Disparities in sleep-wake patterns by labor force status: Population-based findings.

Sleep disturbances have been associated with unemployment, but variation in sleep-wake patterns by labor force status has rarely been examined. With a population-based sample, we investigated differences in sleep-wake patterns by labor force status (employed, unemployed, and not-in-the-labor-force) and potential disparities by sociodemographic variables. The analysis included 130,602 adults aged 25-60 y, who participated in the American Time Use Survey between 2003 and 2019. Individual sleep-wake pattern was extracted from time use logs in a strict 24-h period (04:00 h-03:59 h). Functional nonparametric regression models based on dimensionality reduction and neighborhood matching were applied to model the relationship between sleep-wake patterns and labor force status. Specifically, we predicted changes in intra-person sleep-wake patterns under hypothetical changes of labor force status from employed to unemployed or not-in-the-labor-force. We then studied moderations of this association by gender, race/ethnicity and educational attainment. In comparison to the employed state, unemployed and not-in-the-labor-force states were predicted to have later wake-times, later bedtimes, and higher tendency for taking midday naps. Changes in labor force status led to more apparent shifts in wake-times than in bedtimes. Additionally, sleep schedules of Hispanics and those with higher education level were more vulnerable to the change of labor force status from employed to unemployed.

Longitudinal Assessment of Sleep Apnea in the Year After Stroke in a Population-Based Study.

BACKGROUND: The aim of this study was to characterize change in sleep-disordered breathing severity in the year following stroke, overall, and by ethnicity, within the population-based Brain Attack Surveillance in Corpus Christi Project. METHODS: First-ever ischemic strokes (n=414) were ascertained by active and passive surveillance and validated by stroke-trained physicians. Patients with stroke were invited to participate in portable sleep apnea testing (ApneaLink Plus) at baseline and 3, 6, and 12 months poststroke. Sleep-disordered breathing severity was assessed by the respiratory event index (apneas and hypopneas/hour of recording). The component obstructive apnea index and central apnea index were also assessed. Time and ethnicity effects on outcomes, as well as ethnic differences in time effects, were analyzed using generalized estimating equations with multivariable adjustment for confounding factors. RESULTS: Mean age (n=414) was 63.9 years (SD=10.9); 68.4% were Mexican American. Baseline mean respiratory event index, obstructive apnea index, and central apnea index were 21.3 (SD=16.6), 8.6 (SD=11.5), and 1.5 (SD=3.2), respectively. There was no time effect on respiratory event index (P=0.35) but obstructive apnea index increased over time (P<0.01). Averaged over follow-up, respiratory event index and obstructive apnea index were significantly higher in Mexican American than non-Hispanic White persons. No ethnic difference in the time effect was found for either outcome. For central apnea index, there was an ethnicity-time interaction (P=0.01) such that central apnea index increased in non-Hispanic White but did not change in Mexican American persons. CONCLUSIONS: Sleep-disordered breathing severity was significant and stable for most individuals in the year after stroke. These results do not confirm previous reports of diminishing sleep-disordered breathing severity over time after stroke and would support early assessment and treatment where indicated.

Effects of a Sleep Health Education Program for Children and Parents on Child Sleep Duration and Difficulties: A Stepped-Wedge Cluster Randomized Clinical Trial.

