Management of insomnia in patients with chronic obstructive pulmonary disease

Respiratory safety of lemborexant in adult and elderly subjects with moderate-to-severe chronic obstructive pulmonary disease

Because some hypnotics worsen respiratory conditions, it was important to determine the respiratory safety of lemborexant, a competitive dual orexin-receptor antagonist approved to treat adults with insomnia, in subjects with moderate-to-severe chronic obstructive pulmonary disease. E2006-A001-113 (Study 113; NCT04647383) was a multicentre, multiple-dose, randomised, double-blind, placebo-controlled, two-period crossover study in adult subjects with moderate or severe chronic obstructive pulmonary disease (per spirometry-based Global Initiative for Chronic Obstructive Lung Disease [GOLD] criteria). Subjects (N = 30) were randomised to two treatment sequences comprising 8-night treatment periods (washout ≥ 14 days) with lemborexant 10 mg or placebo. Peripheral oxygen saturation (SpO2; primary endpoint), apnea-hypopnea index, objective sleep parameters and sleep architecture measures were assessed after single (Day 1) and multiple (Day 8) doses. There was no significant difference in least-squares mean SpO2 after a single dose of lemborexant (91.1%) versus placebo (91.5%). Although a statistically significant difference in SpO2 was observed after multiple doses (least-squares mean: lemborexant, 91.3%; placebo, 90.8%) favouring lemborexant, this was not considered clinically meaningful. Apnea-hypopnea index was not significantly different between treatments after single or multiple doses. Total sleep time and total rapid eye movement sleep were significantly greater on Days 1 and 8 with lemborexant versus placebo. Treatment-emergent adverse events were reported in five (16.7%) subjects when taking lemborexant and four (13.3%) subjects when taking placebo; treatment-emergent adverse events were mostly mild. Lemborexant was well tolerated and did not adversely impact SpO2 or apnea-hypopnea index after single and multiple doses relative to placebo in subjects with moderate-to-severe chronic obstructive pulmonary disease.

Sex Differences in the Associations Between Chronic Diseases and Insomnia Symptoms Among Older Adults in India

Background

Sleep problems are a critical issue in the aging population, affecting quality of life, cognitive efficiency, and contributing to adverse health outcomes. The coexistence of multiple diseases is common among older adults, particularly women. This study examines the associations between specific chronic diseases, multimorbidity, and insomnia symptoms among older Indian men and women, with a focus on the interaction of sex in these associations.

Methods

Data were drawn from 31,464 individuals aged 60 and older in the Longitudinal Ageing Study in India, Wave-1 (2017-18). Insomnia symptoms were assessed using four questions adapted from the Jenkins Sleep Scale (JSS-4), covering difficulty falling asleep, waking up, waking too early, and feeling unrested during the day. Multivariable logistic regression models, stratified by sex, were used to analyze the associations between chronic diseases and insomnia symptoms.

Results

Older women had a higher prevalence of insomnia symptoms than men (44.73% vs 37.15%). Hypertension was associated with higher odds of insomnia in both men (AOR: 1.20) and women (AOR: 1.36). Women with diabetes had lower odds of insomnia (AOR: 0.80), while this association was not significant in men. Neurological or psychiatric disorders, stroke, and bone and joint diseases were linked to higher odds of insomnia in both sexes. Chronic lung disease was associated with insomnia in men (AOR: 1.65), but not in women. Additionally, having three or more chronic diseases significantly increased the odds of insomnia in both men (AOR: 2.43) and women (AOR: 2.01).

Conclusion

Hypertension, bone and joint diseases, lung diseases, stroke, neurological or psychiatric disorders, and multimorbidity are linked to insomnia symptoms in older Indian adults. Disease-specific management and routine insomnia screening are crucial for promoting healthy aging in this vulnerable population.

Association Between Hypnotic Use and All-Cause Mortality in Patients with Chronic Obstructive Pulmonary Disease and Insomnia

Purpose

Hypnotics are commonly prescribed in patients with COPD to manage insomnia. Given the considerable risks associated with these drugs, the aim of the study was to evaluate the risk of all-cause mortality associated with hypnotics in a cohort of veterans with COPD presenting with insomnia.

Methods

We conducted a retrospective cohort study that used Veterans Health Administration Corporate Data Warehouse with data supplemented by linkage to Medicare, Medicaid, and National Death Index data from 2010 through 2019. The primary outcome was all-cause mortality. Analyses were conducted using propensity score 1:1 matching to balance baseline characteristics.

Results

Of the 5759 veterans with COPD (mean [SD] age, 71.7 [11.2]; 92% men), 3585 newly initiated hypnotic agents during the study period. During a mean follow-up of 7.4 (SD, 2.7) years, a total of 2301 deaths occurred, with 65.2 and 48.7 total deaths per 1000 person-years among hypnotic users and nonusers, respectively. After propensity matching, hypnotic use was associated with a 22% increased risk of mortality compared with hypnotic nonusers (hazard ratio [HR] 1.22; 95% confidence interval [CI],1.11-1.35). The benzodiazepine receptor agonists (BZRAs) group experienced a higher incidence rate of all-cause mortality compared to hypnotic nonusers (Incidence rate ratio [IRR] 1.27; 95% CI, 1.14-1.43). Conversely, the mortality rate of non-BZRA hypnotics decreased after the first 2 years and was not significantly different for hypnotic nonusers (IRR 1.04; 95% CI, 0.82-1.11).

