Assessing the prioritization of primary care referrals for polysomnograms

Advancements in Wearable EEG Technology for Improved Home-Based Sleep Monitoring and Assessment: A Review

Sleep is a fundamental aspect of daily life, profoundly impacting mental and emotional well-being. Optimal sleep quality is vital for overall health and quality of life, yet many individuals struggle with sleep-related difficulties. In the past, polysomnography (PSG) has served as the gold standard for assessing sleep, but its bulky nature, cost, and the need for expertise has made it cumbersome for widespread use. By recognizing the need for a more accessible and user-friendly approach, wearable home monitoring systems have emerged. EEG technology plays a pivotal role in sleep monitoring, as it captures crucial brain activity data during sleep and serves as a primary indicator of sleep stages and disorders. This review provides an overview of the most recent advancements in wearable sleep monitoring leveraging EEG technology. We summarize the latest EEG devices and systems available in the scientific literature, highlighting their design, form factors, materials, and methods of sleep assessment. By exploring these developments, we aim to offer insights into cutting-edge technologies, shedding light on wearable EEG sensors for advanced at-home sleep monitoring and assessment. This comprehensive review contributes to a broader perspective on enhancing sleep quality and overall health using wearable EEG sensors.

Screening practices for obstructive sleep apnea in healthy community people: a Chinese community-based study

Background

Owing to the lack of clear guidelines, the significance of obstructive sleep apnea (OSA) screening in healthy community people is unclear. This study aimed to screen for OSA in a healthy community population and provide a basis for its screening.

Methods

Permanent residents from five communities in the coastal and mountainous areas of south China were selected. The screening process included demographic and sleep questionnaire surveys, and an OSA screening. To compare the prevalence and risk factors of OSA in different areas, a type IV wearable intelligent sleep monitor (WISM) was used for screening.

Results

A total of 3,650 participants completed all studies, with a mean age of 53.81±12.71 years. In addition, 4,318 participants completed the OSA screening within 30 days, and the objective screening speed was 200 people per day. The recovery rate of the screening equipment was 99.37% (4,291/4,318), the screening success rate was 89.63% (3,846/4,291), and the rejection rate was 2.7% (120/4,438). The prevalence of high-risk OSA screened using the Stop-Bang questionnaire was 42.8% (1,563/3,650) and that screened using the device was 30.7% (1,119/3,650). The prevalence of OSA screened using the Stop-Bang questionnaire was higher than that screened using the device (P<0.01). Further analysis of sleep quality and daytime sleepiness showed that 47.6% (1,736/3,650) of the community population had good sleep quality and 6.6% (240/3,650) had daytime sleepiness. Age, sex, body mass index (BMI), neck circumference, and hypertension were risk factors for OSA in the community population.

Conclusions

The use of objective type IV sleep detection equipment to screen a large sample population in the community in a short time is feasible. The prevalence of high-risk OSA screened using the Stop-Bang questionnaire was higher than that screened using the objective screening device.

Experiences with Continuous Positive Airway Pressure Among African American Patients and their Bed Partners

RATIONALE

Despite having a higher prevalence and severity of obstructive sleep apnea (OSA), African Americans have lower adherence to continuous positive airway pressure (CPAP) compared to other groups. Information regarding challenges faced by African Americans prescribed CPAP are lacking.

OBJECTIVES

To determine the barriers and facilitators to optimal management of OSA with CPAP among African Americans and to understand the role bed partners may play.

METHODS

We conducted semi-structured in-depth interviews via video conferencing with African American patients of an urban safety-net health care system with OSA prescribed CPAP and their bed partners. Recruitment continued until theoretical saturation was achieved. Verbatim transcripts were analyzed using the principles of thematic analysis.

RESULTS

15 patients (12 women) diagnosed with OSA and prescribed CPAP a mean 2.6 years prior along with 15 bed partners (3 women) were individually interviewed. Four themes emerged regarding impediments to CPAP use: 1) inadequate education and support, 2) CPAP maintenance and hygiene, 3) inconvenient design of CPAP interfaces, and 4) impediment to intimacy. Four themes emerged as facilitators to CPAP use: 1) provider and technical support, 2) properly fitted CPAP masks, 3) active support from partner and family, and 4) experiencing positive results from CPAP.

