Sleep complaints and risk factors for excessive daytime sleepiness in adult males in Northern Ireland

The prevalence of excessive daytime sleepiness and associated factors in older diabetic patients

OBJECTIVES

Sleep disorders are a frequent health problem in older patients with diabetes mellitus (DM). There has been no study investigating the factors associated with excessive daytime sleepiness (EDS) in older diabetic patients. We aimed to investigate the prevalence and associated factors of EDS.

METHODS

We performed a retrospective cross-sectional study in older diabetic patients. The Epworth Sleepiness Scale score of ≥ 11 points indicated EDS. All patients underwent comprehensive geriatric assessment including demographic characteristics, blood pressures, comorbid diseases, cognitive and nutritional states, basic and instrumental daily living activity indexes, lower urinary tract symptoms, and laboratory values.

RESULTS

Of 227 patients, 73.1% were females, with a mean age of 78.8 ± 6.5. The prevalence of EDS was 19.8%. Patients with EDS were mostly males with dementia and used significantly more medication with more anticholinergic drug burden, falls, urge incontinence, and nocturia (p < 0.05). They had higher SARC-F and lower Barthel index, Lawton-Brodie, Tinetti, MMSE scores, and high-density lipoprotein than the patients without EDS (p < 0.05). After adjusting for age, sex, and dementia, all parameters that were significant in univariate analysis remained associated with EDS, except for falls, and MMSE scores.

CONCLUSION

The EDS was found in one in five older diabetic patients. There was a significant relationship between EDS and drug use, anticholinergic drug burden, impaired excretory functions, sarcopenia, decreased functional capacity, falls, gait-balance disorder, and cognitive dysfunction. The recognization of EDS and the implementation of interventions may be helpful in the management of geriatric syndromes.

Alzheimer's disease biomarkers in patients with obstructive sleep apnea hypopnea syndrome and effects of surgery: A prospective cohort study

Background

Obstructive sleep apnea hypopnea syndrome (OSAHS) may cause Alzheimer's disease (AD), t-tau, p-tau, Aβ42, and Aβ40 are important elements in the process of AD, and changes in the levels of these biomarkers may affect the cognitive functioning of patients. Our objective was to investigate whether uvulopalatopharyngoplasty could reduce the plasma levels of AD biomarkers in OSAHS patients and the potential correlations of AD biomarkers with cognitive impairment and sleepiness, and explore the independent influencing factors of cognitive function.

Methods

Alzheimer's disease biomarkers were measured in the plasma of 35 patients with severe OSAHS requiring surgical treatment and 16 healthy controls without OSAHS. The cognitive function and sleepiness of OSAHS patients was also evaluated. The case group was given uvulopalatopharyngoplasty and followed at the postoperative sixth month, the follow-up cases were 27, and plasma AD biomarker levels, cognitive function, and sleepiness were re-evaluated. The preoperative and postoperative AD biomarker levels OSAHS patients were compared with each other and those of the control group. Linear stepwise regression and lasso regression were used to explore the relationships of AD biomarkers with cognitive impairment and sleepiness.

Results

Significantly higher Aβ40, t-tau, p-tau in plasma were observed preoperatively in OSAHS patients comparing to controls (29.24 ± 32.52 vs. 13.18 ± 10.78, p = 0.049; 11.88 ± 7.05 vs. 7.64 ± 4.17, p = 0.037; 26.31 ± 14.41 vs. 17.34 ± 9.12, p = 0.027). The sixth month of postoperation, the plasma AD biomarkers (Aβ42, Aβ40, t-tau, p-tau) in plasma levels decreased significantly (0.23 ± 0.17 vs. 0.20 ± 0.16, p = 0.0001; 29.24 ± 32.52 vs. 23.52 ± 24.46, p = 0.0046; 11.88 ± 7.05 vs. 8.88 ± 6.21, p = 0.0001;26.31 ± 14.41 vs. 20.43 ± 10.50, p = 0.0001). A comparison of MMSE and ESS scores from before to after surgery revealed obvious differences (27.14 ± 1.65 vs. 29.07 ± 1.78, p = 0.0001; 11.91 ± 4.84 vs. 5.89 ± 2.83, p = 0.0001). Changes in cognitive function and sleepiness scores from before to after uvulopalatopharyngoplasty were significantly correlated with AD biomarkers. Body mass index and t-tau were potential influencing factors cognitive function.