Conclusion

Among patients with COPD and insomnia, treatment with hypnotics was associated with a higher risk of all-cause mortality. The association was observed in patients prescribed BZRAs. The risk of mortality for non-BZRAs moderated after the first 2 years, indicating a class effect.

Insomnia in primary care: Considerations for screening, assessment, and management

Insomnia, including insomnia disorder, is a common but often overlooked complaint in primary care settings. It is a risk factor for various medical and psychiatric diagnoses and is associated with substantial health care costs. While cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for insomnia disorder, access to CBT-I is limited. This article provides a pragmatic approach to screening, assessment, and treatment of insomnia in the primary care setting, promoting a population health approach. The authors review the role of CBT-I, treatment of comorbid conditions, and pharmacologic recommendations in working with primary care patients with insomnia. In addition, the authors highlight the potential utility of technology in improving access to insomnia care.

Substance Use and Misuse among Adults with Chronic Obstructive Pulmonary Disease in the United States, 2015-2019: Prevalence, Association, and Moderation

BACKGROUND

Despite the advancements in chronic obstructive pulmonary disease (COPD) treatment, complications related to COPD exacerbation remain challenging. One associated factor is substance use/misuse among adults with COPD. Fewer studies, however, examined the prevalence and association between COPD and substance use and misuse. In addition, limited knowledge existed about the moderation effects of serious psychological distress and gender among adults with COPD and substance use/misuse. We aimed, therefore, to measure such prevalence, association, and moderation from nationally representative samples in the United States.

METHOD

Data were drawn from the 2015-2019 National Survey on Drug Use and Health. Weighted logistic regressions were used to measure the associations of last-month tobacco (cigarettes, cigars, pipe, and smokeless tobacco products), other licit and illicit substance use (alcohol, marijuana, cocaine, crack, heroin, hallucinogens, and inhalants), and substance misuse (pain relievers, tranquilizers, stimulants, and sedatives) among adults with COPD. Serious psychological distress and gender were tested as moderators in the association between COPD and substance use/misuse.

RESULTS

The findings revealed that adults with COPD [Weighted N = 53,115,718) revealed greater odds of cigarettes [adjusted odds ratio (aOR) = 2.48 (95%CI = 1.80-3.42)) and smokeless tobacco (aOR = 3.65 (95%CI = 1.75-7.65)). However, they were less likely to use alcohol (aOR = 0.61 (95%CI = 0.45-0.84)). Adults with COPD who had serious psychological distress were more likely to use pipe tobacco and alcohol; however, they were less likely to use hallucinogens and inhalants. Finally, males compared to females with COPD were less likely to use smokeless tobacco.

CONCLUSION

Adults with COPD in the United States were more likely to use tobacco products and less likely to use alcohol. In addition, serious psychological distress and gender were moderators in associations between COPD and substance use but not in substance misuse. Future studies should longitudinally assess the factors that may contribute to the initiation and progression of substance use and misuse among adults with COPD.

The negative health effects of having a combination of snoring and insomnia

STUDY OBJECTIVES

Insomnia and snoring are common sleep disorders. The aim was to investigate the association of having a combination of insomnia symptoms and snoring with comorbidity and daytime sleepiness.

METHODS

The study population comprised 25,901 participants (16-75 years, 54.4% women) from four Swedish cities, who answered a postal questionnaire that contained questions on snoring, insomnia symptoms (difficulties initiating and/or maintaining sleep and/or early morning awakening), smoking, educational level, and respiratory and non-respiratory disorders.

RESULTS

Snoring was reported by 4,221 (16.2%), while 9,872 (38.1%) reported ≥ 1 insomnia symptom. A total of 2,150 (8.3%) participants reported both insomnia symptoms and snoring. The association with hypertension (adj. OR 1.4, 95% CI: 1.2-1.6), chronic obstructive pulmonary disease (COPD) (adj. OR 1.8, 95% CI: 1.3-2.4), asthma (adj. OR 1.9; 95% CI: 1.6-2.3), daytime sleepiness (adj. OR 7.9, 95% CI 7.1-8.8) and the use of hypnotics (adj. OR 7.5, 95% CI: 6.1-9.1) was highest for the group with both insomnia symptoms and snoring.

CONCLUSIONS

Participants with both snoring and insomnia run an increased risk of hypertension, COPD, asthma, daytime sleepiness and the use of hypnotics. It is important to consider snoring in patients seeking medical assistance for insomnia and, vice versa, in patients with snoring inquiring about insomnia.

