Showing papers on "Epworth Sleepiness Scale published in 2013"

Drug therapy for obstructive sleep apnoea in adults

Abstract: Background The treatment of choice for moderate to severe obstructive sleep apnoea (OSA) is continuous positive airways pressure (CPAP) applied via a mask during sleep. However, this is not tolerated by all individuals and its role in mild OSA is not proven. Drug therapy has been proposed as an alternative to CPAP in some patients with mild to moderate sleep apnoea and could be of value in patients intolerant of CPAP. A number of mechanisms have been proposed by which drugs could reduce the severity of OSA. These include an increase in tone in the upper airway dilator muscles, an increase in ventilatory drive, a reduction in the proportion of rapid eye movement (REM) sleep, an increase in cholinergic tone during sleep, an increase in arousal threshold, a reduction in airway resistance and a reduction in surface tension in the upper airway. Objectives To determine the efficacy of drug therapies in the specific treatment of sleep apnoea. Search methods We searched the Cochrane Airways Group Specialised Register of trials. Searches were current as of July 2012. Selection criteria Randomised, placebo controlled trials involving adult patients with confirmed OSA. We excluded trials if continuous positive airways pressure, mandibular devices or oxygen therapy were used. We excluded studies investigating treatment of associated conditions such as excessive sleepiness, hypertension, gastro-oesophageal reflux disease and obesity. Data collection and analysis We used standard methodological procedures recommended by The Cochrane Collaboration. Main results Thirty trials of 25 drugs, involving 516 participants, contributed data to the review. Drugs had several different proposed modes of action and the results were grouped accordingly in the review. Each of the studies stated that the participants had OSA but diagnostic criteria were not always explicit and it was possible that some patients with central apnoeas may have been recruited. Acetazolamide, eszopiclone, naltrexone, nasal lubricant (phosphocholinamine) and physiostigmine were administered for one to two nights only. Donepezil in patients with and without Alzheimer's disease, fluticasone in patients with allergic rhinitis, combinations of ondansetrone and fluoxetine and paroxetine were trials of one to three months duration, however most of the studies were small and had methodological limitations. The overall quality of the available evidence was low. The primary outcomes for the systematic review were the apnoea hypopnoea index (AHI) and the level of sleepiness associated with OSA, estimated by the Epworth Sleepiness Scale (ESS). AHI was reported in 25 studies and of these 10 showed statistically significant reductions in AHI. Fluticasone in patients with allergic rhinitis was well tolerated and reduced the severity of sleep apnoea compared with placebo (AHI 23.3 versus 30.3; P < 0.05) and improved subjective daytime alertness. Excessive sleepiness was reported to be altered in four studies, however the only clinically and statistically significant change in ESS of -2.9 (SD 2.9; P = 0.04) along with a small but statistically significant reduction in AHI of -9.4 (SD 17.2; P = 0.03) was seen in patients without Alzheimer's disease receiving donepezil for one month. In 23 patients with mild to moderate Alzheimer's disease donepezil led to a significant reduction in AHI (donepezil 20 (SD 15) to 9.9 (SD 11.5) versus placebo 23.2 (SD 26.4) to 22.9 (SD 28.8); P = 0.035) after three months of treatment but no reduction in sleepiness was reported. High dose combined treatment with ondansetron 24 mg and fluoxetine 10 mg showed a 40.5% decrease in AHI from the baseline at treatment day 28. Paroxetine was shown to reduce AHI compared to placebo (-6.10 events/hour; 95% CI -11.00 to -1.20) but failed to improve daytime symptoms. Promising results from the preliminary mirtazapine study failed to be reproduced in the two more recent multicentre trials and, moreover, the use of mirtazapine was associated with significant weight gain and sleepiness. Few data were presented on the long-term tolerability of any of the compounds used. Authors' conclusions There is insufficient evidence to recommend the use of drug therapy in the treatment of OSA. Small studies have reported positive effects of certain agents on short-term outcomes. Certain agents have been shown to reduce the AHI in largely unselected populations with OSA by between 24% and 45%. For donepezil and fluticasone, studies of longer duration with a larger population and better matching of groups are required to establish whether the change in AHI and impact on daytime symptoms are reproducible. Individual patients had more complete responses to particular drugs. It is possible that better matching of drugs to patients according to the dominant mechanism of their OSA will lead to better results and this also needs further study.

Clinical, polysomnographic and genome-wide association analyses of narcolepsy with cataplexy: a European Narcolepsy Network study

Abstract: The aim of this study was to describe the clinical and PSG characteristics of narcolepsy with cataplexy and their genetic predisposition by using the retrospective patient database of the European Narcolepsy Network (EU-NN). We have analysed retrospective data of 1099 patients with narcolepsy diagnosed according to International Classification of Sleep Disorders-2. Demographic and clinical characteristics, polysomnography and multiple sleep latency test data, hypocretin-1 levels, and genome-wide genotypes were available. We found a significantly lower age at sleepiness onset (men versus women: 23.74 ± 12.43 versus 21.49 ± 11.83, P = 0.003) and longer diagnostic delay in women (men versus women: 13.82 ± 13.79 versus 15.62 ± 14.94, P = 0.044). The mean diagnostic delay was 14.63 ± 14.31 years, and longer delay was associated with higher body mass index. The best predictors of short diagnostic delay were young age at diagnosis, cataplexy as the first symptom and higher frequency of cataplexy attacks. The mean multiple sleep latency negatively correlated with Epworth Sleepiness Scale (ESS) and with the number of sleep-onset rapid eye movement periods (SOREMPs), but none of the polysomnographic variables was associated with subjective or objective measures of sleepiness. Variant rs2859998 in UBXN2B gene showed a strong association (P = 1.28E-07) with the age at onset of excessive daytime sleepiness, and rs12425451 near the transcription factor TEAD4 (P = 1.97E-07) with the age at onset of cataplexy. Altogether, our results indicate that the diagnostic delay remains extremely long, age and gender substantially affect symptoms, and that a genetic predisposition affects the age at onset of symptoms.

