Fatigue in sleep apnea: the role of depressive symptoms and self-reported sleep quality

Relationship of Sleep Disorder with Neurodegenerative and Psychiatric Diseases: An Updated Review

Sleep disorders affect many people worldwide and can accompany neurodegenerative and psychiatric diseases. Sleep may be altered before the clinical manifestations of some of these diseases appear. Moreover, some sleep disorders affect the physiological organization and function of the brain by influencing gene expression, accelerating the accumulation of abnormal proteins, interfering with the clearance of abnormal proteins, or altering the levels of related hormones and neurotransmitters, which can cause or may be associated with the development of neurodegenerative and psychiatric diseases. However, the detailed mechanisms of these effects are unclear. This review mainly focuses on the relationship between and mechanisms of action of sleep in Alzheimer's disease, depression, and anxiety, as well as the relationships between sleep and Parkinson's disease, Huntington's disease, and amyotrophic lateral sclerosis. This summary of current research hotspots may provide researchers with better clues and ideas to develop treatment solutions for neurodegenerative and psychiatric diseases associated with sleep disorders.

The Effect of Multilevel Surgery for Obstructive Sleep Apnea on Fatigue, Stress and Resilience

OBJECTIVE

To evaluate the effects of surgical treatment on fatigue, stress, and resilience in patients with obstructive sleep apnea (OSA).

METHODS

Sixty patients who underwent multilevel sleep surgery for OSA (OSA group) and 32 non-OSA participants (control group) were recruited at a university hospital in Korea between January 2020 and March 2022. Fatigue, stress, and resilience levels were evaluated in both groups using the Chalder fatigue scale (CFS), daily hassles scale revised (DHS-R), and Connor-Davidson resilience scale (CD-RISC), respectively. The scores of each group were compared before and 6 months after surgery.

RESULTS

The initial CFS and DHS-R scores were significantly higher, while the CD-RISC score was significantly lower, in the OSA group than in the control group (p < 0.05). In the patients with OSA, all three scores significantly improved after surgery (p < 0.05). Additionally, when compared between the groups at 6 months, there were no differences in the CFS, DHS-R, or CD-RISC scores (p > 0.05). Even when the OSA group was divided into a success group and a failure group according to surgical outcomes and compared with the control group, the three scores of both groups did not show statistical differences from the control group (p > 0.05).

CONCLUSIONS

Multilevel surgery may reduce fatigue as well as stress and increase resilience in patients with OSA to levels similar to those in non-OSA individuals.

Impact of purchasing the CPAP device on acceptance and long-term adherence: a Belgian model

RATIONALE

In Belgium, patients with moderate to severe OSA (AHI > 20) who show less than 30 micro-arousals per hour slept (MAI) cannot benefit from CPAP refund by the social security (SS).

OBJECTIVES

To assess the influence of reimbursement on CPAP acceptance, and long-term adherence.

METHODS

OSA patients (AHI > 20) were included regardless of MAI. All patients were offered a CPAP trial of 3-5 days for habituation. Two groups were defined and compared: «Out of pocket money» patients (OOP) with MAI < 30 that were invited to purchase their device and «reimbursed group» that were offered a CPAP reimbursed by the social security.

RESULTS

812 patients were found: 59 in the OOP group, mostly females, sleepier and using more hypnotics. Out of the reimbursed group, 183 patients were matched to the OOP patients on the grounds of age, AHI and BMI. 90% of OOP and 94% of reimbursed patients (p 0.379) accepted a CPAP trial; 74% of OOP and 90% of reimbursed patients acquired a CPAP device (p 0.005) thereafter, whereas 82% and, respectively, 84% of those (p 0.254) were still on CPAP after a mean follow-up of 711 and 604 days with a mean ± SD daily compliance of 5.3 ± 3 and 6.1 ± 2 h, respectively (p 0.159). Only fatigue scale seems to influence the purchase of CPAP by OOP patients.

CONCLUSION

CPAP reimbursement influences the purchase of CPAP but once the device becomes available there is no difference with reimbursed patients in long-term adherence.

Fatigue and sleepiness determine respiratory quality of life among veterans evaluated for sleep apnea

Background

In those with symptoms indicative of obstructive sleep apnea (OSA), respiratory-specific health-related quality of life (HRQL) may be an important patient-centered outcome. The aim of this study was to assess the associations between sleepiness, fatigue, and impaired general and respiratory-specific HRQL among persons with suspected OSA.