Benzodiazepine Prescribing in People with Chronic Obstructive Pulmonary Disease: Clinical Considerations

Benzodiazepines, available clinically for almost six decades, are still one of the most widely prescribed classes of medication. The proportion of the population prescribed benzodiazepines increases with age, and harms also increase with age. The prevalence of prescribing in people > 85 years of age is as high as one in three, including in people with chronic obstructive pulmonary disease (COPD). The prevalence of COPD also increases with age. In COPD, indications cited for prescribing a benzodiazepine include anxiety, sleep disorders, or chronic breathlessness. Each of these symptoms is prevalent in the population with COPD, especially later in the course of the illness. For anxiety and insomnia, there is evidence to support short-term use, with little robust evidence to support prescribing for the symptomatic reduction of chronic breathlessness. People prescribed benzodiazepines are more likely to experience drowsiness or somnolence, exacerbations of their COPD, and respiratory tract infections. Furthermore, the longer people take benzodiazepines, the more likely they will become dependent on them. Prescribing patterns vary internationally but prescriptions of longer-acting benzodiazepines are declining in favour of shorter-acting compounds. Other evidence-based therapies that can more safely treat these problematic symptoms are available. For people already taking benzodiazepines, there are a number of interventions that have been shown to reduce the rate of prescribing. For people with COPD and not taking a benzodiazepine, but with symptoms where there is evidence of benefit, clinicians should weigh carefully the potential net benefit and prescribe at the lowest dose for the briefest time possible.

An update on pulmonary rehabilitation techniques for patients with chronic obstructive pulmonary disease

Introduction: Pulmonary rehabilitation (PR) is one of the core components in the management of patients with chronic obstructive pulmonary disease (COPD). In order to achieve the maximal level of independence, autonomy, and functioning of the patient, targeted therapies and interventions based on the identification of physical, emotional and social traits need to be provided by a dedicated, interdisciplinary PR team.Areas covered: The review discusses cardiopulmonary exercise testing in the selection of different modes of training modalities. Neuromuscular electrical stimulation as well as gait assessment and training are discussed as well as add-on therapies as oxygen, noninvasive ventilator support or endoscopic lung volume reduction in selected patients. The potentials of pulsed inhaled nitric oxide in patients with underlying pulmonary hypertension is explored as well as nutritional support. The impact of sleep quality on outcomes of PR is reviewed.Expert opinion: Individualized, comprehensive intervention based on thorough assessment of physical, emotional, and social traits in COPD patients forms a continuous challenge for health-care professionals and PR organizations in order to dynamically implement and adapt these strategies based on dynamic, more optimal understanding of underlying pathophysiological mechanisms.

The relationship between sleep disturbance and health status in patients with COPD

Introduction

The detection of insomnia in patients with COPD is assumed to be significantly lower than the actual prevalence. In this study, we investigated the prevalence of insomnia and the relationship between insomnia and health status in patients with COPD using two fairly simple and straightforward questionnaires: COPD assessment test (CAT) and insomnia severity index (ISI).

Patients and methods

A cross-sectional study was conducted using data from patients undergoing treatment for COPD at St Paul's Hospital, The Catholic University of Korea, between December 2015 and August 2016. Patients were classified into three groups according to the ISI score: a "clinical insomnia" group (ISI≥15), a "subthreshold insomnia" group (ISI 8-15), and a "non-insomnia" group (ISI<8). Clinical parameters including past medical history, pulmonary function tests, and questionnaire data were collected and analyzed.

Results

A total of 192 patients were recruited, of which 25.0% were found to have clinical insomnia (ISI≥8). Insomnia severity was related to all CAT component items except for cough, and patients with higher CAT scores generally had more severe insomnia. Logistic regression analysis revealed that CAT score was significantly associated with insomnia in these patients (odds ratio, 1.23; 95% CI, 1.13-1.34; p<0.0001). CAT score was also a significant predictor of insomnia (area under receiver operating characteristic curve, 0.779; p<0.001). The optimal predictive cutoff value was a CAT score >14, giving a sensitivity and specificity of 66.7% and 71.5%, respectively.

Conclusion

CAT score was closely related to insomnia severity in patients with COPD. The use of CAT scores to assess for the presence and severity of insomnia in these patients may allow for better detection and management and improve clinical practice.

Analysis of nocturnal actigraphic sleep measures in patients with COPD and their association with daytime physical activity

BACKGROUND

Sleep disturbances are common in patients with chronic obstructive pulmonary disease (COPD) with a considerable negative impact on their quality of life. However, factors associated with measures of sleep in daily life have not been investigated before nor has the association between sleep and the ability to engage in physical activity on a day-to-day basis been studied.

AIMS

To provide insight into the relationship between actigraphic sleep measures and disease severity, exertional dyspnoea, gender and parts of the week; and to investigate the association between sleep measures and next day physical activity.

METHODS

Data were analysed from 932 patients with COPD (66% male, 66.4±8.3 years, FEV₁% predicted=50.8±20.5). Participants had sleep and physical activity continuously monitored using a multisensor activity monitor for a median of 6 days. Linear mixed effects models were applied to investigate the factors associated with sleep impairment and the association between nocturnal sleep and patients' subsequent daytime physical activity.

RESULTS

Actigraphic estimates of sleep impairment were greater in patients with worse airflow limitation and worse exertional dyspnoea. Patients with better sleep measures (ie, non-fragmented sleep, sleeping bouts ≥225 min, sleep efficiency ≥91% and time spent awake after sleep onset <57 min) spent significantly more time in light (p<0.01) and moderate-to-vigorous physical activity (p<0.01).

