Abstract
Study Objectives
To examine associations between positive airway pressure (PAP) therapy, adherence and incident diagnoses of Alzheimer’s disease (AD), mild cognitive impairment (MCI), and ...dementia not otherwise specified (DNOS) in older adults.
Methods
This retrospective study utilized Medicare 5% fee-for-service claims data of 53,321 beneficiaries, aged 65 and older, with an obstructive sleep apnea (OSA) diagnosis prior to 2011. Study participants were evaluated using ICD-9 codes for neurocognitive syndromes (AD n = 1,057, DNOS n = 378, and MCI n = 443) that were newly identified between 2011 and 2013. PAP treatment was defined as the presence of at least one durable medical equipment (Healthcare Common Procedure Coding System HCPCS) code for PAP supplies. PAP adherence was defined as at least two HCPCS codes for PAP equipment, separated by at least 1 month. Logistic regression models, adjusted for demographic and health characteristics, were used to estimate associations between PAP treatment or adherence and new AD, DNOS, and MCI diagnoses.
Results
In this sample of Medicare beneficiaries with OSA, 59% were men, 90% were non-Hispanic whites and 62% were younger than 75 years. The majority (78%) of beneficiaries with OSA were prescribed PAP (treated), and 74% showed evidence of adherent PAP use. In adjusted models, PAP treatment was associated with lower odds of incident diagnoses of AD and DNOS (odds ratio OR = 0.78, 95% confidence interval 95% CI: 0.69 to 0.89; and OR = 0.69, 95% CI: 0.55 to 0.85). Lower odds of MCI, approaching statistical significance, were also observed among PAP users (OR = 0.82, 95% CI: 0.66 to 1.02). PAP adherence was associated with lower odds of incident diagnoses of AD (OR = 0.65, 95% CI: 0.56 to 0.76).
Conclusions
PAP treatment and adherence are independently associated with lower odds of incident AD diagnoses in older adults. Results suggest that treatment of OSA may reduce the risk of subsequent dementia.
Sleepiness is a key symptom in obstructive sleep apnea syndrome (OSAS) and can be objectively assessed with a multiple sleep latency test (MSLT). We studied the terms that patients prefer to describe ...their symptoms—sleepiness, fatigue, tiredness, or lack of energy—and how these terms relate to objective findings.
Observational.
University-based sleep laboratory.
Consecutive OSAS patients referred for diagnostic polysomnography and an MSLT.
Data were obtained from sleep studies and questionnaires.
Subjects included 117 men and 73 women, with a mean (± SD) age of 49 ± 13 years, an apnea and hypopnea rate of 32 ± 28/h of sleep, and an MSLT mean sleep latency of 7 ± 5 min. Subjects more frequently reported problems with fatigue, tiredness, and lack of energy than sleepiness (57%, 61%, and 62% vs 47%). When required to select the one most significant symptom, more patients chose lack of energy (about 40%) than any other problem, including sleepiness (about 22%). Objective measures of sleepiness and apnea severity showed little or no association with any symptom, but female gender showed significant associations with each.
Complaints of fatigue, tiredness, or lack of energy may be as important as that of sleepiness to OSAS patients, among whom women appear to have all such complaints more frequently than men. The diagnosis of OSAS should not be excluded based only on a person's tendency to emphasize fatigue, tiredness, or lack of energy more than sleepiness.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Among patients with multiple sclerosis (MS), fatigue is the most commonly reported symptom, and one of the most debilitating. Despite its high prevalence and significant impact, fatigue is still ...poorly understood and often under-emphasized because of its complexity and subjective nature. In recent years, an abundance of literature from specialists in sleep medicine, neurology, psychiatry, psychology, physical medicine and rehabilitation, and radiology have shed light on the potential causes, impact, and treatment of MS-related fatigue. Though such a diversity of contributions clearly has advantages, few recent articles have attempted to synthesize this literature, and existing overviews have focused primarily on potential causes of fatigue rather than clinical evaluation or treatment. The aims of this review are to examine, in particular for sleep specialists, the most commonly proposed primary and secondary mechanisms of fatigue in MS, tools for assessment of fatigue in this setting, and available treatment approaches to a most common and challenging problem.
