Excessive Daytime Sleepiness in Depression and Obstructive Sleep Apnea: More Than Just an Overlapping Symptom

Risk of Major Depression Associated with Excessive Daytime Sleepiness in Apneic Individuals

Considering the frequent co-occurrence of major depressive disorder and excessive daytime sleepiness in apneic individuals, this study aimed to explore the relationship between excessive daytime sleepiness and the risk of developing major depressive disorder in this specific subpopulation. Demographic and polysomnographic data were retrospectively extracted from the clinical database of 1849 apneic individuals at the Sleep Unit. Excessive daytime sleepiness was considered present when the Epworth Sleepiness Scale score was >10 and major depressive episodes were diagnosed according to DSM criteria. Logistic regression analyses were performed to assess the risk of major depressive disorder associated with excessive daytime sleepiness in apneic individuals. The prevalence of major depressive disorder was 26.3% in apneic individuals. After controlling for major confounding variables, multivariate logistic regression analyses revealed that apneic individuals with complaints of excessive daytime sleepiness had a higher likelihood of developing major depressive disorder compared to those without complaint of excessive daytime sleepiness. This study highlights the strong association between excessive daytime sleepiness and major depressive disorder in apneic individuals, underlining the importance of systematically assessing and adequately treating excessive daytime sleepiness to better manage depressive symptoms and improve overall treatment outcomes in this specific subpopulation.

Management options for excessive daytime sleepiness in patients with obstructive sleep apnea

INTRODUCTION

Excessive daytime sleepiness (EDS) is a symptom of obstructive sleep apnea (OSA) associated with the risk of accidents at work or while driving. OSA treatment decreases EDS, but some patients remain sleepy despite optimal control of OSA. Patients who do not tolerate or refuse OSA treatment may be symptomatically treated for EDS. Solriamfetol and pitolisant are wake-promoting agents (WPA) recently approved for use in sleepy OSA patients accepting or refusing OSA treatment.

AREAS COVERED

This narrative review provides updated information on: how to assess EDS in OSA patients, epidemiology, and management of residual EDS in treated OSA patients and the results of recent studies using new WPAs in patients accepting or refusing CPAP treatment. Literature was accessed from PubMed between 1 December 2024 and 6 January 2025.

EXPERT OPINION

The new WPAs are useful drugs with a favorable safety profile to be included as a possible therapeutic option for sleepy OSA patients. However, it is still uncertain which subgroups of patients should be treated for the symptom of EDS while maintaining a low-risk profile in terms of the consequences of OSA on health. Until such data is available, use of WPA in OSA patients should be managed by Sleep Specialists.

The deficiencies of epworth sleepiness scale in the evaluation of excessive daytime sleepiness in obstructive sleep apnea and related factors

BACKGROUND

Epworth Sleepiness Scale(ESS) is widely used in the assessment of excessive daytime sleepiness (EDS) despite certain deficiencies. It was aimed to evaluate the factors associated with low ESS scores in subjects investigated for OSA.

METHODS

In this cross sectional study, we recorded the ESS and Pittsburg sleep quality index (PSQI) scores of patients undergoing polysomnography in our sleep center between November 2022-January 2023. Additional questions regarding literacy, vehicle use, driver licence and travelling habits were asked. Sleep indices of patients with AHI ≥ 5 were recorded following PSG.

RESULTS

96 patients with mean age 51 ± 12, 68% male, median AHI 34.6 (7-105), ESS 7 (0-22), PSQI 9 (2-15) were included. Among moderate-severe OSA patients without EDS; 10% were illiterate, 67% performed reading only from cellular phone, 88% did not attend the social settings, 53% did not travel frequently and 40% did not use any vehicle. The listed factors were also associated with low ESS (p < 0.001). The sleep indices and PSQI scores of patient groups with and without EDS were similar. There was a correlation between ESS and total PSQI score (β = 0.31, p = 0.002) and subjective sleep quality (β = 0.21, p = 0.04), sleep disturbances (β = 0.29, p = 0.004) and daytime dysfunction (β = 0.49, p < 0.001) domains.

CONCLUSION

ESS may be inadequate in the assessment of the demographical features and daily habits of patients from different sociocultural settings. Clinicians should be aware that the patients may have severe OSA and poor sleep quality despite low ESS scores and should evaluate each patient individually.

