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Alessi CA, Fung CH, Dzierzewski JM, Fiorentino L, Stepnowsky C, Rodriguez Tapia JC, Song Y, Zeidler MR, Josephson K, Mitchell MN, Jouldjian S, Martin JL. Randomized controlled trial of an integrated approach to treating insomnia and improving the use of positive airway pressure therapy in veterans with comorbid insomnia disorder and obstructive sleep apnea. Sleep 2021; 44:zsaa235. [PMID: 33221910 PMCID: PMC8033453 DOI: 10.1093/sleep/zsaa235] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/26/2020] [Indexed: 12/11/2022] Open
Abstract
STUDY OBJECTIVES Cognitive behavioral therapy for insomnia (CBTI) for comorbid insomnia and obstructive sleep apnea (OSA) has had mixed results. We integrated CBTI with a positive airway pressure (PAP) adherence program and tested effects on sleep and PAP use. METHODS 125 veterans (mean age 63.2, 96% men, 39% non-Hispanic white, 26% black/African American, 18% Hispanic/Latino) with comorbid insomnia and newly-diagnosed OSA (apnea-hypopnea index ≥ 15) were randomized to 5-weekly sessions integrating CBTI with a PAP adherence program provided by a "sleep coach" (with behavioral sleep medicine supervision), or 5-weekly sleep education control sessions. Participants and assessment staff were blinded to group assignment. Outcomes (baseline, 3 and 6 months) included Pittsburgh Sleep Quality Index (PSQI), 7-day sleep diary (sleep onset latency [SOL-D], wake after sleep onset [WASO-D], sleep efficiency [SE-D]), 7-day actigraphy (SE-A), and objective PAP use (hours/night and nights ≥ 4 h). Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10) were also collected. RESULTS Compared to controls, intervention participants showed greater improvement (baseline to 3 and 6 months, respectively) in PSQI (-3.2 and -1.7), SOL-D (-16.2 and -15.5 minutes), SE-D (10.5% and 8.5%), SE-A (4.4% and 2.6%) and more 90-day PAP use (1.3 and 0.9 more hours/night, 17.4 and 11.3 more nights PAP ≥ 4 h). 90-day PAP use at 3 months was 3.2 and 1.9 h/night in intervention versus controls. Intervention participants also had greater improvements in ISI, ESS, and FOSQ-10 (all p < 0.05). CONCLUSIONS An intervention integrating CBTI with a PAP adherence program delivered by a supervised sleep coach improved sleep and PAP use in adults with comorbid insomnia and OSA. TRIAL REGISTRATION ClinicalTrials.govStudy name: Novel Treatment of Comorbid Insomnia and Sleep Apnea in Older VeteransURL: https://clinicaltrials.gov/ct2/results?cond=&term=NCT02027558&cntry=&state=&city=&dist=Registration: NCT02027558.
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Affiliation(s)
- Cathy A Alessi
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Constance H Fung
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | | | - Lavinia Fiorentino
- Department of Psychiatry, University of California, San Diego, San Diego, CA
| | - Carl Stepnowsky
- Department of Medicine, University of California, San Diego, San Diego, CA
- VA San Diego Healthcare System, San Diego, CA
| | | | - Yeonsu Song
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
- School of Nursing, University of California Los Angeles, Los Angeles, CA
| | - Michelle R Zeidler
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
- Pulmonary, Critical Care and Sleep Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Karen Josephson
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Michael N Mitchell
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Stella Jouldjian
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Jennifer L Martin
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
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Subramanian S, Hesselbacher SE, Nye P, Aiyer AA, Surani SR. Comorbid insomnia and sleep apnea: characterization of the syndrome and understanding its associations with comorbid sleep conditions. Sleep Breath 2021; 25:1995-2000. [PMID: 33661467 DOI: 10.1007/s11325-021-02331-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 02/09/2021] [Accepted: 02/19/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE Obstructive sleep apnea (OSA) is traditionally associated with excessive daytime sleepiness. Insomnia is characterized by hyperarousal, and is seen as a predominant feature in a subgroup of patients with OSA. The aim of this study was to describe the prevalence of comorbid insomnia and sleep apnea (COMISA) in a sleep apnea population and to characterize its features. METHODS This was a chart review of patients who underwent overnight polysomnography (PSG). All patients completed questionnaires with the Epworth Sleepiness Scale (ESS), and symptoms of insomnia and other sleep-related comorbidities. Patients with OSA on the PSG were included. RESULTS A total of 296 patients with OSA were included, of which 80% reported at least 1 major symptom of insomnia: 57% reported sleep onset insomnia, 68% sleep maintenance insomnia, and 48% had early morning awakenings. COMISA (OSA plus 2 or more major symptoms of insomnia) was seen in 63%. These patients were more likely to report an abnormal ESS score, gastroesophageal reflux (GER), and restless legs (RL) than those without; no difference was seen in self-reported sleep bruxism. Among the patients with COMISA, 85% reported at least 1 representative symptom of psychophysiological insomnia (PPI); each of the 5 PPI symptoms was present in at least 40% of patients with COMISA. CONCLUSIONS Insomnia is extremely prevalent in our population of patients with OSA, accompanied by daytime sleepiness and symptoms of PPI, GER, and RL. Further study is needed to determine the interactions between symptoms and OSA treatments in these patients.
