Costs and Resource Utilization of People with Stable Heart Failure and Insomnia: Evidence from a Randomized Trial of Cognitive Behavioral Therapy for Insomnia

OBJECTIVES

Nearly half of patients with chronic heart failure (HF) report insomnia symptoms. The purpose of this study was to examine the impact of CBT-I versus HF self-management on healthcare costs and resource utilization among patients with stable chronic HF who participated in a clinical trial of the effects of CBT-I compared to HF self-management education (attention control) over 1 year.

METHODS

We measured resource utilization as self-reported (medical record review) physician office visits, emergency department visits, and inpatient admissions at 3-month intervals for 1 year after enrollment. Costs were estimated by applying price weights to visits and adding self-reported out-of-pocket and indirect costs. Univariate comparisons were made of resource utilization and costs between CBT-I and the HF self-management group. A generalized linear model (GLM) was used to model costs, controlling for covariates.

RESULTS

The sample included 150 patients [79 CBT-I; 71 self-management (M age = 62 + 13 years)]. The CBT-I group had 4.2 inpatient hospitalizations vs 4.6 for the self-management group (p = .40). There were 13.1 outpatient visits, in the CBT-I compared with 15.4 outpatient visits (p-value range 0.39-0.81) for the self-management group. Total costs were not significantly different in univariate or ($7,813 CBT-I vs. $7,538 self-management), p = .96) or multivariable analyses.

CONCLUSIONS

Among patients with both HF and insomnia, CBT-I and HF self-management were associated with similar resource utilization and total costs. Additional research is needed to estimate the value of CBT-I relative to usual care and other treatments for insomnia in patients with HF.

Investigating brain dynamics and their association with cognitive control in opioid use disorder using naturalistic and drug cue paradigms

Objectives

Opioid use disorder (OUD) impacts millions of people worldwide. The prevalence and debilitating effects of OUD present a pressing need to understand its neural mechanisms to provide more targeted interventions. Prior studies have linked altered functioning in large-scale brain networks with clinical symptoms and outcomes in OUD. However, these investigations often do not consider how brain responses change over time. Time-varying brain network engagement can convey clinically relevant information not captured by static brain measures.

Methods

We investigated brain dynamic alterations in individuals with OUD by applying a new multivariate computational framework to movie-watching (i.e., naturalistic; N=76) and task-based (N=70) fMRI. We further probed the associations between cognitive control and brain dynamics during a separate drug cue paradigm in individuals with OUD.

Results

Compared to healthy controls (N=97), individuals with OUD showed decreased variability in the engagement of recurring brain states during movie-watching. We also found that worse cognitive control was linked to decreased variability during the rest period when no opioid-related stimuli were present.

Conclusions

These findings suggest that individuals with OUD may experience greater difficulty in effectively engaging brain networks in response to evolving internal or external demands. Such inflexibility may contribute to aberrant response inhibition and biased attention toward opioid-related stimuli, two hallmark characteristics of OUD. By incorporating temporal information, the current study introduces novel information about how brain dynamics are altered in individuals with OUD and their behavioral implications.

Sex-Specific Associations of Obstructive Sleep Apnea Risk With Patient Characteristics and Functional Outcomes After Acute Myocardial Infarction: Evidence From the VIRGO Study

Background Though associations between obstructive sleep apnea (OSA) and cardiovascular outcomes are well described, limited data exist regarding the impact of OSA on sex-specific outcomes after acute myocardial infarction (AMI). Methods and Results The VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study enrolled 3572 adults aged 18 to 55 years with AMI from the United States and Spain during 2008 to 2012. We included patients for whom the Berlin Questionnaire for OSA was scored at the time of AMI admission (3141; 2105 women, 1036 men). We examined the sex-specific association between baseline OSA risk with functional outcomes including health status and depressive symptoms at 1 and 12 months after AMI. Among both groups, 49% of patients were at high risk for OSA (1040 women; 509 men), but only 4.7% (148) of patients had a diagnosed history of OSA. Though patients with a high OSA risk reported worse physical and mental health status and depression than low-risk patients in both sexes, the difference in these functional outcomes was wider in women than men. Moreover, women with a high OSA risk had worse health status, depression, and quality of life than high-risk men, both at baseline and at 1 and 12 months after AMI. Conclusions Young women with a high OSA risk have poorer health status and more depressive symptoms than men at the time of AMI, which may place them at higher risk of poorer health outcomes over the year following the AMI. Further, the majority of patients at high risk of OSA are undiagnosed at the time of presentation of AMI.

