Comorbid Insomnia and Sleep Apnea: mechanisms and implications of an underrecognized and misinterpreted sleep disorder.

Sleep-disordered breathing (SDB) and insomnia have long been recognized as important sleep disrupters often associated with increased morbidity and mortality. Although they are often seen as divergent conditions, mainly because their cardinal symptoms (excessive daytime sleepiness, and sleep loss) differ, these two sleep disorders present with many common symptoms, which may hinder diagnosis and treatment. In addition to possible bidirectional pathways between SDB and insomnia, other factors such as circadian timing may play a role. In this paper, we review the mechanisms, differential clinical aspects, and implications of Comorbid Insomnia and Sleep Apnea, sometimes termed COMISA.

Sleep in the Aging Population.

There are normal changes to sleep architecture throughout the lifespan. There is not, however, a decreased need for sleep and sleep disturbance is not an inherent part of the aging process. Sleep disturbance is common in older adults because aging is associated with an increasing prevalence of multimorbidity, polypharmacy, psychosocial factors affecting sleep, and certain primary sleep disorders. It is also associated with morbidity and mortality. Because many older adults have several factors from different domains affecting their sleep, these complaints are best approached as a multifactorial geriatric health condition, necessitating a multifaceted treatment approach.

Flow limitation/obstruction with recovery breath (FLOW) event for improved scoring of mild obstructive sleep apnea without electroencephalography.

OBJECTIVE: Apnea/hypopnea index (AHI), especially without arousal criteria, does not adequately risk stratify patients with mild obstructive sleep apnea (OSA). We describe and test scoring reliability of an event, Flow Limitation/Obstruction With recovery breath (FLOW), representing obstructive airflow disruptions using only pressure transducer and snore signals available without electroencephalography. METHODS: The following process was used (i) Development of FLOW event definition, (ii) Training period and definition refinement, and (iii) Reliability testing on 10 100-epoch polysomnography (PSG) samples and two 100-sample tests. Twenty full-night in-laboratory baseline PSGs in OSA patients with AHI with ≥4% desaturations <15 were rescored for FLOW events, traditional hypopneas with desaturations, respiratory-related arousal (RRA) events (hypopneas with arousals and respiratory-effort related arousals) and non-respiratory arousals (NRA). RESULTS: Scoring of FLOW events in 100-epoch samples had good reliability with intraclass correlation (ICC) of 0.91. The overall kappa for presence of events on two sets of 100 sample events was 0.84 and 0.87 demonstrating good agreement. Moreover, 80% of RRA and 8% of NRA were concurrent with FLOW events. Furthermore, 56% of FLOW events were independent of RRA events. FLOW stratifies patients in traditional AHI categories with 50%/8% of AHI with ≥3% desaturations (AHI3) <5 and 12%/63% of AHI3 >5 in lowest/highest tertiles of AHI3 plus FLOW index. CONCLUSIONS: Scoring of FLOW after training is reliable. FLOW scores a high proportion of RRA and many currently unrepresented obstructive airflow disruptions. FLOW allows for stratification within the current normal-mild OSA category, which may better identify patients who will benefit from treatment.

Expenditure on health care in obese women with and without sleep apnea.

STUDY OBJECTIVES: To determine the effect of obesity and sleep apnea on health care expenditure in women over 10 years. DESIGN: Retrospective observational study SETTING: Tertiary university-based medical center PATIENTS AND CONTROLS: Three groups of age-matched women: 223 obese women with OSAS (body mass index: 39.3 +/- 0.6 kg/m2), and from the general population, 223 obese controls (BMI 36.3 +/- 0.4) and 223 normal weight controls (BMI 23.9 +/- 0.4). INTERVENTIONS: None. MEASUREMENTS AND RESULTS: We examined health care utilization in the 3 matched groups for the 10 years leading up to the documentation of OSAS. The mean physician fees and the number of physician visits were significantly higher in obese controls than in normal weight controls during the observed period. Physician fees and physician visits progressively increased in the 10 years before diagnosis in the OSAS cases and were significantly higher than in the matched obese controls. Physician fees, in Canadian dollars, one year before diagnosis in the OSAS cases were higher than in obese controls: $547.49 +/- 34.79 vs $246.85 +/- 20.88 (P<0.0001). More was spent for OSAS cases on physician fees for circulatory, endocrine and metabolic diseases, and mental disorders than the obese controls. Physician visits one year before diagnosis in the OSAS cases were more frequent than in the obese controls: 13.2 +/- 0.73 visits vs 7.26 +/- 0.49 visits (P<0.0001). CONCLUSIONS: Obese women are heavier users of health services than normal weight controls. Obese women with OSAS use significantly more health services than obese controls. Since OSAS imposes a greater financial burden, treatment of OSAS may reduce other comorbidities and lower overall medical costs.

Hours of service regulations for professional drivers in continental Latin America.

