Ethical, philosophical, and practical considerations in adherence to therapy in sleep medicine.

PURPOSE OF REVIEW: We consider a series of linked philosophical issues created by non-adherence to therapy in sleep medicine. RECENT FINDINGS: First, the difficulty of measuring rates of adherence creates an epistemic problem regarding the efficacy of prescribed treatments. Secondly, as diseases are often classified as refractory based on apparent failure of standard medicines, the validity of this classification faces a similar epistemic crisis. This in turn produces ethical issues when therapies are restricted to cases deemed refractory. It also calls into question, if the patient does not take the medicines as prescribed, what they do with them; and the prospect of potential drug diversion arises. Education of patients seems to be of limited help in addressing these issues; what may be needed is a revision of the patient-prescriber relationship to move away from blame when nonadherence occurs. We close by revisiting an ancient debate in the philosophy of action, which may shed light on what such a revised relationship would require. SUMMARY: More honest and trusting patient-physician relationships, and a much more accurate sense of when nonadherence is occurring and why, may result from a better practical and philosophical understanding of the patient's decision-making.

Practice Guidelines for Standards of Adult Sleep Medicine Services.

Sleep disorders, i.e. diseases that affect, disrupt or involve sleep, represent major challenges for physicians and healthcare systems worldwide. The high prevalence, the complexity and the health burden of sleep disorders demand the establishment of specific clinical sleep centres where adequate and efficient diagnosis and management of patients with such diseases can be provided. This document describes practice guidelines for standards of adult sleep medicine centres in Ireland. These guidelines are the result of a consensus procedure in which all committee members of the Irish Sleep Society (ISS) were involved. The scope of these guidelines is to define the requirements of sleep medicine services, in terms of personnel, facilities, equipment and procedures.

The two-process model of sleep regulation: a reappraisal.

In the last three decades the two-process model of sleep regulation has served as a major conceptual framework in sleep research. It has been applied widely in studies on fatigue and performance and to dissect individual differences in sleep regulation. The model posits that a homeostatic process (Process S) interacts with a process controlled by the circadian pacemaker (Process C), with time-courses derived from physiological and behavioural variables. The model simulates successfully the timing and intensity of sleep in diverse experimental protocols. Electrophysiological recordings from the suprachiasmatic nuclei (SCN) suggest that S and C interact continuously. Oscillators outside the SCN that are linked to energy metabolism are evident in SCN-lesioned arrhythmic animals subjected to restricted feeding or methamphetamine administration, as well as in human subjects during internal desynchronization. In intact animals these peripheral oscillators may dissociate from the central pacemaker rhythm. A sleep/fast and wake/feed phase segregate antagonistic anabolic and catabolic metabolic processes in peripheral tissues. A deficiency of Process S was proposed to account for both depressive sleep disturbances and the antidepressant effect of sleep deprivation. The model supported the development of novel non-pharmacological treatment paradigms in psychiatry, based on manipulating circadian phase, sleep and light exposure. In conclusion, the model remains conceptually useful for promoting the integration of sleep and circadian rhythm research. Sleep appears to have not only a short-term, use-dependent function; it also serves to enforce rest and fasting, thereby supporting the optimization of metabolic processes at the appropriate phase of the 24-h cycle.

How to measure snoring? A comparison of the microphone, cannula and piezoelectric sensor.

The objective of this study was to compare to each other the methods currently recommended by the American Academy of Sleep Medicine (AASM) to measure snoring: an acoustic sensor, a piezoelectric sensor and a nasal pressure transducer (cannula). Ten subjects reporting habitual snoring were included in the study, performed at Landspitali-University Hospital, Iceland. Snoring was assessed by listening to the air medium microphone located on a patient's chest, compared to listening to two overhead air medium microphones (stereo) and manual scoring of a piezoelectric sensor and nasal cannula vibrations. The chest audio picked up the highest number of snore events of the different snore sensors. The sensitivity and positive predictive value of scoring snore events from the different sensors was compared to the chest audio: overhead audio (0.78, 0.98), cannula (0.55, 0.67) and piezoelectric sensor (0.78, 0.92), respectively. The chest audio was capable of detecting snore events with lower volume and higher fundamental frequency than the other sensors. The 200 Hz sampling rate of the cannula and piezoelectric sensor was one of their limitations for detecting snore events. The different snore sensors do not measure snore events in the same manner. This lack of consistency will affect future research on the clinical significance of snoring. Standardization of objective snore measurements is therefore needed. Based on this paper, snore measurements should be audio-based and the use of the cannula as a snore sensor be discontinued, but the piezoelectric sensor could possibly be modified for improvement.