CONCLUSIONS

African American patients with OSA and their bed partners identified several unique barriers and facilitators to CPAP use. Active involvement by bed partners was considered by both patients and partners as helpful in improving CPAP adherence. Interventions to improve OSA outcomes in this population should focus on patients and their bed partners.

Awareness of Medical Students toward Circadian Rhythm and Sleep Disorder Based on Biomedical Diagnosis

Background

Sleep disorders affect an individual's mental and physical health and vice versa. Sleep medicine is underrecognized as a specialty; therefore, many sleep disorders go undiagnosed. This study is aimed at assessing the knowledge of medical students toward circadian neuroscience and sleep disorder based on biomedical diagnosis.

Methods

This cross-sectional study was conducted in both male and female medical colleges from the third to the sixth year. A self-administered structured questionnaire consisting of sociodemographic data and the Assessment of Sleep Knowledge in Medical Education (ASKME) survey assessed the students' general knowledge and attitude towards sleep disorder and sleep medicine. Chi-square/Fisher exact tests were used to analyse the participants' knowledge level toward specific sociodemographic data. Also, for two-level continuous variables, the Wilcoxon two-sample test was used.

Results

The total number of participants was 296, with 154 female and 142 male participants. The prevalence of inadequate knowledge was considerable with 96.62% of students, compared to adequate knowledge with only 3.38%. The students' attitude to sleep medicine was negative 14.53% and positive among 85.47%. We found that gender was significantly associated with attitude with a p value = 0.0057. The specific interest in sleep medicine had a significant association with knowledge and attitude, p value of 0.0522 and 0.0059, respectively.

Conclusion

This study concluded that medical students possess inadequate knowledge regarding sleep medicine, yet they have a positive attitude towards it.

Differences in Symptoms and Severity of Obstructive Sleep Apnea between Black and White Patients

Rationale: Prior work suggests that Black patients have more severe obstructive sleep apnea (OSA) upon clinical presentation. However, the extent to which this may reflect differences in symptoms or other standard measures of OSA risk is unclear. Objectives: We assessed for racial disparities in OSA characteristics at time of initial clinical diagnosis. Methods: Data from 890 newly diagnosed patients with OSA at an urban academic sleep center were included in this analysis. All patients completed a standardized questionnaire on demographics and sleep-related symptoms and underwent laboratory polysomnography. Symptom severity at the time of evaluation was compared across race and sex. Results: Black men were underrepresented in the sleep lab, making up only 15.8% of the cohort and 31.3% of Black participants (P < 0.001). Despite this, Black men had the most severe OSA with a mean apnea hypopnea index of 52.4 ± 39.4 events/hour, compared with 39.0 ± 28.9 in White men, 33.4 ± 32.3 in Black women, and 26.2 ± 23.8 in White women (P < 0.001 for test of homogeneity). Black men also had the greatest burden of OSA symptoms with the highest mean Epworth Sleepiness Scale score (12.2 ± 5.9 versus 9.4 ± 5.2 in White men, 11.2 ± 5.9, in Black women, and 9.8 ± 5.6 in White women; P < 0.001). Compared with White men, Black men were 1.61 (95% CI [1.04-2.51]) times more likely to have witnessed apneas and 1.56 (95% CI [1.00-2.46]) times more likely to have drowsy driving at the time of OSA diagnosis. Conclusions: At the time of clinical diagnosis, Black men have greater disease severity, suggesting delay in diagnosis. Further, the greater burden of classic OSA symptoms suggests the delayed diagnosis of OSA in Black men is not due to atypical presentation. Further research is needed to identify why screening methods for OSA are not equitably implemented in the care of Black men.

Obstructive sleep apnea: A sharp increase in the prevalence of patients treated with nasal CPAP over the last decade in France

Introduction

Obstructive sleep apnea (OSA) is a frequent condition. In the absence of treatment, OSA is associated with a higher risk of traffic accidents and a large variety of diseases. The objectives of this study were to describe the characteristics of patients treated for OSA in France and assess the time trends in treatment.