Conclusion

Obstructive sleep apnea hypopnea syndrome can increase plasma AD biomarkers levels. Uvulopalatopharyngoplasty can improve patients' cognition and sleepiness, and the mechanism may be related to changes in plasma AD biomarkers. Higher AHI and higher t-tau level were identified as independent risk factors for cognitive decline.

Does upper-body elevation affect sleepiness and memories of hypnagogic images after short daytime naps?

The present study aimed to examine the effects of a somatosensory stimulus on sleepiness and memories of hypnagogic imagery during short daytime naps. Participants experienced two daytime nap conditions: (1) a somatosensory stimulus was created by raising the upper part of the bed 20 min after turning off the light and (2) a somatosensory stimulus was not created; the angle of the upper part of the bed remained flat. Approximately 20 min and 30 s after turning off the light, participants were awakened and questioned regarding their subjective sleepiness and the presence or absence of hypnagogic imagery. Results showed that subjective sleepiness following the nap was reduced only in the raised condition, and hypnagogic imagery in the raised condition was lower than that in the flat condition. These findings may provide insight on developing new techniques for improving subjective conditions after awakening.

Determinants of excessive daytime sleepiness in two First Nation communities

Background

Excessive daytime sleepiness may be determined by a number of factors including personal characteristics, co-morbidities and socio-economic conditions. In this study we identified factors associated with excessive daytime sleepiness in 2 First Nation communities in rural Saskatchewan.

Methods

Data for this study were from a 2012–13 baseline assessment of the First Nations Lung Health Project, in collaboration between two Cree First Nation reserve communities in Saskatchewan and researchers at the University of Saskatchewan. Community research assistants conducted the assessments in two stages. In the first stage, brochures describing the purpose and nature of the project were distributed on a house by house basis. In the second stage, all individuals age 17 years and older not attending school in the participating communities were invited to the local health care center to participate in interviewer-administered questionnaires and clinical assessments. Excessive daytime sleepiness was defined as Epworth Sleepiness Scale score > 10.

Results

Of 874 persons studied, 829 had valid Epworth Sleepiness Scale scores. Of these, 91(11.0%) had excessive daytime sleepiness; 12.4% in women and 9.6% in men. Multivariate logistic regression analysis indicated that respiratory comorbidities, environmental exposures and loud snoring were significantly associated with excessive daytime sleepiness.

Conclusions

Excessive daytime sleepiness in First Nations peoples living on reserves in rural Saskatchewan is associated with factors related to respiratory co-morbidities, conditions of poverty, and loud snoring.

Prevalence and risk factors of excessive daytime sleepiness in insomnia sufferers: A study with 1311 individuals

BACKGROUND

Several studies have investigated the prevalence and risk factors of excessive daytime sleepiness in the general population. However, few studies have investigated these in the particular subpopulation of insomnia sufferers. Thus, the aim of this study was to examine the prevalence and risk factors of excessive daytime sleepiness in a large sample of insomnia sufferers.

METHODS

Data from 1311 insomnia sufferers with age≥18years and recruited from the research database of the sleep laboratory of the Erasme Hospital were analysed. A score>10 on the Epworth scale was used as the cut-off score for excessive daytime sleepiness. Logistic regression analyses were conducted to examine clinical and demographic risk factors of excessive daytime sleepiness in insomnia sufferers.

RESULTS

The prevalence of excessive daytime sleepiness in our sample was 45.61%. Multivariate logistic regression analysis revealed that non-use of Z-drugs, non-use of Trazodone alone or in combination, body mass index≥25 & <30kg/m², body mass index≥30kg/m², age≥18 & <40years, age≥40 & <65years, Beck depression inventory score≥5 & <16, Beck depression inventory score≥16, apnea-hypopnea index≥15/h, and use of selective serotonin reuptake inhibitors were significant risk factors of excessive daytime sleepiness in the subpopulation of insomnia sufferers.

CONCLUSION

Excessive daytime sleepiness is a common complaint for individuals with insomnia. In this subpopulation, most of the risk factors for excessive daytime sleepiness are reversible, which justifies better management of this complaint to avoid its negative consequences.