Insomnia, Excessive Sleepiness, Excessive Fatigue, Anxiety, Depression and Shift Work Disorder in Nurses Having Less than 11 Hours in-Between Shifts

Abstract: Study objective To assess if less than 11 hours off work between work shifts (quick returns) was related to insomnia, sleepiness, fatigue, anxiety, depression and shift work disorder among nurses. Methods A questionnaire including established instruments measuring insomnia (Bergen Insomnia Scale), sleepiness (Epworth Sleepiness Scale), fatigue (Fatigue Questionnaire), anxiety/depression (Hospital Anxiety and Depression Scale) and shift work disorder was administered. Among the 1990 Norwegian nurses who participated in the study; 264 nurses had no quick returns, 724 had 1–30 quick returns and 892 had more than 30 quick returns during the past year. 110 nurses did not report the number of quick returns during the past year. The prevalence of insomnia, excessive sleepiness, excessive fatigue, anxiety, depression and shift work disorder was calculated within the three groups of nurses. Crude and adjusted logistic regression analyses were performed to assess the relation between quick returns and such complaints. Results We found a significant positive association between quick returns and insomnia, excessive sleepiness, excessive fatigue and shift work disorder. Anxiety and depression were not related to working quick returns. Conclusions There is a health hazard associated with quick returns. Further research should aim to investigate if workplace strategies aimed at reducing the number of quick returns may reduce complaints among workers.

Primary Care vs Specialist Sleep Center Management of Obstructive Sleep Apnea and Daytime Sleepiness and Quality of Life: A Randomized Trial

Abstract: Importance Due to increasing demand for sleep services, there has been growing interest in ambulatory models of care for patients with obstructive sleep apnea. With appropriate training and simplified management tools, primary care physicians are ideally positioned to take on a greater role in diagnosis and treatment. Objective To compare the clinical efficacy and within-trial costs of a simplified model of diagnosis and care in primary care relative to that in specialist sleep centers. Design, Setting, and Patients A randomized, controlled, noninferiority study involving 155 patients with obstructive sleep apnea that was treated at primary care practices (n=81) in metropolitan Adelaide, 3 rural regions of South Australia or at a university hospital sleep medicine center in Adelaide, Australia (n = 74), between September 2008 and June 2010. Interventions Primary care management of obstructive sleep apnea vs usual care in a specialist sleep center; both plans included continuous positive airway pressure, mandibular advancement splints, or conservative measures only. Main Outcome and Measures The primary outcome was 6-month change in Epworth Sleepiness Scale (ESS) score, which ranges from 0 (no daytime sleepiness) to 24 points (high level of daytime sleepiness). The noninferiority margin was −2.0. Secondary outcomes included disease-specific and general quality of life measures, obstructive sleep apnea symptoms, adherence to using continuous positive airway pressure, patient satisfaction, and health care costs. Results There were significant improvements in ESS scores from baseline to 6 months in both groups. In the primary care group, the mean baseline score of 12.8 decreased to 7.0 at 6 months (P Conclusions and Relevance Among patients with obstructive sleep apnea, treatment under a primary care model compared with a specialist model did not result in worse sleepiness scores, suggesting that the 2 treatment modes may be comparable. Trial Registration anzctr.org.au Identifier: ACTRN12608000514303

Oral appliance versus continuous positive airway pressure in obstructive sleep apnea syndrome: a 2-year follow-up.

Abstract: Study Objectives: Oral appliance therapy has emerged as an important alternative to continuous positive airway pressure (CPAP) in treating patients with obstructive sleep apnea syndrome (OSAS). In this study we report about the subjective and objective treatment outcome of oral appliance therapy and CPAP in patients with OSAS. Design: Cohort study of a previously conducted randomized clinical trial. Setting: University Medical Center, Groningen, The Netherlands. Patients or Participants: One hundred three patients with OSAS. Interventions: CPAP and oral appliance therapy (Thornton Adjustable Positioner type-1, Airway Management, Inc., Dallas, TX, USA) Measurements and Results: Objective (polysomnography) and subjective (Epworth Sleepiness Scale, Functional Outcomes of Sleep Questionnaire, Medical Outcomes Study 36-item Short Form Health Survey [SF-36]) parameters were assessed after 1 and 2 years of treatment. Treatment was considered successful when the apnea-hypopnea index (AHI) was Conclusions: Oral appliance therapy should be considered as a viable treatment alternative to continuous positive airway pressure (CPAP) in patients with mild to moderate obstructive sleep apnea syndrome (OSAS). In patients with severe OSAS, CPAP remains the treatment of first choice. Clinical Trial Information: The original randomized clinical trial, of which this study is a 2-year follow-up, is registered at ISRCTN.org; identifier: ISRCTN18174167; trial name: Management of the obstructive sleep apnea-hypopnea syndrome: oral appliance versus continuous positive airway pressure therapy; URL: http://www.controlled-trials.com/ISRCTN18174167.