Importance: Preschool-aged children often lack sufficient sleep and experience sleep difficulties. A consistent bedtime routine, falling asleep alone, and other sleep practices reduce difficulties and increase sleep duration. Objective: To evaluate the effects of a preschool-based sleep health literacy program on children's sleep duration and difficulties and on parent sleep knowledge, attitudes, self-efficacy, and beliefs 9 and 12 months after the program. Design, Setting, and Participants: This stepped-wedge cluster randomized clinical trial was implemented across the 2018-2019 school year. Head Start preschool personnel delivered interventions and collected outcomes data at baseline and 4 follow-ups. Seven Head Start agencies across New York State were randomized to implement interventions in either fall 2018 or winter and spring 2019. Outcomes were ascertained at 9- and 12-month follow-up. From March 19 through September 28, 2018, Head Start staff recruited (a) English- or Spanish-speaking parents (b) of children 3 years of age on or about September 2018 (c) who planned to remain at the site through the school year. Altogether, 519 parent-child (aged 3 years) dyads completed baseline and (any) follow-up data. Interventions: A 2-week classroom curriculum for children, a 1-hour parent workshop, and 1-on-1 parent discussions at home or school. Main Outcomes and Measures: Outcomes were the pre- vs postintervention differences measured at baseline and 9-month follow-up for parent-reported child school-night sleep duration per sleep logs, mild or moderate sleep difficulties per a validated questionnaire, and the total and domain scores for parent sleep knowledge, attitudes, self-efficacy, and beliefs. A modified intention-to-treat analysis excluding participants with only baseline data was used. Results: The mean (SD) age at enrollment of 519 children was 2.7 (0.1) years, 264 (50.9%) were girls, 196 (37.8%) lived in Spanish-speaking households, and 5 (0.9%) identified as Alaskan Native or American Indian, 17 (3.2%) as Asian American or Pacific Islander, 57 (10.8%) as Black, 199 (37.8%) as White, and 63 (12.0%) as other. Mean sleep durations increased nonsignificantly from baseline by 5.6 minutes (95% CI, -2.3 to 13.6 minutes; P = .17) at 9-month follow-up and by 6.8 minutes (95% CI, 0.2-13.7 minutes; P = .06) at 12-month follow-up. There was a slight improvement in parental knowledge (1.13 unit increase from baseline; 95% CI, 0.13-2.12 units), but no significant outcomes for parent sleep attitudes (0.16 unit increase from baseline; 95% CI, -0.46 to 0.77 units), self-efficacy (-0.13 unit decrease from baseline; 95% CI, -1.02 to 0.76 units) and beliefs (-0.20 unit decrease from baseline; 95% CI, -0.56 to 0.16 units). Intervention effects for child sleep difficulties were not significant (odds ratio, 1.13; 95% CI, 0.62-2.09). Fewer than 1 in 4 parents accurately perceived their child's sleep difficulty at 12 months. Conclusions and Relevance: The findings of this large pragmatic, stepped-wedge cluster randomized clinical trial, albeit largely negative, may have implications for the sustained impact, focus, and potential population-level effects of sleep education programs. Future research should evaluate the effects of more recurrent programming that emphasizes recognition of sleep problems and whether small increments of sleep across months and years in early childhood have meaningful effects. Trial Registration: ClinicalTrials.gov Identifier: NCT03556462.

Obstructive sleep apnea treatment and dementia risk in older adults.

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.

Obstructive sleep apnea in older adults: geographic disparities in PAP treatment and adherence.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is prevalent among older adults. Although treatment with positive airway pressure (PAP) lowers subsequent morbidity, PAP adherence is inconsistent. Socioeconomic disparities have been observed in OSA treatment, but regional differences in OSA care are unknown. This study examined geographic variations in PAP treatment and adherence among older Americans. METHODS: This study utilized a representative 5% sample of all Medicare fee-for-service beneficiaries aged 65+ years. An OSA diagnosis, treatment, and PAP adherence were confirmed with International Classification of Diseases, Ninth Revision, HCPCS (Health Care Common Procedure Coding System) codes, and ≥2 HCPCS claims for PAP supplies respectively. Descriptive statistics were used to examine proportions of Medicare beneficiaries who obtained and adhered to PAP. Maps described the proportion of treated and adherent beneficiaries by state and hospital referral region. RESULTS: For state-level data, PAP treatment and adherence proportions among beneficiaries with an OSA diagnosis ranged between 54-87% and 59-81%, respectively. Proportions of treated patients were higher in Midwest states (>80%), in comparison to Northwest, Northeast, and Southern states (<73%). Southern states and California had lowest proportions of PAP adherence (<70%). Within-state variability in treatment patterns were apparent along the East and West coasts. Correlations of PAP treatment and adherence proportions were low in Washington, DC, New York, and New Jersey. Discordant treatment and adherence proportions were observed in Alabama and Mississippi. CONCLUSIONS: Significant state-level and regional disparities of PAP treatment and adherence among Medicare beneficiaries with OSA suggest gaps in delivery of OSA care for older Americans.

