Excessive sleepiness: under-recognized and essential marker for sleep/wake disorder management.

BACKGROUND: Research during the past few decades has provided substantial evidence indicating that excessive sleepiness (ES) and associated sleep/wake disorders can result in significant morbidity and mortality. However, symptomatology (e.g., ES) and the relationships among common morbidities (e.g., cardiovascular disease, metabolic disorders, mood impairment) and sleep/wake disorders remain under-recognized in clinical practice, particularly in primary care. Yet assessment of sleep/wakefulness and associated symptoms can often be easily conducted in the primary care setting, providing valuable information to facilitate the diagnosis and management of sleep/wake disorders. OBJECTIVE: To provide a conceptual and educational framework that helps primary care physicians comprehensively assess, differentially diagnosis, and appropriately manage patients presenting with ES or ES-related sleep/wake disorders. METHODS: Comprised of six sleep specialists and six primary care physicians, the Sleep/Wake Disorders Working Group (SWG) used a modified, two-round Delphi approach to create and harmonize consensus recommendations for the assessment, diagnosis, treatment, and ongoing management of patients with common sleep/wake disorders related to ES. RESULTS: After a review of the relevant literature, the SWG arrived at consensus on a number of clinical recommendations for the assessment and management ES and some of the most commonly associated sleep/wake disorders. Ten consensus statements ­ five each for assessment/diagnosis and treatment/ongoing care ­ were created for ES, insomnia, obstructive sleep apnea, circadian rhythm disorders, restless legs syndrome, and narcolepsy. CONCLUSION: ES and ES-related sleep/wake disorders are commonly encountered in the primary care setting. By providing an educational framework for primary care physicians, the SWG hopes to improve patient outcomes by emphasizing recognition, prompt diagnosis, and appropriate ongoing management of ES and associated sleep/wake disorders.

The effect of gastro-oesophageal reflux and omeprazole on key sleep parameters.

BACKGROUND: The effect of gastro-oesophageal reflux on sleep and sleep quality is highly controversial. AIM: To determine the temporal relationship of abnormal objective sleep parameters to gastro-oesophageal reflux during acid suppression in patients with self diagnosed sleep disorders. METHODS: Polysomnography during oesophageal pH monitoring was conducted in 16 subjects with and without gastro-oesophageal reflux as determined by a standardized questionnaire. Subjects were studied before and after omeprazole. RESULTS: All reflux events were followed by a sleep arousal or awakening. Nocturnal acid reflux events were not predicted by the Carlsson score. Omeprazole reduced acid reflux-associated arousals from 11.6 +/- 3.8 to 1.5 +/- 0.8 (P < 0.01) and awakenings from 7.7 +/- 1.2 to 3.7 +/- 0.5 (P < 0.05). Sleep efficiency improved from 70.2% to 81.6% in a small subset of subjects with decreased sleep (P < 0.05); rapid eye movement sleep increased from 55.0 +/- 4.5 to 94.5 +/- 18.9 min (P < 0.05); total sleep time increased from 294.0 +/- 15.9 to 345.6 +/- 55.6 min (P < 0.05). Apnoea, hypopnoea and hypoxaemia were not associated with reflux. CONCLUSIONS: In subjects with gastro-oesophageal reflux, sleep arousals and awakenings are closely related to acid reflux events. Reflux-related arousals and awakenings are decreased by acid suppression. Acid suppression in selected subjects with reflux events and reduced sleep efficiency is associated with increased total sleep time, rapid eye movement sleep and sleep efficiency.

Evaluation of chronic insomnia. An American Academy of Sleep Medicine review.

Insomnia is a condition which affects millions of individuals, giving rise to emotional distress, daytime fatigue, and loss of productivity. Despite its prevalence, it has received scant clinical attention. An adequate evaluation of persistent insomnia requires detailed historical information as well as medical, psychological and psychiatric assessment. Use of a classification system for sleep disorders and familiarity with major diagnostic groups will facilitate the clinician's evaluation and treatment. Thorough assessment also requires attention to the unique aspects of presentation and specific set of etiologies which are associated with particular age groups.

Self-reported sleep quality and quality of life for individuals with chronic pain conditions.