Targeted hypoglossal neurostimulation for obstructive sleep apnoea. A 1 year pilot Study

Abstract: Continuous positive airway pressure (CPAP) is an effective but cumbersome treatment for obstructive sleep apnoea (OSA). Noncompliant patients need alternative therapies. We studied a tongue neurostimulation approach: targeted hypoglossal neurostimulation (THN) therapy with the aura6000™ System. A multi-contact electrode positioned around the main trunk of the twelfth nerve connected to an implanted pulse generator stimulates segments of the nerve, activating dilator muscles. The primary objective was to improve the polysomnographically determined apnoea/hypopnoea index (AHI) at 3 months, and maintain the improvement after 12 months of treatment. 13 out of 14 operated patients were successfully implanted. At 12 months, the AHI decreased from 45±18 to 21±17, a 53% reduction (p<0.001). The 4% oxygen desaturation index fell from 29±20 to 15±16 and the arousal index from 37±13 to 25±14, both p<0.001. The Epworth sleepiness scale decreased from 11±7 to 8±4 (p=0.09). THN was neither painful nor awakened patients, who all complied with therapy. There were two transient tongue paresis. The present study represents the longest study of any hypoglossal neurostimulation reported to date. We conclude that THN is safe and effective to treat OSA in patients not compliant with CPAP.

Residual sleepiness in sleep apnea patients treated by continuous positive airway pressure

Abstract: Hypoxic brain damage might explain persistent sleepiness in some continuous positive airway pressure-compliant obstructive sleep apnea called residual excessive sleepiness. Although continuous positive airway pressure may not be fully efficient in treating this symptom, wake-promoting drug prescription in residual excessive sleepiness is no longer allowed by the European Medicines Agency. The aim of this study is to describe residual excessive sleepiness phenotypes in a large prospective sample of patients with obstructive sleep apnea. Residual excessive sleepiness was defined by an Epworth Sleepiness Scale score ≥ 11. Eligible patients from the French National Sleep Registry attending follow-up continuous positive airway pressure visits numbered 1047. Patients using continuous positive airway pressure 15 h⁻¹ (n = 31) or with major depression were excluded (n = 150). Residual excessive sleepiness prevalence in continuous positive airway pressure-treated obstructive sleep apnea was 13% (18% for those with an initial Epworth Sleepiness Scale score > 11), and significantly decreased with continuous positive airway pressure use (9% in ≥ 6 h night⁻¹ continuous positive airway pressure users, P 30 h⁻¹ versus 18% when AHI 15-30, P < 0.005). There was no relationship between residual excessive sleepiness and body mass index, cardiovascular co-morbidities or diabetes. Continuous positive airway pressure improved symptoms in the whole population, but to a lower extent in patients with residual excessive sleepiness (fatigue scale: -5.2 versus -2.7 in residual excessive sleepiness- and residual excessive sleepiness+ patients, respectively, P < 0.001). Residual excessive sleepiness prevalence decreased with continuous positive airway pressure compliance. Hypoxic insult is unlikely to explain residual excessive sleepiness as obstructive sleep apnea severity does not seem to be critical. Residual symptoms are not limited to sleepiness, suggesting a true 'continuous positive airway pressure-resistant syndrome', which may justify treatment by wake-promoting drugs.

The Epworth Sleepiness Scale: translation and validation study of the Iranian version.

Abstract: The main purpose of this study was to assess the reliability and validity of the Iranian version of the Epworth Sleepiness Scale (ESS-IR). This was a cross-sectional study of 507 suspicious patients either to obstructive sleep apnea (n = 466) or narcolepsy (n = 41) in order to carry out a psychometric evaluation of the ESS-IR by performing reliability, validity, and responsiveness analyses. Reliability of the ESS-IR was assessed by internal consistency and test–retest reliability. Validity of the instrument was assessed using several statistical approaches including construct validity (exploratory factor analysis), discriminant validity, and criterion validity. Responsiveness of the ESS-IR was assessed by comparing the ESS-IR total score before and after 6–9 months of continues positive airway pressure (CPAP) treatment in 16 patients with obstructive sleep apnea (OSA). The ESS-IR had an acceptable internal consistency and test–retest reliability. Factor analysis in both groups showed a two-factor solution for the ESS-IR, but the first factor showed statistically significant loads in all items. In addition, the ESS-IR discriminated well between patients with and without OSA. There is a fair correlation between the ESS-IR total score and multiple sleep latency test results that is not significant at all. Finally, the ESS-IR was found to be responsive to change where the total score was significantly decreased after CPAP treatment (P < 0.001). The findings suggest that the ESS-IR is a reliable and valid measure for evaluating daytime sleepiness and now can be used in research and clinical settings in Iran.

The sleep position trainer: a new treatment for positional obstructive sleep apnoea

Abstract: Positional obstructive sleep apnoea (POSA), defined as a supine apnoea–hypopnoea index (AHI) twice or more as compared to the AHI in the other positions, occurs in 56 % of obstructive sleep apnoea patients. Positional therapy (PT) is one of several available treatment options for these patients. So far, PT has been hampered by compliance problems, mainly because of the usage of bulky masses placed in the back. In this article, we present a novel device for treating POSA patients. Patients older than 18 years with mild to moderate POSA slept with the Sleep Position Trainer (SPT), strapped to the chest, for a period of 29 ± 2 nights. SPT measures the body position and vibrates when the patient lies in supine position. Thirty-six patients were included; 31 patients (mean age, 48.1 ± 11.0 years; mean body mass index, 27.0 ± 3.7 kg/m2) completed the study protocol. The median percentage of supine sleeping time decreased from 49.9 % [20.4–77.3 %] to 0.0 % [range, 0.0–48.7 %] (p < 0.001). The median AHI decreased from 16.4 [6.6–29.9] to 5.2 [0.5–46.5] (p < 0.001). Fifteen patients developed an overall AHI below five. Sleep efficiency did not change significantly. Epworth Sleepiness Scale decreased significantly. Functional Outcomes of Sleep Questionnaire increased significantly. Compliance was found to be 92.7 % [62.0–100.0 %]. The Sleep Position Trainer applied for 1 month is a highly successful and well-tolerated treatment for POSA patients, which diminishes subjective sleepiness and improves sleep-related quality of life without negatively affecting sleep efficiency. Further research, especially on long-term effectiveness, is ongoing.