Objective
To examine the association between sleep‐disordered breathing and stroke outcomes, and determine the contribution of sleep‐disordered breathing to outcome disparities in Mexican Americans.
...Methods
Ischemic stroke patients (n = 995), identified from the population‐based Brain Attack Surveillance in Corpus Christi Project (2010–2015), were offered participation in a sleep‐disordered breathing study including a home sleep apnea test (ApneaLink Plus). Sleep‐disordered breathing (respiratory event index ≥10) was determined soon after stroke. Neurologic, functional, cognitive, and quality of life outcomes were assessed at 90 days poststroke. Regression models were used to assess associations between sleep‐disordered breathing and outcomes, adjusted for sociodemographics, prestroke function and cognition, health‐risk behaviors, stroke severity, and vascular risk factors.
Results
Median age was 67 years (interquartile range IQR = 59–78); 62.1% were Mexican American. Median respiratory event index was 14 (IQR = 6–25); 62.8% had sleep‐disordered breathing. Sleep‐disordered breathing was associated with worse functional outcome (mean difference in activities of daily living/instrumental activities of daily living score = 0.15, 95% confidence interval CI = 0.01–0.28) and cognitive outcome (mean difference in modified Mini‐Mental State Examination = −2.66, 95% CI = −4.85 to −0.47) but not neurologic or quality of life outcomes. Sleep‐disordered breathing accounted for 9 to 10% of ethnic differences in functional and cognitive outcome and was associated with cognitive outcome more strongly for Mexican Americans (β = −3.97, 95% CI = −6.63 to −1.31) than non‐Hispanic whites (β = −0.40, 95% CI = −4.18 to 3.39, p‐interaction = 0.15).
Interpretation
Sleep‐disordered breathing is associated with worse functional and cognitive function at 90 days poststroke. These outcomes are reasonable endpoints for future trials of sleep‐disordered breathing treatment in stroke. If effective, sleep‐disordered breathing treatment may somewhat lessen ethnic stroke outcome disparities. ANN NEUROL 2019;86:241–250
Since the previous parameter and review paper publication on oral appliances (OAs) in 2006, the relevant scientific literature has grown considerably, particularly in relation to clinical outcomes. ...The purpose of this new guideline is to replace the previous and update recommendations for the use of OAs in the treatment of obstructive sleep apnea (OSA) and snoring.
The American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM) commissioned a seven-member task force. A systematic review of the literature was performed and a modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the quality of evidence. The task force developed recommendations and assigned strengths based on the quality of the evidence counterbalanced by an assessment of the relative benefit of the treatment versus the potential harms. The AASM and AADSM Board of Directors approved the final guideline recommendations.
1. We recommend that sleep physicians prescribe oral appliances, rather than no therapy, for adult patients who request treatment of primary snoring (without obstructive sleep apnea). (STANDARD) 2. When oral appliance therapy is prescribed by a sleep physician for an adult patient with obstructive sleep apnea, we suggest that a qualified dentist use a custom, titratable appliance over non-custom oral devices. (GUIDELINE) 3. We recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. (STANDARD) 4. We suggest that qualified dentists provide oversight—rather than no follow-up—of oral appliance therapy in adult patients with obstructive sleep apnea, to survey for dental-related side effects or occlusal changes and reduce their incidence. (GUIDELINE) 5. We suggest that sleep physicians conduct follow-up sleep testing to improve or confirm treatment efficacy, rather than conduct follow-up without sleep testing, for patients fitted with oral appliances. (GUIDELINE) 6. We suggest that sleep physicians and qualified dentists instruct adult patients treated with oral appliances for obstructive sleep apnea to return for periodic office visits—as opposed to no follow-up—with a qualified dentist and a sleep physician. (GUIDELINE).
