention deficit/hyperactivity in children, dementia, and a variety of physical problems. The research diagnostic criteria for insomnia recently developed by the American Academy of Sleep Medicine indeed share many of the criteria of major depressive disorder. Studies to explain these overlaps require determining how often insomnia precedes the disorders with which it is associated and whether it continues to exist if the other disorders go into remission.” Thus, prospective studies that carefully control for comorbidities are needed to assess the impact of sleep complaints. The purpose of this study was to use well-established cohort data to investigate whether specific insomnia complaints, combinations of complaints, or use of hypnotics increased the risk of hypertension or cardiovascular disease.

The scoring of arousal in sleep: reliability, validity, and alternatives.

Abstract: The reliability and validity of EEG arousals and other types of arousal are reviewed. Brief arousals during sleep had been observed for many years, but the evolution of sleep medicine in the 1980s directed new attention to these events. Early studies at that time in animals and humans linked brief EEG arousals and associated fragmentation of sleep to daytime sleepiness and degraded performance. Increasing interest in scoring of EEG arousals led the ASDA to publish a scoring manual in 1992. The current review summarizes numerous studies that have examined scoring reliability for these EEG arousals. Validity of EEG arousals was explored by review of studies that empirically varied arousals and found deficits similar to those found after total sleep deprivation depending upon the rate and extent of sleep fragmentation. Additional data from patients with clinical sleep disorders prior to and after effective treatment has also shown a continuing relationship between reduction in pathology-related arousals and improved sleep and daytime function. Finally, many suggestions have been made to refine arousal scoring to include additional elements (e.g., CAP), change the time frame, or focus on other physiological responses such as heart rate or blood pressure changes. Evidence to support the reliability and validity of these measures is presented. It was concluded that the scoring of EEG arousals has added much to our understanding of the sleep process but that significant work on the neurophysiology of arousal needs to be done. Additional refinement of arousal scoring will provide improved insight into sleep pathology and recovery.

Evaluation of the efficacy and safety of ramelteon in subjects with chronic insomnia.

Abstract: Objective:To evaluate efficacy and safety of ramelteon (MT1/MT2-receptor agonist) in subjects with chronic primary insomnia.Methods:Randomized, multicenter, double-blind, placebo-controlled trial o...

The Cleveland adolescent sleepiness questionnaire: a new measure to assess excessive daytime sleepiness in adolescents.

Abstract: Study Objectives:Developed the Cleveland Adolescent Sleepiness Questionnaire (CASQ), a brief, self-completed instrument to measure excessive daytime sleepiness in adolescents.Design:Cross-sectional...

Interventions to Improve Compliance in Sleep Apnea Patients Previously Non-Compliant with Continuous Positive Airway Pressure

Abstract: Obstructive sleep apnea (OSA) is highly prevalent, conservatively estimated to affect 2%–4% of the middle-aged adult population in the United States1 OSA is widely believed to contribute to impaired cognition,2 hypertension,3 cardiovascular disease,4 cerebrovascular disease,5 and increased risk for accidents6 The most effective therapy is continuous positive airway pressure (CPAP), which improved select signs and symptoms of OSA in several randomized, placebo-controlled trials7,8 However, the efficacy of CPAP may be limited by poor compliance It has been estimated that as many as 50% of OSA patients for whom CPAP is initially recommended are not using this therapy one year later9 Common reasons for discontinuation include mask discomfort, nasal drying or irritation, and intolerance of the pressure10 Numerous studies have evaluated the benefits of various interventions at initial CPAP set-up to improve acceptance and compliance Such interventions include intensified education and follow-up programs,11 the addition of humidification to CPAP,12 and alternative pressure delivery systems13 Gay and colleagues have recently reviewed in detail factors that can affect initial CPAP tolerance and adherence, and interventions that might improve initial CPAP efficacy14 However, few studies have evaluated interventions to improve CPAP compliance in OSA patients previously unable to comply with CPAP therapy We evaluated a two phase intervention program intended to improve CPAP compliance in previously noncompliant OSA patients The first phase assessed several standard interventions to improve CPAP comfort, while the second phase compared the efficacy of flexible bilevel positive airway pressure (BiFlex, Respironics Inc, Murrysville, PA) to standard CPAP BiFlex differs from standard bilevel positive airway pressure (PAP) devices in that it allows reductions of the late inspiratory and early expiratory pressures15

EEG arousal norms by age.