OBJECTIVE: To determine the sleep quality and quality of life for individuals with degenerative spinal disease or failed back surgery syndrome. DESIGN: Cross-sectional survey design utilizing standardized instruments. Data were analyzed with use of hierarchical stepwise multiple regression analyses. PATIENTS: One hundred sixty-seven individuals with degenerative spinal disease or postlaminectomy syndrome who presented to a tertiary care outpatient patient pain center. OUTCOME MEASURES: The Center for Epidemiological Studies Depression Index measured depressive symptomatology. A modified Pittsburgh Sleep Quality Index (PSQI) measured sleep quality. The arithmetic average of least and usual VAS ratings of pain measured everyday pain. A visual analog scale rating of highest pain during the past 2 weeks measured highest pain. The Epworth Sleepiness Scale measured daytime sleepiness. The Medical Outcome Study-Short Form-Health Survey (SF-36) measured the mental health and general health components of quality of life. RESULTS: Higher overall sleep quality and lower sleep latency primarily were related to higher ratings of physical functioning and shorter duration of pain. Ratings of the highest pain, but not everyday pain, were independent predictors of overall sleep quality and sleep latency. Daytime sleepiness was associated with younger age and depressed mood. Pain was not associated independently with daytime sleepiness. The quality of life related to mental functioning was associated positively with depressed mood and with the interaction of pain and depressed mood. None of the variables in the model (i.e., pain intensity, sleep quality, depression, and demographic variables) predicted quality of life related to overall general health. CONCLUSIONS: These data suggest that physical functioning, duration of pain, and age may be more important than pain intensity and depressed mood in contributing to decreased overall sleep quality and sleep latency. The contribution of physical functioning was particularly strong and should be included in subsequent studies of sleep, pain, and mood. The SF-36 should be compared to pain-specific quality-of-life measures to further evaluate the usefulness of this instrument with outpatients with chronic nonmalignant pain conditions.

Sleep disturbance and nonmalignant chronic pain: a comprehensive review of the literature.

Sleep disturbance is an important clinical complaint for individuals with nonmalignant pain conditions. This review is a broad introduction to the literature on sleep disturbance and chronic pain conditions. The article critically reviews studies of sleep disturbance in musculoskeletal pain, arthritis, headache, and fibromyalgia. Current neurobiological hypotheses regarding the pathogenesis of sleep disturbance and chronic pain, common comorbid disorders, and pharmacologic and non-pharmacologic treatments for sleep disturbance are reviewed.

The need for flexibility in dosing of hypnotic agents.

Although a variety of medical and psychiatric disorders are known to cause insomnia, there are many patients for which a cause cannot be determined. When the etiology is unknown, treatment of insomnia must be symptomatic. Epidemiologic studies suggest that insomnia does not occur on a regular basis in most people. In addition, the presentation of insomnia relative to the time of night is often variable, with waking in the middle of the night and initiating sleep upon going to bed being the most common. The intermittent occurrence of most insomnia suggests that treatment is best accomplished by using hypnotics on an "as needed" basis when difficulties with sleep occur. When pharmacological treatment of insomnia is warranted, benzodiazepine receptor agonists (BzRAs) are often the preferred class of agents. Agents with a shorter duration of action and rapid onset of action are preferred for flexible administration, providing an option for middle of the night dosing if this is when insomnia occurs. Of the available hypnotic agents in the BzRA class, triazolam, zolpidem, and zaleplon have rapid onsets of action and short half-lives. However, with a half-life of 1 hour, only zaleplon appears to be suited for middle of the night administration. Other important factors that affect selection of an agent for the treatment of intermittent insomnia include psychomotor or cognitive impairment and rebound insomnia after discontinuation of therapy. In one placebo-controlled trial, residual sedation was seen after flurazepam, but not with zaleplon, following middle-of-the-night administration. In addition, rebound insomnia was not apparent in a 4-week, placebo-controlled trial of zaleplon. In this same study, transient rebound insomnia was apparent with zolpidem compared to placebo. More data are needed on long-term therapy with hypnotic agents given intermittently on nights during which insomnia occurs.

Efficacy of laser-assisted uvulopalatoplasty in obstructive sleep apnea.