CONCLUSIONS

There is a relationship between measures of sleep in patients with COPD and the amount of activity they undertake during the waking day. Identifying groups with specific sleep characteristics may be useful information when designing physical activity-enhancing interventions.

Sleep quality and daytime sleepiness in patients with COPD and asthma

INTRODUCTION

Nocturnal symptoms are common and important in both asthma and COPD but the relationship between sleep quality and diseases' characteristics has not been fully studied.

OBJECTIVE

To compare sleep quality and daytime sleepiness in asthma and COPD patients and to explore its relation to diseases' characteristics.

METHODS

In this cross-sectional study, we examined 217 consecutive asthma and COPD patients who underwent pulmonary function tests at The Center for Pathophysiology of Breathing and Sleep Medicine of The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia between July 2014 and January 2015. All patients completed Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS).

RESULTS

Study included 117 patients with asthma, 100 patients with COPD, and 102 healthy controls. There was no difference in PSQI and ESS between patients with asthma and COPD (4.9 ± 3.9 vs 5.8 ± 4.3, P = .09 and 4.8 ± 3.4 vs 4.7 ± 3.6, P = .69, respectively). PSQI and ESS did not correlate with lung function parameters. Patients with uncontrolled asthma had higher PSQI scores (uncontrolled 7.0 ± 3.7 vs partially controlled 4.6 ± 3.1 vs controlled 3.2 ± 3.7, P < .001). PSQI scores were higher in COPD group D and B compared to A and C (group D 6.9 ±4.6 vs B 6.8 ± 4.1 vs A 2.9 ± 1.3 vs C 3.1 ± 3.9, P < .001). Compared to asthma, COPD patients had longer sleep latency and used sleep regulating medications more often.

CONCLUSIONS

There is no difference in sleep quality and level of daytime sleepiness between patients with asthma and COPD. Poor sleep quality is related to level of asthma control and is associated with COPD groups B and D.

Benzodiazepine use in COPD: empirical evidence from Norway

BACKGROUND

The common comorbidities associated with COPD include, among others, anxiety, depression, and insomnia, for which the typical treatment involves the use of benzodiazepines (BZD). However, these medicines should be used with extra caution among COPD patients, since treatment with traditional BZD may compromise respiratory function.

AIMS

This study investigated the use of BZD among persons suffering from COPD by analyzing three relevant indicators: 1) the sum of defined daily doses (DDD); 2) the number of prescribers involved; and 3) the number of different types of BZD used.

DATA AND METHODS

The study builds on a linkage of national prescription data and patient-administrative data, which includes all Norwegian drug prescriptions to persons hospitalized with a COPD diagnosis during 2009, amounting to a total of 5,380 observations. Regression techniques were used to identify the patients and the clinical characteristics associated with BZD use.

RESULTS

Of the 5,380 COPD patients treated in hospital during 2009, 3,707 (69%) were dispensed BZD during the following 12 months. Moreover, they were dispensed on average 197.08 DDD, had 1.22 prescribers, and used 0.98 types of BZD during the year. Women are more likely to use BZD for all levels of BZD use. Overnight planned care not only increases the risk of BZD use (DDD), but also the number of prescribers and the types of BZD in use.

CONCLUSION

In light of the high levels of BZD prescription found in this study, especially among women, it is recommended that general practitioners, hospital specialists, and others treating COPD patients should aim to acquire a complete picture of their patients' BZD medication before more is prescribed in order to keep the use to a minimum.

The Use of Benzodiazepine Receptor Agonists and Risk of Respiratory Failure in Patients with Chronic Obstructive Pulmonary Disease: A Nationwide Population-Based Case-Control Study

STUDY OBJECTIVES

Insomnia is prevalent in patients with chronic obstructive pulmonary disease (COPD), and benzodiazepine receptor agonists (BZRAs) are the most commonly used drugs despite their adverse effects on respiratory function. The aim of this study was to investigate whether the use of BZRAs was associated with an increased risk of respiratory failure (RF) in COPD patients.

DESIGN

Matched case-control study.

SETTING

National Health Insurance Research Database (NHIRD) in Taiwan.

PARTICIPANTS

The case group consisted of 2,434 COPD patients with RF, and the control group consisted of 2,434 COPD patients without RF, matched for age, sex, and date of enrollment.

MEASUREMENTS AND RESULTS

Exposure to BZRAs during the 180-day period preceding the index date was analyzed and compared in the case and control groups. Conditional logistic regression was performed, and the use of BZRAs was associated with an increased risk of RF (adjusted odds ratio [aOR] 1.56, 95% confidence interval [CI] 1.14-2.13). In subgroup analysis, we found that the benzodiazepine (BZD) users had a higher risk of RF (aOR 1.58, 95% CI 1.14-2.20), whereas the risk in non-benzodiazepine (non-BZD) users was insignificant (aOR 0.85, 95% CI 0.51-1.44). A greater than 2-fold increase in risk was found in those who received two or more kinds of BZRAs and those using a combination of BZD and non-BZD medications.

CONCLUSIONS

The use of benzodiazepine receptor agonists was a significant risk factor for respiratory failure in patients with chronic obstructive pulmonary disease (COPD). Compared to benzodiazepine, the prescription of non-benzodiazepine may be safer for the management of insomnia in COPD patients.