Methods

We evaluated military veterans consecutively referred for suspected OSA with sleep studies yielding apnea-hypopnea index (AHI) values. They also completed the sleepiness (Epworth Sleepiness Scale [ESS]), and fatigue (Fatigue Severity Scale [FSS]) questionnaires, as well as two HRQL instruments (the generic Short-Form SF-12v2 yielding the Physical Component Scale [PCS] and the respiratory-specific Airways Questionnaire [AQ]-20R). Multiple linear regression tested the associations between ESS and FSS (standardized as Z scores for scaling comparability) with AQ-20R, accounting for AHI, SF-12v2-PCS and comorbid respiratory conditions other than OSA.

Results

We studied 1578 veterans (median age 61.1 [IQR 16.8] years; 93.9% males). Of these, 823 (52%) met AHI criteria for moderate to severe OSA (AHI ≥15/h). The majority reported excessive daytime sleepiness (53%; median ESS 11 [IQR 9]) or fatigue (61%; median FSS 42 [IQR 23]). The median AQ-20R was 4 [IQR 1–8]. Controlling for AHI, SF-12v2-PCS, respiratory co-morbid conditions, body mass index, and demographics, both ESS and FSS were significantly associated with poorer AQ-20R: for each; ESS, 1.6 points (95% CI 1.4–1.9), and for FSS, 2.5 points (95% CI, 2.3–2.7).

Conclusions

Greater daytime sleepiness and fatigue are associated with poorer respiratory-specific HRQL, over and above the effects of OSA, respiratory comorbidity, and generic physical HRQL.

A psychometric study of the multidimensional fatigue inventory to assess fatigue in patients with schizophrenia spectrum disorders

Fatigue is frequently reported by patients with mental illness. The multidimensional fatigue inventory (MFI-20) is a self-assessment instrument with 20 items including five dimensions of fatigue. The purpose of this study was to examine the test-retest reliability, internal consistency, convergent construct validity and feasibility of using MFI-20 in patients with schizophrenia spectrum disorders. Patients completed two self-assessment instruments, MFI-20 (n = 93) and Visual Analogue Scale (n = 79), twice within 1 week ± 2 days. Fifty-three patients also rated the feasibility of responding to the MFI-20 with a Likert scale. The test-retest reliability and validity were analysed by using Spearman's correlations and internal consistency by calculating Cronbach's α. The test-retest showed a correlation between .66 and .91 for all subscales of MFI. The internal consistency was .92. The analysis of convergent construct validity showed a correlation of .68 (time 1) and .77 (time 2). No item was systematically identified as being difficult to answer.

Does Positive Airway Pressure Therapy Result in Improved Sleep Quality?

INTRODUCTION

Positive airway pressure (PAP) therapy is the gold-standard for obstructive sleep apnea (OSA) management. While it is known that PAP is efficacious for controlling breathing events during sleep when it is worn at the right pressure for the amount of time prescribed, there is less clear data on how well it improves sleep quality. There are few studies that have examined the effectiveness of PAP therapy on sleep quality.

METHODS

OSA participants (n = 241) from a larger trial examining a PAP adherence were included. Participants were provided with PAP instruction and followed at 2 months and 4 months. PAP adherence was measured as the number of hours per night at prescribed pressure, an objective measure of treatment adherence. The Pittsburgh Sleep Quality Index (PSQI) was used as the primary measure of sleep quality.

RESULTS

The PSQI was significantly correlated with PAP adherence at both the 2-month and 4-month time points, such that lower sleep quality was associated with lower PAP use. This finding held for the sleep disturbance subscale of the PSQI. Over 55% of those using PAP therapy at the 4-month time point continued to report significantly disturbed sleep.

DISCUSSION

This study shows that PAP therapy does not appear to improve sleep quality to a degree that would be expected. Over half of those patients using PAP therapy still experienced disturbed sleep. Whether the disturbed sleep is directly attributable to the PAP device itself or to disturbed sleep secondary to uncontrolled OSA when PAP is not worn is worthy of further investigation.

Prevalence and Correlates of Insomnia and Excessive Sleepiness in Adults with Obstructive Sleep Apnea Symptoms

This study investigated the prevalence and correlates of insomnia and excessive sleepiness in adults presenting symptoms of obstructive sleep apnea (OSA) in the general population. Randomly selected participants ( N = 1,502; 50.7% men, 49.3% women), ages 40 to 70 yr. ( M = 53.6, SD = 8.5) were interviewed over the telephone. Insomnia and excessive sleepiness (hypersomnia) were assessed with the Bergen Insomnia Scale and the Epworth Sleepiness Scale, respectively. OSA symptoms were identified by self- or spouse reports on snoring, breathing cessations during sleep, and being tired or sleepy. The prevalence of OSA was 6.2%. Among these participants with OSA, 57.6% reported insomnia and 30.1% reported excessive sleepiness. Furthermore, OSA symptoms were associated with self-reported obesity, hypertension, diabetes, and depression, but only in participants with comorbid insomnia or excessive sleepiness.

