Associations of Undiagnosed Obstructive Sleep Apnea and Excessive Daytime Sleepiness With Depression: An Australian Population Study

Association between gardening and multiple sleep complaints: A nationwide study of 62,098 adults

BACKGROUND

Physical activity was suggested to be related to sleep health, while the gardening-sleep association among the community population remained unrevealed. Therefore, this study aimed to explore whether gardening was associated with sleep complaints.

METHODS

A total of 62,098 adults from the 2017 Behavioral Risk Factor Surveillance System (BRFSS) were included in this study and further categorized as non-exercisers, gardeners, and other exercisers, based on their self-reported exercise status. Sleep complaints including short/prolonged sleep duration, probable insomnia, daytime sleepiness, and sleep apnea were surveyed via a questionnaire. Primary outcome was multiple sleep complaints (coexistence of ≥2 sleep complaints) and secondary outcomes referred to individual sleep complaints. The adjusted odds ratios (ORs) and 95 % confidence intervals (CIs) were estimated to assess the associations between gardening or tertiles of gardening duration and the outcomes using multivariable logistic regression models.

RESULTS

The sample included 16,707 non-exercisers, 4243 gardeners, and 41,148 other exercisers. Relative to non-exercisers, gardeners (OR 0.58, 95%CI 0.49-0.67) and other exercisers (OR 0.67, 95%CI 0.61-0.72) had a lower likelihood of experiencing multiple sleep complaints. The adjusted OR comparing the highest gardening duration tertile to non-exercise was 0.45 (95%CI 0.33-0.63) for multiple sleep complaints (P for trend <0.001). Similar patterns persisted in several individual sleep complaints, such as short sleep duration, probable insomnia, daytime sleepiness, and sleep apnea.

LIMITATIONS

Cross-sectional study design and use of self-reported variables.

CONCLUSIONS

This nationwide study observed an inverse association of gardening with multiple sleep complaints and several individual sleep complaints, in a dose-response manner.

Obstructive sleep apnea and mental disorders: a bidirectional mendelian randomization study

BACKGROUND

Previous studies have reported associations between obstructive sleep apnea (OSA) and several mental disorders. However, further research is required to determine whether these associations are causal. Therefore, we evaluated the bidirectional causality between the genetic liability for OSA and nine mental disorders by using Mendelian randomization (MR).

METHOD

We performed two-sample bidirectional MR of genetic variants for OSA and nine mental disorders. Summary statistics on OSA and the nine mental disorders were extracted from the FinnGen study and the Psychiatric Genomics Consortium. The primary analytical approach for estimating causal effects was the inverse-variance weighted (IVW), with the weighted median and MR Egger as complementary methods. The MR Egger intercept test, Cochran's Q test, Rucker's Q test, and the MR pleiotropy residual sum and outlier (MR-PRESSO) test were used for sensitivity analyses.

RESULT

MR analyses showed that genetic liability for major depressive disorder (MDD) was associated with an increased risk of OSA (odds ratio [OR] per unit increase in the risk of MDD, 1.29; 95% CI, 1.11-1.49; P < 0.001). In addition, genetic liability for OSA may be associated with an increased risk of attention-deficit/hyperactivity disorder (ADHD) (OR = 1.26; 95% CI, 1.02-1.56; p = 0.032). There was no evidence that OSA is associated with other mental disorders.

CONCLUSION

Our study indicated that genetic liability for MDD is associated with an increased risk of OSA without a bidirectional relationship. Additionally, there was suggestive evidence that genetic liability for OSA may have a causal effect on ADHD. These findings have implications for prevention and intervention strategies targeting OSA and ADHD. Further research is needed to investigate the biological mechanisms underlying our findings and the relationship between OSA and other mental disorders.

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.

Approach the Patient With Obstructive Sleep Apnea and Obesity

Obstructive sleep apnea (OSA) and obesity are highly prevalent and bidirectionally associated. OSA is underrecognized, however, particularly in women. By mechanisms that overlap with those of obesity, OSA increases the risk of developing, or having poor outcomes from, comorbid chronic disorders and impairs quality of life. Using 2 illustrative cases, we discuss the relationships between OSA and obesity with type 2 diabetes, dyslipidemia, cardiovascular disease, cognitive disturbance, mood disorders, lower urinary tract symptoms, sexual function, and reproductive disorders. The differences in OSA between men and women, the phenotypic variability of OSA, and comorbid sleep disorders are highlighted. When the probability of OSA is high due to consistent symptoms, comorbidities, or both, a diagnostic sleep study is advisable. Continuous positive airway pressure or mandibular advancement splints improve symptoms. Benefits for comorbidities are variable depending on nightly duration of use. By contrast, weight loss and optimization of lifestyle behaviors are consistently beneficial.

Multi-night measurement for diagnosis and simplified monitoring of obstructive sleep apnoea

Substantial night-to-night variability in obstructive sleep apnoea (OSA) severity has raised misdiagnosis and misdirected treatment concerns with the current prevailing single-night diagnostic approach. In-home, multi-night sleep monitoring technology may provide a feasible complimentary diagnostic pathway to improve both the speed and accuracy of OSA diagnosis and monitor treatment efficacy. This review describes the latest evidence on night-to-night variability in OSA severity, and its impact on OSA diagnostic misclassification. Emerging evidence for the potential impact of night-to-night variability in OSA severity to influence important health risk outcomes associated with OSA is considered. This review also characterises emerging diagnostic applications of wearable and non-wearable technologies that may provide an alternative, or complimentary, approach to traditional OSA diagnostic pathways. The required evidence to translate these devices into clinical care is also discussed. Appropriately sized randomised controlled trials are needed to determine the most appropriate and effective technologies for OSA diagnosis, as well as the optimal number of nights needed for accurate diagnosis and management. Potential risks versus benefits, patient perspectives, and cost-effectiveness of these novel approaches should be carefully considered in future trials.