Laser-assisted uvulopalatoplasty (LAUP) enlarges the oropharyngeal airway by reshaping the uvula, soft palate, and tonsillar pillars. In contrast to a uvulopalatopharyngoplasty performed in the operating room, LAUP is staged over several office visits, is less costly, is bloodless, and is not associated with velopharyngeal insufficiency or stenosis. Previous studies have documented the efficacy of LAUP in the treatment of snoring. We explore the efficacy of LAUP in the treatment of obstructive sleep apnea. Forty-eight patients comprised the study group. Each patient snored, exhibited >50% palatal collapse on Müller's maneuver, and had nocturnal polysomnography showing a respiratory disturbance index (RDI) >10. Each patient underwent LAUP until he or she reported that snoring had ceased. Of the 29 patients who underwent post-LAUP nocturnal polysomnography, 7 had RDIs <10, oxygen saturation >86%, and no cardiac arrhythmias. LAUP reduced RDI to <10 in patients with pre-LAUP apnea indexes <3 (P = 0.05) or pre-LAUP RDIs <30 (P = 0.01). The following variables did not correlate with the success of LAUP in treating obstructive sleep apnea: age, sex, pre-LAUP weight, pre-LAUP body mass index, perioperative weight change, perioperative body mass index change, pre-LAUP snoring, and post-LAUP snoring. We conclude that LAUP is an effective means of treating patients with RDIs <30.

The Taskforce 2000 survey on medical education in sleep and sleep disorders.

Previous research has shown evidence of a widening gap between scientific research and clinical teaching in sleep and sleep disorders. To address the deficiencies in current medical education in sleep, the Taskforce 2000 was established by the American Sleep Disorders Association. The present study was undertaken to assess the teaching activities, needs and interests of the membership of the two largest professional sleep societies (American Sleep Disorders Association and Sleep Research Society). Survey instruments included a brief, 5-item postcard survey, which was mailed to all members, followed by an in-depth, 34-item questionnaire, which was completed by 158 respondents from the intitial postcard survey (N = 808). Results indicated that the majority of respondents (65.2%) are currently involved in teaching sleep to medical students or postgraduate trainees, although the average amount of teaching time was only 2.1 hours for undergraduate and 4.8 hours for graduate education in sleep. Teaching of sleep laboratory procedures and clinical evaluation of sleep-disordered patients is limited at either an undergraduate or postgraduate level. The major deficiencies noted were the lack of time in the medical curriculum and the need for better resources and teaching facilities. A large majority of respondents indicated their willingness to be involved in sleep education for physicians, and rated this a high priority for the professional organization.

A normative study of the maintenance of wakefulness test (MWT).

The maintenance of wakefulness test (MWT) is a daytime polysomnographic procedure which quantifies wake tendency by measuring the ability to remain awake during soporific circumstances. We present normative data based on 64 healthy subjects (27 males and 37 females) who adhered to uniform MWT procedural conditions including polysomnographic montage, illuminance level, seating position, room temperature, meal timing, and subject instructions. When allowed a maximum trial duration of 40 min, subjects' mean sleep latency to the first epoch of sustained sleep was 35.2 +/- 7.9 min. The lower normal limit, defined as two standard deviations below the mean, was 19.4 min. Calculation of data on the basis of a maximum trial duration of 20 min and sleep latency to the first appearance of brief sleep (a microsleep episode or one epoch of any stage of sleep) yielded a mean sleep latency of 18.1 +/- 3.6 min and a lower normal limit of 10.9 min. Sleep latency scores were significantly higher than those previously reported in patients with disorders of excessive somnolence. Therefore, the MWT appears to be a useful procedure in differentiating groups with normal daytime wake tendency from those with impaired wake tendency and in identifying individuals with pathologic inability to remain awake under soporific circumstances.

Predictors of outcome for uvulopalatopharyngoplasty.