Sleep-related predictors of cognition among adults with chronic insomnia and heart failure enrolled in a randomized controlled trial of cognitive behavioral therapy for insomnia

STUDY OBJECTIVES

Cognitive impairment and insomnia are common in chronic heart failure (HF). We examined the effects of cognitive behavioral therapy for insomnia (CBT-I) and the extent to which demographic, clinical, symptom, and functional characteristics predicted cognition among people with chronic HF and insomnia who participated in a randomized controlled trial of CBT-I.

METHODS

Participants with HF were randomized to group-based CBT-I or an attention control (HF self-management education). Outcomes were measured over 1 year. We measured psychomotor vigilance and self-reported cognitive ability (PROMIS Cognitive Abilities Scale), clinical and demographic characteristics, history of sleep apnea, fatigue, pain, insomnia (Insomnia Severity Index), sleepiness (Epworth Sleepiness Scale), Six Minute Walk, EuroQoL Quality of Life, and wrist actigraphy (sleep characteristics and rest-activity rhythms). We used cosinor analysis to compute rest-activity rhythms and general linear models and general estimating equations to test the effects of predictors over 1 year.

RESULTS

The sample included 175 participants (mean age = 63 SD = 12.9 Years; 43% women). There was a statistically significant group-time effect on self-reported cognitive function and increases in the proportion of participants, with < 3 psychomotor vigilance lapses in the CBT-I group. Controlling for group-time effects and baseline cognition, decreased sleepiness, improved rest-activity rhythms, and 6-minute walk distance predicted a composite measure of cognition (psychomotor vigilance lapses and self-reported cognition).

CONCLUSIONS

CBT-I may improve cognition in adults with chronic HF. A future fully powered randomized controlled trial is needed to confirm the extent to which CBT-I improves multiple dimensions of cognition.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Cognitive Behavioral Therapy for Insomnia: A Self-Management Strategy for Chronic Illness in Heart Failure; URL: https://clinicaltrials.gov/ct2/show/NCT02660385; Identifier: NCT02660385.

CITATION

Redeker NS, Conley S, O'Connell M, Geer JH, Yaggi H, Jeon S. Sleep-related predictors of cognition among adults with chronic insomnia and heart failure enrolled in a randomized controlled trial of cognitive behavioral therapy for insomnia. J Clin Sleep Med. 2023;19(6):1073-1081.

Suboptimal Sleep Duration is Associated with Poorer Neuroimaging Brain Health Profiles

Background

Cardiovascular health optimization during middle age benefits brain health. The American Heart Association's Life's Simple 7 recently added sleep duration as a key determinant of cardiovascular health becoming the Life's Essential 8. We tested the hypothesis that suboptimal sleep duration is associated with poorer neuroimaging brain health profiles in asymptomatic middle-aged adults.

Methods

We conducted a prospective MRI neuroimaging study in middle-aged persons without stroke, dementia, or multiple sclerosis enrolled in the UK Biobank. Self-reported sleep duration was categorized as short (<7 hours), optimal (7-<9 hours), or long (≥9 hours). Evaluated neuroimaging markers of brain health included white matter hyperintensities (presence and volume) and diffusion tensor imaging metrics (fractional anisotropy and mean diffusivity) evaluated in 48 distinct neuroanatomical regions. We used multivariable logistic and linear regression models, as appropriate, to test for association between sleep duration and neuroimaging markers of brain health.

Results

We evaluated 39,502 middle-aged persons (mean age 55, 53% female). Of these, 28,712 (72.7%) had optimal, 8,422 (21.3%) short, and 2,368 (6%) long sleep. Compared to optimal sleep, short sleep was associated with higher risk (OR 1.11; 95% CI 1.05-1.17; P<0.001) and larger volume (beta=0.06, SE=0.01; P<0.001) of white matter hyperintensities, while long sleep was associated with higher volume (beta=0.04, SE=0.02; P=0.01) but not higher risk (P>0.05) of white matter hyperintensities. Short (beta=0.03, SE=0.01; P=0.004) and long sleep (beta=0.07, SE=0.02; P<0.001) were associated with worse fractional anisotropy, while only long sleep associated with worse mean diffusivity (beta=0.05, SE=0.02; P=0.005).