Obstructive sleep apnea treatment disparities among older adults with neurological disorders.

OBJECTIVE: The objective of the study was to characterize obstructive sleep apnea treatment patterns among older Americans with neurological conditions. SETTING AND PARTICIPANTS: Claims data from a 5% fee-for-service sample of Medicare beneficiaries were analyzed to determine the proportion of older adults with OSA who received and were adherent to continuous positive airway pressure therapy and examine potential gaps in OSA care among neurological populations. Logistic regression was used to determine whether gender or race/ethnicity modified the associations between neurological morbidities and OSA treatment or adherence. RESULTS: Data from n = 102,618 beneficiaries with OSA were identified. The prevalence of stroke, cognitive disorders, or Parkinson's disease in this sample was 7%, 3%, and 2% respectively. Overall, OSA-diagnosed individuals (73%) obtained treatment, and most treated were adherent to CPAP (72%). Lower proportions of OSA treatment and adherence were observed in neurological conditions, particularly stroke. In logistic regression models, gender and race/ethnicity each modified associations between neurological comorbidity and OSA treatment and adherence. Women as compared to men with a given neurological condition were uniformly less likely to receive CPAP or adhere to treatment (P < .01 for each condition). Similarly, in comparison to whites with the same neurological condition, OSA treatment was significantly lower among all other races with stroke, and among blacks with cognitive disorders. CONCLUSIONS: Older women and minorities with neurological conditions may be more vulnerable to gaps in OSA care. Targeted strategies to improve treatment disparities and neurological outcomes in older adults could be informed by these data.

Sleep apnea screening is uncommon after stroke.

OBJECTIVE/BACKGROUND: To assess (1) pre and post-stroke screening for sleep apnea (SA) within a population-based study without an academic medical center, and (2) ethnic differences in post-stroke sleep apnea screening among Mexican Americans (MAs) and non-Hispanic whites (NHWs). PATIENTS/METHODS: MAs and NHWs with stroke in the Brain Attack Surveillance in Corpus Christi project (2011-2015) were interviewed shortly after stroke about the pre-stroke period, and again at approximately 90 days after stroke in reference to the post-stroke period. Questions included whether any clinical provider directly asked about snoring or daytime sleepiness or had offered polysomnography. Logistic regression tested the association between these outcomes and ethnicity both unadjusted and adjusted for potential confounders. RESULTS: Among 981 participants, 63% were MA. MAs in comparison to NHWs were younger, had a higher prevalence of hypertension, diabetes, and never smoking, a higher body mass index, and a lower prevalence of atrial fibrillation. Only 17% reported having been offered SA diagnostic testing pre-stroke, without a difference by ethnicity. In the post-stroke period, only 50 (5%) participants reported being directly queried about snoring; 86 (9%) reported being directly queried about sleepiness; and 55 (6%) reported having been offered polysomnography. No ethnic differences were found for these three outcomes, in unadjusted or adjusted analyses. CONCLUSIONS: Screening for classic symptoms of SA, and formal testing for SA, are rare within the first 90 days after stroke, for both MAs and NHWs. Provider education is needed to raise awareness that SA affects most patients after stroke and is associated with poor outcomes.

Key insomnia symptoms and incident pain in older adults: direct and mediated pathways through depression and anxiety.