Abstract: Study Objectives:Brief arousals have been systematically scored during sleep for more than 20 years. Despite significant knowledge concerning the importance of arousals for the sleep process in nor...

Adolescent sleep disturbance and school performance: the confounding variable of socioeconomics.

Abstract: Study objectives To assess how selected socioeconomic variables known to affect school performance alter the association between reported sleep disturbance and poor school performance in a contiguous middle school/high school population. Methods A school district/college IRB approved questionnaire was distributed in science and health classes in middle school and high school. This questionnaire included a frequency scaled pediatric sleep disturbance questionnaire for completion by students and a permission and demographic questionnaire for completion by parents (completed questionnaires n = 238 with 69.3% including GPA). Results Sleep complaints occur at high frequency in this sample (sleep onset insomnia 60% > 1 x /wk.; 21.2% every night; sleepiness during the day (45.7% > 1 x /wk.; 15.2 % every night), and difficulty concentrating (54.6% > 1 x /wk.; 12.9% always). Students with lower grade point averages (GPAs) were more likely to have restless/aching legs when trying to fall asleep, difficulty concentrating during the day, snoring every night, difficulty waking in the morning, sleepiness during the day, and falling asleep in class. Lower reported GPAs were significantly associated with lower household incomes. After statistically controlling for income, restless legs, sleepiness during the day, and difficulty with concentration continued to significantly affect school performance. Conclusions This study provides additional evidence indicating that sleep disturbances occur at high frequencies in adolescents and significantly affect daytime performance, as measured by GPA. The socioeconomic variable of household income also significantly affects GPA. After statistically controlling for age and household income, the number and type of sleep variables noted to significantly affect GPA are altered but persistent in demonstrating significant effects on school performance.

Association of alcohol consumption and sleep disordered breathing in men and women.

Abstract: Study Objectives:Experimental evidence indicates that alcohol use near bedtime may exacerbate sleep disordered breathing (SDB). However, scarce research has examined the relation between moderate h...

Central Sleep Apnea on Commencement of Continuous Positive Airway Pressure in Patients With a Primary Diagnosis of Obstructive Sleep Apnea-Hypopnea

Abstract: Introduction: Central sleep apnea (CSA) may occur in patients with snor- ing and obstructive sleep apnea-hypopnea (OSAH) during commencement of continuous positive airway pressure (CPAP) therapy. The presence of CSA may limit the effectiveness of CPAP therapy. The aims of this study were to assess the prevalence of CSA amongst patients starting CPAP for OSAH and to identify possible predictors of this condition. Methods: We reviewed the polysomnograms (PSGs) and clinical re- cords of 99 consecutive patients with a primary diagnosis of OSAH who were referred for an in-laboratory CPAP titration study. Patients with a CSA Index of ≥5 per hour at or near (±1 cm H 2 O) prescribed CPAP level formed the CSA-CPAP group. The remaining patients made up the noCSA-CPAP group. Demographic, baseline and CPAP titration PSG variables were compared between the 2 two groups. Results: 13 subjects (13.1%) had CSA-CPAP. Patients with and without CSA-CPAP did not differ with respect to age or body mass index. 46% of patients with CSA-CPAP had CSA on their baseline PSGs compared with 8% in the noCSA-CPAP group (p <0.01). CSA-CPAP patients also had a higher apnea-hypopnea index (72.1 vs. 52.7 p = 0.02), a higher arousal index (43.3 vs. 29.2 p <0.01), and a higher mixed apnea index (6.8 vs. 1.3 p = 0.03), on their baseline PSGs. Therapeutic CPAP could not be determined in 2 CSA-CPAP patients due to a very high frequency (of severe) central apneas. In the remaining 11, the CPAP prescription to eliminate obstructive events was higher than in the noCSA-CPAP group (11.0 vs. 9.3 p = 0.08). AHI was greater both at or near prescribed CPAP (48.8 vs. 6.7 p <0.01) and overall (47.4 vs. 14.9 p <0.01). A history of ischemic heart disease or heart failure was more frequent amongst pa- tients with CSA-CPAP than those without (p = 0.03). Conclusion: A significant minority of patients with a primary diagnosis of OSAH have either emergence or persistence of CSA on CPAP. Risk factors include male sex, history of cardiac disease, and CSA on base- line PSG.