Conclusions

Among middle-aged adults without clinically observed neurological disease, suboptimal sleep duration is associated with poorer neuroimaging brain health profiles. Because the evaluated neuroimaging markers precede stroke and dementia by several years, our findings support early interventions aimed at correcting this modifiable risk factor.

0158 Risk perception, outcome expectancy, and treatment self-efficacy among women and men with obstructive sleep apnea (OSA)

Introduction

Continuous positive airway pressure (CPAP) is the first-line therapy for OSA. CPAP improves OSA severity, sleep architecture, and daytime symptoms. The effectiveness of CPAP, however, is limited to poor adherence. Individual's risk perception, outcome expectancy, and treatment self-efficacy predict CPAP adherence. CPAP adherence also differs by sex. However, it is unknown if predictors of CPAP use are different for women and men. We thus assessed sex differences in risk perception, outcome expectancy, and treatment self-efficacy among those with OSA.

Methods

Individuals enrolled to date (target n=267) in the NICEPAP study (NCT05067088), a prospective, observational cohort examining predictors of CPAP adherence, were included. Adults newly diagnosed with OSA prescribed CPAP therapy were included, while those with a need for non-CPAP therapy or unstable medical conditions (e.g., cancer receiving chemotherapy, severe lung, heart, or mental health disorders) were excluded. The exposure was sex. Co-primary outcomes were sub-scale scores from the Self-Efficacy Measure for Sleep Apnea (SEMSA) tool: Perceived Risk, Outcome Expectancies, and Treatment Self-Efficacy before starting CPAP. In addition, we assessed a comprehensive set of established psycho-social and biomedical CPAP adherence predictors using validated measures. SEMSA sub-scale scores for males and females were compared using Kruskal-Wallis statistics.

Results

We analyzed data for 33 females and 19 males. Females and males were 52 (41.0, 60.5) and 52 (35.0, 58) years old respectively (median [Q1, Q3]). Ten of 33 females and 4 of 19 males were Black with majority of others being White. The apnea-hypopnea index was 17.0 (9.1, 27.0) and 19.0 (13.3, 38.4), Epworth sleepiness scale and insomnia severity index scores were 9.0 (5.0, 12.0) & 15.0 (11.0, 18.0) and 6.0 (4.0, 9.0) & 17.0 (8.0, 19.5) for females and males respectively. There were no statistical differences in scores of Perceived Risk 2.4 (1.6, 2.9) vs 2.1 (1.8, 2.5) (p=0.717), Outcome Expectancies 2.8 (2.3, 3.4) vs 3.3 (2.4, 3.5) (p=0.371) or Treatment Self-Efficacy 3.1 (2.3, 3.7) vs 3.1 (2.0, 3.5) (p=0.977) for females vs. males.

Conclusion

We found no statistically significant differences in determinants of self-efficacy between women and men. Our findings may reflect a small sample size recruited to date or that self-efficacy of CPAP therapy is independent of sex.

Support (If Any)

This work was supported by Parker B. Francis Foundation and National Heart, Lung, and Blood Institute/NIH (1K23HL159259-01).

0790 Racial Differences in Self-Efficacy for Positive Airway Pressure Therapy Among Individuals Newly Diagnosed with Obstructive Sleep Apnea

Introduction

Continuous positive airway pressure (CPAP) therapy is the first-line treatment for OSA, yet its effectiveness is limited by poor adherence. Self-efficacy is an individual’s belief that they can successfully execute a behavior to achieve a desired outcome. Evidence shows that self-efficacy predicts adherence to and outcomes of CPAP therapy, as do race and ethnicity. Little, however, is known about how self-efficacy may differ between racial and ethnic groups. Accordingly, we aimed to determine whether self-efficacy for CPAP differs by race and ethnicity among individuals newly diagnosed with OSA.

Methods

Adults newly diagnosed with OSA and prescribed CPAP who were enrolled in the NICEPAP Study (n=267, NCT05067088), a prospective, observational cohort study investigating predictors of CPAP adherence were assessed. Those with need for non-CPAP therapy or with unstable medical conditions (e.g., cancer receiving chemotherapy, severe lung, heart or mental health disorders) were excluded. Exposures were race and ethnicity. Outcomes were subscale scores of the Self-Efficacy Measure for Sleep Apnea (SEMSA) completed prior to CPAP initiation: perceived risk, outcome expectancy, and self-efficacy. SEMSA sub-scale scores for race/ethnicity were compared using Kruskal-Wallis test. Medians (Q1, Q3) are reported.

