Background and purpose
Despite their high prevalence and clinical impact, sleep disorders in Parkinson's disease appear to receive insufficient attention in clinical practice. We compared the ...importance of sleep disorders relative to other symptoms and daily issues. Furthermore, we determined whether relevance as perceived by patients correlated with the subjective presence of sleep disruption scored with a rating scale.
Methods
We studied a cohort of 153 consecutive patients (95 men) who were referred for problems other than sleep to our referral center. Prior to their visit, patients ranked their individual top five clinical priorities (of 23 items), indicating the most problematic domains for which they requested medical attention. Additionally, nocturnal sleep quality and excessive daytime sleepiness (EDS) were assessed with validated questionnaires.
Results
The top three important domains according to the patient were movement (79.9%), medication (73.2%), and physical condition (63.4%). Sleep was the sixth most frequently reported item, marked by 37.9% of the patients. Amongst the patients who scored sleep as a priority, 47 (81%) had a poor sleep quality (Pittsburgh Sleep Quality Index > 5). Although EDS was present in almost 30% of patients, a minority of them put it on their priority list.
Conclusion
A priority list can be used to prioritize patient‐centered quality of life issues. Our results show that sleep is a clinical priority for about one‐third of patients. Surprisingly, EDS was usually not prioritized by patients during the consultation, underscoring the need to use ratings scales alongside subjective priorities.
This study was performed to evaluate the long-term impact of maxillomandibular advancement (MMA) surgery on the apnoea–hypopnoea index (AHI) and quality of life (QoL) in patients with obstructive ...sleep apnoea syndrome (OSAS). The medical files of 12 OSAS patients who underwent MMA by one surgeon between 1995 and 1999 were reviewed retrospectively. Patients received a clinical assessment, polysomnography, and QoL questionnaires as part of routine care preoperatively (n=12), within 2 years postoperative (n=12), and again in 2016 (n=9). A successful surgical outcome was defined as an AHI decrease of >50% with <20 events/h. Of the 66.7% (8/12) of patients who were initially cured, 66.7% (4/6) remained stable at a median follow-up of 19 years. Only the two patients with the highest AHI showed abnormal Epworth Sleepiness Scale scores. After convalescence, most patients reported stable symptomatic improvement. Aesthetic changes were found acceptable and all but one patient stated that they would undergo the surgery again. It is concluded that MMA is a safe and effective procedure. Ageing and weight gain might counterbalance the positive effects of surgery in the long term. It is therefore suggested that re-evaluation every 5 years should be scheduled, since a spontaneous AHI increase over time does not seem to be reflected by symptomatic changes.
Summary
The publication of “The Sleep Apnea Syndromes” by Guilleminault et al. in the 1970s hallmarked the discovery of a new disease entity involving serious health consequences. Obstructive sleep ...apnea was shown to be the most important disorder among the sleep apnea syndromes (SAS). In the course of time, it was found that the prevalence of obstructive sleep apnea reached the proportions of a global epidemic, with a major impact on public health, safety and the economy. Early on, a metric was introduced to gauge the seriousness of obstructive sleep apnea, based on the objective measurement of respiratory events during nocturnal sleep. The apnea index and later on the apnea−hypopnea index, being the total count of overnight respiratory events divided by the total sleep time in hours, were embraced as principle measures to establish the diagnosis of obstructive sleep apnea and to rate its severity. The current review summarises the historical evolution of the apnea−hypopnea index, which has been subject to many changes, and has been criticised for not capturing relevant clinical features of obstructive sleep apnea. In fact, the application of the apnea−hypopnea index as a continuous exposure variable is based on assumptions that it represents a disease state of obstructive sleep apnea and that evocative clinical manifestations are invariably caused by obstructive sleep apnea if the apnea−hypopnea index is above diagnostic threshold. A critical appraisal of the extensive literature shows that both assumptions are invalid. This conclusion prompts a reconsideration of the role of the apnea−hypopnea index as the prime diagnostic metric of clinically relevant obstructive sleep apnea.