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Affiliation(s)
| | - Sean E Hesselbacher
- Eastern Virginia Medical School, Norfolk, VA, USA. .,Hampton VA Medical Center, 100 Emancipation Drive, Hampton, VA, 23667, USA.
| | - Phillip Nye
- Eastern Virginia Medical School, Norfolk, VA, USA
| | | | - Salim R Surani
- TORR Sleep Center, Corpus Christi, TX, USA.,Texas A&M University, Corpus Christi, TX, USA
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Colvonen PJ, Almklov E, Tripp JC, Ulmer CS, Pittman JOE, Afari N. Prevalence rates and correlates of insomnia disorder in post-9/11 veterans enrolling in VA healthcare. Sleep 2020; 43:zsaa119. [PMID: 32529231 PMCID: PMC8479677 DOI: 10.1093/sleep/zsaa119] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/22/2020] [Indexed: 12/12/2022] Open
Abstract
STUDY OBJECTIVES Post-9/11 veterans are particularly vulnerable to insomnia disorder. Having accurate prevalence rates of insomnia disorder in this relatively young, diverse population, is vital to determine the resources needed to identify and treat insomnia disorder. However, there are no accurate prevalence rates for insomnia disorder in post-9/11 veterans enrolling in the VA Healthcare System (VHA). We present accurate prevalence of insomnia disorder, and correlates, in a large sample of post-9/11 veterans enrolling in a VHA. METHODS This was an observational study of 5,552 post-9/11 veterans newly enrolling for health care in a VHA. Data were collected using VA eScreening. Insomnia diagnosis was determined using a clinical cutoff score of ≥ 11 on the Insomnia Severity Index. Measures also included sociodemographic, service history, posttraumatic stress disorder (PTSD), depression, suicidal ideation, alcohol misuse, military sexual trauma, traumatic brain injury (TBI), and pain intensity. RESULTS About 57.2% of the sample population had insomnia disorder. Our sample was nationally representative for age, sex, ethnicity, branch of the military, and race. The sample also was at high-risk for a host of clinical disorders, including PTSD, TBI, and pain; all of which showed higher rates of insomnia disorder (93.3%, 77.7%, and 69.6%, respectively). CONCLUSIONS The findings suggest alarmingly high rates of insomnia disorder in this population. Examining and treating insomnia disorder, especially in the context of co-occurring disorders (e.g. PTSD), will be a necessity in the future.
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Affiliation(s)
- Peter J. Colvonen
- VA San Diego Healthcare System, San Diego, CA
- Department of Psychiatry, University of California San Diego, San Diego, CA
- VA Center of Excellence for Stress and Mental Health, San Diego, CA
- National Center for PTSD, White River Junction, VT
| | | | - Jessica C. Tripp
- VA San Diego Healthcare System, San Diego, CA
- Department of Psychiatry, University of California San Diego, San Diego, CA
| | - Christi S. Ulmer
- VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC
- Department of Psychiatry and Behavioral Science, Duke University School of Medicine, Durham, NC
| | - James O. E. Pittman
- VA San Diego Healthcare System, San Diego, CA
- Department of Psychiatry, University of California San Diego, San Diego, CA
- VA Center of Excellence for Stress and Mental Health, San Diego, CA
| | - Niloofar Afari
- VA San Diego Healthcare System, San Diego, CA
- Department of Psychiatry, University of California San Diego, San Diego, CA
- VA Center of Excellence for Stress and Mental Health, San Diego, CA
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Wallace DM, Wohlgemuth WK. Predictors of Insomnia Severity Index Profiles in United States Veterans With Obstructive Sleep Apnea. J Clin Sleep Med 2019; 15:1827-1837. [PMID: 31855168 PMCID: PMC7099195 DOI: 10.5664/jcsm.8094] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 08/23/2019] [Accepted: 08/23/2019] [Indexed: 12/19/2022]
Abstract
STUDY OBJECTIVES The Insomnia Severity Index (ISI) has been used to define insomnia symptoms in individuals with obstructive sleep apnea (OSA). However, whether distinct ISI profiles exist in individuals with OSA is unclear. The aims of this study were to determine (1) empirically-based ISI profiles in veterans with OSA and (2) predictors of these ISI profiles. METHODS Participants were 630 veterans with a new diagnosis of OSA over a 12-month period. Individuals completed the ISI and other questionnaires on the polysomnography (PSG) night. Latent profile analysis was performed to detect ISI subgroups based on individual ISI items. Age, Charlson Comorbidity Index, apnea-hypopnea index (AHI), mood disorder, posttraumatic stress disorder, and chronic pain diagnoses were used to predict between ISI profiles. RESULTS Latent profile analysis identified five ISI subgroups in veterans with OSA. The "asymptomatic" group (12% prevalence) had low scores across all ISI items. The "moderate insomnia" (30% prevalence) and "severe insomnia" (44% prevalence) groups had elevated scores for all ISI items but differing in severity. Last, the "moderate" (6% prevalence) and "severe daytime symptoms" groups (8% prevalence) were characterized by absence of nocturnal complaints but high scores on daytime impairment items. Age, AHI, mood disorder, posttraumatic stress disorder and chronic pain diagnoses discriminated between ISI profiles. CONCLUSIONS We describe data-driven ISI profiles in veterans with OSA. Older age was associated with lower insomnia and daytime symptom complaints whereas psychological comorbidities were related to more severe insomnia. Caution should be used in interpreting the ISI score in individuals with OSA because a subset had elevated total scores without insomnia.