Bi-level VNS therapy with different therapy modes at night and daytime improves seizures and quality of life in a patient with drug-resistant epilepsy

Induction or aggravation of sleep apnea is a known side effect of vagus nerve stimulation (VNS). We report the case of a 44 year old male with drug-resistant epilepsy and depression who did not experience any seizure reduction after 1 year of VNS but a worsening of depression and daytime sleepiness. After confirming VNS-associated sleep apnea we started the first bi-level VNS therapy with standard VNS settings during daytime and reduced settings during nighttime. Anti-seizure medication remained unchanged. Within 12 months his seizure frequency was reduced by 90 % and his depression improved, permitting a cessation of his antidepressant medication. The observations made in this case have contributed to the manufacturer of VNS developing new generator models that can automatically provide bi-level VNS.

Influence of excessive daytime sleepiness on the treatment adherence of obstructive sleep apnea

OBJECTIVES

To compare positive airway pressure (PAP) adherence between patients with or without excessive daytime sleepiness (EDS) in mild, moderate and severe obstructive sleep apnea (OSA).

METHODS

Patients ≥18 years diagnosed with OSA in 2018 and 2019, without previous history of PAP usage and with adherence registration in the first medical consultation after treatment initiation, were included. EDS was defined as a score of ≥10 on the Epworth Scale. Patients were divided into two groups according to the adherence to PAP: "Adherent" if using the device for ≥4 h for ≥70% of the nights and "Nonadherent" otherwise. Simple and multiple logistic regression models for adherence were determined.

RESULTS

321 patients were included, most male (64.2%), with mean age 56.56 years. Most patients had severe OSA (n = 159; 49.5%), and median AHI was 29.3/h [16.8; 47.5]. Being older or having a severe OSA resulted in an increased adherence (OR = 1.020, CI95% = [1.002; 1.039] and OR = 2.299, CI95% = [1.273; 4.191], respectively). In patients without EDS a statistically significant difference was found in adherence between those with severe OSA and both mild and moderate OSA categories (OR = 0.285, p = 0.023 and OR = 0.387, p = 0.026, respectively), with patients with severe OSA being adherent. There was no statistical difference in adherence between patients with or without EDS (OR 1.083; p = 0.876), nor in the different degrees of severity in those with EDS.

CONCLUSION

In our study there were no differences in PAP therapy adherence between patients with or without excessive daytime sleepiness. Older age and higher OSA severity resulted in higher adherence rates.

Daytime sleepiness is associated with increased coronary plaque burden among patients with obstructive sleep apnea

PURPOSE

To investigate the cross-sectional associations of daytime sleepiness with coronary plaque volume and composition in patients with obstructive sleep apnea (OSA), and whether or not these associations are modified by age, gender, and obesity.

METHODS

Patients who were confirmed with OSA through respiratory polygraphy and also underwent coronary CTA at a tertiary hospital were consecutively enrolled. The interval between the sleep monitoring and coronary CTA scan was  < 3 months. Every patient completed the Epworth sleepiness scale (ESS) to assess daytime sleepiness, and an ESS score of ≥ 11 was recognized as excessive daytime sleepiness (EDS). Coronary plaque volume and composition were measured using semi-automatic software.

RESULTS

Of the 394 patients with OSA (median [IQR] age, 56.0 [49.0-64.0] years; median [IQR] body mass index, 27.9 [25.5-30.2] kg/m2; median [IQR] apnea-hypopnea index, 21.3 [11.7, 36.3] events/h), a total of 200 patients had EDS. In the overall participants, a significant dose-response relationship between ESS scores and low-attenuation plaque volume was found in the fully adjusted model (P = 0.019). Further analysis demonstrated that there was a significant interactive effect of ESS levels and obesity on coronary plaque volume (all P values for interaction analysis < 0.05). Specifically, ESS levels were associated with total plaque volume, volumes of noncalcified, low-attenuation, and calcified plaque (P = 0.008, 0.006, 0.005, and 0.043 respectively) in obese patients with OSA.

CONCLUSION

Daytime sleepiness is significantly correlated with increased coronary plaque burden among patients with OSA. Thus, clinicians should recognize that patients with OSA reporting high ESS scores, especially those with obesity, are more prone to experience adverse coronary events.

Work-Related Sleep Disorders: Causes and Impacts

Insufficient sleep syndrome, shift work disorder, and obstructive sleep apnea (OSA) not only significantly impact the health of affected individuals, but also pose a threat to public safety. This article describes the clinical manifestations and impact of these sleep disorders, particularly as they pertain to workers' health and those with safety-sensitive positions. Sleep deprivation, circadian rhythm disruptions, and excessive daytime sleepiness-hallmarks of insufficient sleep, shift work disorder, and OSA, respectively-all lead to a series of cognitive deficits and impaired concentration that affect workers in a wide variety of fields. We describe the health consequences of these disorders along with treatment strategies, with a focus on current regulatory standards and the under-recognition of OSA in commercial drivers. Given its large scale, there is a need for improved guidelines and regulations for the screening, diagnosis, treatment, and long-term follow-up of OSA in commercial motor vehicle drivers. Increased recognition of the ways in which these sleep disorders impact workers will pave the way for significant improvements in occupational health and safety.

High night-to-night variability in sleep apnea severity is associated with uncontrolled hypertension

Obstructive sleep apnea (OSA) severity can vary markedly from night-to-night. However, the impact of night-to-night variability in OSA severity on key cardiovascular outcomes such as hypertension is unknown. Thus, the primary aim of this study is to determine the effects of night-to-night variability in OSA severity on hypertension likelihood. This study uses in-home monitoring of 15,526 adults with ~180 nights per participant with an under-mattress sleep sensor device, plus ~30 repeat blood pressure measures. OSA severity is defined from the mean estimated apnea-hypopnoea index (AHI) over the ~6-month recording period for each participant. Night-to-night variability in severity is determined from the standard deviation of the estimated AHI across recording nights. Uncontrolled hypertension is defined as mean systolic blood pressure ≥140 mmHg and/or mean diastolic blood pressure ≥90 mmHg. Regression analyses are performed adjusted for age, sex, and body mass index. A total of 12,287 participants (12% female) are included in the analyses. Participants in the highest night-to-night variability quartile within each OSA severity category, have a 50-70% increase in uncontrolled hypertension likelihood versus the lowest variability quartile, independent of OSA severity. This study demonstrates that high night-to-night variability in OSA severity is a predictor of uncontrolled hypertension, independent of OSA severity. These findings have important implications for the identification of which OSA patients are most at risk of cardiovascular harm.