Summary
This European guideline for the diagnosis and treatment of insomnia was developed by a task force of the European Sleep Research Society, with the aim of providing clinical recommendations ...for the management of adult patients with insomnia. The guideline is based on a systematic review of relevant meta‐analyses published till June 2016. The target audience for this guideline includes all clinicians involved in the management of insomnia, and the target patient population includes adults with chronic insomnia disorder. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to grade the evidence and guide recommendations. The diagnostic procedure for insomnia, and its co‐morbidities, should include a clinical interview consisting of a sleep history (sleep habits, sleep environment, work schedules, circadian factors), the use of sleep questionnaires and sleep diaries, questions about somatic and mental health, a physical examination and additional measures if indicated (i.e. blood tests, electrocardiogram, electroencephalogram; strong recommendation, moderate‐ to high‐quality evidence). Polysomnography can be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep‐related breathing disorders), in treatment‐resistant insomnia, for professional at‐risk populations and when substantial sleep state misperception is suspected (strong recommendation, high‐quality evidence). Cognitive behavioural therapy for insomnia is recommended as the first‐line treatment for chronic insomnia in adults of any age (strong recommendation, high‐quality evidence). A pharmacological intervention can be offered if cognitive behavioural therapy for insomnia is not sufficiently effective or not available. Benzodiazepines, benzodiazepine receptor agonists and some antidepressants are effective in the short‐term treatment of insomnia (≤4 weeks; weak recommendation, moderate‐quality evidence). Antihistamines, antipsychotics, melatonin and phytotherapeutics are not recommended for insomnia treatment (strong to weak recommendations, low‐ to very‐low‐quality evidence). Light therapy and exercise need to be further evaluated to judge their usefulness in the treatment of insomnia (weak recommendation, low‐quality evidence). Complementary and alternative treatments (e.g. homeopathy, acupuncture) are not recommended for insomnia treatment (weak recommendation, very‐low‐quality evidence).
Introduction The interrelationship of different dimensions (fatigue, neuroticism, sleep quality, global mental and physical health) in patients with unexplained chronic fatigue, referred with ...presumed chronic fatigue syndrome (CFS), was explored. Materials and methods Patients with unexplained chronic fatigue filled out two independent fatigue scales (Fatigue Questionnaire, FQ and Checklist Individual Strength, CIS), NEO-Five Factor Inventory (NEO-FFI), Pittsburgh Sleep Quality Index (PSQI) and Medical Outcomes Study 36-item Short Form Health Survey (SF36). Path and regression analyses were performed. Results Out of 296 eligible patients, 203 subjects were included (mean age 39.0 years, SD 10.37, 89% female). In a first path analysis, using FQ for assessment of fatigue, night-time PSQI sleep quality had a direct effect on SF36 physical health quality of life (PHQL) and no effect on FQ fatigue. This was confirmed by a subsequent path analysis with CIS fatigue and by regression analyses. These unexpected results raised the question whether FQ or CIS fatigue sufficiently reflects fatigue. For both scales, the introduction of a latent variable into the model resulted in a significant improvement of fit, with an indirect effect of PSQI sleep quality on SF36 PHQL through this latent variable. Furthermore, this variable had a direct effect on FQ or CIS fatigue, respectively, and on the two SF36 variables. Conclusion A latent variable was introduced as missing link in the relationship between different subjective complaints of patients with presumed CFS and outcome measures of quality of life. Hence, this finding holds promise for a more cohesive framework of the different dimensions in the construct of chronic fatigue and CFS and needs to be developed as a clinical tool.