Sleep and Quality of Life in People With COPD

Sleep disorders are very common in patients with chronic obstructive pulmonary disease (COPD). However, it is not clear how sleep disorders and quality of life (QoL) affect each other in the different stages of disease progression. This descriptive-correlational study investigated the relationship between QoL, quality of sleep, and degree of disease progression in 102 outpatients with COPD. The results showed that the QoL in patients with COPD is compromised and worsens with disease progression, and the quality of sleep is significantly associated with QoL and worsened as the disease progressed. The early identification of a risk of alteration of the quality of sleep, especially in nursing care, could facilitate a preventive approach for COPD patients that could positively affect their QoL.

Effects of suvorexant, an orexin receptor antagonist, on breathing during sleep in patients with chronic obstructive pulmonary disease

OBJECTIVES

There is a general concern that hypnotic medications in patients with respiratory disorders have the potential to decrease respiratory effort and blunt the arousal response to hypoxemia which may lead to sleep breathing disorders. We investigated whether suvorexant, an orexin receptor antagonist approved for treatment of insomnia at a maximum daily dose of 20 mg in the US, causes sleep breathing disorders in patients with chronic obstructive pulmonary disease (COPD).

DESIGN

This was a randomized, double-blind, placebo-controlled, 2-period, cross-over, study performed in 9 sleep laboratories/clinical research units in the United States. The participants were 25 COPD patients aged 39-72 y with mild-to-moderate airflow limitation based on GOLD spirometry criteria. In each period, patients received suvorexant (40 mg in <65 y-olds; 30 mg in ≥65 y-olds) or placebo for four consecutive nights. Respiratory function during sleep was measured by oxygen saturation using pulse oximetry (SpO2, primary endpoint) and Apnea Hypopnea Index (AHI, secondary endpoint). The study was powered to rule out a difference between treatments of -2 percentage points in SpO2 on Day 4.

RESULTS

There was no treatment effect following single and multiple doses of suvorexant on mean SpO2 during total sleep time (Day 1: suvorexant = 93.14%, placebo = 93.24%, difference = -0.10 [90% CI: -0.50, 0.31]; Day 4: suvorexant = 93.38%, placebo = 92.99%, difference = 0.39 [90% CI: -0.12, 0.91]). There was no clinically meaningful increase in mean AHI by suvorexant compared with placebo on Day 1 (difference = 0.72 [90% CI: -0.60, 2.04]) or Day 4 (difference = 2.05 [90% CI: 0.33, 3.77]).

CONCLUSIONS

These data do not suggest an overt respiratory depressant effect with 30-40 mg daily doses of suvorexant, up to twice the maximum recommended dose for treating insomnia in the US, in patients with mild-to-moderate COPD. Trial registration Clinicaltrials.gov identifier: NCT01293006.

Interventions to support a palliative care approach in patients with chronic obstructive pulmonary disease: an integrative review

BACKGROUND

End-stage chronic obstructive pulmonary disease (COPD) is a debilitating, life-limiting condition. A palliative approach is appropriate for individuals with end-stage COPD, yet currently few interventions embrace this holistic, multidisciplinary and inclusive perspective.

OBJECTIVE

To describe interventions to support a palliative care approach in patients with end-stage COPD.

DESIGN

Integrative review. DATA SOURCES AND REVIEW METHOD: Peer reviewed articles meeting the search criteria were accessed from Medline, PsychINFO, CINAHL and Google Scholar databases as well as Caresearch online resource. The domains of quality palliative care developed by Steinhauser were used as the conceptual framework to synthesise information.

RESULTS

This review has shown that a range of palliative interventions are used to address the needs of individuals with end-stage COPD. Although evidence exists for discrete elements of palliative management in this patient group, there is limited evidence for health service coordination and models that integrate the multiple domains of palliative care with active management.

CONCLUSION

Further investigation is required to address the complex personal, provider and system elements associated with managing end-stage COPD. A comprehensive and collaborative approach is required to address the complex and varied needs of individuals with end-stage COPD and their families.

Medical comorbidity of sleep disorders

PURPOSE OF REVIEW

Recently published literature indicates that sleep disorders present with medical comorbidities quite frequently. The coexistence of a sleep disorder with a medical disorder has a substantial impact for both the patient and the health system.

RECENT FINDINGS

Insomnia and hypersomnia are highly comorbid with medical conditions, such as chronic pain and diabetes, as well as with various cardiovascular, respiratory, gastrointestinal, urinary and neurological disorders. Restless legs syndrome and periodic leg movement syndrome have been associated with iron deficiency, kidney disease, diabetes, and neurological, autoimmune, cardiovascular and respiratory disorders. Rapid eye movement behaviour disorder has been described as an early manifestation of serious central nervous system diseases; thus, close neurological monitoring of patients referring with this complaint is indicated.

SUMMARY

Identification and management of any sleep disorder in medical patients is important for optimizing the course and prognosis. Of equal importance is the search for undetected medical disorder in patients presenting with sleep disorders.