Association of sleep apnea and depressive symptoms among US adults: a cross-sectional study

BACKGROUND

Sleep apnea exerts adverse health effects due to inflammation and metabolic disruption. It is associated with metabolic diseases. However, the evidence of its relationship with depression is inconsistent. Therefore, this study aimed to investigate the relationship between sleep apnea and depressive symptoms in adults in the United States.

METHODS

This study utilized data from the National Health and Nutrition Examination Survey (NHANES), wherein the data from 2005 to 2018 of 9,817 individuals were obtained. Sleep apnea was self-reported by the participants using a questionnaire on sleep disorders. The 9-item Patient Health Questionnaire (PHQ-9) was used to assess depressive symptoms. We implemented multivariable logistic regression and stratified analyses to assess the correlation between sleep apnea and depressive symptoms.

RESULTS

A total of 515 (6.6%) participants among 7,853 non-sleep apnea participants and 269 (13.7%) subjects among 1,964 sleep apnea participants had a depression score ≥ 10, they were deemed to have depressive symptoms. The multivariable regression model, showed that individuals with sleep apnea were 1.36-fold more likely to experience depressive symptoms when adjusted for potential covariates (odds ratios [OR] with 95% confidence intervals of 2.36 [1.71-3.25]), and a positive correlation between depressive symptoms and sleep apnea severity was found. The stratified analyses, revealed that sleep apnea was related to an increased incidence of depressive symptoms in most subgroups, except for those with coronary heart disease. Further, there was no interaction between sleep apnea and the covariates.

CONCLUSIONS

Adults with sleep apnea in the US have a relatively high prevalence of depressive symptoms. and the severity of sleep apnea positively correlated with the depressive symptoms.

Single-Night Diagnosis of Sleep Apnea Contributes to Inconsistent Cardiovascular Outcome Findings

BACKGROUND

Single-night disease misclassification of OSA due to night-to-night variability may contribute to inconsistent findings in OSA trials.

RESEARCH QUESTION

Does multinight quantification of OSA severity provide more precise estimates of associations with incident hypertension?

STUDY DESIGN AND METHODS

A total of 3,831 participants without hypertension at baseline were included in simulation analyses. Included participants had ≥ 28 days of nightly apnea-hypopnea index (AHI) recordings via an under-mattress sensor and ≥ 3 separate BP measurements over a 3-month baseline period followed by ≥ 3 separate BP measurements 6 to 9 months postbaseline. Incident hypertension was defined as a mean systolic BP ≥ 140 mm Hg or a mean diastolic BP ≥ 90 mm Hg. Simulated trials (1,000) were performed, using bootstrap methods to investigate the effect of variable numbers of nights (x = 1-56 per participant) to quantify AHI and the ability to detect associations between OSA and incident hypertension via logistic regression adjusted for age, sex, and BMI.

RESULTS

Participants were middle-aged (mean ± SD, 52 ± 12 y), mostly men (91%), and overweight (BMI, 28 ± 5 kg/m²). Single-night quantification of OSA failed to detect an association with hypertension risk in 42% of simulated trials (α = 0.05). Conversely, 100% of trials detected an association when AHI was quantified over ≥ 28 nights. Point estimates of hypertension risk were also 50% higher and uncertainty was 5 times lower during multinight vs single-night simulation trials.

INTERPRETATION

Multinight monitoring of OSA allows for better estimates of hypertension risk and potentially other adverse health outcomes associated with OSA. These findings have important implications for clinical care and OSA trial design.

Screening for obstructive sleep apnoea in patients with serious mental illness

OBJECTIVE

Patients with serious mental illness (SMI) are at increased risk of obstructive sleep apnoea (OSA). Despite this, OSA is frequently under-recognised in the psychiatric population. This study describes the results of OSA screening in SMI patients.

METHOD

Patients with SMI attending a metropolitan mental health clinic were screened for OSA using the OSA50, STOP-BANG Questionnaire (SBQ), Epworth Sleep Score (ESS) and the Pittsburgh Sleep Quality Index (PSQI). They were then offered diagnostic sleep testing via ResMed ApneaLink^TM and polysomnography.

RESULTS

Of the 65 patients recruited, 65% had a primary diagnosis of schizophrenia or schizoaffective disorder, 85% were on antipsychotic medications and the majority were obese. Approximately 50% of patients reported poor sleep quality via the PSQI, in contrast to 12% with elevated daytime sleepiness via the ESS. 46% of our cohort were at risk of OSA due to an elevated OSA50 or SBQ. Of the five patients who agreed to proceed to diagnostic sleep testing, three were diagnosed with OSA.

CONCLUSION

A high proportion of patients with psychiatric illness are at risk of sleep-disordered breathing. Sleep dissatisfaction is high. The low uptake of sleep investigation requires improved patient engagement to improve OSA diagnosis in this high-risk group.

Application value of joint STOP-Bang questionnaire and Epworth Sleepiness Scale in screening for obstructive sleep apnea

Objective

This paper evaluates the application value of the STOP-Bang questionnaire combined with the Epworth Sleepiness Scale (ESS) in screening for obstructive sleep apnea (OSA) in the population.

Method

Thousand-six hundred seventy-one patients with suspected OSA who visited the Sleep Medicine Center of the First Affiliated Hospital of Guangzhou Medical University from August 2017 to August 2020 were monitored by overnight polysomnography (PSG) after completing the ESS scale and STOP-Bang questionnaire. The sensitivity, specificity, positive predictive value, negative predictive value and receiver operating characteristic (ROC) curves of the two scales were calculated, and the accuracy in predicting OSA of the STOP-Bang questionnaire combined with ESS was analyzed.