OBJECTIVES: To describe the hours of service provisions in continental Latin America. DESIGN: Information on regulations of service hours was extracted from either the national transportation authorities or ministries of transportation (or the equivalent institution) from each country. SETTING: Seventeen sovereign countries in continental Latin America (Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Uruguay, Venezuela). PARTICIPANTS: N/A INTERVENTION (IF ANY): N/A MEASUREMENT: Data on (a) limit on work hours, (b) mandatory daily time off (or rest), (c) overall schedule (mandatory weekly time off), and (d) daily breaks were extracted and summarized. RESULTS: Of the 17 countries surveyed, 9 countries have provisions limiting the daily amount of hours of service for professional drivers. Ten have provisions for mandatory daily rest, but only 5 have explicit provisions limiting the number of continuous working days, with mandatory uninterrupted time off >35 hours. Eight countries have provisions for mandatory breaks that limit the hours of continuous driving (ranging from 3 to 5:30 hours). CONCLUSION: Regulations that govern a population with 6 million injuries and over 100,000 deaths per year due to motor vehicle accidents leave important gaps. A minority, 6, of the countries regulated all 3 aspects; daily hours, breaks, and time off, and 3 regulate none of these. The regulations are less precise and restrictive than those in high-income countries, despite the doubled road injury mortality, and likely expose professional drivers and other road users to an increased risk of fatigue-related accidents.

Sleep apnea: clinical investigations in humans.

Sleep apnea syndrome (SAS), a common disorder, is characterized by repetitive episodes of cessation of breathing during sleep, resulting in hypoxemia and sleep disruption. The consequences of the abnormal breathing during sleep include daytime sleepiness, neurocognitive dysfunction, development of cardiovascular disorders, metabolic dysfunction, and impaired quality of life. There are two types of SAS: obstructive sleep apnea syndrome (OSAS) and central sleep apnea syndrome (CSAS). OSAS is a prevalent disorder in which there is snoring, repetitive apneic episodes, and daytime sleepiness. Anatomical conditions causing upper airway obstruction (obesity or craniofacial abnormalities such as retrognathia or micrognathia) can cause OSAS. CSAS, much less common than OSAS, is a disorder characterized by cessation of breathing which is caused by reduced respiratory drive from the central nervous system to the muscles of respiration. The latter condition is common in patients with heart failure and cerebral neurologic diseases. The diagnosis of SAS requires assessment of subjective symptoms and apneic episodes during sleep documented by polysomnography. Treatments of OSAS include continuous positive airway pressure (CPAP), oral appliances, and surgery; patients with CSAS are treated with oxygen, adaptive servo-ventilation, or CPAP. With assessment and treatment of the SAS, patients usually have resolution of their disabling symptoms, subsequently resulting in improved quality of life.

Sleep in the Aging Population.

There are normal changes to sleep architecture throughout the lifespan. There is not, however, a decreased need for sleep and sleep disturbance is not an inherent part of the aging process. Sleep disturbance is common in older adults because aging is associated with an increasing prevalence of multimorbidity, polypharmacy, psychosocial factors affecting sleep, and certain primary sleep disorders. It is also associated with morbidity and mortality. Because many older adults have several factors from different domains affecting their sleep, these complaints are best approached as a multifactorial geriatric health condition, necessitating a multifaceted treatment approach.

Healthcare utilization in women with obstructive sleep apnea syndrome 2 years after diagnosis and treatment.

UNLABELLED: SUBJECTIVE OBJECTIVES: To document healthcare utilization 2 years after diagnosis in women with obstructive sleep apnea syndrome (OSAS). DESIGN: Retrospective observational cohort study. SETTING: Tertiary university-based medical center. PATIENTS AND CONTROLS: Four hundred and fourteen women with OSAS were matched with 1404 women from the general population who served as controls. INTERVENTIONS: Patients were treated with continuous positive airway pressure (CPAP) or were recommended weight loss alone. MEASUREMENTS AND RESULTS: There were 231 treatment compliant (TC) patients, 91 patients not using CPAP (NCU), and 92 patients who were only recommended weight loss (WL). In the entire group, there was increase in fees of $123.43+/-$25.01 in the 2 years before diagnosis and a reduction of fees of $37.96+/-$21.35 in the 2 years after diagnosis (p < .0001). Physician claims increased in the 2 years before diagnosis by $111.22+/-31.35 in TC and by $152.77+/-59.55 in the NCU groups and then decreased in TC by $20.96+/-$26.60 (p < .01) and NCU by $72.20 +/-45.91 in the 2 years after diagnosis (p < .01). The fees in WL group did not change significantly. The number of clinic visits of the entire group increased in the 2 years before diagnosis by 2.32+/-0.43 and decreased over the next 2 years by 1.48+/-0.42 visits (p < .0001). There was an increase of clinic visits in the 3 subgroups in the 2 years before diagnosis (2.30+/-0.57 in TC, 2.55+/-0.99 in NCU, and 2.18+/-0.82 in WL groups) followed by a reduction of clinic visits over the next 2 years (1.56+/-0.55 fewer visits in TC [p < .0001], 1.70+/-0.90 in NCU [p < .01], and 1.04+/-0.90 in the WL group [p < .05] ). CONCLUSIONS: Healthcare utilization in women with OSAS increased in the years before sleep-clinic evaluation and then decreased in the following 2 years.