The evaluation and management of insomnia

Insomnia is a highly prevalent malady and adversely affects many dimensions of daily human function. Although its pathophysiology is poorly understood, it seems to arise in the context of heightened arousal in neurophysiologic and psychological systems. Because it often coexists with a wide variety of medical and psychiatric conditions, the first task in the management of this condition is to identify comorbid disorders through a comprehensive evaluation. Once identified, specific treatments can be tailored to the underlying conditions. Effective cognitive/behavioral and pharmacologic management techniques are available for primary insomnia.

Sleep disorders and their management in patients with COPD

Chronic obstructive pulmonary disease (COPD) is a prevalent progressive condition that adversely affects quality of life and sleep. Patients with COPD suffer from variety of sleep disorders including insomnia, sleep disordered breathing and restless leg syndrome. The sleep disorders in COPD patients may stem from poor control of primary disease or due to side effects of pharmacotherapy. Thus, optimization of COPD therapy is the main step in treating insomnia in these patients. Further, pharmacotherapy of sleep disorders may result in respiratory depression and related complications. Therefore, clear understanding of respiratory physiology during transition from wakefulness to sleep and during various stages of sleep plays an important role in therapies that are recommended in patients with significant airway obstruction. In this publication, we review respiratory physiology as it relates to sleep and discuss sleep disorders and their management in patients with COPD.

Caregiver-assisted coping skills training for patients with COPD: background, design, and methodological issues for the INSPIRE-II study

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) is a progressive illness characterized by airflow obstruction and dyspnea that afflicts over 12 million people and represents a leading cause of death in the United States. Not surprisingly, COPD is often associated with emotional distress and reduced psychosocial adjustment, which can negatively impact physical functioning and impair quality of life. However, the psychosocial consequences of COPD remain largely untreated. A previous randomized trial from our research team demonstrated that coping skills training (CST) can improve pulmonary-specific quality of life among pulmonary patients awaiting lung transplant (the INSPIRE study). To date, however, no studies have examined the effects of a caregiver-assisted CST intervention in patients with COPD with less severe disease.

PURPOSE

INSPIRE II is a randomized clinical trial (RCT) funded by the NHLBI to evaluate the effects of telephone-based enhanced CST for patients with COPD and their caregivers compared to standardized medical care (SMC) including COPD education and symptom monitoring on medical outcomes, physical functioning, and quality of life.

METHODS

Six hundred COPD patients and their respective caregivers recruited from Duke University and Ohio State University will be evaluated and randomized (in a 1:1 ratio) to enhanced CST (including sessions promoting physical activity, relaxation, cognitive restructuring, communication skills, and problem solving) or to SMC. The primary outcomes include all-cause mortality, COPD-related hospitalizations/ physician visits, and quality of life. These endpoints will be measured through self-report questionnaires, behavioral measures of functional capacity (i.e., accelerometer and six minute walk test) and pulmonary function tests (e.g., FEV(1)).

RESULTS

This article reviews prior studies in the area and describes the design of INSPIRE-II. Several key methodological issues are discussed including the delivery of CST over the telephone, encouraging physical activity, and inclusion of caregivers as patient coaches to enhance the effectiveness of the intervention.

LIMITATIONS

We recognize that SMC does not adequately control for attention, support, and non-specific factors, and that, in theory, non-specific effects of the intervention could account for some, or all, of the observed benefits. However, our fundamental question is whether the telephone intervention produces benefits over-and-above the usual care that patients typically receive. The SMC condition will provide education and additional weekly telephone contact, albeit less than the attention received by the CST group. We recognize that this attention control condition may not provide equivalent patient contact, but it will minimize group differences due to attention. We considered several alternative designs including adding a third usual care only arm as well as an education only control arm. However, these alternatives would require more patients, reduce the power to detect significant effects of our primary medical endpoints, and add a significant additional expense to the cost of the study that would make such an undertaking neither scientifically or financially viable.

CONCLUSIONS

We believe that this novel approach to patient care in which caregivers are used to assist in the delivery of coping skills training to patients with COPD has the potential to change the way in which COPD patients are routinely managed in order to reduce distress, enhance quality of life, and potentially improve medical outcomes.

The effect of chronic disorders on sleep in the elderly

Sleep disorders are increasingly common as people age. Along with the numerous physiologic changes that occur with aging, sleep patterns are also altered. Inability to get to sleep, shorter sleep times, and changes in the normal circadian patterns can have an impact on an individual's overall well being. In addition, many common chronic conditions, such as chronic obstructive pulmonary disease, diabetes, dementia, chronic pain, and cancer, that are more common in the elderly, can also have significant effects on sleep and increase the prevalence of insomnia as compared with the general population. This is a result not only of the chronic medical illnesses themselves, but of the psychologic and social factors associated with the disease processes.

Depressive und Angststörungen bei somatischen Krankheiten

Depressiv-ängstliche Störungen sind bei den unterschiedlichen somatischen Erkrankungen häufig. Sie sind nicht nur als Reaktion auf die Situation der Erkrankung zu verstehen, sondern in ein komplexes Bedingungsgefüge eingebettet. Sie sind besonders häufig bei Erkrankungen, die das Zentralnervensystem oder endokrine Regulationssysteme direkt betreffen. Es besteht ein enger Zusammenhang zur Chronizität, Schwere und Prognose der Erkrankung. Eigenständige Effekte von diversen pharmakologischen Substanzgruppen sind wahrscheinlich.