The objective of this study was to assess the value of preoperative fiberoptic nasopharyngoscopy with the Müller maneuver (FNMM) and cephalometric radiography in predicting response to uvulopalatopharyngoplasty (UPPP) in patients with obstructive sleep apnea syndrome. Fifty-three such patients having significant obstruction at the soft palatal level and variable degrees of obstruction at the base-of-tongue level underwent both diagnostic procedures before UPPP. Outcome was assessed by the apnea-plus-hypopnea index (AHI) as determined by polysomnography, which was performed before and after surgery. As a group, patients exhibited a significant 10-point reduction in AHI (46.5 to 36.7). However, 17 (32.1%) were judged to be responders as defined by a reduction of the AHI by an increment of 50% or greater with respect to baseline. Of all the cephalometric variables assessed, soft palate length was the only one that differed between responders and nonresponders (45.5 mm versus 42.6 mm, respectively). However, this difference only approached significance (P = .067). Similarly, FNMM results did not discriminate between responders and nonresponders. These results indicate that preoperative cephalometric radiography and FNMM cannot be reliably used to enhance surgical success.

Triazolam diminishes daytime sleepiness and sleep fragmentation in patients with periodic leg movements in sleep.

Fifteen subjects (9 men and 6 women) exhibiting objective evidence of excessive daytime somnolence and periodic leg movements in sleep underwent 4-7 days of treatment with triazolam (0.25 or 0.50 mg) and placebo in a double-blind crossover design. One night of polysomnography followed by daytime multiple sleep latency testing were conducted on the first and last days of each treatment block. By the last day of treatment, the mean multiple sleep latency test score after triazolam (9.0 minutes) was significantly greater than that after placebo (5.7 minutes). Thus, triazolam treatment led to a decrease in daytime somnolence. Triazolam also improved sleep architecture and continuity; it increased total sleep time, decreased the number of awakenings and arousals, and decreased stage 1 and increased stage 2 percentages. Although the frequency of periodic electromyographic bursts remained unchanged, the frequency of associated arousals decreased after treatment. Short-term treatment with triazolam is thus effective in diminishing daytime sleepiness and in improving sleep architecture, continuity and duration in patients with periodic leg movements in sleep. These effects do not seem to be mediated through a decrease in periodic leg movement activity.

2- versus 4-hour evening phototherapy of seasonal affective disorder.

Seasonal affective disorder (SAD) has been successfully treated with bright light, and morning exposure has been deemed more effective than exposure at other times. Evening treatment may offer a practical advantage, but the optimal duration of exposure has not been established. Six SAD patients were treated at home for 1 week with 2500 lux of light given either from 6 p.m. to 8 p.m. or from 6 p.m. to 10 p.m. using a counterbalanced crossover design with a minimal withdrawal period of 1 week between conditions. Both treatments were effective in reversing SAD symptoms, but neither treatment was superior. These results suggest that evening phototherapy for as little as 2 hours may be a useful and reasonable alternative for the treatment of SAD.

Light-induced plasma melatonin suppression in seasonal affective disorder.

1. Subjects with seasonal affective disorder were exposed to 0, 500 and 1000 lux of white light for one hour beginning at 0300 hours. 2. Plasma samples were taken periodically and analysed for melatonin. 3. Plasma melatonin levels were suppressed by exposure to both 500 and 1000 lux light levels, suggesting that SAD patients show no neuroendocrine insensitivity to light but may show supersensitive responses to light.

Treatment of winter depression with a portable, head-mounted phototherapy device.

1. A portable, head-mounted device was developed for administration of light therapy. A randomized crossover protocol was used to test the therapeutic efficacy of this device, compared to a standard light box, for treatment of winter depression. 2. Depressive symptoms were significantly reduced by both the head-mounted device and the light box. 3. Therapeutic efficacy of the two devices was not significantly different. 4. The head-mounted device was rated by patients as significantly more convenient than the conventional light box; this may be important in improving patient compliance.

Sleep disorders: a selective update.

Recent years have seen significant advances in sleep disorders medicine, including effective treatments for chronic psychophysiological insomnia and obstructive sleep apnea syndrome; greater understanding of biological rhythms and of the nature of sleep in depression, including seasonal affective disorder; and the discovery of REM behavior disorder. The author reviews selected developments in the sleep disorders field over the last three years. Developments are presented in the framework of the diagnostic classification of the American Sleep Disorders Association, with emphasis on areas relevant to the practice of psychiatry.