The Scoring of Movements in Sleep

Abstract: The International Classification of Sleep Disorders (ICSD-2) has separated sleep-related movement disorders into simple, repetitive movement disorders (such as periodic limb movements in sleep [PLMS], sleep bruxism, and rhythmic movement disorder) and parasomnias (such as REM sleep behavior disorder and disorders of partial arousal, e.g., sleep walking, confusional arousals, night terrors). Many of the parasomnias are characterized by complex behaviors in sleep that appear purposeful, goal directed and voluntary but are outside the conscious awareness of the individual and therefore inappropriate. All of the sleep-related movement disorders described here have specific polysomnographic findings. For the purposes of developing and/or revising specifications and polysomnographic scoring rules, the AASM Scoring Manual Task Force on Movements in Sleep reviewed background literature and executed evidence grading of 81 relevant articles obtained by a literature search of published articles between 1966 and 2004. Subsequent evidence grading identified limited evidence for reliability and/or validity for polysomnographic scoring criteria for periodic limb movements in sleep, REM sleep behavior disorder, and sleep bruxism. Published scoring criteria for rhythmic movement disorder, excessive fragmentary myoclonus, and hypnagogic foot tremor/alternating leg muscle activation were empirical and based on descriptive studies. The literature review disclosed no published evidence defining clinical consequences of excessive fragmentary myoclonus or hypnagogic foot tremor/alternating leg muscle activation. Because of limited or absent evidence for reliability and/or validity, a standardized RAND/UCLA consensus process was employed for recommendation of specific rules for the scoring of sleep-associated movements.

The Flinders Fatigue Scale: Preliminary psychometric properties and clinical sensitivity of a new scale for measuring daytime fatigue associated with insomnia.

Abstract: Study objectives:To evaluate the psychometric properties and clinical significance of a new scale for measuring daytime fatigue associated with insomnia: The Flinders Fatigue Scale (FFS).Methods:Th...

Hypersomnia following traumatic brain injury.

Abstract: Study Objectives:To evaluate the prevalence and natural history of sleepiness following traumatic brain injury.Methods:This prospective cohort study used the Sickness Impact Profile to evaluate sle...

Evaluation of eszopiclone discontinuation after cotherapy with fluoxetine for insomnia with coexisting depression.