Effect of age and gender in the prevalence of excessive daytime sleepiness among a sample of the Saudi population

The aim of this study is to assess whether the effect of gender on the excessive daytime sleepiness (EDS) is influenced by two confounders (age and hours of sleep per night). A cross-sectional study was conducted at King Abdulaziz Medical City-Riyadh (KAMC-R). A total of 2095 respondents answered a questionnaire that included questions regarding gender, age, hours of sleep per night, and daytime sleepiness using the Epworth Sleepiness Scale (ESS). The prevalence of EDS was 20.5% (females 22.2%, males 19.5%, p-value = 0.136). The EDS did not differ between genders, age groups, or hours of sleep per night (<6 vs. ⩾6 h). However, stratified statistical analysis shows that the prevalence of EDS did differ according to gender (25.3% in females, 19.0% in males, p-value = 0.036) in respondents with shorter hours of sleep per night. EDS was strongly related to female gender and young age (ages ⩽ 29 years) in respondents with short hours of sleep. This study reveals that one out of five of the general Saudi population has EDS. The effect of gender on EDS appeared to be influenced by hours of sleep per night. High EDS strongly related to female gender with short hours of sleep.

Excessive daytime sleepiness among rural residents in Saskatchewan

BACKGROUND

Obstructive sleep apnea (OSA) is a common diagnosis in clinical practice. Excessive daytime sleepiness may be a warning for possible OSA.

OBJECTIVES

To assess the prevalence of excessive daytime sleepiness as measured by the Epworth Sleepiness Scale (ESS) in a rural community population; potential risk factors for OSA were also assessed.

METHODS

In 2010, a baseline respiratory health questionnaire within the Saskatchewan Rural Health Study was mailed to 11,982 households in Saskatchewan. A total of 7597 adults within the 4624 (42%) respondent households completed the ESS questionnaire. Participants were categorized according to normal or high (>10) ESS scores. Data obtained included respiratory symptoms, doctor-diagnosed sleep apnea, snoring, hypertension, smoking and demographics. Body mass index was calculated. Multivariable logistic regression analysis examined associations between high ESS scores and possible risk factors. Generalized estimating equations accounted for the two-tiered sampling procedure of the study design.

RESULTS

The mean age of respondents was 55.0 years and 49.2% were male. The prevalence of ESS>10 and 'doctor diagnosed' OSA were 15.9% and 6.0%, respectively. Approximately 23% of respondents reported loud snoring and 30% had a body mass index >30 kg⁄m2. Of those with 'doctor-diagnosed' OSA, 37.7% reported ESS>10 (P<0.0001) and 47.7% reported loud snoring (P<0.0001). Risk of having an ESS>10 score increased with age, male sex, obesity, lower socioeconomic status, marriage, loud snoring and doctor-diagnosed sinus trouble.

CONCLUSIONS

High levels of excessive daytime sleepiness in this particular rural population are common and men >55 years of age are at highest risk. Examination of reasons for residual sleepiness and snoring in persons with and without sleep apnea is warranted.

The relationship between excessive daytime sleepiness and depressive and anxiety disorders in women

OBJECTIVE

Excessive daytime sleepiness (EDS) is a common clinical symptom that affects women more than men. However, the association of excessive sleepiness with depressive and anxiety disorders in the broader population is unclear. The aim of this study was, therefore, to examine the association between excessive daytime sleepiness as measured by the Epworth Sleepiness Scale, and depressive and anxiety disorders in a population-based sample of women.

METHODS

Using the Structured Clinical Interview for DSM-IV Disorders (Non-Patient) (SCID-I/NP), 944 women aged 20-97 years (median 49 years, IQR 33-65 years) were assessed for depressive and anxiety disorders as part of the Geelong Osteoporosis Study. EDS was assessed using the Epworth Sleepiness Scale (ESS, cut-off > 10). Lifestyle factors were documented by self-report, height and weight were measured, and socioeconomic status categorised according to the Index of Relative Socio-Economic Advantage and Disadvantage.