Results

We analyzed data for 52 participants (33 women) enrolled to date who identified as White (n=29), Black (n=14), More than one race (n=5) and Other (N=5). Participants were 51.0 (36.8, 58.8) years old with an apnea-hypopnea index of 17.0/hour (11.1, 26.0) and body-mass-index of 35.0 (31.6, 43.5) kg/m2. Baseline characteristics did not differ by race, except higher poverty (p=0.005) and less completed years of education (p=0.010) for Black participants. The SEMSA scores were not statistically different between each race. However, self-efficacy was significantly lower for Black participants vs. rest of the cohort combined (2.4 (1.9, 3.1) vs. 3.3 (2.7, 3.8) p=0.020). Poverty, but not education, may be a potential mediator of this relationship (mediation analysis p=0.052). There were no differences in SEMSA scores between Hispanic and Non-Hispanic participants.

Conclusion

In our cohort, self-efficacy for OSA therapy was lower for Black participants compared to those of other races. Targeting early interventions to improve CPAP self-efficacy in Black patients may improve OSA therapy outcomes.

Support (If Any)

 

0321 Poor Agreement Among Self-Reported and Objective Sleep Deficiency Assessments in Older Persons

Introduction

Many traditional sleep questionnaires were developed in younger populations and may have poor sensitivity to detect objective sleep deficiency in older persons due to atypical presentations, aging-related decreases in symptom awareness, and different expectations about health.

Methods

In a secondary analysis of data from the Osteoporotic Fractures in Men (MrOS; Sleep Visit 1) and the Study of Osteoporotic Fractures (SOF Visit 9), we evaluated the prevalence of objective sleep deficiency among persons with scores in the normal range on traditional sleep questionnaires (Pittsburgh Sleep Quality Index [PSQI] &lt;6 and Epworth Sleepiness Scale [ESS] &lt;11). Objective sleep deficiency was established based on presence of sleep-disordered breathing (SDB; apnea hypopnea index [at &gt;4% desaturation] per hour of sleep ≥15 on polysomnography), insufficient sleep duration (average sleep duration &lt;6 hours on actigraphy), or impairment in daytime sustained attention/alertness (falling in the worst quartile of Digit Vigilance Test scores for the sex-specific cohort).

Results

Average ages were 76±6 and 84±4 years in men and women, respectively. Among men with normal scores on the PSQI and ESS, 359/1527 (25%) had SDB, 428/1519 (28%) had insufficient sleep duration, and 346/1527 (23%) had impaired daytime attention/alertness. Among women with normal scores on both the PSQI and ESS, 72/185 (40%) had SDB, 318/1332 (24%) had insufficient sleep duration, and 140/546 (26%) had impaired daytime attention/alertness.

Conclusion

A substantial proportion of older men and women with normal scores on traditional sleep questionnaires have objective sleep deficits, suggesting a need to develop instruments to improve detection of sleep deficiency in this population.

Support (If Any)

American Academy of Sleep Medicine Foundation, Yale Claude D. Pepper Older Americans Independence Center, Patterson Trust, National Institute on Aging

441 Influence Of Chronotype On CPAP Adherence

Introduction

Continuous positive airway pressure therapy (CPAP) is an efficacious treatment for obstructive sleep apnea (OSA). However, despite interventions targeting established determinants of CPAP use, adherence to CPAP remains poor. An Individual’s chronotype can influence behavior including adherence to dietary changes and alcohol abstinence. We hypothesized that chronotype will be associated with CPAP adherence and aimed to identify the mechanisms of this association.

Methods

Secondary data analysis of the active CPAP arm (n=469) from the Apnea Positive Pressure Long-term Efficacy Study, a multicenter randomized controlled trial of CPAP therapy in a sleep clinic population was performed. The Morningness-Eveningness Questionnaire (MEQ) was used to identify three chronotype categories: Evening (MEQ score: 16–41), Neither (42–58) and Morning (59–86) types. CPAP adherence over 6-months (hours/night) was objectively measured using smart-card downloads. Linear mixed modelling evaluated the association between the chronotype and CPAP adherence, adjusting for confounders (e.g., age). Mechanisms of this association were examined by change in beta estimates for the chronotype with addition of a potential mediator (e.g., sleep duration).