Results

With Apnea Hypopnea Index (AHI) cutoffs of ≥5, ≥15 and ≥30 events/h, the areas under the ROC curve scored by STOP-Bang were 0.724, 0.703 and 0.712, and those of ESS were 0.632, 0.634 and 0.695; the diagnostic odds ratio (DOR) values of STOP-Bang for OSA, moderate to severe OSA, and severe OSA were 3.349, 2.651 and 3.189, and those of ESS were 2.665, 2.279 and 3.289. The STOP-Bang score of three was used as the cut-off point for OSA diagnosis with higher sensitivity and lower specificity, while ESS had higher specificity. STOP-Bang (≥3) combined with ESS significantly improved its specificity for predicting OSA.

Conclusion

The STOP-Bang questionnaire is a simple and effective new tool for screening patients for OSA, while a STOP-Bang score of ≥3 combined with ESS can further improve its specificity. Thus, we suggest further screening with ESS after a STOP-Bang score of ≥3 in suspected patients.

The Number of Monthly Night Shift Days and Depression Were Associated with an Increased Risk of Excessive Daytime Sleepiness in Emergency Physicians in South Korea

This study aimed to report the prevalence and identify the factors associated with excessive daytime sleepiness (EDS) among emergency physicians in South Korea. We analyzed the Korean Emergency Physicians Survey data from 15 January to 26 February 2021. EDS was evaluated using the Epworth sleepiness scale, and a score of 11 or more indicated the presence of EDS. We conducted univariable and multivariable logistic regression analyses to verify the associated factors. A total of 1307 participants responded to the survey, and the response rate was 61.3%. Nine hundred fifty-four participants were included in the study. Two hundred ninety-three participants were classified as the EDS group, and six hundred sixty-one were classified as the non-EDS group. The prevalence of EDS was 30.7% (95% confidence interval (CI), 27.8–33.6%). Monthly night-shift days (odds ratio (OR) 1.106, 95% CI 1.028–1.191) and depression (OR 2.635, 95% CI 1.799–3.861) were significantly associated with an increased risk of EDS, and fair sleep quality (OR 0.560, 95% CI 0.318–0.985) was associated with a decreased risk of EDS. Almost one in three emergency physicians in South Korea suffer from daytime sleepiness. The number of monthly night-shift days and depression were associated with an increased risk of EDS.

Age and sex differences on the association between anxiety disorders and obstructive sleep apnea: A nationwide case-control study in Taiwan

AIM

The aim of this study was to examine the association between anxiety disorders and obstructive sleep apnea (OSA).

METHODS

This is a population-based, retrospective case-control study using Taiwan's nationwide database. We included patients with OSA aged ≥12 years, diagnosed according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes: 327 and 780. Each enrolled patient with OSA needed to undergo a polysomnography examination within 1 year pre- or post-OSA occurrence. Patients with OSA and controls were selected in a 1:4 ratio. Patients with anxiety disorders (ICD-9-CM code 300) were diagnosed by board-certified psychiatrists and required to visit the outpatient clinic at least three times per year. Multivariate logistic regression and interaction analyses were used to evaluate the objective association.

RESULTS

This study enrolled 7987 and 31 948 participants with and without OSA, respectively. A significant difference in anxiety exposure was observed only pre-OSA diagnosis but not post-OSA diagnosis. Compared with patients without anxiety disorders: (i) those with anxiety disorders had an adjusted odds ratio (aOR) of ≈1.864 in OSA comorbidity (aOR = 1.864; 95% confidence interval [CI] = 1.337-2.405); and (ii) subgroup analysis showed a significant interaction that anxiety patients of male sex, aged 18 to 44 years, aged 45 to 64 years, and hypertension had a higher aOR in OSA comorbidity (aOR = 2.104 [95% CI = 1.436-2.589], aOR = 1.942 [95% CI = 1.390-2.503], aOR = 2.179 [95% CI = 1.564-2.811], and aOR = 2.092 [95% CI = 1.497-2.706], respectively).

CONCLUSION

The study revealed a higher ratio of previous anxiety exposure in patients with OSA. Compared with those without anxiety, anxiety patients of male sex, aged 18 to 64 years, and with hypertension had a higher risk of OSA comorbidity.

Obstructive Sleep Apnoea Severity Is Negatively Associated with Depressive Symptoms: A Cross-Sectional Survey of Outpatients with Suspected Obstructive Sleep Apnoea in Japan

Background: Multiple clinical departments are involved in the provision of obstructive sleep apnoea (OSA) therapy in Japan. Inconsistent results regarding the association between depression and OSA have been reported. Methods: This cross-sectional survey compared newly diagnosed OSA patients at two outpatient sleep apnoea units in Shiga Prefecture, Japan: one associated with the psychiatry department (n = 583), and the other with the otolaryngology department (n = 450). Results: The unit associated with the psychiatry department had more patients referred by psychiatrists than that with the otolaryngology department (11% vs. 3% p < 0.05). Sleepiness, insomnia, and depression were assessed using the Epworth Sleepiness Scale (ESS), Athens Insomnia Scale (AIS), and Patient Health Questionnaire-9 (PHQ-9), respectively. The ESS, AIS, and PHQ-9 scores were higher in the sleep unit in the psychiatry department (p < 0.001 each). Snoring and moderate to severe OSA were more prevalent in the unit attached to the otolaryngology department (p < 0.001 each). Patients with moderate to severe OSA had lower PHQ-9 scores than those with no to mild OSA (OR: 0.96, 95% CI: 0.92−1.00, p = 0.042). Conclusion: Patients with sleepiness, insomnia, and depressive symptoms were more likely to attend a sleep outpatient unit associated with a psychiatry department, whereas those with snoring and sleep apnoea attended that associated with an otolaryngology department. OSA severity was negatively associated with depressive symptoms.