Depression may reduce adherence during CPAP titration trial

STUDY OBJECTIVES

Depression is a risk factor for medication non-compliance. We aimed to identify if depression is associated with poorer adherence during home-based autotitrating continuous positive airway pressure (autoPAP) titration.

DESIGN

Mixed retrospective-observational study.

SETTING

Academic center.

PARTICIPANTS

Two-hundred forty continuous positive airway pressure-naïve obstructive sleep apnea (OSA) patients.

MEASUREMENTS

Patients underwent approximately 1 week of home-based autoPAP titration with adherence data downloaded from the device. Electronic hospital records were reviewed in a consecutive manner for inclusion. Three areas of potential predictors were examined: (i) demographics and clinical factors, (ii) disease severity, and (iii) device-related variables. Depression and anxiety were assessed using the Hospital Anxiety and Depression Scale (HADS). Scores on the subscales were categorized as normal or clinical diagnoses of depression (≥ 8) and anxiety (≥ 11). The primary outcome variable was the mean hours of autoPAP used per night.

RESULTS

Patients were diagnosed with OSA by either attended polysomnography (n = 73, AHI 25.5[15.1-41.5]) or unattended home oximetry (n = 167, ODI3 34.0[22.4-57.4]) and had home-based autoPAP titration over 6.2 ± 1.2 nights. Mean autoPAP use was 4.5 ± 2.4 hours per night. Multiple linear regression analysis revealed that depression and lower 95(th) percentile pressures significantly predicted lesser hours of autoPAP use (R(2) = 0.19, p < 0.001). Significantly milder OSA in those requiring lower pressures may have confounded the relationship between 95(th) percentile pressure and autoPAP use.

CONCLUSION

Depression was independently associated with poorer adherence during home-based autoPAP titration. Depression may be a potential target for clinicians and future research aimed at enhancing adherence to autoPAP therapy.

The comorbidity of sleep apnea and mood, anxiety, and substance use disorders among obese military veterans within the Veterans Health Administration

OBJECTIVES

To determine the relations between obstructive sleep apnea (OSA) diagnosis, the likelihood of being diagnosed with a psychological condition, among obese veterans, after accounting for severity of obesity and the correlated nature of patients within facility. We hypothesized that (1) individuals with a diagnosis of OSA would be more likely to receive a diagnosis of a (a) mood disorder and (b) anxiety disorder, but not (c) substance use disorder.

DESIGN

Cross-sectional retrospective database review of outpatient medical records between October 2009 and September 2010, conducted across all 140 Veterans Health Administration (VHA) facilities.

SETTING

The entire VA Health Care System.

PATIENTS OR PARTICIPANTS

Population-based sample of veterans with obesity (N = 2,485,658).

MAIN OUTCOME MEASURES

Physician- or psychologist-determined diagnosis of psychological conditions including mood, anxiety, and substance use disorders.

RESULTS

Using generalized linear mixed modeling, after accounting for the correlated nature of patients within facility and the severity of obesity, individuals with a diagnosis of sleep apnea had increased odds of receiving a mood disorder diagnosis (OR = 1.85; CI = 1.71-1.72; p < 0.001), anxiety disorder diagnosis (OR = 1.82; CI = 1.77-1.84; p < 0.001), but not a diagnosis of substance use disorder.

CONCLUSIONS

Among obese veterans within VA, OSA is associated with increased risk for having a mood and anxiety disorder, but not substance use disorder, with the strongest associations observed for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). In addition, this relation remained after accounting for severity of BMI.

The role of daytime sleepiness in psychosocial outcomes after treatment for obstructive sleep apnea

We investigated the role of daytime sleepiness and sleep quality in psychosocial outcomes of patients with obstructive sleep apnea (OSA) treated with continuous positive airway pressure (CPAP). Thirty-seven individuals with moderate to severe OSA and compliant with CPAP treatment for at least 3 months were compared to 27 age- and education-matched healthy controls. The OSA group and the control group were studied with overnight polysomnography (PSG) and compared on measures of daytime sleepiness (Epworth Sleepiness Scale), sleep quality (Pittsburg Sleep Quality Index), mood (Beck Depression Inventory, Profile of Mood States), and functional outcomes (Functional Outcomes of Sleep Questionnaire). After CPAP treatment, the OSA group improved on sleep quality and sleepiness. As a group, they did not differ from controls on sleep architecture after CPAP. The OSA group also showed significant improvements in functional outcomes and was comparable to controls on mood and functional outcomes. Persistent difficulties included lowered activity level and residual sleepiness in some individuals. Sleepiness was found to be a significant predictor of mood and affective states, while both sleepiness and sleep quality predicted functional outcomes. These results highlight the importance of assessment and intervention targeting psychosocial functioning and sleepiness in individuals with OSA after treatment.