Introduction This study aimed to assess objective parameters of sleep and sleepiness in a large sample of patients with unexplained chronic fatigue and to compare the results with data from a ...reference population. Furthermore, the relation was assessed between these objective parameters and subjective scores probing mental and physical health, sleep quality, daytime sleepiness and fatigue. Materials and methods Objective sleep parameters were derived from polysomnography (PSG) and multiple sleep latency testing (MSLT). Subjective assessment consisted of the administration of validated questionnaires: Medical Outcomes Study 36-item Short Form Health Survey for the assessment of global mental and physical health, Epworth Sleepiness Scale for excessive daytime sleepiness, Pittsburgh Sleep Quality Index for global sleep quality and Fatigue Questionnaire for fatigue severity. Results Out of 377 eligible patients, 245 subjects were included (mean age 38.6 years, SD 10.69, 86.1% female). Sleep disorders were prevalent in 55.5% (sleep apnea, 32.7%; insomnia, 16.7%; periodic limb movements, 13.9%). Significant differences in several objective sleep parameters were observed between the unexplained chronic fatigue and reference groups (i.e. decreased total sleep time, sleep efficiency and %REM; increased sleep latency, %NREM1, wake after sleep onset and arousal index). Neither PSG nor MSLT data were correlated with fatigue, and were only weakly correlated with mental health and subjective sleepiness. Increased sleepiness in the Epworth Sleepiness Scale was not substantiated by objective data from the MSLT. Conclusion An insomnia phenotype was suggested in patients with unexplained chronic fatigue, based on the observed sleep profile. The overall lack of correlation between subjective scores and objective indices derived from PSG and MSLT may suggest that the latter are inappropriate to explain symptoms of daytime sleepiness and fatigue in patients with unexplained chronic fatigue. However, their application remains justified for the demonstration of comorbid primary sleep disorders in this patient group.
Chronic fatigue syndrome (CFS) is characterised by incapacitating fatigue in combination with a number of minor criteria, including unrefreshing sleep without further specifications, in the absence ...of psychiatric and internal disease. As little data exist on subjective sleep quality and daytime sleepiness, these parameters were assessed in a large sample of CFS patients.
Consecutive patients with a diagnosis of CFS in a tertiary referral centre filled out the Fatigue Questionnaire (FQ), Medical Outcomes Study 36-Item Short Form Health Survey (MOS SF-36), Epworth Sleepiness Scale (ESS) and Pittsburgh Sleep Quality Index (PSQI).
Inclusion comprised 415 individuals (mean age 40.5 yr, SD 7.9, range 18-64; 86% female). Mean FQ (26.90; SD 4.04), mean Global Physical Health from the MOS SF-36 (29.30; SD 12.25) and Global Mental Health from the MOS SF-36 (49.62; SD 18.31) scores corresponded with literature data for similar CFS samples. High mean ESS (10.51; SD 5.52) and global PSQI (10.17; SD 4.02) were observed. No significant relationship was found between ESS and global PSQI. In contrast, regression analysis demonstrated a significant cubic relation between ESS and 'PSQI without daytime dysfunction'. A subgroup (n = 69) with an insomnia-like phenotype low ESS (< 5), high PSQI (mean 11.51; SD 3.86) was observed.
The assessment of subjective sleep quality and daytime sleepiness in a large sample of CFS patients indicated high mean PSQI and ESS values. ESS and 'PSQI without daytime dysfunction' were inversely related at the spectral ends of ESS. A distinct subgroup with clinical features of insomnia was identified.
Summary
Progress in the field of insomnia since 2017 necessitated this update of the European Insomnia Guideline. Recommendations for the diagnostic procedure for insomnia and its comorbidities are: ...clinical interview (encompassing sleep and medical history); the use of sleep questionnaires and diaries (and physical examination and additional measures where indicated) (A). Actigraphy is not recommended for the routine evaluation of insomnia (C), but may be useful for differential‐diagnostic purposes (A). Polysomnography should be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep‐related breathing disorders, etc.), treatment‐resistant insomnia (A) and for other indications (B). Cognitive‐behavioural therapy for insomnia is recommended as the first‐line treatment for chronic insomnia in adults of any age (including patients with comorbidities), either applied in‐person or digitally (A). When cognitive‐behavioural therapy for insomnia is not sufficiently effective, a pharmacological intervention can be offered (A). Benzodiazepines (A), benzodiazepine receptor agonists (A), daridorexant (A) and low‐dose sedating antidepressants (B) can be used for the short‐term treatment of insomnia (≤ 4 weeks). Longer‐term treatment with these substances may be initiated in some cases, considering advantages and disadvantages (B). Orexin receptor antagonists can be used for periods of up to 3 months or longer in some cases (A). Prolonged‐release melatonin can be used for up to 3 months in patients ≥ 55 years (B). Antihistaminergic drugs, antipsychotics, fast‐release melatonin, ramelteon and phytotherapeutics are not recommended for insomnia treatment (A). Light therapy and exercise interventions may be useful as adjunct therapies to cognitive‐behavioural therapy for insomnia (B).
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