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Affiliation(s)
- Douglas M. Wallace
- Department of Neurology, Sleep Medicine Division, University of Miami Miller School of Medicine, Miami, Florida
- Neurology Service, Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, Florida
| | - William K. Wohlgemuth
- Neurology Service, Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, Florida
- Psychology Service, Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, Florida
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Krakow B, McIver ND, Ulibarri VA, Krakow J, Schrader RM. Prospective Randomized Controlled Trial on the Efficacy of Continuous Positive Airway Pressure and Adaptive Servo-Ventilation in the Treatment of Chronic Complex Insomnia. EClinicalMedicine 2019; 13:57-73. [PMID: 31517263 PMCID: PMC6734001 DOI: 10.1016/j.eclinm.2019.06.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 05/28/2019] [Accepted: 06/19/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Complex insomnia, the comorbidity of chronic insomnia and obstructive sleep apnea (OSA), is a common sleep disorder, but the OSA component, whether presenting overtly or covertly, often goes unsuspected and undiagnosed due to a low index of suspicion. Among complex insomniacs, preliminary evidence demonstrates standard CPAP decreases insomnia severity. However, CPAP causes expiratory pressure intolerance or iatrogenic central apneas that may diminish its use. An advanced PAP mode-adaptive servo-ventilation (ASV)-may alleviate CPAP side-effects and yield superior outcomes. METHODS In a single-site protocol investigating covert complex insomnia (ClinicalTrials.gov identifier: NCT02365064), a low index of suspicion for this comorbidity was confirmed by exclusion of 455 of 660 eligible patients who presented during the study period with overt OSA signs and symptoms. Ultimately, stringent inclusion/exclusion criteria to test efficacy yielded 40 adult, covert complex insomnia patients [average Insomnia Severity Index (ISI) moderate-severe 19.30 (95% CI 18.42-20.17)] who reported no definitive OSA symptoms or risks and who failed behavioral or drug therapy for an average of one decade. All 40 were diagnosed with OSA and randomized (using block randomization) to a single-blind, prospective protocol, comparing CPAP (n = 21) and ASV (n = 19). Three successive PAP titrations fine-tuned pressure settings, facilitated greater PAP use, and collected objective sleep and breathing data. Patients received 14 weeks of treatment including intensive biweekly coaching and follow-up to foster regular PAP use in order to accurately measure efficaciousness. Primary outcomes measured insomnia severity and sleep quality. Secondary outcomes measured daytime impact: OSA-induced impairment, fatigue severity, insomnia impairment, and quality of life. Performance on these seven variables was assessed using repeated measures ANCOVA to account for the multiple biweekly time points. FINDINGS At intake, OSA diagnosis and OSA as a cause for insomnia were denied by all 40 patients, yet PAP significantly decreased insomnia severity scores (p = 0.021 in the primary ANCOVA analysis). To quantify effect sizes, mean intake vs endpoint analysis was conducted with ASV yielding nearly twice the effects of CPAP [- 13.2 (10.7-15.7), Hedges' g = 2.50 vs - 9.3 (6.3-12.3), g = 1.39], and between mode effect size was in the medium-large range 0.65. Clinically, ASV led to remission (ISI < 8) in 68% of cases compared to 24% on CPAP [Fisher's exact p = 0.010]. Two sleep quality measures in the ANCOVA analysis again demonstrated superior significant effects for ASV compared to CPAP (both p < 0.03), and pre- and post-analysis demonstrated substantial effects for both scales [ASV (g = 1.42; g = 1.81) over CPAP (g = 1.04; g = 0.75)] with medium size effects between modes (0.54, 0.51). Measures of impairment, residual objective sleep breathing events, and normalized breathing periods consistently demonstrated larger beneficial effects for ASV over CPAP. INTERPRETATION PAP therapy was highly efficacious in decreasing insomnia severity in chronic insomnia patients with previously undiagnosed co-morbid OSA. ASV proved superior to CPAP in this first efficacy trial to compare advanced to traditional PAP modes in complex insomnia. Future research must determine the following: pathophysiological mechanisms to explain how OSA causes chronic insomnia; general population prevalence of this comorbidity; and, cost-effectiveness of ASV therapy in complex insomnia. Last, efforts to raise awareness of complex insomnia are urgently needed as patients and providers appear to disregard both overt and covert signs and symptoms of OSA in the assessment of chronic insomnia.