Globus sensation in obstructive sleep apnea patients; A cross-sectional study of 120 patients

PURPOSE

Globus pharyngeus (GP) is a common complaint in many disciplines, especially otolaryngology. Pharyngeal symptoms and abnormalities, including GP, are frequent in obstructive sleep apnea (OSA) patients. This study aims to investigate globus sensation in non-operated OSA patients.

METHODS

After translation and validation, the Laryngopharyngeal Measure of Perceived Sensation (LUMP) was administered to 120 untreated OSA patients. All patients underwent polysomnography and thorough physical examination. The association between LUMP scores and OSA measures was evaluated.

RESULTS

LUMP score had a significant correlation with the Epworth Sleepiness Scale (ESS) (Spearman's ρ = 0.269, p = 0.004), and BMI (Spearman's ρ = 0.249, p = 0.007), the anatomical position of the tongue (ρ = -0.191, p = 0.04) and the Friedman grade of tonsils (ρ = 0.241, p = 0.01). It correlated with SpO2 nadir, though it did not reach statistical significance.

CONCLUSION

The results of our study depict a relationship between a self-report measure of globus sensation and daytime sleepiness, BMI and tonsil size. In the absence of a direct relationship between OSA severity parameters and GP, we hypothesize a role for shared comorbidities and anatomical phenotypes. The increased frequency of GP in OSA patients should be considered when evaluating the complications of surgical interventions in these patients.

Excessive Daytime Sleepiness in Hypertensive Patients: The Role of Major Depressive Disorder

There is a special relationship between major depressive disorder and excessive daytime sleepiness. However, given the negative impact of excessive daytime sleepiness on life quality and cardiovascular outcome in hypertensive patients, the objective of this study was to investigate the potential role played by major depressive disorder in the occurrence of this complaint for this particular subpopulation. Data from 1404 hypertensive patients recruited from the Sleep Unit's polysomnographic recordings database were analyzed. A score >10 on the Epworth Sleepiness Scale was used to define excessive daytime sleepiness in this study. Logistic regression analyses were performed to investigate the risk of excessive daytime sleepiness associated with major depressive disorder in hypertensive patients. Excessive daytime sleepiness was frequent (40.0%) in our sample of hypertensive patients. After adjustments for major confounding factors, multivariate logistic regression analyses demonstrated that unlike remitted major depressive disorder, only current major depressive disorder was associated with a higher risk of excessive daytime sleepiness in hypertensive patients. Given this potential implication of current major depressive disorder in the occurrence of excessive daytime sleepiness for hypertensive patients, it is therefore essential to achieve the complete remission of this psychiatric disorder to avoid negative consequences associated with this complaint in this particular subpopulation.

Obstructive Sleep Apnea after COVID-19: An Observational Study

The risk factors of hospitalized COVID-19 and obstructive sleep apnea (OSA) overlap. The aim of this study is to evaluate the prevalence and associated factors of post-COVID-19 OSA in hospitalized adult patients from southeastern Romania. A follow-up study was conducted on patients hospitalized for COVID-19 at the Pneumology Hospital in Galati, Romania, between 2021 and 2022. OSA was evaluated using the Epworth and STOP-BANG questionnaires and nocturnal polygraphy monitoring. Out of 331 patients, 257 were evaluated for sleep apnea in the 12th week. The prevalence of severe OSA was 57.97%. Significant associations were found with male gender, an age over 60, obesity, and cardiovascular co-morbidities. Non-invasive ventilatory therapy (NIV) and a hygienic-dietary regimen were recommended based on severity following a control visit after a month. Developing strategies for diagnosing and monitoring sleep disorders, including home sleep apnea tests and patient education, are the next directions for post-COVID-19 management.

Excessive daytime sleepiness in nursing technicians: association with sleep quality and memory

OBJECTIVE

to investigate excessive daytime sleepiness prevalence among nursing technicians and the association with sleep quality and memory.

METHODS

a cross-sectional, inferential study, carried out in a hospital unit in the state of Goiás between December 2020 and January 2021. Assessments were carried out using the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index and the Prospective and Retrospective Memory Questionnaire, instruments validated for the Brazilian context. Bivariate and multivariate logistic regression analyzes were performed.

RESULTS

the sample consisted of 189 nursing technicians with a 40.9% excessive daytime sleepiness prevalence. In multivariate models, excessive daytime sleepiness was not associated with sleep quality, however there was a significant association with overall memory failures.