RESULTS

Overall, 125 (13.2%) of the women were identified with EDS. EDS was associated with an increased likelihood for both current (OR = 2.11, 95% CI 1.10-4.06) and lifetime history (OR = 1.95, 95% CI 1.28-2.97) of depressive disorders, but not anxiety disorders, independent of age and alcohol consumption. These findings were not explained by antidepressant or sedative use, body mass index, physical activity, smoking, or socioeconomic status.

CONCLUSIONS

These results suggest that excessive daytime sleepiness is associated with current and lifetime depressive, but not anxiety disorders. Clinically, this highlights the need to take into account the possible bidirectional relationship between depressive disorders and excessive sleepiness when assessing mental health issues in patients with EDS.

Sleep habits, insomnia, and daytime sleepiness in a large and healthy community-based sample of New Zealanders

STUDY OBJECTIVES

To determine the relationship between sleep complaints, primary insomnia, excessive daytime sleepiness, and lifestyle factors in a large community-based sample.

DESIGN

Cross-sectional study.

SETTING

Blood donor sites in New Zealand.

PATIENTS OR PARTICIPANTS

22,389 individuals aged 16-84 years volunteering to donate blood.

INTERVENTIONS

N/A.

MEASUREMENTS

A comprehensive self-administered questionnaire including personal demographics and validated questions assessing sleep disorders (snoring, apnea), sleep complaints (sleep quantity, sleep dissatisfaction), insomnia symptoms, excessive daytime sleepiness, mood, and lifestyle factors such as work patterns, smoking, alcohol, and illicit substance use. Additionally, direct measurements of height and weight were obtained.

RESULTS

One in three participants report < 7-8 h sleep, 5 or more nights per week, and 60% would like more sleep. Almost half the participants (45%) report suffering the symptoms of insomnia at least once per week, with one in 5 meeting more stringent criteria for primary insomnia. Excessive daytime sleepiness (evident in 9% of this large, predominantly healthy sample) was associated with insomnia (odds ratio [OR] 1.75, 95% confidence interval [CI] 1.50 to 2.05), depression (OR 2.01, CI 1.74 to 2.32), and sleep disordered breathing (OR 1.92, CI 1.59 to 2.32). Long work hours, alcohol dependence, and rotating work shifts also increase the risk of daytime sleepiness.

CONCLUSIONS

Even in this relatively young, healthy, non-clinical sample, sleep complaints and primary insomnia with subsequent excess daytime sleepiness were common. There were clear associations between many personal and lifestyle factors-such as depression, long work hours, alcohol dependence, and rotating shift work-and sleep problems or excessive daytime sleepiness.

[The effects of self-awakening on daytime sleepiness]

This study investigated the effects of self-awakening on daytime sleepiness. Eleven undergraduate and graduate students without the habit of self-awakening participated. They were instructed to follow their usual sleep-wake schedule at home during the experimental weeks and were required to awaken at their usual time by themselves every morning for one week without the aid of an alarm (self-awakening condition) or in response to a telephone call from the experimenter every morning for another one week (forced-awakening condition). On the last day of each week, daytime tests were conducted in the laboratory. The participants would arrive at the laboratory 2 h after awakening, and 1 h later, they performed the auditory simple reaction time task, the digit-symbol substitution task, the letter cancellation test, and the multiple sleep latency test, and assessment of sleepiness, fatigue, comfort, and work motivation every 2 h. In the week when the participants underwent the self-awakening condition, self-awakening had a higher success rate (82%) than failure rate (18%) on the seventh day. In comparison with forced-awakening, self-awakening resulted in an improvement in subjective fatigue; however, sleepiness did not deteriorate.

Determining the level of sleepiness in the American population and its correlates

OBJECTIVE

To assess the prevalence, to determine the risk factors and to evaluate the impacts of excessive sleepiness in the general population.

METHOD

It is a cross-sectional telephone study using a representative sample consisting of 8937 non-institutionalized individuals aged 18 or over living in Texas, New York and California. They represented a total of 62.8 million inhabitants. The participation rate was 85.6% in California, 81.3% in New York and 83.2% in Texas. Interviews were managed by the Sleep-EVAL expert system. The questionnaire included questions on sleeping habits, life habits, health, DSM-IV mental disorders, DSM-IV and ICSD sleep disorders.