Prevalence and effects of sleep-disordered breathing on middle-aged patients with sedative-free generalized anxiety disorder: A prospective case-control study

OBJECTIVE

Generalized anxiety disorder (GAD) and sleep-disordered breathing (SDB) share similar symptoms, such as poor sleep quality, irritability, and poor concentration during daily activities. This study aims to investigate the proportion of undiagnosed SDB and its impacts on anxiety severity and autonomic function in newly diagnosed, sedative-free GAD patients.

METHODS

This prospective case-control study included newly diagnosed GAD patients and control participants with matched age, sex, and body mass index (BMI) in Taiwan. All participants completed questionnaires for sleep and mood symptoms and a resting 5-min heart rate variability (HRV) examination during enrollment. The participants also used a home sleep apnea test to detect SDB. An oxygen desaturation index (ODI) ≥ 5 was considered indicative of SDB.

RESULTS

In total, 56 controls and 47 newly diagnosed GAD participants (mean age 55.31 ± 12.36 years, mean BMI 23.41 ± 3.42 kg/m²) were included. There was no significant difference in the proportion of undiagnosed SDB in the control and sedative-free GAD groups (46.43 vs. 51.06%). Sedative-free GAD patients with SDB scored significantly higher on Beck Anxiety Inventory (23.83 ± 11.54) than those without SDB (16.52 ± 10.61) (p < 0.001). Both control and sedative-free GAD groups with SDB had worse global autonomic function than the control group without SDB, as evidenced by the HRV results (p < 0.05 for all).

CONCLUSION

Average age 55 years and mean BMI 23 kg/m² patients with GAD and matched controls had an undiagnosed SDB prevalence of approximately 50%. SDB correlated with worsening anxiety severity and reduced cardiac autonomic function. Moreover, age and BMI were considered major risk factors for predicting undiagnosed SDB.

Multi-night Prevalence, Variability, and Diagnostic Misclassification of Obstructive Sleep Apnea

Rationale Recent studies suggest that obstructive sleep apnea (OSA) severity can vary markedly from night to night which may have important implications for diagnosis and management. Objectives This study aimed to assess OSA prevalence from multi-night in-home recordings and the impact of night-to-night variability in OSA severity on diagnostic classification in a large, global, non-randomly selected community sample from a consumer database of people that purchased a novel, validated, under-mattress sleep analyzer. Methods 67,278 individuals aged between 18 and 90 years underwent in-home nightly monitoring over an average of ~170 nights per participant between July 2020 to March 2021. OSA was defined as a nightly mean apnea-hypopnea index (AHI) >15 events/h. Outcomes were multi-night global prevalence and likelihood of OSA misclassification from a single night AHI value. Measurements and Main Results Over 11.6 million nights of data were collected and analyzed. OSA global prevalence was 22.6% (95% CI: 20.9-24.3%). The likelihood of misdiagnosis in people with OSA based on a single night ranged between ~20% and 50%. Misdiagnosis error rates decreased with increased monitoring nights (e.g. 1-night F1-score=0.77 vs. 0.94 for 14-nights); and remained stable after 14-nights of monitoring. Conclusions Multi-night in-home monitoring using novel non-invasive under mattress sensor technology indicates a global prevalence of moderate to severe OSA of ~20%, and that ~20% of people diagnosed with a single night study may be misclassified. These findings highlight the need to consider night-to-night variation on OSA diagnosis and management. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Current Management of Residual Excessive Daytime Sleepiness Due to Obstructive Sleep Apnea: Insights for Optimizing Patient Outcomes

Although excessive daytime sleepiness (EDS) attributable to obstructive sleep apnea (OSA) can be resolved by consistent usage of and effective treatment (often with the use of continuous positive airway pressure therapy), 12–58% of patients report residual EDS (REDS). While REDS is difficult to treat, a proportion of cases are possibly due to reversible issues, and wake-promoting medications can prove useful for the remaining cases. Given the challenges associated with effective management of REDS and its relationship to multiple comorbidities, multidisciplinary management of patients with REDS is often recommended. Here we aim to bridge the knowledge gap on the burden, risk factors, prevalence, and potential pathophysiologic mechanisms of REDS in patients with OSA after first-line treatment. The roles of primary care physicians and sleep specialists, as well as the importance of the use of objective assessment tools for the evaluation of REDS and the effective management of comorbidities, are discussed. An update of approved treatments and emerging candidate treatments is also presented.

Association of Excessive Daytime Sleepiness with the Zung Self-Rated Depression Subscales in Adults with Coronary Artery Disease and Obstructive Sleep Apnea

Excessive daytime sleepiness (EDS) is a factor associated with both obstructive sleep apnea (OSA) and depressive symptoms. Continuous positive airway pressure (CPAP) treatment may decrease EDS in adults with OSA; however, the modulatory role of depressive symptoms on the improvement of EDS is not known. We aimed to explore the association between subscales of the Zung Self-rated Depression Scale (SDS) and Epworth Sleepiness Scale (ESS) over a 2-year period in coronary artery disease (CAD) patients with OSA. This was a post-hoc analysis of the RICCADSA cohort, in which 399 adults with CAD (155 sleepy OSA [apnea-hypopnea index ≥ 15/h] and ESS score ≥ 10, who were offered CPAP; and 244 nonsleepy OSA [ESS < 10]), randomized to CPAP [n = 122] or no-CPAP [n = 122]) were included. Three factors were extracted from the Zung SDS, based on the principal component analysis: F1, cognitive symptoms and anhedonia; F2, negative mood; and F3, appetite. In a mixed model, the ESS score decreased by 3.4 points (p < 0.001) among the sleepy OSA phenotype, which was predicted by the decline in the F2, but not in the F1 and F3 scores. The fixed effects of time were not significant in the nonsleepy OSA groups, and thus, further analyses were not applicable. Additional within-group analyses showed a significant decrease in all subscales over time both in the sleepy and nonsleepy OSA patients on CPAP whereas there was a significant increase in the nonsleepy OSA group randomized to no-CPAP. We conclude that the improvement in negative mood symptoms of depression, but not changes in cognitive symptoms and anhedonia as well as appetite, was a significant predictor of decline in the ESS scores over a 2-year period in this CAD cohort with sleepy OSA on CPAP treatment.