CONCLUSIONS

study results demonstrate a high excessive daytime sleepiness occurrence, an association with overall memory failures and the need for psychosocial interventions for nursing technicians.

Relationship of quality and duration of sleep with arterial hypertension in a Colombian population

Introduction. Alterations in the quality and duration of sleep are risk factors for the development of arterial hypertension in Eastern countries. However, in Latin America there are few studies researching this association. Objective. To analyze the association between the quality and duration of sleep and the rate of arterial hypertension in a Colombian population. Materials and methods. An observational, longitudinal, prospective and analytical study nested in the INEFAC population-based cohort, was conducted with participants over 18 years of age from Bucaramanga (Colombia). Sleep quality was assessed using the Pittsburgh Sleep Quality Index. Sleep duration was assessed using standardized questions. Multivariate analysis was performed with logistic regression models adjusted for possible confounding variables. Results. A total of 1,306 non-hypertensive participants with a mean age of 40 ± 12 years were included. In this population, 92.8% had one or more sleep issues. 45.15% slept 6 hours or less and 28.6% slept 8 hours or more. Multivariate analysis showed a higher risk of hypertension in participants with diabetes (OR = 5.27; 95% CI: 2.27-12.26), obesity (OR = 2.81; 95% CI: 1.11-7.13), active smoking (OR = 2.02; 95% CI: 1.01-4.04) and higher socioeconomic level (OR = 4.94; 95% CI: 1.59-15.38 for level 4), but no higher risk was found in participants with poor sleep quality or short sleep duration. Conclusions. No association was found between the duration or quality of sleep and the rate of arterial hypertension in the Colombian population. More studies are required in this population to reach definitive conclusions.

Excessive daytime sleepiness is associated with relative delta frequency power among patients with mild OSA

Background

Excessive daytime sleepiness (EDS) is a cause of low quality of life among obstructive sleep apnoea (OSA) patients. Current methods of assessing and predicting EDS are limited due to time constraints or differences in subjective experience and scoring. Electroencephalogram (EEG) power spectral densities (PSDs) have shown differences between OSA and non-OSA patients, and fatigued and non-fatigued patients. Therefore, polysomnographic EEG PSDs may be useful to assess the extent of EDS among patients with OSA.

Methods

Patients presenting to Israel Loewenstein hospital reporting daytime sleepiness who recorded mild OSA on polysomnography and undertook a multiple sleep latency test. Alpha, beta, and delta relative powers were assessed between patients categorized as non-sleepy (mean sleep latency (MSL) ≥10 min) and sleepy (MSL <10 min).

Results

139 patients (74% male) were included for analysis. 73 (53%) were categorized as sleepy (median MSL 6.5 min). There were no significant differences in demographics or polysomnographic parameters between sleepy and non-sleepy groups. In multivariate analysis, increasing relative delta frequency power was associated with increased odds of sleepiness (OR 1.025 (95% CI 1.024-1.026)), while relative alpha and beta powers were associated with decreased odds. The effect size of delta PSD on sleepiness was significantly greater than that of either alpha or beta frequencies.

Conclusion

Delta PSD during polysomnography is significantly associated with a greater degree of objective daytime sleepiness among patients with mild OSA. Further research is needed to corroborate our findings and identify the direction of potential causal correlation between delta PSD and EDS.

Recovery Mimicking "Ideal" CPAP Adherence Does Not Improve Wakefulness or Cognition in Chronic Murine Models of OSA: Effect of Wake-Promoting Agents

INTRODUCTION

Obstructive sleep apnea (OSA) is a chronic condition characterized by intermittent hypoxia (IH) and sleep fragmentation (SF). OSA can induce excessive daytime sleepiness (EDS) and is associated with impaired cognition and anxiety. Solriamfetol (SOL) and modafinil (MOD) are widely used wake-promoting agents in OSA patients with EDS.

METHODS

Male C57Bl/6J mice were exposed to SF along with sleep controls (SC) or to IH and room air (RA) controls during the light (inactive) phase for 4 and 16 weeks, respectively. Both IH and SF exposures were then discontinued to mimic "ideal" continuous positive airway pressure (CPAP) adherence. All groups were then randomly assigned to receive once daily intraperitoneal injections of SOL, MOD, or vehicle (VEH) for 6 days. Sleep/wake activity was assessed along with tests of explicit memory, anxiety and depression were performed before and after treatments.