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Affiliation(s)
- Barry Krakow
- Sleep & Human Health Institute, 6739 Academy Rd NE, Ste 380, Albuquerque, NM 87109, USA
- Maimonides Sleep Arts & Sciences, Ltd., 6739 Academy Rd NE, Ste 380, Albuquerque, NM 87109, USA
- Corresponding author at: 6739 Academy Rd, NE Ste. 380, Albuquerque, NM 87109, USA.
| | - Natalia D. McIver
- Sleep & Human Health Institute, 6739 Academy Rd NE, Ste 380, Albuquerque, NM 87109, USA
- Maimonides Sleep Arts & Sciences, Ltd., 6739 Academy Rd NE, Ste 380, Albuquerque, NM 87109, USA
| | - Victor A. Ulibarri
- Sleep & Human Health Institute, 6739 Academy Rd NE, Ste 380, Albuquerque, NM 87109, USA
- Maimonides Sleep Arts & Sciences, Ltd., 6739 Academy Rd NE, Ste 380, Albuquerque, NM 87109, USA
| | - Jessica Krakow
- Sleep & Human Health Institute, 6739 Academy Rd NE, Ste 380, Albuquerque, NM 87109, USA
- Maimonides Sleep Arts & Sciences, Ltd., 6739 Academy Rd NE, Ste 380, Albuquerque, NM 87109, USA
| | - Ronald M. Schrader
- RMS Biostatistics Services, 13129 Bluemist Ln NE, Albuquerque, NM 87111, USA
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Psychological Interventions for Late-life Insomnia: Current and Emerging Science. CURRENT SLEEP MEDICINE REPORTS 2018; 4:268-277. [PMID: 31106115 DOI: 10.1007/s40675-018-0129-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Purpose of Review Late-life insomnia is a serious medical condition associated with many untoward consequences. The high prevalence of late-life insomnia, along with the concomitant risks inherent in the use of hypnotic medications in older adults necessitates non-pharmacological (i.e., psychological) treatment options. We aim to summarize and evaluate the state-of-the-science of psychological treatment options for late-life insomnia. Recent Findings Cumulative scientific evidence suggests the efficacy of psychological treatment of late-life insomnia. During the previous decade, trials of psychological treatments for insomnia have begun to test various modifications to treatments that have the potential to improve access for older adults, along with expanding their focus to include individuals with comorbid conditions that are common to older adults. While these modifications represent positive advances in the science of treatment for late-life insomnia, the evidence is still largely explanatory/efficacious in nature. Summary Psychological strategies represent the best approaches for the treatment of late-life insomnia. Future investigations would be wise to progressively move towards increasingly pragmatic/effectiveness investigations, adding to the literature base regarding the treatment of late-life insomnia under usual/real-world conditions as opposed to ideal/artificial conditions.
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Okun ML, O'Brien LM. Concurrent insomnia and habitual snoring are associated with adverse pregnancy outcomes. Sleep Med 2018; 46:12-19. [DOI: 10.1016/j.sleep.2018.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/01/2018] [Accepted: 03/06/2018] [Indexed: 11/25/2022]
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Brock MS, Mysliwiec V. Comorbid insomnia and sleep apnea: a prevalent but overlooked disorder. Sleep Breath 2018; 22:1-3. [DOI: 10.1007/s11325-018-1628-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/04/2018] [Accepted: 01/11/2018] [Indexed: 10/18/2022]
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Prevalence and risk factors of excessive daytime sleepiness in insomnia sufferers: A study with 1311 individuals. J Psychosom Res 2017; 103:63-69. [PMID: 29167048 DOI: 10.1016/j.jpsychores.2017.10.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 10/08/2017] [Accepted: 10/08/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Several studies have investigated the prevalence and risk factors of excessive daytime sleepiness in the general population. However, few studies have investigated these in the particular subpopulation of insomnia sufferers. Thus, the aim of this study was to examine the prevalence and risk factors of excessive daytime sleepiness in a large sample of insomnia sufferers. METHODS Data from 1311 insomnia sufferers with age≥18years and recruited from the research database of the sleep laboratory of the Erasme Hospital were analysed. A score>10 on the Epworth scale was used as the cut-off score for excessive daytime sleepiness. Logistic regression analyses were conducted to examine clinical and demographic risk factors of excessive daytime sleepiness in insomnia sufferers. RESULTS The prevalence of excessive daytime sleepiness in our sample was 45.61%. Multivariate logistic regression analysis revealed that non-use of Z-drugs, non-use of Trazodone alone or in combination, body mass index≥25 & <30kg/m2, body mass index≥30kg/m2, age≥18 & <40years, age≥40 & <65years, Beck depression inventory score≥5 & <16, Beck depression inventory score≥16, apnea-hypopnea index≥15/h, and use of selective serotonin reuptake inhibitors were significant risk factors of excessive daytime sleepiness in the subpopulation of insomnia sufferers. CONCLUSION Excessive daytime sleepiness is a common complaint for individuals with insomnia. In this subpopulation, most of the risk factors for excessive daytime sleepiness are reversible, which justifies better management of this complaint to avoid its negative consequences.