Sleepiness Behind the Wheel and the Implementation of European Driving Regulations

Sleep disturbance and sleepiness are established risk factors for driving accidents and obstructive sleep apnea (OSA) is the most prevalent medical disorder associated with excessive daytime sleepiness. Because effective treatment of OSA reduces accident risk, several jurisdictions have implemented regulations concerning the ability of patients with OSA to drive, unless effectively treated. This review provides a practical guide for clinicians who may be requested to certify a patient with OSA as fit to drive regarding the scope of the problem, the role of questionnaires and driving simulators to evaluate sleepiness, and the benefit of treatment on accident risk.

Economic evaluation of diagnostic sleep studies for obstructive sleep apnoea: a systematic review protocol

BACKGROUND

Obstructive sleep apnoea (OSA) is a significant public health problem affecting a large proportion of the population and is associated with adverse health consequences and a substantial economic burden. Despite the existence of effective treatment, undiagnosed OSA remains a challenge. The gold standard diagnostic tool is polysomnography (PSG), yet the test is expensive, labour intensive and time-consuming. Home-based, limited channel sleep study testing (levels 3 and 4) can advance and widen access to diagnostic services. This systematic review aims to summarise available evidence regarding the cost-effectiveness of limited channel tests compared to laboratory and home PSG in diagnosing OSA.

METHODS

Eligible studies will be identified using a comprehensive strategy across the following databases from inception onwards: MEDLINE, PsychINFO, SCOPUS, CINAHL, Cochrane Library, Emcare and Web of Science Core Collection and ProQuest databases. The search will include a full economic evaluation (i.e. cost-effectiveness, cost-utility, cost-benefit, cost-consequences and cost-minimisation analysis) that assesses limited channel tests and PSG. Two reviewers will screen, extract data for included studies and critically appraise the articles for bias and quality. Meta-analyses will be conducted if aggregation of outcomes can be performed. Qualitative synthesis using a dominance ranking matrix will be performed for heterogeneous data.

DISCUSSION

This systematic review protocol uses a rigorous, reproducible and transparent methodology and eligibility criteria to provide the current evidence relating to the clinical and economic impact of limited channel and full PSG OSA diagnostic tests. Evidence will be examined using standardised tools specific for economic evaluation studies.

TRIAL REGISTRATION

PROSPERO (CRD42020150130).

Validation of the STOP-Bang questionnaire for screening of obstructive sleep apnea in the general population and commercial drivers: a systematic review and meta-analysis

Purpose

Obstructive sleep apnea (OSA) is a critical occupational health concern, but is often undiagnosed in the general population and commercial drivers. The STOP-Bang questionnaire is a simple, reliable tool to screen for OSA, which could improve public health in a cost-effective manner. The objective of this systematic review and meta-analysis is to assess the validity of the STOP-Bang questionnaire to detect OSA in these key populations.

Methods

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, Journals @ Ovid, Web of Science, Scopus, and CINAHL for relevant articles from 2008 to March 2020. The quality of studies was appraised using Cochrane Methods criteria. To calculate pooled predictive parameters, we created 2 × 2 contingency tables and performed random-effects meta-analyses.

Results

Of 3871 citations, five studies that evaluated STOP-Bang in the general population (n = 8585) and two in commercial drivers (n = 185) were included. In the general population, prevalence of all OSA (AHI ≥ 5), moderate-to-severe OSA (AHI ≥ 15), and severe OSA (AHI ≥ 30) was 57.6%, 21.3%, and 7.8% respectively. In commercial drivers, the prevalence of moderate-to-severe OSA was 37.3%. The trends of high sensitivity and negative predictive value of a STOP-Bang score ≥ 3 illustrates that the questionnaire helps detect and rule out clinically significant OSA in the general population and commercial drivers.

Conclusion

This meta-analysis demonstrates that the STOP-Bang questionnaire is a valid and effective screening tool for OSA in the general population and commercial drivers.

Trial registration

PROSPERO No. CRD42020200379; 08/22/2020

Supplementary Information

The online version contains supplementary material available at 10.1007/s11325-021-02299-y.

Increased risk of major depressive disorder in sleep apnea patients in Taiwan

The association between sleep apnea (SA) and depression had been reported in a few previous studies. However, whether SA increases the risk of major depressive disorder (MDD) has not been studied comprehensively in a large-scale study. We performed this population-based cohort study to assess the association between SA and MDD. We identified adult patients having SA from the Taiwan National Health Insurance Research Database and excluded those having MDD before SA diagnosis. Thirty control subjects were randomly selected to match to each SA patient by age and sex. Totally, 10,259 SA patients were matched to 102,590 control subjects. The incidence rate and cumulative incidence of MDD were significantly higher in SA patients than in the control subjects (both p < 0.0001). Multivariable Cox regression analysis showed that SA remained an independent risk factor for incident MDD after adjusting for age, sex, residency, income level, and comorbidities (hazard ratio = 2.9 [95% CI 2.8–3.1], p < 0.0001). In summary, SA patients have an increased risk to develop MDD. Physicians caring for SA patients must pay attention to their psychosocial health status.

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

Excessive daytime sleepiness (EDS) is a significant public health concern, with obstructive sleep apnea (OSA) being a common cause, and a particular relationship exists with the severity of depression. A literature search on OSA, depression, and EDS was performed in PubMed. The chosen evidence was limited to human studies. Available evidence was systematically reviewed to ascertain the association of EDS with depression and OSA according to the general population and some specific population subgroups. In addition, effectiveness of continuous positive airway pressure (CPAP) was analyzed as a standard therapy for improving EDS and depression in patients with OSA. In the general population, patients with OSA, and some other subpopulations, the review contributed to: (1) delineating the prevalence of EDS; (2) substantiating the relationship of EDS and depression; (3) presenting the relationship between EDS and OSA; and (4) revealing that the duration of CPAP is crucial for its therapeutic effects in improving EDS and depressive symptoms in patients with OSA.