Pain is common among older adults and negatively impacts functioning. Sleep disturbances and mood disorders, specifically depression and anxiety, are closely associated with pain in older individuals, but the directionality of these associations remains unclear. In this study, we deconstruct long-term temporal effects of two key insomnia symptoms on incident pain into direct and indirect pathways, with focus on depression and anxiety symptoms, within a nationally representative sample. We utilized 2011-2013 data from the National Health and Aging Trends Study, a longitudinal survey of 2239 community-dwelling Medicare beneficiaries. Participants completed annual in-person interviews with assessments of sleep initiation and maintenance; depression, and anxiety (using the Patient Health Questionnaire-2 [PHQ-2] and the Generalized Anxiety Disorder Scale-2 [GAD-2] respectively); and bothersome pain. Causal mediation analysis was applied to examine direct effects of the two insomnia symptoms at baseline on incident pain, and their indirect effects through depression and anxiety symptoms. Almost one-third of the study participants were 69 years old or younger. A similar proportion reported bothersome pain in 2013. The two baseline insomnia symptoms predicted the development of pain. Adjusted analyses suggested that compared to older adults without the two baseline insomnia symptoms, participants with sleep initiation or maintenance difficulties had 24% (95% confidence interval [CI] 2%,51%) and 28% (95% CI 4%,55%) higher odds of incident pain, respectively. Anxiety symptoms partially mediated the relationship between the insomnia symptoms and incident pain, accounting for up to 17% of the total effect, but depressive symptoms did not. These results suggest that improved sleep or anxiety could reduce the risk for future pain.

Recognition and Diagnosis of Obstructive Sleep Apnea in Older Americans.

OBJECTIVES: To estimate the proportion of older Americans at risk for obstructive sleep apnea (OSA) who receive OSA evaluations, diagnosis, and treatment. DESIGN: Cross sectional study. SETTING: National Health and Aging Trends Study (NHATS), Round 3 survey. PARTICIPANTS: Community-dwelling Medicare beneficiaries age 65 and older (N=1,052). MEASUREMENTS: NHATS participants were asked specific questions about sleep disturbances, including items that resembled critical elements of a validated instrument used to assess OSA risk (the STOP-Bang questionnaire). The proportion of older Americans at risk for OSA who received evaluations with home or in-laboratory sleep studies, OSA diagnosis, and OSA treatment was examined, as well as clinical, social, and demographic correlates of OSA. RESULTS: Of 1,052 participants who completed the sleep module, 56% (95% confidence interval (CI)=53-59%) were estimated to be at high risk of OSA. Only 8% (95% CI=5-11%) of the high-risk individuals had been tested for it. Of those tested, 94% (95% CI=87-100%) were diagnosed with OSA. Treatment with positive airway pressure was prescribed for 82% (95% CI=65-99%) of participants with an OSA diagnosis. CONCLUSIONS: Evidence from this nationally representative sample of community-dwelling Medicare beneficiaries suggests that high OSA risk is common but seldom investigated. When investigated, OSA is almost always confirmed and usually treated. These findings suggest a significant gap in OSA assessment for older Americans that could have public health implications.

Delaying Middle School and High School Start Times Promotes Student Health and Performance: An American Academy of Sleep Medicine Position Statement.

ABSTRACT: During adolescence, internal circadian rhythms and biological sleep drive change to result in later sleep and wake times. As a result of these changes, early middle school and high school start times curtail sleep, hamper a student's preparedness to learn, negatively impact physical and mental health, and impair driving safety. Furthermore, a growing body of evidence shows that delaying school start times positively impacts student achievement, health, and safety. Public awareness of the hazards of early school start times and the benefits of later start times are largely unappreciated. As a result, the American Academy of Sleep Medicine is calling on communities, school boards, and educational institutions to implement start times of 8:30 AM or later for middle schools and high schools to ensure that every student arrives at school healthy, awake, alert, and ready to learn.

The Past Is Prologue: The Future of Sleep Medicine.

ABSTRACT: The field of sleep medicine has gone through tremendous growth and development over a short period of time, culminating in recognition of the field as an independent medical subspecialty by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS). However, the fellowship training requirement that is now mandatory for sleep medicine board certification eligibility has had the unintended consequence of restricting the influx of young physicians to the field. In response to the potential workforce shortage confronting the field of sleep medicine, the American Academy of Sleep Medicine (AASM) board of directors has developed a comprehensive plan to strengthen the field by growing sleep fellowship programs, exploring novel sleep medicine training opportunities, creating and fostering the sleep team (with special emphasis on engagement of primary care providers), embracing the role of consumer sleep technologies, and expanding the reach of sleep specialists through telemedicine. The AASM plans summarized in this special article represent efforts to confront serious workforce challenges and turn them into opportunities that will improve the health of both our patients and our field.