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Abstract
Sleep-disordered breathing (SDB) is a highly prevalent chronic disease in older adults. A growing body of evidence demonstrates that SDB in older adults is linked to many adverse cardiovascular, neurocognitive, and metabolic sequelae. However, several unanswered questions remain regarding the diagnosis, consequences, and treatment of SDB in older adults. This review presents the current evidence pertaining to the management of SDB in older adults and identifies crucial gaps in knowledge that need further investigation.
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Affiliation(s)
- Susmita Chowdhuri
- Sleep Medicine Section, John D. Dingell VA Medical Center, Detroit, MI 48201, USA; Department of Medicine, Wayne State University, Detroit, MI 48201, USA.
| | - Pragnesh Patel
- Department of Medicine, Wayne State University, Detroit, MI 48201, USA
| | - M Safwan Badr
- Sleep Medicine Section, John D. Dingell VA Medical Center, Detroit, MI 48201, USA; Department of Medicine, Wayne State University, Detroit, MI 48201, USA
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Crawford MR, Chirinos DA, Iurcotta T, Edinger JD, Wyatt JK, Manber R, Ong JC. Characterization of Patients Who Present With Insomnia: Is There Room for a Symptom Cluster-Based Approach? J Clin Sleep Med 2017. [PMID: 28633722 DOI: 10.5664/jcsm.6666] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
STUDY OBJECTIVES This study examined empirically derived symptom cluster profiles among patients who present with insomnia using clinical data and polysomnography. METHODS Latent profile analysis was used to identify symptom cluster profiles of 175 individuals (63% female) with insomnia disorder based on total scores on validated self-report instruments of daytime and nighttime symptoms (Insomnia Severity Index, Glasgow Sleep Effort Scale, Fatigue Severity Scale, Beliefs and Attitudes about Sleep, Epworth Sleepiness Scale, Pre-Sleep Arousal Scale), mean values from a 7-day sleep diary (sleep onset latency, wake after sleep onset, and sleep efficiency), and total sleep time derived from an in-laboratory PSG. RESULTS The best-fitting model had three symptom cluster profiles: "High Subjective Wakefulness" (HSW), "Mild Insomnia" (MI) and "Insomnia-Related Distress" (IRD). The HSW symptom cluster profile (26.3% of the sample) reported high wake after sleep onset, high sleep onset latency, and low sleep efficiency. Despite relatively comparable PSG-derived total sleep time, they reported greater levels of daytime sleepiness. The MI symptom cluster profile (45.1%) reported the least disturbance in the sleep diary and questionnaires and had the highest sleep efficiency. The IRD symptom cluster profile (28.6%) reported the highest mean scores on the insomnia-related distress measures (eg, sleep effort and arousal) and waking correlates (fatigue). Covariates associated with symptom cluster membership were older age for the HSW profile, greater obstructive sleep apnea severity for the MI profile, and, when adjusting for obstructive sleep apnea severity, being overweight/obese for the IRD profile. CONCLUSIONS The heterogeneous nature of insomnia disorder is captured by this data-driven approach to identify symptom cluster profiles. The adaptation of a symptom cluster-based approach could guide tailored patient-centered management of patients presenting with insomnia, and enhance patient care.
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Affiliation(s)
- Megan R Crawford
- Department of Psychology, Swansea University, Swansea, United Kingdom.,Department of Behavioral Sciences, Rush University Medical Center, Chicago, Illinois
| | | | - Toni Iurcotta
- Hofstra Northwell School of Medicine, Hempstead, New York
| | - Jack D Edinger
- Department of Medicine, National Jewish Health, Denver, Colorado
| | - James K Wyatt
- Department of Behavioral Sciences, Rush University Medical Center, Chicago, Illinois
| | - Rachel Manber
- Department of Psychiatry, Stanford University Medical Center, Palo Alto, California
| | - Jason C Ong
- Department of Behavioral Sciences, Rush University Medical Center, Chicago, Illinois.,Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Hein M, Lanquart JP, Loas G, Hubain P, Linkowski P. Prevalence and risk factors of moderate to severe obstructive sleep apnea syndrome in insomnia sufferers: a study on 1311 subjects. Respir Res 2017; 18:135. [PMID: 28683800 PMCID: PMC5501425 DOI: 10.1186/s12931-017-0616-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 06/28/2017] [Indexed: 11/10/2022] Open
Abstract
Background Several studies have investigated the prevalence and risk factors of insomnia in subjects with obstructive sleep apnea syndrome. However, few studies have investigated the prevalence and risk factors for obstructive sleep apnea syndrome in insomnia sufferers. Thus, the aim of this study was to examine the prevalence and risk factors of moderate to severe obstructive sleep apnea syndrome in a large sample of insomnia sufferers. Methods Data from 1311 insomnia sufferers who were recruited from the research database of the sleep laboratory of the Erasme Hospital were analysed. An apnea-hypopnea index of ≥15 events per hour was used as the cut-off score for moderate to severe obstructive sleep apnea syndrome. Logistic regression analyses were conducted to examine clinical and demographic risk factors of moderate to severe obstructive sleep apnea syndrome in insomnia sufferers. Results The prevalence of moderate to severe obstructive sleep apnea syndrome in our sample of insomnia sufferers was 13.88%. Multivariate logistic regression analysis revealed that male gender, snoring, excessive daytime sleepiness, lower maintenance insomnia complaint, presence of metabolic syndrome, age ≥ 50 & <65 years, age ≥ 65 years, BMI ≥ 25 & <30 kg/m2, BMI >30 kg/m2, and CRP >7 mg/L were significant risk factors of moderate to severe obstructive sleep apnea syndrome in insomnia sufferers. Conclusion Moderate to severe obstructive sleep apnea syndrome is a common pathology in insomnia sufferers. The identification of these different risk factors advances a new perspective for more effective screening of moderate to severe obstructive sleep apnea syndrome in insomnia sufferers.
