Excessive daytime sleepiness and adherence to antihypertensive medications among Blacks: analysis of the counseling African Americans to control hypertension (CAATCH) trial

Excessive daytime sleepiness, but not sleep apnea, sleep duration or insomnia, was associated with poor adherence to anti-hypertensive treatment: The ELSA-Brasil study

Hypertension is the leading risk factor for cardiovascular mortality. Poor adherence may partially explain this scenario. Beyond traditional factors, it is conceivable that sleep conditions such as Obstructive Sleep Apnea (OSA), Sleep Duration (SDUR), sleepiness and insomnia may contribute to impair adherence but the evidence is scanty. Consecutive participants with hypertension from the ELSA-Brasil study performed a home sleep monitoring and 7-days actigraphy to determine OSA (apnea-hypopnea index ≥15 events/hour) and SDUR, respectively. Excessive daytime sleepiness (EDS) and insomnia were evaluated by Epworth Sleepiness Scale (ESS) and Clinical Interview Scheduled Revised (CIS-R), respectively. The 4-itens Morisky questionnaire was used to evaluate adherence to anti-hypertensive therapy. A total of 411 patients were including in the analysis (mean age: 54 ± 8 years, 47% men). Medium/low adherence to anti-hypertensive therapy was observed in 62%. Compared to the high adherence group, the participants with medium/low adherence had lower frequencies of Whites (64.1 vs. 47.8%), high-degree education (50.6 vs. 40%), and monthly per-capita income ($1021.90 vs. $805.20). In contrast, we observed higher frequency of EDS (35.9 vs. 46.1%). No differences were observed for OSA, short SDUR (<6 h) and insomnia. Logistic regression analysis showed that race other than White (OR: 1.80; 95% IC:1.15-2.82), lower monthly income (OR: 1.74; 95% IC:1.01-3.0) and EDS (OR: 1.63; 95% IC:1.05-2.53) were independently associated with medium/low adherence to the anti-hypertensive treatment. Interestingly, EDS mediated the abdominal obesity-adherence outcome. In conclusion, among sleep-related parameters, EDS, but not OSA, short SDUR or insomnia, were associated to impaired adherence to anti-hypertensive therapy.

Frequency of sleep-disordered breathing in a referral population of Somali-Americans

STUDY OBJECTIVES

To study the frequency of obstructive sleep apnea (OSA) in individuals of Somali ancestry referred to a clinical sleep laboratory.

METHODS

This was a retrospective study using a large registry of patients who underwent diagnostic polysomnography between 17 November 2009 and 15 April 2017. Adult patients self-reporting as being of Somali origin were confirmed using the electronic medical record.

RESULTS

Somali-American patients comprised approximately 0.2% of all patients undergoing polysomnography at the Mayo Clinic Center for Sleep Medicine. The median (interquartile range) age was 52.6 (35, 64) years with 66% males and a median (interquartile range) body mass index of 31.2 (27, 34) kg/m². OSA was diagnosed in 77% of patients, with approximately 50% having moderate to severe OSA. OSA was more frequent in older patients and similar between men and women, and only age predicted an OSA diagnosis while sex and body mass index did not. All patients with diabetes mellitus type 2 (n = 7) and all but one of the hypertensive patients (n = 11) had significant OSA.

CONCLUSIONS

Less than 0.2% of all patients undergoing polysomnography at Mayo Clinic were of Somali origin. Moderate-to-severe OSA was frequent in this select sample of individuals who underwent polysomnography. Hypertension and diabetes were present in most Somali-Americans with OSA. Given the rising prevalence of diabetes and hypertension in Somali-Americans, and the likely high prevalence of undiagnosed OSA, screening Somali-Americans for sleep disorders may contribute importantly to prevention, early detection, and reduction of cardiovascular and metabolic diseases in this population.

Prevalence, risk factors, and trajectories of sleep disturbance in a cohort of African-American breast cancer survivors

PURPOSE

Sleep disturbance may be an overlooked modifiable risk factor for health disparities among African-American breast cancer survivors (AABCS). This study aimed to identify the prevalence of and risk factors for sleep disturbance in a cohort of AABCS.

METHODS

The study was conducted among participants in the Women's Circle of Health Follow-up Study, a longitudinal study of breast cancer in 10 counties in New Jersey. Cases were identified shortly after diagnosis by the New Jersey State Cancer Registry. Self-reported sleep disturbance (Pittsburgh Sleep Quality Index) and other factors (e.g., socioeconomic status, menopausal status) were assessed at pre-diagnosis (n = 637), 10 months post-diagnosis (n = 261), and 24 months post-diagnosis (n = 632). Clinical data were obtained via medical record abstraction, and height and weight were measured by study staff.