Methods

The French National Health Data System is an individual database with data on all healthcare reimbursements for the entire French population. Based on this database, we included all patients aged 20 years or over who were treated with continuous positive airway pressure (CPAP) or mandibular advancement splint (MAS) between 2009 and 2018. Negative binomial models, adjusted for age, were used to assess time trends in treatment prevalence and incidence rates.

Results

In 2017, 2.3% of French adults aged ≥20 years were treated with CPAP (men: 3.3%; women: 1.3%). The highest prevalence was observed in people aged 70–74 years (5.0%). From 2009 to 2018, the annual prevalence of CPAP increased 3-fold and the annual incidence 1.9-fold. During the same period, the rate of patients reimbursed for MAS (first prescription or renewal) was multiplied by 7.6. The proportion of patients treated with CPAP in 2017 who were no longer treated in the subsequent year was 6.9%.

Discussion

The sharp increase in the incidence of OSA treatment probably reflects a better recognition of the disease in France. However, the prevalence of OSA treatment remains lower than expected based on the international literature. Further studies are needed to identify the obstacles to an optimal management of individuals with OSA in France.

Knowledge and Attitude Regarding Sleep Medicine among Medical Students at Qassim University, Saudi Arabia

BACKGROUNDS:

Sleep disorders and sleep medicine are underrecognized by both the general public and health care workers. Lack of education and training in sleep medicine has resulted in a culture of physicians who have very limited knowledge about sleep disorders and, as a result, are likely to underdiagnose and under-treat patients.

AIM:

This study aimed to assess the knowledge of and attitude regarding sleep medicine among medical students at Qassim University.

METHODS:

This was a cross-sectional study of 4^th and 5^th-year medical students, conducted at Qassim University (Central and Unaizah branches), Saudi Arabia. We used a self-administered data collection tool to collect personal information (age, name, sex, medical school), and assessed general attitude toward sleep medicine and the students’ current knowledge about sleep medicine using the Assessment of Sleep Knowledge in Medical Education (ASKME) survey.

RESULTS:

The prevalence of medical students who had a special interest in sleep medicine was 23.3%. Poor knowledge about sleep medicine was detected in 94.8% of students, while good knowledge was observed in only 5.2%. The attitude of the students toward sleep medicine was negative among 40.5% and positive among 59.5%. University branches, gender, and preferred speciality were all significantly associated with attitude score, whereas interest in sleep medicine and knowledge of sleep disorders were associated with both knowledge and attitude scores.

CONCLUSION:

This study found that medical students’ knowledge of sleep medicine was very low, despite the majority of them having a positive attitude toward it.

Legal and Regulatory Aspects of Sleep Disorders

Sleep disorders may interact with the law, making awareness important. Insufficient sleep and obstructive sleep apnea (OSA) are prevalent and associated with excessive sleepiness. Patients with excessive sleepiness may have civil or criminal liability if they fall asleep and cause a motor vehicle accident. Awareness of screening and treatment of OSA is increasing in certain industries. Parasomnia associated sleep-related violence represents a challenge to clinicians, who may be called on to consider parasomnia as a contributing, mitigating, or exculpatory factor in criminal proceedings. Improving access to sleep medicine care is an important aspect in reducing the consequences of sleep disorders.

Incidence, Characterization, and Predictors of Sleep Apnea in Consecutive Brain Injury Rehabilitation Admissions

OBJECTIVE

To prospectively examine the incidence and risk factors for sleep apnea in consecutive brain injury rehabilitation admissions.

SETTING

Inpatient neurorehabilitation hospital.

PARTICIPANTS

Participants (n = 86) were consecutive neurorehabilitation admissions.

DESIGN

Retrospective analysis of prospectively collected data.

MAIN MEASURES

Polysomnography.