RESULTS

As many as 19.5% of the sample reported having moderate excessive sleepiness and 11.0% reported severe excessive sleepiness. Moderate excessive sleepiness was comparable between men and women but severe excessive sleepiness was higher in women (8.6% vs. 13.0%). Factors associated with moderate excessive sleepiness were sleeping 6 h or less per main sleep episode (OR:2.0); OSAS (OR:2.0); insomnia disorder (OR:2.4); Restless Legs Syndrome (OR: 1.8) major depressive disorder (OR: 1.7); anxiety disorder (OR:1.5) and use of tricyclic antidepressant (OR: 2.1) presence of heart disease (OR: 1.5), cancer (1.8) and chronic pain (1.3). Factors associated with severe excessive sleepiness were similar with the addition of being a woman (OR:1.5), alcohol dependence (OR: 1.4), bipolar disorder (OR: 2.1), use of over-the-counter sleeping pills (OR: 2.5), narcotic analgesics (OR: 3.4), Antidepressants (other than SSRI or tricyclic) and presence of gastro-esophageal reflux disease (OR:1.6). Sleepy individuals were twice as likely than non-sleepy participants to have had accidents while they were at the wheel of a vehicle during the previous year.

CONCLUSIONS

Excessive sleepiness is highly prevalent in the American population. It was strongly associated with insufficient sleep and various sleep disorders as well as mental and organic diseases.

The size and burden of mental disorders and other disorders of the brain in Europe 2010

AIMS

To provide 12-month prevalence and disability burden estimates of a broad range of mental and neurological disorders in the European Union (EU) and to compare these findings to previous estimates. Referring to our previous 2005 review, improved up-to-date data for the enlarged EU on a broader range of disorders than previously covered are needed for basic, clinical and public health research and policy decisions and to inform about the estimated number of persons affected in the EU.

METHOD

Stepwise multi-method approach, consisting of systematic literature reviews, reanalyses of existing data sets, national surveys and expert consultations. Studies and data from all member states of the European Union (EU-27) plus Switzerland, Iceland and Norway were included. Supplementary information about neurological disorders is provided, although methodological constraints prohibited the derivation of overall prevalence estimates for mental and neurological disorders. Disease burden was measured by disability adjusted life years (DALY).

RESULTS

Prevalence: It is estimated that each year 38.2% of the EU population suffers from a mental disorder. Adjusted for age and comorbidity, this corresponds to 164.8million persons affected. Compared to 2005 (27.4%) this higher estimate is entirely due to the inclusion of 14 new disorders also covering childhood/adolescence as well as the elderly. The estimated higher number of persons affected (2011: 165m vs. 2005: 82m) is due to coverage of childhood and old age populations, new disorders and of new EU membership states. The most frequent disorders are anxiety disorders (14.0%), insomnia (7.0%), major depression (6.9%), somatoform (6.3%), alcohol and drug dependence (>4%), ADHD (5%) in the young, and dementia (1-30%, depending on age). Except for substance use disorders and mental retardation, there were no substantial cultural or country variations. Although many sources, including national health insurance programs, reveal increases in sick leave, early retirement and treatment rates due to mental disorders, rates in the community have not increased with a few exceptions (i.e. dementia). There were also no consistent indications of improvements with regard to low treatment rates, delayed treatment provision and grossly inadequate treatment. Disability: Disorders of the brain and mental disorders in particular, contribute 26.6% of the total all cause burden, thus a greater proportion as compared to other regions of the world. The rank order of the most disabling diseases differs markedly by gender and age group; overall, the four most disabling single conditions were: depression, dementias, alcohol use disorders and stroke.

CONCLUSION

In every year over a third of the total EU population suffers from mental disorders. The true size of "disorders of the brain" including neurological disorders is even considerably larger. Disorders of the brain are the largest contributor to the all cause morbidity burden as measured by DALY in the EU. No indications for increasing overall rates of mental disorders were found nor of improved care and treatment since 2005; less than one third of all cases receive any treatment, suggesting a considerable level of unmet needs. We conclude that the true size and burden of disorders of the brain in the EU was significantly underestimated in the past. Concerted priority action is needed at all levels, including substantially increased funding for basic, clinical and public health research in order to identify better strategies for improved prevention and treatment for disorders of the brain as the core health challenge of the 21st century.