Other systemic manifestations of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) no longer is regarded simply as a disease of the lungs and airways. There is growing awareness of the multisystemic nature of this disease. Research has shown increased levels of systemic inflammation and cardiovascular, neurologic, psychiatric, and endocrine system dysfunction associated with COPD. Skeletal muscle dysfunction associated with COPD is discussed in the article by Schols in this issue of Clinics in Chest Medicine. In this article, other systemic manifestations of COPD are discussed. Although this field is expanding rapidly, this article focuses on recent advances and reviews.

Benzodiazepine use and mortality of incident dialysis patients in the United States

Benzodiazepines and other omega-receptor agonists are frequently used for sleep and anxiety disorders. We studied the rates, correlates, and safety of individual benzodiazepines and zolpidem use from the records of 3690 patients in a national cohort of Dialysis Morbidity and Mortality Study Wave 2 data. We assessed drug utilization and an association between drug use and all-cause mortality. Overall, 14% of incident dialysis patients used a benzodiazepine or zolpidem. Women, Caucasians, current smokers, and patients with chronic obstructive pulmonary disease were more likely to use these drugs, whereas patients with cerebrovascular disease were less likely to use these drugs. In adjusted analyses, benzodiazepine or zolpidem use was associated with a 15% higher mortality rate. Chronic obstructive pulmonary disease significantly modified this association, suggesting that these patients were at higher risk. No association was found between benzodiazepine use and greater risk for hip fracture. We conclude that benzodiazepine or zolpidem use is common in incident dialysis patients and may be associated with greater mortality. Further studies are needed to elucidate the safety of these drugs in the dialysis population, which may lead to cautious and restrictive utilization of omega-receptor agonists in dialysis patients.

Sleep and quality of life in long-term lung cancer survivors

BACKGROUND

Sleep problems are common in lung cancer survivors, yet little is known about the prevalence, determinants, and effects on quality of life (QoL) of these sleep problems in long-term lung cancer survivors.

METHODS

A case-control study design comparing 76 elderly lung cancer survivors (LCS, >5 years post diagnosis with mean survival time of 8 years+/-2.1 years) and 78 elderly non-cancer controls (NCC). Measurements included a standardized questionnaire for sleep (Pittsburgh Sleep Quality Index-PSQI), and analogue scales for dyspnea, pain, and other comorbid symptoms, as well as demographic factors and cancer history.

RESULTS

Overall, 56.6% of LCS had poor sleep (PSQI global score >5) as compared to only 29.5% of NCC (p<0.001), and 49.2% of LCS who did not have sleep difficulties prior to their lung cancer diagnosis ultimately developed them. There was also evidence of significant impairments in sleep efficiency in LCS (78.3%) relative to NCC (89.6%, p<0.001), predominantly due to increased nocturnal awakenings. A single-item analogue scale for sleep quality was not as effective in identifying sleep problems as more specific questions about sleep duration and sleep efficiency. Poor sleep quality was significantly correlated with impairments in quality of life, even when controlling for other factors, such as dyspnea.

CONCLUSIONS

Even 8 years after diagnosis, LCS continue to have significant sleep difficulties. By asking specific questions about sleep medication use, nocturnal awakenings and sleep efficiency, health care providers can identify sleep problems that could be treated and potentially improve the quality of life of their patients.

Rehabilitation in a Warm Versus a Colder Climate in Chronic Obstructive Pulmonary Disease

PURPOSE

The primary aim of this study was to evaluate if pulmonary rehabilitation in a subtropical climate during winter had better long-term effects on health-related quality of life and symptoms of anxiety and depression than an equivalent pulmonary rehabilitation program in a colder climate. The secondary aim was to assess short-term differences in the same outcomes.

METHODS

Referred patients with chronic obstructive pulmonary disease were randomized to and completed rehabilitation in a subtropical climate in Spain (n=60) or in a temperate climate in Norway (n=36). Health-related quality of life was assessed with St. George's Respiratory Questionnaire, and symptoms of anxiety and depression were assessed with the Hospital Anxiety and Depression Scale at the start of rehabilitation, at discharge, and 8 months later.

RESULTS

There were no significant differences between the 2 groups in mean changes in St George's Respiratory Questionnaire dimensions or total score (-3.0; 97.5% confidence interval [CI], -8.6 to 2.6, P = .22) or Hospital Anxiety and Depression Scale anxiety (-1.2; 97.5% CI, -2.7 to 0.3, P = .08) or depression (-0.3; 97.5% CI, -1.7 to 1.1, P = .62) score from the start of rehabilitation to 9 months thereafter. During rehabilitation, the Spain group improved more than the Norway group in the activity score of the St George's Respiratory Questionnaire (-6.2; 97.5% CI, -12.4 to -0.1, P= .02) and in the Hospital Anxiety and Depression Scale anxiety score (-1.7; 97.5% CI, -2.9 to -0.6, P = .001).

CONCLUSIONS

No significant long-term differences in improvement in health-related quality of life or psychological well-being was demonstrated after chronic obstructive pulmonary disease rehabilitation in a subtropical versus a temperate climate.