Obstructive sleep apnea is common in patients with interstitial lung disease.

Abstract: The incidence of obstructive sleep apnea (OSA) in interstitial lung disease (ILD) has been reported at different frequencies in several studies. The aims of our study were to evaluate the frequency of OSA in ILD and to analyze the relationship between polysomnography (PSG) findings and pulmonary function, disease severity, parenchymal involvement, and Epworth Sleepiness Scale (ESS) scores. ILD patients with parenchymal involvement were evaluated. The disease severity was assessed using an index consisting of body mass index (BMI), carbon monoxide diffusion capacity, the Modified Medical Research Council dyspnea scale, and the 6-min walking distance. All of the patients had lung function, chest X-ray, PSG, ESS scoring, and an upper airway examination. Patients with a BMI ≥ 30 or significant upper airway pathologies were excluded. Of 62 patients, 50 patients comprised the study group (14 male, 36 female; mean age 54 ± 12.35 years, mean BMI 25.9 ± 3.44 kg/m2) with diagnoses of idiopathic pulmonary fibrosis (IPF; n = 17), stage II–III sarcoidosis (n = 15), or scleroderma (n = 18). The frequency of OSA was 68 %. The mean apnea–hypopnea index (AHI) was 11.4 ± 12.5. OSA was more common in IPF patients (p = 0.009). The frequency of rapid eye movement-related sleep apnea was 52.9 %. The frequency of OSA was higher in patients with a disease severity index ≥3 (p = 0.04). The oxygen desaturation index and the AHI were higher in patients with diffuse radiological involvement (p = 0.007 and p = 0.043, respectively). OSA is common in ILD. PSG or at minimum nocturnal oximetry should be performed, particularly in patients with functionally and radiologically severe disease.

Effect of Poor Sleep Quality and Excessive Daytime Sleepiness on Factors Associated With Diabetes Self-Management

Abstract: PurposeThe purpose of this study is to investigate the association of impaired sleep quality and daytime sleepiness on self-reported diabetes control and psychological and social factors that affect diabetes self-management.MethodsParticipants were 107 adults with type 2 diabetes (T2DM) with self-reported daytime sleepiness. Subjective sleepiness was assessed using the Epworth Sleepiness Scale (ESS); sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI) Global score and its 3 factors of Perceived Sleep Quality, Sleep Efficiency, and Daily Disturbances. The Diabetes Care Profile (DCP) scales (Control Problems, Social and Personal Factors, Positive Attitude, Negative Attitude, Self-Care Adherence, and Diet Adherence) were used to measure difficulty in maintaining glycemic control and factors important for diabetes control.ResultsPoor sleep quality was associated with significantly worse scores on the DCP scales, with lower diabetes control, negative attitude, decreased positive attitude...

Associations of neighborhood characteristics with sleep timing and quality: the Multi-Ethnic Study Of Atherosclerosis.

Abstract: Author(s): Desantis, Amy S; Diez Roux, Ana V; Moore, Kari; Baron, Kelly G; Mujahid, Mahasin S; Nieto, F Javier | Abstract: Study objectivesTo investigate the associations of specific neighborhood features (disorder, safety, social cohesion, physical environment, and socioeconomic status) with sleep duration and quality.DesignCross-sectional. One wave of a population-based study (Multi-Ethnic Study of Atherosclerosis).SettingCommunity-dwelling participants in New York, NY and Los Angeles, CA.ParticipantsThere were 1,406 participants (636 males, 770 females).InterventionsNA.Measurements and resultsSleep was assessed using reported hours of sleep, the Epworth Sleepiness Scale, and insomnia symptoms. Neighborhood characteristics were assessed via questionnaires administered to neighbors of study participants and were aggregated to the neighborhood (census tract) level using empirical Bayes estimation. An adverse social environment (characterized by high disorder, and low safety and social cohesion) was associated with shorter sleep duration after adjustment for the physical environment, neighborhood and individual-level socioeconomic status (SES), and other short sleep risk factors (mean difference per standard deviation increase in summary social environment scale 0.24 h 95% confidence interval 0.08, 0.43). Adverse neighborhood social and physical environments, and neighborhood SES were associated with greater sleepiness, but associations with physical environments were no longer statistically significant after adjustment for sociodemographic characteristics. Neighborhood SES was a weaker and less consistent predictor of specific measures of neighborhood social and physical environments. Neighborhood characteristics were not associated with insomnia.ConclusionsShortened sleep related to adverse social environments represents one potential pathway through which neighborhoods may influence health.

The impact of diet and lifestyle management strategies for obstructive sleep apnoea in adults: a systematic review and meta-analysis of randomised controlled trials

Abstract: To systematically evaluate the impact of diet, exercise and lifestyle modification programmes on indices of obesity, Obstructive Sleep Apnoea (OSA) parameters and quality of life (QoL) in adults with OSA. Electronic databases were searched to identify randomised controlled trials published in English with an intervention based on dietary weight loss, exercise and/or lifestyle programme in adults with OSA. Meta-analyses were conducted using random-effects models. Twelve studies met the inclusion criteria with nine comparing similar interventions. Diet and diet plus continuous positive airway pressure (CPAP) therapy were compared in three studies (n = 261), and intensive lifestyle programmes and routine care were compared in six studies (n = 483). Diet with CPAP therapy reduced weight by −2.64 kg (95 % Confidence Interval (CI) −3.98, −1.30, I 2 = 0 %) compared with diet alone. No differences were observed for QoL or Epworth Sleepiness Scale. A significant reduction in weight was seen in participants receiving an intensive lifestyle intervention of −5.65 kg (95 % CI −10.91, −0.40, I 2 = 95.7 %) compared with controls. Reductions were also observed for waist circumference (−5.80 cm, 95 % CI −8.64, −2.96, I2 = 77.7 %), body mass index (BMI) (−2.33 kg/m2, 95 % CI −3.41, −1.24, I2 = 78.8 %) and the Apnoea Hypopnoea Index (AHI) (−4.55 events/h, 95 % CI −7.12, −1.98, I 2 = 54.4 %) but with high levels of heterogeneity. Intensive lifestyle management can significantly reduce obesity indices and improve AHI. Future research is required to investigate this effect due to a limited number of studies identified.