Prolonged-release melatonin for insomnia - an open-label long-term study of efficacy, safety, and withdrawal

Background

Prolonged-release melatonin (PRM) 2 mg is indicated for insomnia in patients aged 55 years and older. A recent double-blind placebo-controlled study demonstrated 6-month efficacy and safety of PRM in insomnia patients aged 18–80 and lack of withdrawal and rebound symptoms upon discontinuation.

Objective

To investigate the efficacy, safety, and withdrawal phenomena associated with 6–12 months PRM treatment.

Methods

Data from a prospective 6–12-month open-label study of 244 community dwelling adults with primary insomnia, who had participated in a placebo-controlled, double-blind dose-ranging trial of PRM. Patients received PRM nightly, followed by a 2-week withdrawal period. Main outcome measures were patient-reported sleep quality ratings (diary), adverse events, vital signs, and laboratory tests recorded at each visit, and withdrawal symptoms (CHESS-84 [Check-list Evaluation of Somatic Symptoms]). Nocturnal urinary 6-sulfatoxymelatonin excretion, a measure of the endogenous melatonin production, was assessed upon discontinuing long-term PRM.

Results

Of the 244 patients, 36 dropped out, 112 completed 6 months of treatment, and the other 96 completed 12 months of treatment. The mean number of nights by which patients reported sleep quality as “good” or “very good” was significantly higher during PRM than before treatment. There was no evidence of tolerance to PRM. Discontinuation of PRM was not associated with rebound insomnia or withdrawal symptoms; on the contrary, residual benefit was observed. PRM was well tolerated, and there was no suppression of endogenous melatonin production.

Conclusion

Results support the efficacy and safety of PRM in primary insomnia patients aged 20–80 throughout 6–12 months of continuous therapy. PRM discontinuation even after 12 months was not associated with adverse events, withdrawal symptoms, or suppression of endogenous melatonin production.

From wakefulness to excessive sleepiness: what we know and still need to know

The epidemiological study of hypersomnia symptoms is still in its infancy; most epidemiological surveys on this topic were published in the last decade. More than two dozen representative community studies can be found. These studies assessed two aspects of hypersomnia: excessive quantity of sleep and sleep propensity during wakefulness excessive daytime sleepiness. The prevalence of excessive quantity of sleep when referring to the subjective evaluation of sleep duration is around 4% of the population. Excessive daytime sleepiness has been mostly investigated in terms of frequency or severity; duration of the symptom has rarely been investigated. Excessive daytime sleepiness occurring at least 3 days per week has been reported in between 4% and 20.6% of the population, while severe excessive daytime sleepiness was reported at 5%. In most studies, men and women are equally affected. In the International Classification of Sleep Disorders, hypersomnia symptoms are the essential feature of three disorders: insufficient sleep syndrome, hypersomnia (idiopathic, recurrent or posttraumatic) and narcolepsy. Insufficient sleep syndrome and hypersomnia diagnoses are poorly documented. The co-occurrence of insufficient sleep and excessive daytime sleepiness has been explored in some studies and prevalence has been found in around 8% of the general population. However, these subjects often have other conditions such as insomnia, depression or sleep apnea. Therefore, the prevalence of insufficient sleep syndrome is more likely to be between 1% and 4% of the population. Idiopathic hypersomnia would be rare in the general population with prevalence, around 0.3%. Narcolepsy has been more extensively studied, with a prevalence around 0.045% in the general population. Genetic epidemiological studies of narcolepsy have shown that between 1.5% and 20.8% of narcoleptic individuals have at least one family member with the disease. The large variation is mostly due to the method used to collect the information on the family members; systematic investigation of all family members provided higher results. There is still a lot to be done in the epidemiological field of hypersomnia. Inconsistencies in its definition and measurement limit the generalization of the results. The use of a single question fails to capture the complexity of the symptom. The natural evolution of hypersomnia remains to be documented.