RESULTS

Half (49%) of the sample was diagnosed with sleep apnea. For the full sample, univariate logistic regression revealed age (odds ratio: 1.08; 95% confidence interval: 1.04-1.11) and hypertension (odds ratio: 7.77; 95% confidence interval: 2.81-21.47) as significant predictors of sleep apnea diagnosis. Results of logistic regression conducted within the traumatic brain injury group revealed age (odds ratio: 1.07; 95% confidence interval: 1.02-1.13) as the only significant predictor of apnea diagnosis after adjustment for other variables. Hierarchical generalized linear regression models for the prediction of apnea severity (ie, apnea-hypopnea index found that Functional Independence Measure Cognition Score (P = .01) and age (P < .01) were significant predictors. Following adjustment for all other terms, only age (P < .01) remained significant.

CONCLUSION

Sleep apnea is prevalent in acute neurorehabilitation admissions and traditional risk profiles for sleep apnea may not effectively screen for the disorder. Given the progressive nature of obstructive sleep apnea and morbidity associated with even mild obstructive sleep apnea, early identification and intervention may address comorbidities influencing acute and long-term outcome.

Feasibility of portable sleep monitors to detect obstructive sleep apnea (OSA) in a vulnerable urban population

PURPOSE

Portable sleep monitors may offer a convenient method to expand detection of obstructive sleep apnea (OSA), yet few studies have evaluated this technology in vulnerable populations. We therefore aimed to assess the feasibility and acceptability of portable sleep monitors for detection of OSA in a prediabetic, urban minority population.

METHODS

We recruited a convenience sample of participants at their 12-month follow-up for a community-partnered, peer-led lifestyle intervention aimed to prevent diabetes in prediabetic and overweight patients in this prospective mixed-methods pilot study. All participants wore portable sleep monitors overnight at home. We qualitatively explored perceptions about OSA and portable monitors in a subset of participants.

RESULTS

We tested 72 people, predominantly non-White, female, Spanish speaking, uninsured, and of low income. Use of portable sleep monitors was feasible: 100% of the monitors were returned and all participants received results. We detected OSA in 49% (defined as an Apnea-Hypopnea Index [AHI] >5) and moderate-severe OSA in 14% (AHI >15) requiring treatment in 14%. In 21 qualitative interviews, participants supported increased use of portable sleep monitors in their community, were appropriately concerned that OSA could cause progression to diabetes, and thought weight loss could prevent or improve OSA.

CONCLUSIONS

Portable sleep monitors may represent a feasible method for detecting OSA in high-risk urban minority populations.

The effect of adding gender item to Berlin Questionnaire in determining obstructive sleep apnea in sleep clinics

BACKGROUND AND AIM

We aimed to validate the Turkish version of Berlin Questionnaire (BQ) and developped a BQ-gender (BQ-G) form by adding gender component. We aimed to compare the two forms in defining patients with moderate to severe obstructive sleep apnea (OSA) in sleep clinics.

METHODS

Four hundred and eighty five consecutive patients, refered to our sleep clinic for snoring, witnessed apnea and/or excessive daytime sleepiness were enrolled to the study. All patients underwent in-laboratory polysomnography (PSG). Patients with sleep efficiency less than 40% and total sleep time less than 4 hours, chronic anxiolitic/sedative drug usage, respiratory tract infection within past two weeks were excluded from the study. All the patients fulfilled BQ. The test and retest for BQ were applied in 15-day interval in 30 patients.

RESULTS

Totally 433 patients were enrolled to the study (285 male, 148 female). The mean age of the patients was 47,5 ± 10.5 (21-79). 180 patients (41.6%) had apnea-hypopnea index (AHI) ≤ 15, while 253 patients (58,4%) had AHI > 15. The κ value was 48-94 and the the truth value was 69-94% for the test-retest procedure. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and area under the curve AUC were 84.2%, 31.7%, 48.7%, 63.4%, and 0.579 in order for BQ and 79.9 %, 51.7%, 63.2% , 69.6%, and 0.652 for BQ-G.

CONCLUSION

The results showed that BQ-G is relatively better than BQ in determining moderate to severe OSA in sleep clinics where most of the patients are sleep apneic but both of the tests were found to have insufficient validities in defining moderate to severe OSA in sleep clinics.