Limits of the Epworth Sleepiness Scale in older adults.

Abstract: Excessive daytime sleepiness (EDS) in older adults is associated with obstructive sleep apnea, falls, reduced quality of life, and mortality. The Epworth Sleepiness Scale (ESS) is widely used to assess sleepiness. However, EDS assessment with the ESS may not be accurate in older adults. We aimed to (1) describe the responsiveness of nondemented older subjects to the ESS and (2) compare the self-report ESS scores to those of close relatives (CR) proxy and identify factors influencing any discrepancies between them. This is a cross-sectional observational study including 104 independently living nondemented older subjects with daytime sleepiness complaints and 104 nondemented CRs. Cognitive tests (Mini-Mental State Examination) and the ESS were completed separately by subjects and CRs to assess the subject’s daytime sleepiness. Almost 60 % of subjects and CRs were not able to answer at least one question on the ESS. Despite the fact that all subjects complained of EDS, only 24 % of them had an abnormal ESS score (>10). Subjects rated their sleepiness lower (7.10 ± 4.31) than their CR proxy did (9.70 ± 5.14) (p < 0.0001). In multivariate analysis, an increase in age and a decrease in cognitive status of the subjects appeared related to the difference in ESS between subject and CR. The majority of older adults were not able to answer all of the ESS items. The ESS may underestimate sleepiness severity in older subjects. Despite EDS complaints in all subjects, only one quarter of them had a pathological ESS score.

Impact of sleep disorder treatment on fatigue in multiple sclerosis.

Abstract: Background:We recently reported that sleep disorders are significantly associated with fatigue in multiple sclerosis (MS).Objective:The objective of this paper is to assess the effects of sleep disorder treatment on fatigue and related clinical outcomes in MS.Methods:This was a controlled, non-randomized clinical treatment study. Sixty-two MS patients completed standardized questionnaires including the Fatigue Severity Scale (FSS), Multidimensional Fatigue Inventory (MFI), Epworth Sleepiness scale (ESS) and Pittsburgh Sleep Quality Index (PSQI), and underwent polysomnography (PSG). Patients with sleep disorders were offered standard treatment. Fifty-six subjects repeated the questionnaires after ≥ three months, and were assigned to one of three groups: sleep disorders that were treated (SD-Tx, n=21), sleep disorders remaining untreated (SD-NonTx, n=18) and no sleep disorder (NoSD, n=17).Results:FSS and MFI general and mental fatigue scores improved significantly from baseline to follow-up in SD-Tx (p <0.0...

The comparison of CPAP and oral appliances in treatment of patients with OSA: a systematic review and meta-analysis

Abstract: BACKGROUND: A systematic review and meta-analysis was performed to compare the outcomes of oral appliances (OAs) with those of CPAP in treatment of patients with obstructive sleep apnea (OSA). METHODS: Relevant studies were retrieved from the following electronic databases, up to and including September 2012: MEDLINE, PubMed, EMBASE, and Central Register of Controlled Trials. The main outcomes were Epworth Sleepiness Scale score, health-related quality of life, cognitive performance, blood pressure, apnea-hypopnea index (AHI), arousal index, minimum SpO2, percent rapid eye movement sleep, treatment usage, side effects, treatment preference, and withdrawals. RESULTS: Fourteen trials were finally included in this review. Our results demonstrated that the effects on Epworth Sleepiness Scale score ( P = .31 and .09 in crossover and parallel-group trials), health-related quality of life, cognitive performance, and blood pressure of OAs and CPAP were similar. Besides, pooled estimates of crossover trials suggested a significant difference in favor of CPAP regarding AHI ( P < .001), arousal index ( P = .001), and minimum SpO2 ( P < .001), while pooled estimates of parallel-group trials showed a significant difference in favor of CPAP regarding AHI ( P < .001) and percent rapid eye movement sleep ( P = .02). Moreover, OAs and CPAP yielded fairly similar results in terms of treatment usage ( P = .26 for hours/night in crossover trials, and P = .14 for hours/night and P = .19 for nights/week in parallel-group trials), treatment preference, side effects, and withdrawals ( P = .34 in parallel-group trials). CONCLUSIONS: CPAP yielded better polysomnography outcomes, especially in reducing AHI, than OAs, indicating that OAs were less effective than CPAP in improving sleep-disordered breathing. However, similar results from OAs and CPAP in terms of clinical and other related outcomes were found, suggesting that it would appear proper to offer OAs to patients who are unable or unwilling to persist with CPAP.

Insomnia symptoms influence CPAP compliance.