Associations among Neighborhood, Race, and Sleep Apnea Severity in Children. A Six-City Analysis.

RATIONALE: Prior researchers found that individual-level environmental and social indicators did not explain the racial disparity in obstructive sleep apnea syndrome. Neighborhood socioeconomic variables, as well as risk factors for a range of adverse behavioral and health outcomes, may better explain this racial disparity and help identify modifiable intervention targets. OBJECTIVES: To evaluate the associations of neighborhood socioeconomic variables with obstructive sleep apnea severity and to assess whether the neighborhood variables explain the association between race and obstructive sleep apnea severity. METHODS: We performed a cross-sectional analysis of data of 774 children in six cities who participated in the Childhood Adenotonsillectomy Trial. The outcome variable was the apnea-hypopnea index (AHI). Neighborhood socioeconomic variables were obtained on the basis of the children's residential addresses and information in the American Community Survey. Regression models were used to assess the associations among neighborhood conditions, race, and AHI. MEASUREMENTS AND MAIN RESULTS: Higher poverty rate and percentage of single-female-headed households were associated with higher AHI (P = 0.008 and 0.002, respectively). African American race was associated with a 1.33 (1.08-1.64 95% confidence interval)-fold increase in AHI, adjusting for age and sex. After controlling for poverty rate or percentage of single-female-headed households with children, the association between race and AHI levels was no longer significant (P = 0.15 and 0.26, respectively), and the magnitude of race association decreased 34 or 55%, suggesting that the association between race and AHI levels was largely explained by poverty rate or percentage of single-female-headed households with children. CONCLUSIONS: Neighborhood socioeconomic variables in comparison with individual-level socioeconomic indicators provides better explanations for the racial disparity in pediatric obstructive sleep apnea syndrome. Further research aimed at identifying factors that aggregate in disadvantaged neighborhoods and increase sleep apnea risk may suggest modifiable intervention targets. Clinical trial registered with clinicaltrials.gov (NCT00560859).

The Humanistic and Economic Burden of Narcolepsy.

STUDY OBJECTIVES: To evaluate the burden of narcolepsy--with respect to psychiatric comorbidities, Health-Related Quality of Life (HRQoL), direct costs for healthcare resource utilization, and indirect costs for reported work loss-through comparison of patients to matched controls. METHODS: This analysis was conducted on data from the 2011, 2012, and 2013 US National Health and Wellness Survey (NHWS; 2011 NHWS n = 75,000, 2012 NHWS n = 71,157, and 2013 NHWS n = 75,000). Patients who reported a narcolepsy diagnosis (n = 437) were matched 1:2 with controls (n = 874) on age, sex, race/ethnicity, marital status, education, household income, body mass index, smoking status, alcohol use, exercise, and physical comorbidity. Chi-square tests and one-way analyses of variance were used to assess whether the narcolepsy and control groups differed on psychiatric comorbidities, HRQoL, labor force participation, work productivity, and healthcare resource utilization. RESULTS: Patients with narcolepsy, in comparison to matched controls, reported substantially (two to four times) greater psychiatric comorbidity, HRQoL impairment, prevalence of long-term disability, absenteeism, and presenteeism, and greater resource use in the past 6 mo as indicated by higher mean number of hospitalizations, emergency department visits, traditional healthcare professional visits, neurologist visits, and psychiatrist visits (each p < 0.05). CONCLUSIONS: These population-based data suggest that a narcolepsy diagnosis is associated with substantial adverse impact on mental health, HRQoL, and key economic burdens that include work impairment, resource use, and both direct and indirect costs. Although this study is cross-sectional, the results highlight the magnitude of the potential opportunity to improve mental health, lower costs, and augment work-related productivity through effective assessment and treatment of narcolepsy.