RESULTS

IH and SF exposures increased sleep percentage in the dark phase and reduced wake bouts lengths (i.e., EDS), and induced cognitive deficits and impulsivity in mice. Both SOL and MOD treatments effectively mitigated EDS when combined with recovery, while recovery alone did not improve EDS over the 6-day period. Furthermore, improvements explicit memory emerged only after SOL.

CONCLUSION

Chronic IH and SF induce EDS in young adult mice that is not ameliorated by recovery except when combined with either SOL or MOD. SOL, but not MOD, significantly improves IH-induced cognitive deficits. Thus, SOL emerges as a viable adjuvant medication for residual EDS in OSA along with its positive impact on cognition.

Analysis of the relationship between sleep-related disorder and systemic immune-inflammation index in the US population

BACKGROUND

The association between sleep-related disorders and inflammation has been demonstrated in previous studies. The systemic immune-inflammation index (SII) is a novel inflammatory index based on leukocytes, but its relationship with sleep-related disorder is unclear. We aimed to investigate the relationship between sleep-related disorder and SII in a nationally representative nonhospitalized sample.

METHODS

Data were obtained from the 2005-2008 National Health and Nutrition Examination Survey (NHANES). Exposure variables included self-reported sleep-related disorders, such as sleep duration, sleep problems, high risk of OSA, and daytime sleepiness. SII and other traditional markers of inflammation were considered as outcome variables, including platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR). Multiple linear regression models were employed to examine the correlation between sleep-related disorders and inflammatory markers. Subgroup interactions were analyzed using likelihood ratio tests, and nonlinear relationships were explored by fitting restricted cubic splines.

RESULTS

A total of 8,505 participants were enrolled in this study. Overall, sleep-related disorders were found to have a stronger association with SII compared to the PLR and NLR. The results of multiple linear regression analysis revealed that participants who experienced sleep problems (β: 21.421; 95% CI 1.484, 41.358), had symptoms of OSA (β: 23.088; 95% CI 0.441, 45.735), and reported daytime sleepiness (β: 30.320; 95% CI 5.851, 54.789) exhibited a positive association with higher SII. For the analysis of other inflammatory markers, we only found that daytime sleepiness was associated with increased NLR levels (β: 0.081; 95% CI 0.002, 0.159).

CONCLUSION

Sleep problems, symptoms of OSA, and daytime sleepiness were found to have a positive association with the SII in US adults. However, further prospective studies are necessary to establish whether there is a causal relationship between these factors.

Bayesian network modeling of risk and prodromal markers of Parkinson's disease

Parkinson's disease (PD) is characterized by a long prodromal phase with a multitude of markers indicating an increased PD risk prior to clinical diagnosis based on motor symptoms. Current PD prediction models do not consider interdependencies of single predictors, lack differentiation by subtypes of prodromal PD, and may be limited and potentially biased by confounding factors, unspecific assessment methods and restricted access to comprehensive marker data of prospective cohorts. We used prospective data of 18 established risk and prodromal markers of PD in 1178 healthy, PD-free individuals and 24 incident PD cases collected longitudinally in the Tübingen evaluation of Risk factors for Early detection of NeuroDegeneration (TREND) study at 4 visits over up to 10 years. We employed artificial intelligence (AI) to learn and quantify PD marker interdependencies via a Bayesian network (BN) with probabilistic confidence estimation using bootstrapping. The BN was employed to generate a synthetic cohort and individual marker profiles. Robust interdependencies were observed for BN edges from age to subthreshold parkinsonism and urinary dysfunction, sex to substantia nigra hyperechogenicity, depression, non-smoking and to constipation; depression to symptomatic hypotension and excessive daytime somnolence; solvent exposure to cognitive deficits and to physical inactivity; and non-smoking to physical inactivity. Conversion to PD was interdependent with prior subthreshold parkinsonism, sex and substantia nigra hyperechogenicity. Several additional interdependencies with lower probabilistic confidence were identified. Synthetic subjects generated via the BN based representation of the TREND study were realistic as assessed through multiple comparison approaches of real and synthetic data. Altogether our work demonstrates the potential of modern AI approaches (specifically BNs) both for modelling and understanding interdependencies between PD risk and prodromal markers, which are so far not accounted for in PD prediction models, as well as for generating realistic synthetic data.