Abstract: The aim of this study is to determine parameters which influence 6-month compliance of continuous positive airway pressure therapy (CPAP) in patients with obstructive sleep apnea syndrome (OSAS). This prospective study investigated 73 patients (24 females) with OSAS and medical indication for CPAP therapy: age 55.1 ± 11.5 years, body mass index (BMI) 30.8 ± 5.0 kg/m2, Apnea–Hypopnea Index (AHI) 39.2 ± 26.7/h, Oxygen Desaturation Index (ODI) 33.2 ± 25.4/h, minimum O2 saturation 78.9 ± 7.6%. The influence of baseline parameters (demographic and polysomnographic data, sleeping medication intakes, BMI, psychometrics [Epworth Sleepiness Scale, Regensburg Insomnia Scale, Vigilance test and Beck Depression Inventory]) on 6-month compliance was evaluated with a correlation and a linear regression analysis. The baseline value of the Regensburg Insomnia Scale (RIS) predicts 6-month CPAP compliance (r = −0.376, R 2 = 0.14, p < 0.001), although no other baseline parameter correlates. Patients with a compliance of <4 h/night show higher RIS scores, i.e., more insomnia symptoms (17.6 ± 8.8) compared to those with ≥4 h/night (12.6 ± 6.9; p < 0.05). Insomnia symptoms prior to the beginning of CPAP treatment show a negative influence on CPAP compliance. Further studies should clarify, if a treatment of insomnia symptoms leads to a benefit in compliance.

Symptoms of sleep disordered breathing and risk of cancer: a prospective cohort study.

Abstract: Study objectives Sleep disordered breathing (SDB) has been associated with oxidative stress, inflammation, and altered hormonal levels, all of which could affect the risk of cancer. The aim of the study is to examine if symptoms of SDB including snoring, breathing cessations, and daytime sleepiness affect the incidence of total cancer and subtypes of cancer. Design Prospective cohort study. Setting The third wave (1991-1993) of the Copenhagen City Heart Study. Participants There were 8,783 men and women in whom cancer had not been previously diagnosed. Measurements and results Participants answered questions about snoring and breathing cessations in 1991-1993, whereas information about daytime sleepiness based on the Epworth Sleepiness Scale was collected in a subset of the participants (n = 5,894) in 1998. First-time incidence of cancer was followed until December 2009 in a nationwide cancer register. We found no overall association between symptoms of SDB and incident cancer. Yet, in the small group with high daytime sleepiness, we observed a surprisingly higher cancer incidence (hazard ratio = 4.09; 95% CI 1.58-10.55) in persons younger than 50 years. We also found a higher risk of virus/immune-related cancers (2.73; 1.27-5.91) and alcohol-related cancers (4.92; 1.45-16.76) among persons with daytime sleepiness. More SDB symptoms were associated with a higher risk of smoking-related cancers (Ptrend: 0.04). Apart from these findings there were no clear associations between symptoms of sleep disordered breathing and cancer subtypes. Conclusion We found very limited evidence of relationship between symptoms of sleep disordered breathing and incidence of cancer.

Sleep disturbances in psoriasis

Abstract: BACKGROUND: Psoriasis negatively impacts sleep, but the factors that cause this sleep disturbance are not well characterized. PURPOSE: To assess sleep quality in subjects with psoriasis. METHODS: 35 outpatients diagnosed with chronic plaque psoriasis affecting at least 10 percent BSA and 44 controls completed the Pittsburgh Sleep Quality Index, Patient Health Questionnaire, Itch Severity Scale, Insomnia Severity Index, and Epworth Sleepiness Scale. For multiple testing, alpha was set at 0.008. RESULTS: Adjusting for age, BMI, and gender, patients with psoriasis had 4.3 times the odds to score in a higher insomnia category (OR 95% CI: 1.7, 11.2; p=0.01), a trend toward experiencing "poor sleep" (p=0.04), and no difference in odds to be "sleepy" (p=0.83). Patients with psoriasis had greater itch than those without psoriasis (mean ISS 8.5 vs. 2.0; p<0.0001). When adjusting for age, BMI, gender, and depression, those with psoriasis were not more likely to experience poor sleep quality (p=0.25), nor to score in a higher insomnia category (p=0.20) or be more "sleepy" (p=0.53). CONCLUSIONS: Patients with psoriasis suffer from sleep disturbances and pruritus more than those without psoriasis. Although sleep disturbances are more prevalent, this may be secondary to depression rather than related to a direct effect of psoriasis.

Predictive abilities of the STOP-Bang and Epworth Sleepiness Scale in identifying sleep clinic patients at high risk for obstructive sleep apnea†

Abstract: This study compared the predictive abilities of the STOP-Bang and Epworth Sleepiness Scale (ESS) for screening sleep clinic patients for obstructive sleep apnea (OSA) and sleep-disordered breathing (SDB). Forty-seven new adult patients without previous diagnoses of OSA or SDB were administered the STOP-Bang and ESS and were assigned to OSA or SDB risk groups based on their scores. STOP-Bang responses were scored with two Body Mass Index cut points of 35 and 30 kg/m2 (SB35 and SB30). The tools� predictive abilities were determined by comparing patients� predicted OSA and SDB risks to their polysomnographic results. The SB30 correctly identi?ed more patients with OSA and SDB than the ESS alone. The ESS had the highest speci?city for OSA and SDB.

Transoral robotic surgery for treatment of obstructive sleep apnea-hypopnea syndrome.

Abstract: Objectives/Hypothesis To evaluate the efficacy of base of tongue (BOT) resection via transoral robotic surgery (TORS) in the treatment of obstructive sleep apnea/hypopnea syndrome (OSAHS). Study Design Case series Methods Between June 2010 and May 2012, BOT resection via TORS was performed on 27 patients with OSAHS. Patients were excluded from this analysis if other concomitant upper airway procedures such as uvulopalatopharyngoplasty were performed, or if postoperative polysomnograms were not available. Results Twelve patients who underwent BOT resection alone were included in this study. The median age for these 12 patients was 48.5 (range, 19–64) and included nine females and three males. The mean apnea-hypopnea index (AHI) was 43.9 ± 41.1 preoperatively and 17.6 ± 16.2 postoperatively. This difference in AHI was statistically significant (P = 0.007) and reflected an average AHI reduction of 56.2 ± 28.3%. Statistical significant reductions in daytime somnolence level, as measured by Epworth Sleepiness Scale (13.7 ± 5.2 preoperatively vs. 6.4 ± 4.5 postoperatively, P <0.001), and snoring intensity, as reported by a bed partner using a Visual Analogue Scale (8.6 ± 1.2 preoperatively vs. 4.2 ± 1.9 postoperatively, P <0.001), were achieved. There was no statistical significant difference between the preoperative and postoperative body mass index (34.5 ± 7.3 vs. 33.5 ± 6.7, P = 0.296) or minimum oxygen saturation (83.3 ± 5.5% vs. 84.0 ± 6.4%, P = 0.680). Conclusions This is the first study looking at the use of TORS to address obstruction at the level of BOT only, not confounded by surgical alterations at other levels of upper airway. This preliminary result on the use of BOT resection via TORS for the treatment of patients with OSAHS is encouraging and warrants further investigations. Level of Evidence 4. Laryngoscope, 2012