Prolonged-release melatonin improves sleep quality and morning alertness in insomnia patients aged 55 years and older and has no withdrawal effects

Melatonin, secreted nocturnally by the pineal gland, is an endogenous sleep regulator. Impaired melatonin production and complaints on poor quality of sleep are common among the elderly. Non-restorative sleep (perceived poor quality of sleep) and subsequently poor daytime functioning are increasingly recognized as a leading syndrome in the diagnostic and therapeutic process of insomnia complaints. The effects of 3-weeks prolonged-release melatonin 2 mg (PR-melatonin) versus placebo treatment were assessed in a multi-center randomized placebo-controlled study in 170 primary insomnia outpatients aged > or =55 years. Improvements in quality of sleep (QOS) the night before and morning alertness (BFW) were assessed using the Leeds Sleep Evaluation Questionnaire and changes in sleep quality (QON) reported on five categorical unit scales. Rebound insomnia and withdrawal effects following discontinuation were also evaluated. PR-melatonin significantly improved QOS (-22.5 versus -16.5 mm, P = 0.047), QON (0.89 versus 0.46 units; P = 0.003) and BFW (-15.7 versus -6.8 mm; P = 0.002) compared with placebo. The improvements in QOS and BFW were strongly correlated (Rval = 0.77, P < 0.001) suggesting a beneficial treatment effect on the restorative value of sleep. These results were confirmed in a subgroup of patients with a greater symptom severity. There was no evidence of rebound insomnia or withdrawal effects following treatment discontinuation. The incidence of adverse events was low and most side-effects were judged to be of minor severity. PR-melatonin is the first drug shown to significantly improve quality of sleep and morning alertness in primary insomnia patients aged 55 years and older-suggesting more restorative sleep, and without withdrawal symptoms upon discontinuation.

Secondary insomnia in the primary care setting: review of diagnosis, treatment, and management

INTRODUCTION

Insomnia is associated with a number of medical and psychiatric disorders, including chronic pain and clinical depression. Until recently, it was assumed that effective treatment of the underlying medical condition would also correct the sleep disturbance. However, some evidence indicates that treatment of secondary or comorbid insomnia should be considered separately from, and perhaps in addition to, optimizing treatment of the primary condition.

METHODS

This article reviews the extant literature to examine the impact of secondary and comorbid insomnia on the patient, and on healthcare economics, in the primary care setting, and discusses current diagnostic and treatment approaches. A MEDLINE search was performed for literature published from 1980 to 2005, and retrieved randomized, controlled clinical trials and key review articles for the conditions most often accompanied by secondary insomnia: depression, chronic pain, and menopause/perimenopause. The search terms included those for commonly used pharmacologic treatments and behavioral therapy.

RESULTS

Due to the paucity of clinical trial data in secondary insomnia patients, physicians have had to rely on evidence derived from primary insomnia trials. These data indicate that hypnotic medications are effective in treating sleep onset insomnia. However, few of these agents are effective against the most commonly occurring insomnia symptom - poor sleep maintenance - and many are associated with problematic residual sedation. Nevertheless, the cost of not treating these insomnia symptoms is often greater than the treatment inadequacies. Physicians should thus consider treating what they perceive as secondary insomnia with one of the available forms of therapy.

CONCLUSION

Patients experiencing sleep problems associated with a potential medical or psychiatric primary condition would likely benefit from increased physician awareness of secondary insomnia and the subsequent increased attention to diagnosing and treating this prevalent condition. Recommendations for managing secondary or comorbid insomnia in the primary care setting are discussed.

Prevalence and correlates of excessive daytime sleepiness in high school students in Korea

The purpose of the present study was to determine the prevalence of excessive daytime sleepiness (EDS) and its associations with sleep habits, sleep problems, and school performance in high school students in South Korea. A total of 3871 students (2703 boys and 1168 girls with a mean age of 16.8 years and 16.9 years, respectively) aged 15-18 years in the 11th grade of high school completed a questionnaire that contained items about individual sociodemographic characteristics, sleep habits, and sleep-related problems. The overall prevalence of EDS was 15.9% (14.9% for boys and 18.2% for girls). Mean reported total sleep time was similar in EDS and non-EDS (6.4 +/- 1.6 and 6.4 +/- 1.3 h/day, respectively). The increased risk of EDS was related to perceived sleep insufficiency (P < 0.001), teeth grinding > or = 4 days/week (P < 0.001), witnessed apnea > or = 1-3 days/week (P < 0.01), nightmares > or = 4 days/week (P < 0.05), low school performance (P < 0.01), and two or more insomnia symptoms (P < 0.05). Students with low school performance had a 60% excess in the odds of EDS compared to those whose school performance was high. These findings suggest that EDS is associated with multiple sleep-related factors in adolescents. Whether interventions to modify associated correlates can alter EDS warrants consideration, especially because it may also improve academic performance in high school students.