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Affiliation(s)
- Matthieu Hein
- Department of Psychiatry and Sleep Laboratory, Erasme Hospital, Université Libre de Bruxelles, ULB, Route de Lennik, 808, 1070, Anderlecht, Brussels, Belgium.
| | - Jean-Pol Lanquart
- Department of Psychiatry and Sleep Laboratory, Erasme Hospital, Université Libre de Bruxelles, ULB, Route de Lennik, 808, 1070, Anderlecht, Brussels, Belgium
| | - Gwénolé Loas
- Department of Psychiatry and Sleep Laboratory, Erasme Hospital, Université Libre de Bruxelles, ULB, Route de Lennik, 808, 1070, Anderlecht, Brussels, Belgium
| | - Philippe Hubain
- Department of Psychiatry and Sleep Laboratory, Erasme Hospital, Université Libre de Bruxelles, ULB, Route de Lennik, 808, 1070, Anderlecht, Brussels, Belgium
| | - Paul Linkowski
- Department of Psychiatry and Sleep Laboratory, Erasme Hospital, Université Libre de Bruxelles, ULB, Route de Lennik, 808, 1070, Anderlecht, Brussels, Belgium
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Abstract
Excessive daytime sleepiness is defined as the inability to maintain wakefulness during waking hours, resulting in unintended lapses into sleep. It is important to distinguish sleepiness from fatigue. The evaluation of a sleep patient begins with a careful clinical assessment that includes a detailed sleep history, medical and psychiatric history, a review of medications, as well as a social and family history. Physical examination should include a general medical examination with careful attention to the upper airway and the neurologic examination. Appropriate objective testing with a polysomnogram and a multiple sleep latency test if needed will help confirm the diagnosis and direct the appropriate treatment plan.
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Affiliation(s)
- Renee Monderer
- Sleep-Wake Disorders Center, Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210(th) Street, Bronx, NY 10467, USA.
| | - Imran M Ahmed
- Sleep-Wake Disorders Center, Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210(th) Street, Bronx, NY 10467, USA
| | - Michael Thorpy
- Sleep-Wake Disorders Center, Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210(th) Street, Bronx, NY 10467, USA
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El-Solh AA, Vermont L, Homish GG, Kufel T. The effect of continuous positive airway pressure on post-traumatic stress disorder symptoms in veterans with post-traumatic stress disorder and obstructive sleep apnea: a prospective study. Sleep Med 2017; 33:145-150. [DOI: 10.1016/j.sleep.2016.12.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 12/07/2016] [Accepted: 12/17/2016] [Indexed: 11/26/2022]
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17
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Rissling MB, Gray KE, Ulmer CS, Martin JL, Zaslavsky O, Gray SL, Hale L, Zeitzer JM, Naughton M, Woods NF, LaCroix A, Calhoun PS, Stefanick M, Weitlauf JC. Sleep Disturbance, Diabetes, and Cardiovascular Disease in Postmenopausal Veteran Women. THE GERONTOLOGIST 2017; 56 Suppl 1:S54-66. [PMID: 26768391 DOI: 10.1093/geront/gnv668] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE OF THE STUDY To compare the prevalence and cardiometabolic health impact of sleep disturbance among postmenopausal Veteran and non-Veteran participants in the Women's Health Initiative (WHI). DESIGN AND METHODS The prevalence of five categories of sleep disturbance--medication/alcohol use for sleep; risk for insomnia; risk for sleep disordered breathing [SDB]; risk for comorbid insomnia and SDB (insomnia + SDB); and aberrant sleep duration [SLD]--was compared in 3,707 Veterans and 141,354 non-Veterans using logistic or multinomial regression. Cox proportional hazards models were used to evaluate the association of sleep disturbance and incident cardiovascular disease (CVD) and Type 2 diabetes in Veterans and non-Veterans. RESULTS Women Veterans were more likely to have high risk for insomnia + SDB relative to non-Veteran participants. However, prevalence of other forms of sleep disturbance was similar across groups. Baseline sleep disturbance was not differentially associated with cardiometabolic health outcomes in Veteran versus non-Veteran women. Risks for SDB and insomnia + SDB were both linked to heightened risk of CVD and diabetes; SLD was consistently linked with greater risk of CVD and diabetes in non-Veterans but less strongly and consistently in Veterans. IMPLICATIONS Efforts to identify and treat sleep disturbances in postmenopausal women are needed and may positively contribute to the attenuation of cardiometabolic morbidity risk. Increased awareness of women Veterans' vulnerability to postmenopausal insomnia + SDB may be particularly important for health care providers who treat this population.