Sleep quality, arousal and pain thresholds in migraineurs: a blinded controlled polysomnographic study

Abstract: Our aim was to compare subjective and objective sleep quality and arousal in migraine and to evaluate the relationship between sleep quality and pain thresholds (PT) in controls, interictal, preictal and postictal migraine. Polysomnography and PT (to pressure, heat and cold) measurements were done in 34 healthy controls and 50 migraineurs. Subjective sleep quality was assessed by sleep diaries, Epworth sleepiness scale, Karolinska sleep questionnaire and Pittsburgh sleep quality index. Migraineurs who had their sleep registration more than 48 h from an attack were classified as interictal while those who were less than 48 h from an attack were classified as either preictal or postictal. Migraineurs reported more insomnia and other sleep-related symptoms than controls, but the objective sleep differences were smaller and we found no differences in daytime sleepiness. Interictal migraineurs had more awakenings (p=0.048), a strong tendency for more slow-wave sleep (p=0.050), lower thermal pain thresholds (TPT) (heat pain thresholds p=0.043 and cold pain thresholds p=0.031) than controls. Migraineurs in the preictal phase had shorter latency to sleep onset than controls (p=0.003). Slow-wave sleep correlated negatively with pressure PT and slow bursts correlated negatively with TPT. Lower PT in interictal migraineurs seems related to increased sleep pressure. We hypothesize that migraineurs on the average suffer from a relative sleep deprivation and need more sleep than healthy controls. Lack of adequate rest might be an attack-precipitating- and hyperalgesia-inducing factor.

CPAP Adherence of Patients With Obstructive Sleep Apnea

Abstract: BACKGROUND: Continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BPAP) are the gold standard treatments for obstructive sleep apnea syndrome (OSAS), but CPAP/BPAP is not well tolerated and requires long-term follow-up. OBJECTIVE: We prospectively assessed subjective and objective adherence and factors that affect adherence in OSAS patients. METHODS: Subjects using CPAP/BPAP were questioned about adverse effects of CPAP/BPAP and were assessed with the Epworth Sleepiness Scale (ESS) at the first, third, sixth, and twelfth month, and once every 6 months after the first year. CPAP/BPAP use and objective and subjective adherence were assessed. Subjects who used CPAP/BPAP for at least 4 hours per night for at least 70% of the days monitored were regarded as adherent, and those who did not were considered non-adherent. The relationships between adherence and demographic data, polysomnography findings, ESS scores, and adverse effects were statistically analyzed. RESULTS: Six-hundred forty-eight subjects who were diagnosed with OSAS by polysomnography and accepted to use CPAP/BPAP in our sleep center between January 2005 and June 2011 were included. Four-hundred fifty-one subjects (69.6%) were men, and 197 (30.4%) were women. Two-hundred forty-eight (38.3%) subjects attended follow-ups, 246 (37.9%) were called by telephone, and 154 (23.8%) could not be reached. Of the whole population, 63.9% had obtained their CPAP/BPAP machine. In the 248 subjects who attended follow-ups, subjective adherence was 85.1% and objective adherence was 64.5%. Improvement in ESS score (P CONCLUSIONS: Of the whole population, just 38.3% attended follow-ups. The objective adherence was lower than the subjective adherence in subjects who attended follow-ups. Younger subjects were more adherent, and the most important factors that correlated with adherence were substantial improvement of daytime sleepiness and effect of CPAP/BPAP on satisfactory sleep. CONCLUSIONS: CPAP/BPAP adherence should be followed with objective monitoring.

Clinical characteristics of a novel subgroup of chronic fatigue syndrome patients with postural orthostatic tachycardia syndrome

Abstract: Objectives A significant proportion of patients with chronic fatigue syndrome (CFS) also have postural orthostatic tachycardia syndrome (POTS). We aimed to characterize these patients and differentiate them from CFS patients without POTS in terms of clinical and autonomic features. Methods A total of 179 patients with CFS (1994 Centers for Disease Control and Prevention criteria) attending one of the largest Department of Health-funded CFS clinical services were included in this study. Outcome measures were as follows: (i) symptom assessment tools including the fatigue impact scale, Chalder fatigue scale, Epworth sleepiness scale (ESS), orthostatic grading scale (OGS) and hospital anxiety and depression scale (HADS-A and -D, respectively), (ii) autonomic function analysis including heart rate variability and (iii) haemodynamic responses including left ventricular ejection time and systolic blood pressure drop upon standing. Results CFS patients with POTS (13%, n = 24) were younger (29 ± 12 vs. 42 ± 13 years, P < 0.0001), less fatigued (Chalder fatigue scale, 8 ± 4 vs. 10 ± 2, P = 0.002), less depressed (HADS-D, 6 ± 4 vs. 9 ± 4, P = 0.01) and had reduced daytime hypersomnolence (ESS, 7 ± 6 vs. 10 ± 5, P = 0.02), compared with patients without POTS. In addition, they exhibited greater orthostatic intolerance (OGS, 11 ± 5; P < 0.0001) and autonomic dysfunction. A combined clinical assessment tool of ESS ≤9 and OGS ≥9 identifies accurately CFS patients with POTS with 100% positive and negative predictive values. Conclusions The presence of POTS marks a distinct clinical group of CFS patents, with phenotypic features differentiating them from those without POTS. A combination of validated clinical assessment tools can determine which CFS patients have POTS with a high degree of accuracy, and thus potentially identify those who require further investigation and consideration for therapy to control heart rate.