European Respiratory Society statement on sleep apnoea, sleepiness and driving risk

Obstructive sleep apnoea (OSA) is highly prevalent and is a recognised risk factor for motor vehicle accidents (MVA). Effective treatment with continuous positive airway pressure has been associated with a normalisation of this increased accident risk. Thus, many jurisdictions have introduced regulations restricting the ability of OSA patients from driving until effectively treated. However, uncertainty prevails regarding the relative importance of OSA severity determined by the apnoea–hypopnoea frequency per hour and the degree of sleepiness in determining accident risk. Furthermore, the identification of subjects at risk of OSA and/or accident risk remains elusive. The introduction of official European regulations regarding fitness to drive prompted the European Respiratory Society to establish a task force to address the topic of sleep apnoea, sleepiness and driving with a view to providing an overview to clinicians involved in treating patients with the disorder. The present report evaluates the epidemiology of MVA in patients with OSA; the mechanisms involved in this association; the role of screening questionnaires, driving simulators and other techniques to evaluate sleepiness and/or impaired vigilance; the impact of treatment on MVA risk in affected drivers; and highlights the evidence gaps regarding the identification of OSA patients at risk of MVA.

Obstructive sleep apnea and depression: A systematic review and meta-analysis

INTRODUCTION

The present study aimed to review the association between obstructive sleep apnea (OSA) and depression and compare the prevalence of depression among people with and without OSA.

METHODS

Systematic review and meta-analysis following PRISMA guidelines. We searched for papers published between 1 January 2010 and 20 October 2019 listed on the following databases: Embase, Ovid MEDLINER(R) and PsychINFO. The search terms included a combination of keywords related to sleep apnea and depression. We also completed a manual search of the references listed in the articles retrieved and grouped them according to study design: cross-sectional, case-control and longitudinal. Scale scores were standardised for comparison.

RESULTS

Our search strategy yielded 1158 papers, of which 34 were considered suitable of review and 11 reported data that could be used for meta-analysis. Data from the 6 cross-sectional studies found no compelling evidence of an association between OSA and depression (odds ratio = 1.12, 95 % confidence interval, 95 %CI = 0.78, 1.47), but the meta-analysis of 5 longitudinal studies indicated that people with OSA were at greater risk of developing depression during follow-up than those without OSA (non-specific risk ratio (RR) = 2.18, 95 %CI = 1.47, 2.88), although there was evidence of high study heterogeneity (I² = 72.8 %).

DISCUSSION

The results of this systematic review and meta-analysis of observational studies is consistent with the hypothesis that OSA may increase the risk of depression. Sample characteristics and various methodological issues create uncertainty about the validity and generalizability of these associations.

The economic and societal burden of excessive daytime sleepiness in patients with obstructive sleep apnea

Excessive daytime sleepiness (EDS) is common in patients with obstructive sleep apnea (OSA) and continues to persist in many patients despite adequate OSA treatment. EDS in OSA is associated with decreased quality of life (QOL) as well as increased societal burden, which may impact health care utilization and costs. However, economic burden is often not the primary focus in the treatment of EDS in OSA. This targeted literature review aimed to examine the published literature on the economic burden of EDS in OSA. This review identified available literature using a targeted PubMed search strategy using search terms related to EDS in OSA in adults. Results demonstrate that there are few studies that detailed the direct costs associated with EDS in OSA, though several studies indicated an association between EDS in OSA and indirect economic burdens, including motor vehicle accidents (MVAs), near misses, work productivity, mood, and QOL. Data from the literature confirmed that persistent EDS in OSA following continuous positive airway pressure persists in 12%-65% of patients. Future studies should further describe the direct costs of EDS in OSA, quantify the cost associated with MVAs and lost work productivity, and detail QOL and social impacts of the condition.

Association between Macronutrient Intake and Excessive Daytime Sleepiness: An Iso-Caloric Substitution Analysis from the North West Adelaide Health Study

Epidemiological evidence on the association between macronutrient intake and excessive daytime sleepiness (EDS) is scarce. Using data from the North West Adelaide Health Study, we aimed to determine the association between iso-caloric substitution of macronutrients and EDS. Data from 1997 adults aged ≥ 24 years were analyzed. Daytime sleepiness was measured using the Epworth Sleepiness Scale, a score ≥ 11 was considered EDS. Dietary intake data were collected using a food frequency questionnaire. We determined absolute and relative energy intake based on consumption of saturated and unsaturated fats, protein, and carbohydrate. Odds ratios (ORs) were used to determine the associations using log-binomial logistic regression with and without iso-caloric substitution methods, and models were adjusted for confounders. The prevalence of EDS in the sample was 10.6%. After adjusting for potential confounders, substituting 5% energy intake from protein with an equal amount of saturated fat (OR = 1.57; 95% CI: 1.00–2.45) and carbohydrate (OR = 1.23; 95% CI: 0.92–1.65) increased the odds of EDS. When carbohydrate was substituted with saturated fat (OR = 1.27; 95% CI: 0.93–1.59), the odds of EDS were increased. The odds of EDS were lower when saturated fat was substituted with unsaturated fat (OR = 0.74; 95% CI: 0.51–1.06), protein (OR = 0.63; 95% CI: 0.41–0.99) or carbohydrate (OR = 0.79; 95% CI: 0.57–1.08). While these results were consistent over different iso-caloric substitution methods, inconsistent results were found with standard regression. While substitution of fat and carbohydrate with protein was inversely associated with EDS, substitution of protein with fat and carbohydrate was positively associated with EDS. Randomized trials are needed to confirm if dietary interventions can be used to improve daytime alertness in those with EDS.