Results

There were 206(44%), 38(8%) and 219(47%) Morning, Evening and Neither chronotype patients respectively. Evening types were youngest (48.0±13.4 vs. 50.3±11.3 and 56.3±11.4 years, p&lt;0.001) with highest body mass index (BMI, 34.9±10.5 vs. 31.2±10.5 and 32.7±10.5 kg/m2, p=0.006) and longest sleep on weekends (7.9±2.0 vs. 7.3±1.3 and 7.6±1.5 hours, p=0.017) compared to Morning and Neither types. A higher proportion of Evening types also reported symptoms of insomnia and fatigue (p-values 0.017 and 0.048 respectively). CPAP adherence, however, did not differ between Evening and Neither types (p=0.276). Compared to the Neither types, Morning types exhibited significantly higher CPAP adherence (β= 40mins/night, p=0.001) with a slight decrease after adjusting for age, sex, race, marital status, education, and OSA severity (β= 33mins/night, p=0.012). Sleep duration, insomnia, BMI and fatigue mediated a minimal proportion of this effect (0.7–3.7%).

Conclusion

In this cohort of sleep clinic patients, the Morning chronotype was associated with better CPAP adherence. Only a small proportion of this association was mediated by observed clinical differences between the chronotypes. Understanding the influence of chronotype on CPAP use may provide novel insight for improving OSA therapy effectiveness.

Support (if any):

342 CBT-I Has Sustained Effects on Insomnia Versus Heart-Failure Self-Management Education among Adults with Chronic Heart Failure

Introduction

Insomnia is common among adults with chronic heart failure (HF), often not explained by sleep apnea (SA), and associated with daytime symptoms and poor daytime function. The purpose of this randomized controlled trial was to evaluate the sustained effects of cognitive behavioral therapy for insomnia (CBT-I) on insomnia severity and sleep characteristics over 6 months among adults with stable chronic HF.

Methods

We included adults with HF who had at least mild insomnia [Insomnia Severity Index (ISI) &gt; 8] and no more than mild SA or SA treated with continuous positive airway pressure. We randomized in groups to 8 weeks of group CBT-I (Healthy Sleep: HS) [4 group sessions + calls on alternate weeks] or attention control (Healthy Hearts: HH) [HF self-management education + brief sleep hygiene] in the same format. We administered the ISI, the Pittsburgh Sleep Quality Index (PSQI), the Dysfunctional Beliefs & Attitudes about Sleep Scale (DBAS), and the Sleep Disturbance Questionnaire (SDQ) at baseline (T0), 2 weeks after treatment ended (T1) and at 6 months (T2). Statistical analysis included descriptive statistics and mixed effects models with random intercepts and slopes.

Results

The sample include 175 participants (HS: N = 91; 62 + 13 years; 58% Male; 15% Black; 68% NY Heart Class II-III) (HH: N = 84; 64 + 12.5 years; 56% Male; 17% Black; 70% NY Heart Class II-III). There was no significant difference at baseline in demographic characteristics or the mean ISI [HS: 15.3 (4.5); HH: 14.4 (4.5)], but a greater percentage in the HS group had clinical/moderate-severe insomnia (ISI &gt; 15) (HS: 60.4% vs. HH: 47%). The CBT-I intervention (HS) was associated with significant improvement in insomnia severity (ISI: p = .001), sleep quality (PSQI: p = .002), and sleep-related cognitions (DBAS: p = .0006; SDQ: p = .0138), and a modest effect on self-reported sleep duration (46 vs. 20 mins, p = .054), but no effect on sleep efficiency. At 6 months, 12.9% of the HS group, compared with 24.9% of the HH group had clinical insomnia.

Conclusion

CBT-I has sustained effects on insomnia, sleep-quality, and sleep-related cognitions in people with HF.