Rationale and Methodology of the Impact of Continuous Positive Airway Pressure on Patients With ACS and Nonsleepy OSA: The ISAACC Trial

Abstract: Background Obstructive sleep apnea (OSA) is common in acute coronary syndrome (ACS) and a possible cause of increased morbidity and mortality. Objectives The main objective is to determine in patients with ACS and OSA if CPAP treatment reduces the incidence of cardiovascular events (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, hospitalization for heart failure, and hospitalization for unstable angina or transient ischemic attack). The secondary objectives are to determine the prevalence of nonsleepy OSA in patients with ACS; assess the effect of CPAP on the incidence of newly diagnosed diabetes mellitus, symptoms, and quality of life; identify biomarkers of risk involved in cardiovascular complications in these patients; and conduct a cost-effectiveness analysis of diagnosis and treatment. Population and Methodology Multicenter, prospective, randomized and controlled study. Patients are admitted to the coronary care unit with diagnosis of ACS and without daytime sleepiness (Epworth Sleepiness Scale ≤10) at 15 teaching hospitals in Spain. All patients undergo a sleep study by cardiorespiratory polygraphy. Patients with an apnea-hypopnea index ≥15/hour will be randomized to treatment with CPAP (group 1, 632 patients) or conservative treatment (group 2, 632 patients). Patients with an apnea-hypopnea index <15/hour (group 3, 600 patients) will be followed as a reference group. Patients will be monitored at baseline (T0), 1 month (T1), 3 months (T2), 6 months (T3), 12 months (T4), and every 6 months thereafter (where applicable) during the follow-up period. Conclusions The ISAACC trial will contribute to evaluating the effect of CPAP treatment on cardiovascular events in patients with ACS and OSA.

Self-relaxation training can improve sleep quality and cognitive functions in the older: a one-year randomised controlled trial.

Abstract: Aims and objective To evaluate the effects of self-relaxation training on sleep quality and cognitive functions in the older. Background Ageing causes declines in sleep quality and cognitive functions in older adults, and decreased sleep quality also accelerates declines in cognitive functions. Therefore, it is necessary to find cost-effective interventions to enhance sleep quality in the older, thereby improving their cognitive functions or delaying cognitive decline. Design Randomised controlled study. Methods The study was conducted between July 2010 and June 2011 at Wangyuehu Community in Changsha, China. Eighty older adults with reduced sleep quality were selected and randomly assigned to experimental (n = 40) or control (n = 40) group. Subjects in the experimental group received self-relaxation training including progressive muscle relaxation and meditation based on sleep hygiene education, while the control group received sleep hygiene education only. Sleep quality and cognitive functions of the two groups were measured prior to training and at the end of the 3rd, 6th and 12th months using four reliable and valid questionnaires. Results Repeated measures anova revealed that the self-relaxation training had significant main effect as well as interaction effect with time on sleep quality and cognitive functions. Except for scores of Epworth Sleepiness Scale, Mini-Mental State Examination and number memory, time had significant main effect on scores of Pittsburgh Sleep Quality Index, picture memory, associative memory and understanding memory. Conclusion Self-relaxation training can improve sleep quality and cognitive functions in the older. Relevance to clinical practice Self-relaxation training is a non-invasive, simple and inexpensive therapeutic method of improving sleep quality and cognitive functions in community-dwelling older people.

The Complex Associations Among Sleep Quality, Anxiety-Depression, and Quality of Life in Patients with Extreme Obesity

Abstract: INTRODUCTION Sleep duration and quality have been associated with obesity. Sleep disturbance has been reported to be associated with stress and depression among non-obese populations, but these relationships have not been previously examined in the obese population. The objective of the current study was to examine the complex associations among sleep disturbance, quality of life, anxiety, and depression in a patient sample with severe obesity. METHODS Two hundred seventy consecutively recruited patients with a mean body mass index (BMI) of 47.0 kg/m² were studied. The correlation coefficient, multiple linear regressions, and structural equation modeling (SEM) analysis were used to evaluate the association between the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Impact of Weight on Quality of Life-Lite (IWQOL-Lite) and Hospital Anxiety and Depression Scale (HADS). RESULTS The mean (standard deviation; SD) PSQI score was 8.59 (5.11), and mean ESS score was 8.84 (5.79). After controlling for potential confounders, poor sleep quality and excessive daytime sleepiness were found to be significantly associated of all the components of IWQOL-Lite; physical function (β = -0.32, β = -0.27; P < 0.01), self-esteem (β = -0.23, β = -0.30; P < 0.05), sexual-life (β = -0.30, β = -0.35; P < 0.05), public distress (β = -0.39, β = -0.39; P < 0.01), and work (β = -0.26, β = -0.48; P < 0.01). We also found that the PSQI global score had a positive significant association with anxiety (β = 0.29; P = 0.01) and depression (β = 0.31; P = 0.01) components of HADS. CONCLUSION Poor sleep quality was strongly associated with mood disturbance and poor quality of life among extremely obese patients. Future interventions are needed to address sleep disturbance to prevent further development of psychological co-morbidity and potentially worsening of obesity among these individuals.