Association between poor sleep quality and an increased risk of dry eye disease in patients with obstructive sleep apnea syndrome

Purpose

Obstructive sleep apnea (OSA) is related to an increased incidence of dry eye disease (DED). However, their exact relationship is unknown and requires further well-designed studies with advanced mechanisms detection.

Patients and methods

This case–control study included 125 OSA cases and 125 age–gender-matched controls enrolled in the hospital between 1 January and 1 October 2021. OSA diagnosis and classification were performed using a polysomnography (PSG) assay. Detailed ophthalmological examinations, including the Schirmer I test, corneal staining, and ocular surface disease index (OSDI), were used to detect DED-related parameters. A comprehensive ocular surface assay was performed to measure a series of parameters, including first non-invasive first tear film break-up time (f-NIBUT), average non-invasive first tear film break-up time (av-NIBUT), tear meniscus height (TMH), and loss of meibomian gland. In addition, the Pittsburgh Sleep Quality Index (PSQI) scale was used to assess sleep quality.

Results

Compared to the control, the OSA group showed an increased DED risk (P = 0.016) along with an increased PSQI score and a higher rate of poor quality sleep (P < 0.001 and P = 0.007, respectively). Stratification of OSA cases indicated that DED-related parameters were impaired in patients with severe OSA (P < 0.05). The analysis of DED-parameters-related factors showed significant correlations between OSA-related indexes and PSQI (P < 0.05). Moreover, the poor sleep quality group in the OSA cases showed worse DED-related parameters (P < 0.05), which was not observed in the control group.

Conclusion

OSA, especially the severe stage OSA, was related to an increased risk of DED. Also, sleep quality was correlated with the onset of both OSA and DED, where poor sleep quality revealed a relationship between OSA and the risk of DED. Overall, our findings provided evidence for advanced management of DED and OSA in future.

Persistent Depressive Disorder-Related Effect of Sleep Disorder on the Highest Risk of Suicide in Taiwan, 2000-2015

OBJECTIVE

to investigate whether persistent depressive disorder (PDD) affects sleep disorders (SDs) and increased suicide risk.

METHODS

in this study, we used the National Health Insurance Research Database (NHIRD) to select 117,033 SD patients, of whom 137 died by suicide, and 468,132 non-SD patients, of whom 118 died by suicide, and analyzed gender, age, and co-existing diseases. Hazard ratios (HRs) and 95% confidence intervals (CI) were calculated using a multivariate Cox proportional hazards model.

RESULTS

the hazard ratio of suicide in SD patients was 1.429 times that of non-SD patients. The hazard ratio of suicide in female patients was 1.297 times higher than in males. Compared with people without PDD, people with PDD had a 7.195 times higher hazard ratio for suicide than those without PDD. PDD patients with SDs had a 2.05 times higher hazard ratio for suicide than those with no SDs.

CONCLUSIONS

suicide risk was increased in SD patients, and the maximum suicide risk was greater in SD patients with PDD than in non-PDD patients. PDD affected SDs and increased suicide risk. Clinicians should be aware of the possibility that PDD affects patients with SDs and contributes to suicide risk.

“Leaky Gut” as a Keystone of the Connection between Depression and Obstructive Sleep Apnea Syndrome? A Rationale and Study Design

Obstructive sleep apnea (OSA) and depression are highly comorbid. Immune alterations, oxidative stress or microbiota dysfunction have been proposed as some mechanisms underlying this association. The aim of the proposed study is to assess the severity and profile of OSA and depressive symptoms in the context of serum microbiota metabolites, biomarkers of intestinal permeability, inflammation and oxidative stress in adult patients diagnosed with OSA syndrome. The study population consists of 200 subjects. An apnoea-hypopnoea index ≥ 5/hour is used for the diagnosis. Depressive symptoms are assessed with Beck Depression Inventory. Measured serum markers are: tumour necrosis factor–alpha and interleukin-6 for inflammation, total antioxidant capacity and malondialdehyde concentration for oxidative stress, zonulin, calprotectin, lipopolisaccharide-binding protein and intestinal fatty acids-binding protein for intestinal permeability. All of the above will be measured by enzyme-linked immunosorbent assay (ELISA). Associations between clinical symptoms profile and severity and the above markers levels will be tested. It would be valuable to seek for overlap indicators of depression and OSA to create this endophenotype possible biomarkers and form new prophylactic or therapeutic methods. The results may be useful to establish a subpopulation of patients sensitive to microbiota therapeutic interventions (probiotics, prebiotics, and microbiota transplantation).