Abstract: BACKGROUND: Insomnia and major depressive disorder (MDD) may coexist. This study evaluated hypnotic discontinuation effects following an 8-week placebo-controlled study of eszopiclone/fluoxetine cotherapy in patients with insomnia and comorbid MDD. METHODS: Patients meeting DSM-IV criteria for MDD and insomnia received fluoxetine each morning for 8 weeks and were randomized to concomitant treatment with nightly eszopiclone 3 mg (cotherapy) or placebo (monotherapy). Thereafter, patients received 2 weeks of continued fluoxetine plus single-blind placebo. RESULTS: Incidence rates of central nervous system (CNS) and potentially CNS-related adverse events (AEs) during the run-out period were similar between treatment groups (8.8% with monotherapy vs 9.8% with cotherapy), and there was no evidence of benzodiazepine withdrawal AEs. Physician-assessed Clinical Global Impression improvements in depressive symptoms were maintained after eszopiclone discontinuation. Improvements in 17-item Hamilton-Depression Rating Scale (HAMD-17) scores with cotherapy versus monotherapy seen at Week 8 (p = .0004) were maintained at Week 10 (p < .0001) and significantly higher depression response and remission rates were observed after cotherapy at Week 10 (p < .02). Patients discontinued from eszopiclone maintained improvements in SL (sleep latency), WASO (wake after sleep onset), and TST (total sleep time) during the 2 weeks following discontinuation (p < .05). CONCLUSIONS: In this study, eszopiclone discontinuation did not result in significant CNS or benzodiazepine withdrawal AEs, rebound insomnia, or rebound depression; and improvements in sleep and depressive symptoms were maintained.

Treating the health, quality of life, and functional impairments in insomnia

Abstract: Study objectives Impairments in health, function, and quality of life (QOL) are a central feature of insomnia, yet insomnia treatment is targeted solely to improving problems falling and staying asleep. It is not even known if the nonsleep deficits improve with current treatment. We hypothesized that therapy that improves sleep also improves these nonsleep difficulties and carried out this review to test that hypothesis. Methods A literature search identified the health, function, and QOL deficits of insomnia patients. A second search determined the effect of insomnia treatments on those problems, capturing randomized controlled treatment trials in insomnia patients that included relevant measures. Results Insomnia patients report a variety of symptoms, including daytime sleepiness, fatigue, cognitive impairment, symptoms of depression, anxiety, health decrements, and impairment in social and occupational function. However, the reported deficits are generally not paralleled by objective evidence of impairment. Nineteen treatment studies reported measures related to these deficits. At least one treatment (eszopiclone [5 studies], zopiclone [2 studies], progressive muscle relaxation [2], zolpidem [2], multi-component cognitive-behavioral therapy [1], doxepin [1], valerian/hops [1], and stimulus control [1]) led to a significant improvement compared with placebo in at least one of these measures in 14/20 studies. Conclusions Treatment can improve the perceived health, function, and QOL of insomnia patients. This potential improvement signals the need to shift the attention of research and clinical practice to include aspects other than sleep difficulties and move towards defining successful therapy as not only improving sleep but also eliminating deficits in health, function, and QOL.

Sleep Apnea in an Urban Public Hospital: Assessment of Severity and Treatment Adherence

Abstract: Objective: To assess obstructive sleep apnea (OSA) severity, continuous positive airway pressure (CPAP) adherence, and factors associated with CPAP adherence among a group of patients with OSA receiving care at a publicly funded county hospital.

For individuals with obstructive sleep apnea, institution of CPAP therapy is associated with an amelioration of symptoms of depression which is sustained long term.

Abstract: Objective:To assess the sustainability of an improvement in symptoms of depression using CPAP therapy in patients with obstructive sleep apneaPatients/Methods:Patients referred to our center for e

The treatment of parasomnias with hypnosis: a 5-year follow-up study.

Abstract: Study Objectives:This study involves a replication and extension of a previous one reported by Hurwitz et al (1991) on the treatment of certain parasomnias with hypnosis.Methods:Thirty-six patients...

Zolpidem and amnestic sleep related eating disorder.

Abstract: Nocturnal eating disorders are more common than previously thought. Sleep related eating disorder has been described in association with zolpidem. A review of the literature revealed the presence of 6 previously reported cases. In this presentation, the case of a 46-year-old female who developed sleep related eating disorder when she was treated with zolpidem for insomnia is reported. The patient recovered totally when zolpidem was stopped. Drug-induced sleep related eating disorders should be considered when evaluating patients with nocturnal eating. Citation: Najjar M. Zolpidem and amnestic sleep related eating disorder. J Clin Sleep Med 2007;3(6):637-638.