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Affiliation(s)
- Michelle B Rissling
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), Durham VA Medical Center, North Carolina.
| | - Kristen E Gray
- Department of Veterans Affairs Puget Sound Health Care System, Health Services Research and Development, Seattle, Washington. Department of Health Services, University of Washington School of Public Health, Seattle
| | - Christi S Ulmer
- Health Services R&D, Durham VA Medical Center, North Carolina. Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, North Carolina
| | - Jennifer L Martin
- David Geffen School of Medicine, University of California Los Angeles. VA Sepulveda Ambulatory Care Center, Geriatric Research, Education and Clinical Center, North Hills, California
| | - Oleg Zaslavsky
- Faculty of Health Sciences and Social Welfare, University of Haifa, Israel
| | - Shelly L Gray
- University of Washington School of Pharmacy, Seattle
| | - Lauren Hale
- Program in Public Health, Stony Brook University School of Medicine, New York
| | - Jamie M Zeitzer
- VA Palo Alto Health Care System, Sierra Pacific Mental Illness Research, Education and Clinical Center, California. Department of Psychiatry and Behavioral Sciences, Stanford University, California
| | - Michelle Naughton
- College of Medicine, Division of Population Sciences, Department of Internal Medicine, Ohio State University
| | - Nancy F Woods
- Seattle WHI Clinical Center, Biobehavioral Nursing, University of Washington
| | - Andrea LaCroix
- Department of Epidemiology, University of California San Diego School of Medicine
| | - Patrick S Calhoun
- Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), Durham VA Medical Center, North Carolina. Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, North Carolina
| | - Marcia Stefanick
- Stanford Prevention Research Center, Department of Medicine and Obstetrics and Gynecology, Stanford University, California
| | - Julie C Weitlauf
- VA Palo Alto Health Care System, Sierra Pacific MIRECC and Center for Innovation to Implementation, California. Department of Psychiatry & Behavioral Sciences and Stanford Cancer Institute, Stanford University, California
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18
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[Basic medical management of sleep disordered breathing in elderly]. Nihon Ronen Igakkai Zasshi 2017; 54:335-342. [PMID: 28855457 DOI: 10.3143/geriatrics.54.335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Alexander M, Ray MA, Hébert JR, Youngstedt SD, Zhang H, Steck SE, Bogan RK, Burch JB. The National Veteran Sleep Disorder Study: Descriptive Epidemiology and Secular Trends, 2000-2010. Sleep 2016; 39:1399-410. [PMID: 27091538 DOI: 10.5665/sleep.5972] [Citation(s) in RCA: 121] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 03/16/2016] [Indexed: 12/31/2022] Open
Abstract
STUDY OBJECTIVES A large proportion of individuals affected by sleep disorders are untreated and susceptible to accidents, injuries, long-term sequelae (e.g., risk of cardiovascular disease, cancer, psychiatric disorders), and increased mortality risk. Few studies have examined the scope and magnitude of sleep disorder diagnoses in the United States (US) or factors influencing them. Veterans are particularly vulnerable to factors that elicit or exacerbate sleep disorders. METHODS This serial cross-sectional study characterized secular trends in diagnosed sleep disorders among veterans seeking care in US Veterans Health Administration facilities over an eleven-year span (FY2000-2010, n = 9,786,778). Electronic medical records from the national Veterans Administration Informatics and Computing Infrastructure database were accessed. Cases were defined using diagnostic codes specified by the American Academy of Sleep Medicine. Age-adjusted annual prevalence was summarized by sex, race, combat exposure, body mass index, and comorbid diagnoses (cardiovascular disease, cancer, mental disorders). RESULTS Sleep apnea (47%) and insomnia (26%) were the most common diagnoses among patients with any sleep disorder. There was a six-fold relative increase in total sleep disorder prevalence over the study period. Posttraumatic stress disorder, which tripled over the same time period, was associated with the highest prevalence of sleep disorders (16%) among the comorbid conditions evaluated. CONCLUSIONS The results indicate a growing need for integration of sleep disorder management with patient care and health care planning among US veterans. COMMENTARY A commentary on this article appears in this issue on page 1331.