RESULTS

Most AABCS (57%) reported clinically significant sleep disturbance before diagnosis, and this rate remained largely unchanged at 10 months (53%) and 24 months post-diagnosis (61%). Average sleep disturbance scores indicated clinically significant disturbance at all three assessments (M range = 6.67-7.57). Most reported sleeping fewer than the recommended 7 hours per night at each assessment (range 57-65%). Risk factors for sleep disturbance were identified at each assessment, including pre-diagnosis (less education), 10 months post-diagnosis (lack of insurance, treatment with chemotherapy), and 24 months post-diagnosis (younger age, less education, lower income, obesity, and lymphedema). Treatment with endocrine therapy was a protective factor at 10 months post-diagnosis.

CONCLUSION

Most AABCS report clinically significant sleep disturbance from before diagnosis through 24 months post-diagnosis. These rates appear indicate AABCS experience significant sleep-related disparities.

Benefits of Community-Based Approaches in Assessing and Addressing Sleep Health and Sleep-Related Cardiovascular Disease Risk: a Precision and Personalized Population Health Approach

PURPOSE OF REVIEW

In this current review, we describe the benefits of community-based and "precision and personalized population health" (P3H) approaches to assessing and addressing sleep health problems and sleep-related cardiovascular diseases (CVD) among vulnerable populations such as racial/ethnic minorities, the elderly, and the socioeconomically disadvantaged.

RECENT FINDINGS

Very few sleep health programs utilize a community-based or P3H approach, which may account for low estimates of sleep health problems, related CVD outcomes, and inadequate healthcare infrastructure to address sleep-related health outcomes at the community and population level. We describe community-based and P3H approaches and programs as solutions to accurately capture estimates of sleep health and reduce burden of sleep health problems and corollary CVD outcomes at the level of the community and population. Specifically, we describe seven critical steps needed to successfully implement a community-based and P3H approach to address sleep health problems. Community-based and P3H approaches are effective strategies to assessing and addressing sleep health problems and related health conditions.

Influence of high risk of obstructive sleep apnea on adherence to antihypertensive treatment in outpatients

Obstructive sleep apnea (OSA) is a common cause of high blood pressure (BP). Many patients, however, have uncontrolled BP because of nonadherence to antihypertensive medication. The possibility that OSA influences adherence has not been investigated to date. The authors sought to explore the possible association between high risk of OSA and nonadherence. This study was carried out in a hypertension outpatient clinic. Adherence to medication, high risk of OSA, and sleepiness were evaluated in a cross-sectional study. These variables were identified using the eight-item Morisky, STOP-Bang, and Epworth scales, respectively. A total of 416 patients with hypertension were enrolled (32% male, aged 65±11 years). Nonadherence was identified in 71 (17%) individuals. The prevalence of high risk of OSA was 323 (78%) and of somnolence was 136 (33%). High risk of OSA was associated with nonadherence, showing a prevalence ratio (PR) of 2.6 (95% confidence interval [CI], 1.3-5.6) and retained significance after adjustment for sleepiness (PR, 2.3; 95% CI, 1.1-4.9 [P=.011]). Sleepiness was also associated with nonadherence (PR, 1.7; 95% CI, 1.1-2.6 [P=.003]). High risk of OSA and sleepiness are associated with nonadherence. These conditions, if treated, may allow for achieving better outcomes and improvement of adherence to medication.

Impact of Sleep-Disordered Breathing Treatment on Patient Reported Outcomes in a Clinic-Based Cohort of Hypertensive Patients

STUDY OBJECTIVES

We hypothesized that patient reported outcomes (PROs) improve with positive airway pressure (PAP) in patients with sleep-disordered breathing (SDB) and hypertension (HTN).

METHODS

Questionnaire-based PROs (sleepiness [Epworth Sleepiness Scale, (ESS)], depression [Patient Health Questionnaire-9 (PHQ-9)], and fatigue [Fatigue Severity Scale (FSS)]) were retrospectively examined in patients with SDB and HTN at baseline and within a year following PAP initiation. PRO changes were estimated using multivariable linear mixed-effect models adjusted for baseline age, sex, race, body mass index, resistant hypertension (RHTN) status, cardiac and diabetes history, and correlation between repeated measurements. Age and race by PAP interaction terms (mean change, 95% CI) were examined.

RESULTS

894 patients with HTN and SDB were examined. 130 (15%) had baseline RHTN (age 58 ± 12 y, 52.9 % male, BMI 36.2 ± 9.1 kg/m²). In multivariable models, a significant improvement in sleepiness ESS (-2.09, 95% CI: -2.37, -1.82), PHQ-9 (-1.91, 95% CI: -2.25, -1.56), and FSS scores (-4.06 95% CI: -4.89, -3.22) was observed. A significant race by PAP effect interaction was observed (p < 0.0001 for all PROs); Caucasians had greater improvements than non-Caucasians. The interaction term of effect of PAP and age was significant for ESS (p = 0.04) and PHQ-9 (p = 0.0003), indicating greater improvement in younger patients.

CONCLUSIONS

Consistent improvement of broad PRO domains in response to PAP in SDB was observed in this clinic-based hypertensive cohort; Caucasians and younger patients derived greater benefit.