The AASM and AADSM expect these guidelines to have a positive impact on professional behavior, patient outcomes, and, possibly, health care costs. This guideline reflects the state of knowledge at the time of publication and will require updates if new evidence warrants significant changes to the current recommendations.
Examine statistical effects of sleep-disordered breathing (SDB) symptom trajectories from 6 months to 7 years on subsequent behavior.
Parents in the Avon Longitudinal Study of Parents and Children ...reported on children's snoring, mouth breathing, and witnessed apnea at ≥2 surveys at 6, 18, 30, 42, 57, and 69 months, and completed the Strengths and Difficulties Questionnaire at 4 (n = 9140) and 7 (n = 8098) years. Cluster analysis produced 5 "Early" (6-42 months) and "Later" (6-69 months) symptom trajectories ("clusters"). Adverse behavioral outcomes were defined by top 10th percentiles on Strengths and Difficulties Questionnaire total and subscales, at 4 and 7 years, in multivariable logistic regression models.
The SDB clusters predicted ≈20% to 100% increased odds of problematic behavior, controlling for 15 potential confounders. Early trajectories predicted problematic behavior at 7 years equally well as at 4 years. In Later trajectories, the "Worst Case" cluster, with peak symptoms at 30 months that abated thereafter, nonetheless at 7 years predicted hyperactivity (1.85 1.30-2.63), and conduct (1.60 1.18-2.16) and peer difficulties (1.37 1.04-1.80), whereas a "Later Symptom" cluster predicted emotional difficulties (1.65 1.21-2.07) and hyperactivity (1.88 1.42-2.49) . The 2 clusters with peak symptoms before 18 months that resolve thereafter still predicted 40% to 50% increased odds of behavior problems at 7 years.
In this large, population-based, longitudinal study, early-life SDB symptoms had strong, persistent statistical effects on subsequent behavior in childhood. Findings suggest that SDB symptoms may require attention as early as the first year of life.
Sleep disorders and the risk of stroke McDermott, Mollie; Brown, Devin L.; Chervin, Ronald D.
Expert review of neurotherapeutics,
07/2018, Letnik:
18, Številka:
7
Journal Article
Recenzirano
Odprti dostop
Introduction: Stroke is a major cause of disability and death in the United States and across the world, and the incidence and prevalence of stroke are expected to rise significantly due to an aging ...population. Obstructive sleep apnea, an established independent risk factor for stroke, is a highly prevalent disease that is estimated to double the risk of stroke. It remains uncertain whether non-apnea sleep disorders increase the risk of stroke.
Areas covered: This paper reviews the literature describing the association between incident stroke and sleep apnea, rapid eye movement sleep behavior disorder, restless legs syndrome, periodic limb movements of sleep, insomnia, and shift work.
Expert commentary: Trials of continuous positive airway pressure for stroke prevention in sleep apnea patients have been largely disappointing, but additional trials that target populations not yet optimally studied are needed. Self-reported short and long sleep duration may be associated with incident stroke. However, abnormal sleep duration may be a marker of chronic disease, which may itself be associated with incident stroke. The relationship between non-apnea sleep disorders and incident stroke deserves further attention. Identification of specific non-apnea sleep disorders or sleep problems that convey an increased risk for stroke may provide novel targets for stroke prevention.
Consumer sleep technologies (CSTs) are widespread applications and devices that purport to measure and even improve sleep. Sleep clinicians may frequently encounter CST in practice and, despite lack ...of validation against gold standard polysomnography, familiarity with these devices has become a patient expectation. This American Academy of Sleep Medicine position statement details the disadvantages and potential benefits of CSTs and provides guidance when approaching patient-generated health data from CSTs in a clinical setting. Given the lack of validation and United States Food and Drug Administration (FDA) clearance, CSTs cannot be utilized for the diagnosis and/or treatment of sleep disorders at this time. However, CSTs may be utilized to enhance the patient-clinician interaction when presented in the context of an appropriate clinical evaluation. The ubiquitous nature of CSTs may further sleep research and practice. However, future validation, access to raw data and algorithms, and FDA oversight are needed.