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Affiliation(s)
- Melannie Alexander
- South Carolina Statewide Cancer Prevention & Control Program, University of South Carolina, Columbia, SC.,Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Meredith A Ray
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, TN
| | - James R Hébert
- South Carolina Statewide Cancer Prevention & Control Program, University of South Carolina, Columbia, SC.,Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC.,Department of Family and Preventive Medicine, School of Medicine, University of South Carolina, Columbia, SC
| | - Shawn D Youngstedt
- College of Nursing and Health Innovation, College of Health Solutions, Arizona State University, Phoenix VA Health Care System, Phoenix, AZ
| | - Hongmei Zhang
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, TN
| | - Susan E Steck
- South Carolina Statewide Cancer Prevention & Control Program, University of South Carolina, Columbia, SC.,Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | | | - James B Burch
- South Carolina Statewide Cancer Prevention & Control Program, University of South Carolina, Columbia, SC.,Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC.,WJB Dorn Department of Veterans Affairs Medical Center, Columbia, SC
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Abstract
OBJECTIVES The aims of the study were to determine whether mild, occult sleep-disordered breathing (SDB) moderates the efficacy of cognitive behavioral therapy for insomnia (CBTI) in older adults and to explore whether CBTI reduces the number of patients eligible for positive airway pressure (PAP) therapy. METHODS Data were analyzed for 134 adults 60 years or older with insomnia and apnea-hypopnea index (AHI) of less than 15 who were randomized to a larger study of CBTI versus a sleep education control. Sleep outcomes (sleep onset latency, total wake time, wake after sleep onset, sleep efficiency, Pittsburgh Sleep Quality Index) were compared between CBTI and control at 6 months using repeated-measures analysis of variance adjusted for baseline values. AHI of 5 or greater versus less than 5 was included as an interaction term to evaluate changes in sleep outcomes. The number of participants at baseline and 6 months with mild SDB for whom insomnia was their only other indication for PAP was also compared between CBTI and control. RESULTS AHI status (AHI ≥ 5 [75.5% of participants] versus AHI < 5) did not moderate improvements in sleep associated with CBTI (all p values ≥ .12). Nine (45.0%) of 20 participants with mild SDB for whom insomnia was their only other indication for PAP therapy at baseline no longer had another indication for PAP at 6 months, with no significant difference between CBTI and control. CONCLUSIONS CBTI improves sleep in older veterans with insomnia and untreated mild SDB. Larger trials are needed to assess whether CBTI reduces the number of patients with mild SDB eligible for PAP.
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Cognitive Behavioral Social Rhythm Group Therapy for Veterans with posttraumatic stress disorder, depression, and sleep disturbance: Results from an open trial. J Affect Disord 2016; 192:234-43. [PMID: 26748739 DOI: 10.1016/j.jad.2015.12.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 11/09/2015] [Accepted: 12/11/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Cognitive Behavioral Social Rhythm Therapy (CBSRT) is a group psychotherapy tailored for Veterans with Posttraumatic Stress Disorder (PTSD), Major Depressive Disorder (MDD), and sleep disturbances. The aims of this study were to introduce and present initial outcomes of Cognitive Behavioral Social Rhythm Therapy (CBSRT), a 12-week skills group therapy designed to improve sleep and mood by reducing chaotic or isolated lifestyles in Veterans with PTSD. METHODS Twenty-four male Veterans with at least moderate PTSD and MDD participated in this open trial. Main outcomes were the daily sleep diary for sleep disturbances, the Clinician-Administered PTSD Scale (CAPS) for PTSD, and the Hamilton Depression Rating scale for MDD. RESULTS Veterans improved on all measures (a) with large within subject effects on PTSD symptoms, MDD symptoms, and sleep quality, and (b) with 46-58% of the sample receiving clinically significant benefits on MDD and PTSD symptoms respectively. The consistency of social rhythms was associated with the average reduction in global CAPS scores over time. Only 13% of participants dropped-out of the group therapy prematurely suggesting that this new group therapy is relatively well-tolerated by Veterans. LIMITATIONS Future research that employs a control condition is necessary to establish efficacy of CBSRT. CONCLUSIONS Data from this initial pilot study demonstrate that CBSRT may be an effective group treatment option for Veterans presenting with all three symptom complaints. These data also suggest that daily routine may be an important mechanism to consider in the treatment of PTSD symptoms comorbid with depression.
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The Determining Risk of Vascular Events by Apnea Monitoring (DREAM) study: design, rationale, and methods. Sleep Breath 2015; 20:893-900. [DOI: 10.1007/s11325-015-1254-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 08/25/2015] [Accepted: 09/03/2015] [Indexed: 12/13/2022]
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Krakow B, Ulibarri VA, McIver ND. Pharmacotherapeutic failure in a large cohort of patients with insomnia presenting to a sleep medicine center and laboratory: subjective pretest predictions and objective diagnoses. Mayo Clin Proc 2014; 89:1608-20. [PMID: 25236429 DOI: 10.1016/j.mayocp.2014.04.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 04/02/2014] [Accepted: 04/17/2014] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Barry Krakow
- Sleep & Human Health Institute, Albuquerque, NM; Maimonides Sleep Arts & Sciences, Ltd, Albuquerque, NM; Los Alamos Medical Center, Los Alamos, NM.
| | - Victor A Ulibarri
- Sleep & Human Health Institute, Albuquerque, NM; Maimonides Sleep Arts & Sciences, Ltd, Albuquerque, NM
| | - Natalia D McIver
- Sleep & Human Health Institute, Albuquerque, NM; Maimonides Sleep Arts & Sciences, Ltd, Albuquerque, NM
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