Hemodynamics and oxygen saturation during intravenous sedation for office-based laser-assisted uvuloplasty

PURPOSE

Patients undergoing office-based laser-assisted uvuloplasty (LAUP) for snoring or mild obstructive sleep apnea are generally obese and have a high Mallampati score. Because avoidance of supplemental oxygen during laser procedures is generally mandated, the potential for intraoperative desaturation is high. This study was designed to look at intraoperative hemodynamic changes, respiration patterns, and oxygen saturations during intravenous sedation with midazolam and fentanyl during LAUP procedures.

MATERIALS AND METHODS

This was a retrospective anesthesia chart review of 15 consecutive patients undergoing midazolam/fentanyl intravenous sedation for office-based LAUP treatment for snoring and/or mild obstructive sleep apnea. Data recorded were noninvasive baseline and intraoperative hemodynamic measurements at 5-minute intervals for systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), pulse pressure (PP), pulse (P), and rate-pressure product (RPP). Data collected were reported as mean values with standard deviation. Statistical analysis using the Student's t test was performed and found significant for P<.05.

RESULTS

All changes from baseline were statistically insignificant, SBP (P=.4), DBP (P=.2), MAP (P=.2), P (P=.1), PP (P=.9), RPP (P=.5), RR (P=.9), and SpO2 (P=.4), and all within +/-20% of baseline (range, -5.0% to +7.5%).

CONCLUSION

Midazolam and fentanyl intravenous sedation with local anesthesia maintained intraoperative hemodynamic and oxygenation variables close to baseline for office-based LAUP procedures.

Correlates and consequences of chronic insomnia

Approximately one half of patients with insomnia have a primary psychiatric disorder such as a depression or anxiety. Insomnia is associated with increased risk of new or recurrent psychiatric disorders, increased daytime sleepiness with consequent cognitive impairment, poorer prognoses, reduced quality of life and high healthcare-related financial burden. Emerging data suggest that resolution of insomnia may improve psychiatric outcomes, which underscores the importance of vigorous treatment. Unfortunately, only a small percentage of patients receive such care. An ideal monotherapeutic strategy would treat both depression and insomnia. There are, however, only a handful of modern antidepressants that objectively improve sleep maintenance problems, and none do so without causing adverse next-day effects such as sedation. Thus, a significant number of patients must take adjunctive hypnotic medications, even though longer-term efficacy has not been established. New and emerging anti-insomnia agents may prove useful in the long-term treatment of chronic insomnia. Further research is needed to establish the benefits of such treatment.

Excessive daytime sleepiness among the Japanese general population

BACKGROUND: Excessive daytime sleepiness is one of the principal symptoms of sleep disturbances, and is often associated with serious consequences including traffic and industrial accidents, decreased productivity, and interpersonal problems. However, there are few epidemiologic studies on excessive daytime sleepiness in a large scale sample targeting Japanese general population.

METHODS: The survey was performed using a self-administered questionnaire in June 2000, targeting a population randomly selected from among 300 communities throughout Japan. This questionnaire included information about sleep habits and sleep problems. Excessive daytime sleepiness measured according to a question “Do you fall asleep when you must not sleep (for example when you are driving a car)?”

RESULTS: A total of 28,714 subjects completed the questionnaire. The prevalence of excessive daytime sleepiness was 2.5% (male=2.8% and female=2.2%). Backward elimination analysis showed that the following were associated with excessive daytime sleepiness: male sex, young age, short sleep duration, subjective insufficient sleep, loss of deep sleep, disagreeable sensations in the legs, interruption of sleep by snoring or dyspnea, and feeling psychological stress. Interruption of sleep by snoring or dyspnea was the strongest associated factor (adjusted odds ratio=2.46, 95% confidence interval=1.76-3.43) of excessive daytime sleepiness.

CONCLUSIONS: These results suggest that excessive daytime sleepiness in Japanese is associated with several sleep problems. These findings may be useful in attempts to prevent excessive daytime sleepiness in the general population of Japan.