Sleep Hygiene Practices and Bedtime Resistance in Low-Income Preschoolers: Does Temperament Matter?

This study examined sleep hygiene practices and bedtime resistance and tested whether associations differed by child temperament. Parents of Head Start preschoolers (n = 374, 56% non-Hispanic white) completed the Going to Bed subscale of the Children's Sleep-Wake Scale (GTB; higher score reflects less bedtime resistance), Children's Sleep Hygiene Scale (CSHS; higher score reflects better sleep hygiene), and Child Behavior Questionnaire (Anger, Activity, Impulsivity subscales indicated difficult temperament). Monte Carlo simulation adjusted for demographic covariates tested associations of CSHS with GTB in children with more- vs. less-difficult temperaments. Children with more- vs. less-difficult temperaments experienced worse sleep hygiene (p < .0001) and had more bedtime resistance (p < .0001). Among children with more difficult temperaments, better sleep hygiene was linearly associated with less bedtime resistance (ß = 1.28, 95% CI 0.77, 1.78). Among children with less difficult temperaments, the association followed a piecewise linear trend: sleep hygiene was not associated with bedtime resistance when CSHS scores were < 4.1 (ß = 0.15, 95% CI -4.87, 3.13), but for CSHS scores ≥ 4.1, an increase in CSHS was associated with lower bedtime resistance (ß = 1.33, 95% CI 1.00, 1.79). Consistent sleep hygiene is associated with less bedtime resistance and may be helpful in reducing bedtime resistance among children with more difficult temperaments.

Approaches to the assessment of arousals and sleep disturbance in children.

Childhood arousals, awakenings, and sleep disturbances during the night are common problems for both patients and their families. Additionally, inadequate sleep may contribute to daytime sleepiness, behavioral problems, and other important consequences of pediatric sleep disorders. Arousals, awakenings, and sleep disturbances can be quantified by routine polysomnography, and arousal scoring is generally performed as part of the standard polysomnogram. Here, we review current approaches to quantification of arousals and sleep disturbances and examine outcomes that have been associated with these measures. Initial data suggest that computer-assisted identification of non-visible arousals, cyclic alternating patterns, or respiratory cycle-related EEG changes may complement what can be accomplished by human scorers. Focus on contiguous bouts of sleep or specific sleep stages may prove similarly useful. Incorporation of autonomic arousal measures-such as heart rate variability, pulse transit time, or peripheral arterial tone-into standard reports may additionally capture subtle sleep fragmentation.

EMG variance during polysomnography as an assessment for REM sleep behavior disorder.

STUDY OBJECTIVES: In a previous study, we validated a polysomnographic assessment for REM sleep behavior disorder (RBD). The method proved to be reliable but required slow, labor-intensive visual scoring of surface electromyogram (EMG) activity. We therefore developed a computerized metric to assess EMG variance and compared the results to those previously published for visual scoring, bed partner-rated RBD symptom scores, and clinical assessments by sleep medicine specialists. DESIGN: Retrospective validation of new computer algorithm. SETTING: Sleep research laboratory PARTICIPANTS: Twenty-three subjects: 17 with neurodegenerative disorders (9 with probable or possible RBD), and 6 controls. INTERVENTIONS: N/A METHODS: We visually scored 2 consecutive nocturnal polysomnograms for each subject. A computer algorithm calculated the variance of the chin EMG during all 3-second mini-epochs, and compared variances during REM sleep to a threshold defined by variances during quiet NREM sleep. The percentage of all REM mini-epochs with variance above this threshold created a metric, which we refer to as the supra-threshold REM EMG activity metric (STREAM) for each subject. RESULTS: The STREAM correlated highly with the visually-derived score for RBD severity (Spearman rho = 0.87, P < 0.0001). A clinical impression of probable or possible RBD was associated to a similar extent with both STREAM (Wilcoxon rank sum test, P = 0.009) and the visually-derived score (P = 0.018). An optimal STREAM cutoff identified probable or possible RBD with 100% sensitivity and 71% specificity. The RBD symptom score correlated with both STREAM (rho = 0.42, P = 0.046) and the visual score (rho = 0.42, P = 0.048). CONCLUSIONS: These results suggest that a new, automated assessment for RBD may provide as much utility as a more time-consuming manual approach.