Factors associated with referrals for obstructive sleep apnea evaluation among community physicians

STUDY OBJECTIVES

This study assessed knowledge and attitudes toward obstructive sleep apnea (OSA) among community physicians and explored factors that are associated with referrals for OSA evaluation.

METHODS

Medical students and residents collected data from a convenience sample of 105 physicians practicing at community-based clinics in a large metropolitan area. Average age was 48 ± 14 years; 68% were male, 70% black, 24% white, and 6% identified as "other." Physicians completed the Obstructive Sleep Apnea Knowledge and Attitudes questionnaire.

RESULTS

The average year in physician practice was 18 ± 19 years. Of the sample, 90% reported providing care to black patients. The overall OSA referral rate made by physicians was 75%. OSA knowledge and attitudes scores ranged from 5 to 18 (mean = 14 ± 2) and from 7 to 20 (mean = 13 ± 3), respectively. OSA knowledge was associated with white race/ ethnicity (rp = 0.26, p < 0.05), fewer years in practice (rp = -0.38, p < 0.01), patients inquiring about OSA (rp = 0.31, p < 0.01), and number of OSA referrals made for OSA evaluation (rp = 0.30, p < 0.01). Positive attitude toward OSA was associated with patients inquiring about OSA (rp = 0.20, p < 0.05). Adjusting for OSA knowledge and attitudes showed that physicians whose patients inquired about OSA were nearly 10 times as likely to make a referral for OSA evaluation (OR = 9.38, 95% CI: 2.32-38.01, p < 0.01).

CONCLUSION

Independent of physicians' knowledge and attitudes toward obstructive sleep apnea, the likelihood of making a referral for obstructive sleep apnea evaluation was influenced by whether patients inquired about the condition.

Pharmacotherapeutic failure in a large cohort of patients with insomnia presenting to a sleep medicine center and laboratory: subjective pretest predictions and objective diagnoses

OBJECTIVE

To measure the frequency of pharmacotherapeutic failure and its association with the diagnosis of sleep-disordered breathing among patients with chronic insomnia disorder.

PATIENTS AND METHODS

In a retrospective review of medical records from January 1, 2005, through December 31, 2012, we identified an inclusive, consecutive series of 1210 patients with insomnia disorder, 899 (74.3%) of whom used sleep aids either occasionally (168 [18.7%]) or regularly (731 [81.3%]). Patients presented to a community-based sleep medicine center in Albuquerque, New Mexico, with typical referral patterns: 743 (61.4%) were referred by primary care physicians, 211 (17.4%) by specialists, 117 (9.7%) by mental health professionals, and 139 (11.5%) by self-referral. Pharmacotherapeutic failure was assessed from subjective insomnia reports and a validated insomnia severity scale. Polysomnography with pressure transducer (an advanced respiratory technology not previously used in a large cohort of patients with insomnia) measured sleep-disordered breathing. Objective data yielded accuracy rates for 3 pretest screening tools used to measure risk for sleep-disordered breathing.

RESULTS

Of the total sample of 1210 patients, all 899 (74.3%) who were taking over-the-counter or prescription sleep aids had pharmacotherapeutic failure. The 710 patients taking prescription drugs (79.0%) reported the most severe insomnia, the fewest sleep-associated breathing symptoms, and the most medical and psychiatric comorbidity. Of the 942 patients objectively tested (77.9%), 860 (91.3%) met standard criteria, on average, for a moderate to severe sleep-associated breathing disorder, yet pretest screening sensitivity for sleep-disordered breathing varied widely from 63.7% to 100%. Positive predictive values were high (about 90%) for all screens, but a tool commonly used in primary care misclassified 301 patients (32.0% false-negative results).

CONCLUSION

Pharmacotherapeutic failure and sleep-disordered breathing were extremely common among treatment-seeking patients with chronic insomnia disorder. Screening techniques designed from the field of sleep medicine predicted high rates for sleep-disordered breathing, whereas a survey common to primary care yielded many false-negative results. Although the relationship between insomnia and sleep-disordered breathing remains undefined, this research raises salient clinical questions about the management of insomnia in primary care before sleep center encounters.