Gaps in the care of patients admitted to hospital with an exacerbation of chronic obstructive pulmonary disease

BACKGROUND

Patients admitted to hospital because of an exacerbation of chronic obstructive pulmonary disease (COPD) are at high risk of adverse events. We evaluated the association between gaps in care and adverse events during the hospital stay and after discharge.

METHODS

We retrospectively reviewed the charts of 105 consecutive patients discharged from hospital between Jan. 1 and Dec. 31, 2001, with a diagnosis of COPD exacerbation. On the basis of published guidelines, prior studies and discussions with colleagues, we defined a care gap as having occurred if any of 9 important inpatient and 7 discharge-related processes of care did not take place correctly. Inpatient adverse events included worsening of condition after admission, transfer to a higher level of care, cardiac arrest and death. Discharge-related adverse events were defined as including readmission to the hospital, revisit to the emergency department or death within 30 days after discharge.

RESULTS

Of the 105 patients studied, 88 (84%) had at least 1 inpatient gap in care and 16 (15%) an inpatient adverse event; 2 of the 16 died. Patients who had an inpatient adverse event had more gaps in their care (2.0 v. 1.3 gaps, p = 0.004) and longer stays (16.4 v. 8.6 days, p = 0.007). There were 6 adverse events (frequency 38%) among the 16 patients with 3 or more gaps in their care, 6 adverse events (28%) among the 21 patients with 2 gaps, 1 adverse event (2%) among the 51 patients with 1 gap and 3 adverse events (18%) among the 17 patients with no gaps in their care (p = 0.001 for trend). Of the 103 patients discharged alive, 102 (99%) had at least 1 gap in discharge-related care, but we found no association between these gaps and adverse events within 30 days after discharge.

INTERPRETATION

Gaps in the inpatient care of patients with COPD exacerbation were common and were associated with inpatient adverse events. Gaps in discharge-related care were also common but were not associated with postdischarge adverse events.

Sleep and chronic obstructive pulmonary disease

PURPOSE OF REVIEW

Sleep disorders are pervasive in patients with chronic obstructive pulmonary disease (COPD). The patient with COPD is especially vulnerable to sleep-induced gas exchange aberrations. Most sleep disturbances affect the quality of life and some potentially affect survival in these patients. These issues impact treatment of these patients.

RECENT FINDINGS

Insomnia is very common in COPD but might respond to inhaled anticholinergic agents. The use of hypnotics in the hypercapnic patient with severe COPD might be dangerous. The incidence of sleep apnea in COPD patients is allegedly very high, but recent studies suggest this association to be artifactual. Nocturnal oxygen desaturation, which is common in these patients, occurs even in mild COPD. This clinical complication might reflect sleep-disordered breathing or REM sleep-related hypoventilation. We need cost-effective and reliable methods to help distinguish between these causes without routinely resorting to formal polysomnography.

SUMMARY

Development of sound clinical algorithms to address this clinical dilemma is indeed a focus for future research. Some of these patients might require continuous positive pressure therapy, whereas others might need long-term oxygen therapy. Although oxygen therapy in COPD patients with only mild hypoxemia and nocturnal desaturation has not uniformly been shown to be beneficial, it is perhaps too soon to abandon this important clinical intervention in these patients.

Age-dependent cell death in the olfactory cortex: lack of transneuronal degeneration in neonates

Adult olfactory cortical neurons in layer IIa undergo fulminant transneuronal degeneration after removal of afferent olfactory bulb fibers (Price, '76, Neurosci Abst. 2:161; Heimer and Kalil, '78, J. Comp. Neurol. 178:559-609). This provides an unusual example of dependence of a mature population of neurons on axonal input. In order to investigate whether similar transneuronal degeneration occurs in immature animals, a series of rats were subjected to unilateral olfactory bulb removal at various ages during the first 3 postnatal weeks. The brains were examined for degeneration after short survivals by use of the de Olmos cupric silver method, which selectively stains degenerating neurons. In addition, animals with long survivals were examined with the HRP retrograde tracing method, in order to determine if cells that survive the acute effects of deafferentation develop normal patterns of connections. Young neurons are more resistant to the effects of olfactory bulb removal than more mature neurons. There was little degeneration of cortical neurons after bulb ablation during the first 2 postnatal weeks. Although layer IIa does not become distinct from layer IIb in these experimental animals, cells that have connections normally characteristic of the cells of layer IIa, and are situated at the superficial edge of layer II, were identified with the HRP method. The severity of transneuronal degeneration increases and becomes adultlike between the second and third postnatal weeks. This increase in transneuronal degeneration is temporally associated with a progressive reduction in axonal sprouting following deafferentation during the first 3 postnatal weeks, as described in the companion paper (Friedman and Price, '86). Thus, axon sprouting may "protect" the immature IIa neurons from the effects of removal of the fibers from the olfactory bulb. A period of normal cell death has also been identified in olfactory cortex by the use of the de Olmos cupric silver method. This cellular degeneration is much less severe and has a different time course and laminar distribution than the transneuronal degeneration produced by olfactory bulb ablation in adults. Although normal cell death appears to be potentiated by removal of the olfactory bulb on postnatal day 1, it is clearly a different process from the transneuronal reaction.