Longitudinal assessment of noninvasive positive pressure ventilation adjustments in ALS patients.

The absence of data guiding optimal titration of noninvasive positive pressure ventilation (NIPPV) over time in ALS patients may contribute to the under-prescribing of NIPPV. We conducted a retrospective, single-center, chart review assessment of NIPPV pressure settings used for symptomatic treatment of ALS patients to determine NIPPV adjustments, and to compare survival between those who were tolerant and intolerant to NIPPV. All subjects were started on nocturnal NIPPV at 8 and 3 cm H2O inspiratory and expiratory pressure, respectively. Of the 18 tolerant subjects identified, 4 (22%) had no NIPPV pressure changes before death; 8 (44%), 1 change; 4 (22%), 2 changes; 1 (6%), 3 changes; and 1 (6%), 5 changes. Most pressure changes occurred during the first year of NIPPV initiation. The maximum pressure needed for comfort by any patient in this study was 19/5 cm H2O, while 4 (22%) found the original 8/3 cm H2O settings to be sufficient until death. Subjects in the tolerant group had better survival, when adjusting for age and site of symptom onset (bulbar versus limb), with a hazard ratio of 0.23 [95% confidence interval: 0.10, 0.54]. The current data suggest that ALS patients who are tolerant to NIPPV typically need at least one upward change in pressure settings. Tolerance to relatively low NIPPV inspiratory pressures is associated with improved survival.

Screening for obstructive sleep apnea in stroke patients: a cost-effectiveness analysis.

BACKGROUND AND PURPOSE: Obstructive sleep apnea (OSA) is common after acute ischemic stroke and predicts poor stroke recovery, but whether screening for OSA and treatment by continuous positive airway pressure (CPAP) improves neurological outcome is unknown. We used a cost-effectiveness model to estimate the magnitude of benefit that would be necessary to make polysomnography (PSG) and OSA treatment cost-effective in stroke patients. METHODS: A decision tree modeled 2 alternative strategies: PSG followed by 3 months of CPAP for those found to have OSA versus no screening. The primary outcome was the utility gained through OSA screening and treatment in relation to 2 common willingness-to-pay thresholds of $50,000 and $100,000 per quality-adjusted life year (QALY). RESULTS: Screening resulted in an incremental cost-effectiveness ratio of $49,421 per QALY. Screening is cost-effective as long as the treatment of stroke patients with OSA by CPAP improves patient utilities by >0.2 for a willingness-to-pay of $50,000 per QALY and 0.1 for a willingness-to-pay of $100,000 per QALY. CONCLUSIONS: A clinical trial assessing the effectiveness of CPAP in improving stroke outcome is warranted from a cost-effectiveness standpoint.

Toward cost-effectiveness analysis in the diagnosis and treatment of insomnia.

Insomnia is believed to have high prevalence, cost, and impact. However, comprehensive cost-effectiveness analyses (CEAs) of different diagnostic and treatment strategies have not been performed. Part of the reason is that limited data are available on prevalence, costs, and outcomes, each of which is key elements of any CEA. The authors conducted a MEDLINE search to review available literature. Epidemiological surveys have yielded variable results, depending on operational definitions and populations studied. Cost estimates have varied widely depending on whether indirect costs are included and which costs are considered. Impact on health-related quality of life appears to be substantial, but effects on utility scores-necessary to compare cost-effectiveness of insomnia management to that of other health care interventions-have not been reported. Furthermore, much of the data on health-related quality of life is cross-sectional, and cannot be used to test whether the identified associations are causal. The authors conclude that effective insomnia management holds promise as a cost-effective health care intervention. However, the CEA models that eventually may support this hypothesis will require accurate measures of direct and indirect costs, health state utility in treated and untreated insomnia, and prevalence data based on widely-accepted case definitions.