Sleep and Cognitive Function in Multiple Sclerosis Braley, Tiffany J; Kratz, Anna L; Kaplish, Neeraj ...
Sleep (New York, N.Y.),
2016-Aug-01, 2016-08-01, 20160801, Letnik:
39, Številka:
8
Journal Article
Recenzirano
Odprti dostop
To examine associations between cognitive performance and polysomnographic measures of obstructive sleep apnea in patients with multiple sclerosis (MS).
Participants underwent a comprehensive ...MS-specific cognitive testing battery (the Minimal Assessment of Cognitive Function in MS, or MACFIMS) and in-laboratory overnight PSG.
In adjusted linear regression models, the oxygen desaturation index (ODI) and minimum oxygen saturation (MinO2) were significantly associated with performance on multiple MACFIMS measures, including the Paced Auditory Serial Addition Test (PASAT; 2-sec and 3-sec versions), which assesses working memory, processing speed, and attention, and on the Brief Visuospatial Memory Test-Revised, a test of delayed visual memory. The respiratory disturbance index (RDI) was also significantly associated with PASAT-3 scores as well as the California Verbal Learning Test-II (CVLT-II) Discriminability Index, a test of verbal memory and response inhibition. Among these associations, apnea severity measures accounted for between 12% and 23% of the variance in cognitive test performance. Polysomnographic measures of sleep fragmentation (as reflected by the total arousal index) and total sleep time also showed significant associations with a component of the CVLT-II that assesses response inhibition, explaining 18% and 27% of the variance in performance.
Among patients with MS, obstructive sleep apnea and sleep disturbance are significantly associated with diminished visual memory, verbal memory, executive function (as reflected by response inhibition), attention, processing speed, and working memory. If sleep disorders degrade these cognitive functions, effective treatment could offer new opportunities to improve cognitive functioning in patients with MS.
A commentary on this article appears in this issue on page 1489.
BACKGROUND AND PURPOSE—Limited data are available about the relationship between sleep-disordered breathing (SDB) and recurrent stroke and mortality, especially from population-based studies, large ...samples, or ethnically diverse populations.
METHODS—In the BASIC project (Brain Attack Surveillance in Corpus Christ), we identified patients with ischemic stroke (2010–2015). Subjects were offered screening for SDB with the ApneaLink Plus device, from which a respiratory event index (REI) score ≥10 defined SDB. Demographics and baseline characteristics were determined from chart review and interview. Recurrent ischemic stroke was identified through active and passive surveillance. Cause-specific proportional hazards models were used to assess the association between REI (modeled linearly) and ischemic stroke recurrence (as the event of interest), and all-cause poststroke mortality, adjusted for multiple potential confounders.
RESULTS—Among 842 subjects, the median age was 65 (interquartile range, 57–76), 47% were female, and 58% were Mexican American. The median REI score was 14 (interquartile range, 6–26); 63% had SDB. SDB was associated with male sex, Mexican American ethnicity, being insured, nonsmoking status, diabetes mellitus, hypertension, lower educational attainment, and higher body mass index. Among Mexican American and non-Hispanic whites, 85 (11%) ischemic recurrent strokes and 104 (13%) deaths occurred, with a median follow-up time of 591 days. In fully adjusted models, REI was associated with recurrent ischemic stroke (hazard ratio, 1.02 hazard ratio for one-unit higher REI score, 95% CI, 1.01–1.03), but not with mortality alone (hazard ratio, 1.00 95% CI, 0.99–1.02).
CONCLUSIONS—Results from this large population-based study show that SDB is associated with recurrent ischemic stroke, but not mortality. SDB may therefore represent an important modifiable risk factor for poor stroke outcomes.
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