Clinical and Polysomnographic Correlates of Subjective Sleepiness in Mild Obstructive Sleep Apnea

Purpose

The decision to treat mild obstructive sleep apnea (OSA) often hinges on the presence of subjective daytime sleepiness. This study was done to identify clinical and polysomnographic features which correlate with subjective sleepiness in mild OSA.

Methods

Utilizing data from the Apnea Positive Pressure Long-term Efficacy Study, 199 participants with mild OSA were identified. Participants were grouped as "sleepy" or "non-sleepy" based on their responses to a question regarding excessive daytime sleepiness, and Epworth Sleepiness Scores. We compared demographic, clinical and baseline polysomnographic data between the groups.

Results

The prevalence of subjective sleepiness was 74.4%. The sleepy group was younger (46.1 ± 12.6 vs. 53.3 ± 13.1 years, p=0.001), reported lower quality of life (4.5 ± 0.69 vs. 4.9 ± 0.61, p=0.0002), had higher depression scores (5.4 ± 4.7 vs. 3.1 ± 3.5, p=0.003) and reported more naps per week (2.6 ± 2.9 vs. 1.3 ± 1.9, p=0.01). Total sleep time and sleep efficiency were notably higher in the sleepy (254.2 ± 106 vs. 220.4 ± 114 min, p=0.08) and (80.2 ± 12.6 vs. 75.7 ± 14.9 %, p=0.06), approaching statistical significance. The non-sleepy group had slightly higher apnea hypopnea index (AHI: 12.2 ± 1.5 vs. 11.2 ± 2.4 events/hour, p=0.01) and worse desaturation indices.

Conclusions

Subjective sleepiness in mild OSA is associated with younger age, worsened mood and quality of life. This study suggests that evidence of increased sleep drive on polysomnography may correlate with subjective sleepiness in mild OSA.

Pathophysiology of swallowing following oropharyngeal surgery for obstructive sleep apnea syndrome

BACKGROUND

Uvulopalatopharyngoplasty (UPPP) and coblation channeling of the tongue (CCT) are oropharyngeal surgeries used to treat obstructive sleep apnea syndrome. The extent to which UPPP and CCT affect pharyngeal swallow has not been determined. We therefore conducted a novel case series study employing high-resolution impedance manometry (HRIM) to quantify the swallowing-related biomechanics following UPPP and/or CCT surgery.

METHODS

Twelve patients who underwent UPPP+CCT or CCT only were assessed an average 2.5 years postsurgery. Swallow function data were compared with ten healthy controls. All patients completed the Sydney swallow questionnaire (SSQ). Pharyngeal pressure-flow analysis of HRIM recordings captured key distension, contractility and pressure-flow timing swallow parameters testing 5, 10, and 20 mL volumes of thin and thick fluid consistencies.

KEY RESULTS

Postoperative patients had more dysphagia symptoms with five returning abnormal SSQ scores. Swallowing was biomechanically altered compared to controls, consistent with diminished swallowing reserve, largely driven by elevated hypopharyngeal intrabolus pressure due to a reduced capacity to open the upper esophageal sphincter to accommodate larger volumes.

CONCLUSIONS & INFERENCES

Patients who have undergone UPPP and/or CCT surgery appear to have a deficiency in normal modulation of the swallowing mechanism and a reduced swallowing functional reserve. We speculate that these changes may become relevant in later life with the onset of age-related stressors to the swallowing mechanism. This case series strikes a note of caution that further studies are needed to determine the role of preoperative swallow assessment in patients undergoing UPPP and/or CCT surgery.

Factors associated with undiagnosed obstructive sleep apnoea among hypertensive patients: A multisite cross-sectional survey study in Taiwan

AIMS AND OBJECTIVES

To investigate the distribution and risk factors associated with undiagnosed obstructive sleep apnoea among hypertensive patients.

BACKGROUND

Obstructive sleep Apnoea has been deemed a cardinal risk factor affecting cardiovascular event, and the condition is still frequently overlooked clinically. The lack of advanced diagnosis often causes hypertensive patients with obstructive sleep apnoea to miss opportunities for preventing chronic diseases.

DESIGN

A cross-sectional design.

METHODS

A total of 215 hypertensive participants were recruited from the cardiovascular outpatients of medical centre in northern and middle Taiwan. The Chinese version of Pittsburgh Sleep Quality Index, the Chinese version of the Epworth Sleep Scale and a portable sleep monitoring device were used for data collection. Logistic regression analysis was conducted to identify the factors affecting hypertensive patients with obstructive sleep apnoea, and a multinomial logistic regression analysis was used to examine the major influence factors for each obstructive sleep apnoea severity level.

RESULTS

81.9% of the hypertensive participants were found having obstructive sleep apnoea. Concerning to the obstructive sleep apnoea severity, 50.0% of participants had mild obstructive sleep apnoea. After controlling the confounding variables, the supine position (odds ratio, 1.04; 95% CI, 1.01-1.07), SO₂ (odds ratio, 0.58; 95% CI, 0.38-0.89) and oxygen desaturation index (odds ratio, 2.70; 95% CI, 1.18-6.18) were significantly associated with obstructive sleep apnoea. Furthermore, severe obstructive sleep apnoea was significantly correlated with gender (odds ratio, 0.04; 95% CI, 0.00-0.66), excessive daytime sleepiness (odds ratio, 20.27; 95% CI, 1.58-26.97) and oxygen desaturation index (odds ratio, 4.05; 95% CI, 1.86-8.81).

CONCLUSIONS

Nearly 82% of the hypertensive participants were found having undiagnosed obstructive sleep apnoea, and 80% of them were mild or moderate severity. Oxygen desaturation index, SO₂ and the supine position were found to be major predictors for obstructive sleep apnoea. Remarkably, oxygen desaturation index was the most significant predictor for mild, moderate and severe obstructive sleep apnoea.

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers should enhance their sensitivities to hypertensive patients at a high risk for obstructive sleep apnoea by actively assessing common obstructive sleep apnoea symptoms and providing strategies to alleviate obstructive sleep apnoea symptoms.