Support (if any)

R01NR01691 (NSR, PI)

Evaluating Recruitment Strategies for a Randomized Clinical Trial with Heart Failure Patients

Recruiting participants with chronic medical conditions is time-consuming and expensive. Electronic medical record databases and patient portals may enable outreach to larger numbers of patients in comparison to face-to-face methods. We aimed to describe the yields, benefits, and limitations of recruitment strategies used for a randomized clinical trial of cognitive behavioral therapy for insomnia among patients with chronic stable heart failure (NCT02660385). We used multiple recruitment strategies including clinic-based recruitment, letters to patients identified from electronic databases, the patient portal, brochures and posters placed in clinics, presentations to heart failure support groups, and online advertising. We screened 10,291 medical records, enrolled 231 participants, and 195 participants completed baseline data collection. We enrolled 92 (23%) participants using clinic-based recruitment, 24 and 29 (6% and 10%) using letters to patients from two electronic databases, and 42 (55%) via the patient portal. Multiple recruitment strategies and flexibility are needed to achieve recruitment goals.

0568 Physiologic OSA Traits and CPAP Adherence Among Patients with Coronary Artery Disease and OSA

Introduction

Obstructive sleep apnea (OSA) is common in patients with coronary artery disease (CAD), but adherence to continuous positive airway pressure (CPAP) in this population is poor. Low arousal threshold (ArTH), a pathophysiologic OSA trait, is associated with low rates of regular CPAP use in sleep clinic populations. We aimed to determine whether ArTH or other physiologic OSA traits (i.e. pharyngeal collapsibility, muscle compensation, loop gain) are associated with CPAP adherence in patients with CAD and OSA.

Methods

A secondary analysis of a randomized controlled trial of OSA treatment in patients with CAD (RICCADSA) was performed. OSA (apnea hypopnea index, AHI≥5/hour) was assessed by polysomnography. Arousal threshold (% eupneic ventilation, %Ve), loop gain (LG), pharyngeal collapsibility (%Ve) and compensation (%Ve) were estimated from polysomnography using a validated method. Adherence to auto-titrated CPAP (hours/night) was obtained from machine downloads at 1, 3, 6, 12 and 24 months. Mixed modelling was used to assess the association between OSA traits and CPAP adherence.

Results

Participants (n=262) were 64.1±7.9 years old, with BMI of 29.2±4.2 and 86% were men. The mean AHI was 40.8±23.6 events/hour with oxygen nadir of 81.3±7.1%. The median (IQR) CPAP adherence (hrs/night) was 3.0 (0.9, 5.8) at 1-mo and 3.0 (0.0, 5.6) at 24-mo. Compared to reference studies, the CAD patients exhibited an elevated LG 0.63 (0.53, 0.79), similar ArTH (%Ve) of 117.5% (106.5%, 136.4%), higher collapsibility (%Ve) at 90.1% (82.3%, 94.8%) and lower compensation (%Ve) at 3.7% (-0.7%, 8.7%).Only increasing pharyngeal muscle compensation was associated with lower CPAP adherence (β -0.04, p-value 0.048), effect modified by pharyngeal collapsibility (Compensation x Collapsibility, β &lt;0.01, p-value 0.042).

Conclusion

In this group of patients with CAD, increasing muscle compensation was associated with lower CPAP adherence. Physiologic OSA traits may provide insight into prediction of CPAP adherence among patients with OSA and CAD.

Support

Zinchuk: Parker B. Francis Fellowship Program in Clinical Research. Sands: American Heart Association. Peker: Swedish Research Council, Swedish Heart-Lung Foundation.

Abstract TP347: Obstructive Sleep Apnea Frequency in Intracerebral Hemorrhage

Introduction: Obstructive sleep apnea (OSA) is a treatable condition and well-established risk factor for ischemic stroke, but the prevalence in ICH is unknown. We aim to characterize the frequency of OSA in spontaneous intracerebral hemorrhage (ICH).

Methods: The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study is a prospective observational study evaluating risk factors for ICH among whites, blacks, and Hispanics. OSA status was determined using two different strategies: (1) the Berlin Questionnaire, a validated screening tool to identify those with a high likelihood of OSA where “high risk” is defined as > 1 point in at least 2 of 3 categories assessing snoring, fatigue, and hypertension, and (2) self-reported history of diagnosed sleep apnea.