Self-reported sleep, sleepiness, and repeated alcohol withdrawals: a randomized, double blind, controlled comparison of lorazepam vs gabapentin.

Abstract: Study objectives Insomnia is a central symptom of alcohol withdrawal and increases relapse potential. The primary objective of this study was to compare the efficacy of gabapentin to lorazepam in alleviating sleep disturbances and daytime sleepiness during an episode of alcohol withdrawal. The secondary objective of this study was to determine if drug treatment efficacy differed by the patient history of previous treatments for alcohol withdrawal. Methods Outpatients in treatment for alcohol withdrawal received a 4-day fixed-dose taper of gabapentin or lorazepam in a double-blind, randomized, controlled trial with an 8-day follow-up. Daily across a 5 day outpatient treatment and Days 7 and 12 post-treatment, patients self-reported daytime sleepiness using the Epworth Sleepiness Scale. Self-reports of depression (Beck Depression Inventory) were completed at Days 1, 5, 7 and 12. Staff assessed daily alcohol withdrawal using the Clinical Institute Withdrawal Assessment for Alcohol. From these instruments, self-reported sleep and sleepiness were extracted and assessed in the context of limited (0-1) or multiple (2 or more) previously treated alcohol withdrawal episodes. Results Patients with limited previous withdrawals reported similar treatment effects on self-reports of sleep and sleepiness for gabapentin and lorazepam. In contrast, patients with multiple previous alcohol withdrawals receiving gabapentin reported reduced sleep disturbances and sleepiness in comparison to those receiving lorazepam. Conclusions During treatment for alcohol withdrawal, gabapentin as compared to standard therapy with lorazepam, was superior on multiple sleep measures, in patients who had previous withdrawals. Lorazepam subjects experienced rebound symptoms. Early drinking was related to persisting insomnia with both drugs.

Exploratory Polysomnographic Evaluation of Pregabalin on Sleep Disturbance in Patients with Epilepsy

Abstract: Objectives: To evaluate the effects of adjunctive pregabalin 300 mg/day versus placebo on polysomnographic (PSG) variables in patients with well controlled partial seizures and subjectively reported sleep disturbance.

Evaluation of the safety of modafinil for treatment of excessive sleepiness.

Abstract: Study Objectives:Modafinil is a wake-promoting agent shown to improve wakefulness in patients with excessive sleepiness (hypersomnolence) associated with shift work sleep disorder, obstructive slee...

Melatonin and Its Receptors: A New Class of Sleep-Promoting Agents

Abstract: Melatonin plays a crucial role in the synchronization of internal biological events to external environmental cues Its rhythmic secretion by the pineal gland is regulated by the suprachiasmatic nucleus (SCN) of the anterior hypothalamus, with the light-dark cycle being the main synchronizer Melatonin secretion is stimulated by darkness and inhibited by light, and in coordination with the SCN, it is centrally involved in maintaining circadian rhythmicity and regulating sleep The SCN regulates the timing of melatonin release, while melatonin feeds back to the SCN to decrease SCN neuronal firing This process is controlled by two high-affinity melatonin (MT) receptors located in the SCN: MT1 and MT2 The ability of melatonin to entrain, or synchronize, the circadian clock by its direct action on the SCN has led to the investigation of melatonin as a remedy for treating disordered circadian rhythms that occur in jet lag, shift work, and certain types of insomnia However, results on its effectiveness have not been conclusive Ramelteon is a selective agonist at the MT1 and MT2 receptors and is approved by the US Food and Drug Administration (FDA) for the treatment of insomnia Other melatonin receptor agonists that are currently being investigated for the treatment of sleep disorders include agomelatine: a high-affinity MT1 and MT2 receptor agonist; VEC-162; and LY 156735, a melatonin analog