Sleep disturbances in persons living with HIV

Up to 70% of persons living with HIV (PLWH) experience sleep disturbances. Insomnia and obstructive sleep apnea syndrome (OSAS) are common disorders seen in the primary care of PLWH. This paper reviews the current evidence and practice recommendations for treating these conditions. Insomnia is evaluated by clinical interview, questionnaires, and sleep diaries. The recommended first-line treatment is cognitive-behavioral therapy for insomnia (CBT-I) delivered by a trained therapist. Certain sedative medications may be useful, but over-the-counter treatments (particularly those containing antihistamines) are not recommended. OSAS is diagnosed by overnight sleep study but can be screened for in primary care. The STOP-BANG is a useful eight-item screening tool. The gold standard of treatment for OSAS is the use of a continuous positive airway pressure device. Treatment of insomnia and OSAS is important for improving quality of life and preventing associated health problems (especially cardiovascular disease in OSAS) in PLWH.

Long-term effect of weight loss on obstructive sleep apnea severity in obese patients with type 2 diabetes

STUDY OBJECTIVES

To examine whether the initial benefit of weight loss on obstructive sleep apnea (OSA) severity at 1 year is maintained at 4 years.

DESIGN

Randomized controlled trial with follow-up at 1, 2, and 4 years.

SETTING

4 Look AHEAD clinical centers.

PARTICIPANTS

Two hundred sixty-four obese adults with type 2 diabetes and OSA.

INTERVENTIONS

Intensive lifestyle intervention with a behavioral weight loss program or diabetes support and education.

MEASUREMENTS

Change in apnea-hypopnea index on polysomnogram.

RESULTS

The intensive lifestyle intervention group's mean weight loss was 10.7 ± 0.7 (standard error), 7.4 ± 0.7, and 5.2 ± 0.7 kg at 1, 2, and 4 years respectively, compared to a less than 1-kg weight loss for the control group at each time (P < 0.001). Apnea-hypopnea index difference between groups was 9.7 ± 2.0, 8.0 ± 2.0, and 7.7 ± 2.3 events/h at 1, 2 and 4 years respectively (P < 0.001). Change in apnea-hypopnea index over time was related to the amount of weight loss (P < 0.0001) and intervention, independent of weight loss (P = 0.001). Remission of OSA at 4 years was 5 times more common with intensive lifestyle intervention (20.7%) than diabetes support and education (3.6%).

CONCLUSIONS

Among obese adults with type 2 diabetes and OSA, intensive lifestyle intervention produced greater reductions in weight and apnea-hypopnea index over a 4 year period than did diabetes support and education. Beneficial effects of intensive lifestyle intervention on apneahypopnea index at 1 year persisted at 4 years, despite an almost 50% weight regain. Effect of intensive lifestyle intervention on apnea-hypopnea index was largely, but not entirely, due to weight loss.

Sleep medicine in Saudi Arabia: Current problems and future challenges

Sleep medicine is a relatively new specialty in the medical community. The practice of sleep medicine in Saudi Arabia (KSA) began in the mid to late nineties. Since its inception, the specialty has grown, and the number of specialists has increased. Nevertheless, sleep medicine is still underdeveloped in the KSA, particularly in the areas of clinical service, education, training and research. Based on available data, it appears that sleep disorders are prevalent among Saudis, and the demand for sleep medicine service is expected to rise significantly in the near future. A number of obstacles have been defined that hinder the progress of the specialty, including a lack of trained technicians, specialists and funding. Awareness about sleep disorders and their serious consequences is low among health care workers, health care authorities, insurance companies and the general public. A major challenge for the future is penetrating the educational system at all levels to demonstrate the high prevalence and serious consequences of sleep disorders. To attain adequate numbers of staff and facilities, the education and training of health care professionals at the level of sleep medicine specialists and sleep technologists is another important challenge that faces the specialty. This review discusses the current position of sleep medicine as a specialty in the KSA and the expected challenges of the future. In addition, it will guide clinicians interested in setting up new sleep medicine services in the KSA or other developing countries through the potential obstacles that may face them in this endeavor.