Results: We evaluated 3000 ICH cases. Within this group, 2896 (96.5%) completed the Berlin questionnaire, with 2064 (71%) patients being high risk for OSA. Compared to patients with low risk of OSA, those at high risk were more likely to be male (61% versus 53%, p<0.001) with hypertension (93% versus 65%, p<0.001), diabetes (32% versus 20%, p<0.001), hyperlipidemia (49% versus 38%, p<0.001), and higher BMI (29.8 +/- 8.1 versus 26.8 +/- 6.5, p<0.001), and less likely to have lobar ICH location (29% versus 35%, p<0.001). Self-reported history of prior sleep apnea diagnosis was present in only 175 (9.5%) of ICH cases.

Conclusions: OSA is highly prevalent and underdiagnosed in our cohort of ICH patients. Given the effective treatments available for OSA, which have been shown to improve morbidity and mortality in patients with ischemic stroke, further studies are needed to assess the role of OSA as both a determinant of both risk and outcome in ICH.

Pilot study: an intensive care unit sleep promotion protocol

Purpose

Disturbances, such as in-room activity and sound, are significant sources of sleep disruption among critically ill patients. These factors are potentially modifiable. We tested the impact of an intensive care unit (ICU) sleep promotion protocol on overnight in-room disturbance.

Methods

Our protocol restricted non-urgent bedside care from 00:00 to 03:59. Patients were assigned to usual care (n=30) or the sleep protocol (n=26). The primary outcomes were measures of in-room activity, sound and light. These three types of disturbance were compared between arms during a baseline time block (20:00–23:59) and a rest time block (00:00–03:59). We assessed the sleep protocol effect with generalised linear models.

Results

Usual care and sleep protocol patients had equivalent levels of in-room activity, sound and light during the baseline time block (20:00–23:59). In contrast, during the rest time block (00:00–03:59), the sleep protocol arm had 32% fewer room entries (rate ratio (RR) 0.68, p=0.001) and 9.1 fewer minutes of in-room activity (p=0.0002). Also, the length of time between room entrances increased from 26.4 to 45.8 min (p=0.0004). The sleep protocol arm also had lower sound during the rest time block. Mean A-weighted sound was 2.5 decibels lower (p=0.02), and there were 36% fewer peaks (RR 0.64, p=0.02). Light levels were highly variable and not changed by the sleep protocol.

Conclusions

Sleep promotion protocols can improve in-room activity and sound. This provides a better sleep opportunity and may, therefore, improve ICU sleep.

Trial registration number

1112009428

Obstructive sleep apnoea and stroke

Many patients with stroke have concomitant sleep apnoea, which can affect recovery potential. Although stroke can lead to the development of sleep-disordered breathing, the current evidence suggests that sleep-disordered breathing may function as a risk factor for stroke. In this review, we focus on the association between obstructive sleep apnoea and stroke reviewing both the epidemiological data with respect to causation and the biological data, which explores pathogenesis. There is convincing evidence to believe that sleep apnoea is a modifiable risk factor for stroke; however, prospective studies are needed to establish the cause-and-effect relationship.

Sleep-disordered breathing and stroke

Sleep-related breathing disorders are strongly associated with increased risk of stroke independent of known risk factors. The direction of causation favors sleep-disordered breathing leading to stroke rather than the other way around, although definitive proof of this awaits the results of prospective cohort studies. If causal, even a moderately elevated risk of stroke coupled with the high prevalence of sleep-disordered breathing could have significant public health implications. The relationship between sleep-disordered breathing and stroke risk factors is complex, and likely part of the risk for cerebrovascular events is because of higher cardiovascular risk factors in patients with increased RDI. The mechanisms underlying this increased risk of stroke are multi-factorial and include reduction in cerebral blood flow, altered cerebral autoregulation, impaired endothelial function, accelerated atherogenesis, thrombosis, and paradoxic embolism. Because of the effects of sleep-disordered breathing on vascular tone, hypertension is believed to be a major mechanism by which sleep-disordered breathing might influence risk of stroke. Because sleep-related breathing disorders are treatable patients with stroke/TIA should undergo investigation, with a thorough sleep history interview, physical examination, and polysomnography. Treatment of sleep apnea has been shown to improve quality of life, lower blood pressure, improve sleep quality, improve neurocognitive functioning, and decrease symptoms of excessive daytime sleepiness [98]. Further treatment trials are needed to determine whether treatment improves outcome after stroke and whether treatment may serve as secondary prophylaxis and modify the risk of recurrent stroke or death.