Understanding the Importance of Race/Ethnicity in the Care of the Hypertensive Patient

Although several risk factors contribute to cardiovascular disease (CVD) overall, hypertension (HTN) is the major controllable risk factor. Hypertension is disproportionately more prevalent among Blacks or African-Americans compared with other race/ethnic populations, and the control rates among this disparate population are alarming. Several pathophysiologic mechanisms have been demonstrated and evaluated among hypertensives and the conglomeration of genetics, environmental, and personal lifestyle activities concurrently impact the progression of hypertension-related comorbidities (i.e., chronic renal disease, CVD, stroke, etc.). Specific pharmacotherapeutic choices are discussed and the most up-to-date data is presented to optimize the care of hypertensives. National and international guidelines for the treatment of HTN are reviewed and analyzed, presenting the most appropriate approach to the care of hypertensive patients overall. Additionally, national efforts supporting the goal of early HTN screening and treatment, as well as the variety of evidence-based pharmacotherapy, are summarized, applying to the public health impact overall.

Blinded Patient Preference for Morphine Compared to Placebo in the Setting of Chronic Refractory Breathlessness--An Exploratory Study

CONTEXT

Patients' preference for morphine therapy has received little attention in the setting of chronic refractory breathlessness. However, this is one important factor in considering longer term therapy.

OBJECTIVES

The aim of this secondary analysis was to explore blinded patient preference of morphine compared to placebo for this indication and to define any predictors of preference.

METHODS

Data were pooled from three randomized, double-blind, crossover, placebo-controlled studies of morphine (four days each) in chronic refractory breathlessness. Blinded patient preferences were chosen at the end of each study. A multivariable regression model was used to establish patient predictors of preference.

RESULTS

Sixty-five participants provided sufficient data (60 men; median age 74 years; heart failure 55%, chronic obstructive pulmonary disease 45%; median Eastern Cooperative Oncology Group performance status 2). Forty-three percent of participants preferred morphine (32% placebo and 25% no preference). Morphine preference and younger age were strongly associated: odds ratio = 0.85, 95% confidence interval 0.78-0.93; P < 0.001). There was also an inverse association between morphine preference and sedation (odds ratio = 0.77, 95% confidence interval 0.60-0.99; P < 0.05). An inverse association was also seen between nausea and morphine preference in the univariate model only (P < 0.05). No association was seen between morphine preference and breathlessness intensity, either at baseline or change from baseline.

CONCLUSION

Participants preferred morphine over placebo for the relief of chronic refractory breathlessness. Morphine offers clinically important improvement, but net benefit can be easily outweighed by side effects, reducing net benefits. Side effects require aggressive management to allow more patients to realize benefits.

Depressive symptoms and fatigue as mediators of relationship between poor sleep factors and medication adherence in HIV-positive women

Patients living with HIV commonly experience sleep disturbances, depression, excessive daytime sleepiness and fatigue, which negatively affect antiretroviral medication adherence. Few studies have examined relationships between these symptoms and medication adherence in women living with HIV or examine the mechanisms through which these symptoms affect adherence. The purpose of this study was to examine the associations between sleep quality, excessive daytime sleepiness and medication adherence, and energy/fatigue and depression as mediators of these relationships among 206 women living with HIV. Correlations, t-tests and hierarchical regression analysis were utilised. The majority of participants (93.2%) were African American or Black. The average age of participants was 43.3 years and average years infected was 9.6. More than half of the women reported poor sleep quality and, on average, participants reported moderate daytime sleepiness, high depressive symptoms and moderate levels of fatigue. Additionally, both depression and low energy/fatigue were identified as significant mediators of the relationship between sleep quality and medication adherence. Depression also significantly mediated the relationship between excessive daytime sleepiness and medication adherence. The findings from this study highlight the impact of sleep on medication adherence and associated mechanisms and emphasise the need for healthcare providers to assess and address sleep factors when providing care for patients living with HIV.

Cross-Cultural Adaptation, Reliability, and Validity of the Turkish Version of the Compliance Questionnaire on Rheumatology in Patients With Behçet's Disease

PURPOSE

The aim of this study was to examine the psychometric properties of the Turkish versionof the Compliance Questionnaire on Rheumatology (CQR-T) for patients with Behçet's disease (BD).

METHOD

A sample of 105 Turkish patients with BD participated in this study. The scale was cross-culturally adapted through a process including translation, comparison with versions in other languages, back translation, and pretesting. Construct validity was evaluated by factor analysis, and criterion validity was evaluated using the Morisky Medication Adherence Scale.

RESULTS

The CQR-T demonstrated acceptable internal consistency (Cronbach's α = .832), adequate test-retest reliability (intraclass correlation coefficient = .630), and correlations with Morisky Medication Adherence Scale scores (r = -.389, p< .001), indicating convergent validity.

CONCLUSION

The CQR-T was found to be a valid and reliable instrument for evaluating the compliance of Turkish BD patients with prescribed medications.

IMPLICATIONS FOR PRACTICE

The CQR-T might be a helpful tool in two ways: for determining the level of compliance of patients with BD and for adjusting their management and follow-up based on the results.