Comparison of a single-channel EEG sleep study to polysomnography.

An accurate home sleep study to assess electroencephalography (EEG)-based sleep stages and EEG power would be advantageous for both clinical and research purposes, such as for longitudinal studies measuring changes in sleep stages over time. The purpose of this study was to compare sleep scoring of a single-channel EEG recorded simultaneously on the forehead against attended polysomnography. Participants were recruited from both a clinical sleep centre and a longitudinal research study investigating cognitively normal ageing and Alzheimer's disease. Analysis for overall epoch-by-epoch agreement found strong and substantial agreement between the single-channel EEG compared to polysomnography (κ = 0.67). Slow wave activity in the frontal regions was also similar when comparing the single-channel EEG device to polysomnography. As expected, Stage N1 showed poor agreement (sensitivity 0.2) due to lack of occipital electrodes. Other sleep parameters, such as sleep latency and rapid eye movement (REM) onset latency, had decreased agreement. Participants with disrupted sleep consolidation, such as from obstructive sleep apnea, also had poor agreement. We suspect that disagreement in sleep parameters between the single-channel EEG and polysomnography is due partially to altered waveform morphology and/or poorer signal quality in the single-channel derivation. Our results show that single-channel EEG provides comparable results to polysomnography in assessing REM, combined Stages N2 and N3 sleep and several other parameters, including frontal slow wave activity. The data establish that single-channel EEG can be a useful research tool.

Mediator Effect of Sleep Hygiene Practices on Relationships Between Sleep Quality and Other Sleep-Related Factors in Chinese Mainland University Students.

This study examined the mediator effect of sleep hygiene practices (SHP) on relationships between sleep quality and other sleep-related factors in Chinese mainland university students using structural equation modeling analysis. Of the 413 students, 41.4% had poor sleep quality. Gender, academic stress, relaxed psychological status, good physical status, and SHP had significant direct effects on sleep quality; relaxed psychological status had significant direct effect on SHP and indirect effect on sleep quality via SHP. The direct, indirect, and total effects of gender, academic stress, relaxed psychological status, good physical status, and SHP explained 25% of the variance in sleep quality. The Chinese mainland university students had relative poor sleep quality. SHP was a mediator between sleep quality and relaxed psychological status.

Psychometric properties of the Turkish version of the Sleep Hygiene Index in clinical and non-clinical samples.

OBJECTIVE: Sleep is one of the most significant of human behaviors, occupying roughly one third of human life. Sleep is a process the brain requires for proper functioning. Sleep hygiene can be described as practices to ease sleep and to avoid factors which decrease sleep quality. Inadequate sleep hygiene generally results in disturbance of daily life activities due to inability to sustain sleep quality and daytime wakefulness. Therefore, the importance of development and utilization of measures of sleep hygiene increases. The aim of the study was to assess psychometric properties of the Sleep Hygiene Index (SHI) in clinical and non-clinical Turkish samples. METHOD: Data were collected from 106 patients with major depression consecutively admitted to the psychiatry clinic of Yüzüncü Yil University School of Medicine and 200 were volunteers recruited from community sample who were enrolled at the university. The SHI, Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI) and Epworth Sleepiness Scale (ESS) were administered to the subjects. Factor structure of the SHI was evaluated with explanatory and multi-sample confirmatory factor analyses. Pearson product-moment correlation coefficients of the SHI with the PSQI, ISI and ESS were computed. Item analyses, internal consistency coefficients and intra-class correlations between two repeated applications in both patient and healthy subjects were calculated. RESULTS: The SHI revealed a unidimensional factor structure. Significant strong partial associations of the SHI with depression, insomnia and poor sleep quality and a modest partial association with sleepiness were detected. Cronbach's alphas for the SHI in community sample and patients with major depression were 0.70 and 0.71, respectively. Additionally, we found acceptable three-week temporal reliability in terms of intra-correlation coefficients of r=0.62, p<0.01 for the community sample and of r=0.67, p<0.01 among patients with major depression. CONCLUSION: The SHI revealed adequate validity and reliability to be used by researchers in Turkish sample. Current results were discussed in light of previous findings and theoretical considerations.

Conducting actigraphy research in children with neurodevelopmental disorders--a practical approach.

The literature has been highly informative for when to use actigraphy and its validity in pediatric research. However, minimal literature exists on how to perform actigraphy, especially in special populations. We determined whether providing actigraphy training to parents and coordinators increased the nights of actigraphy data that could be scored. We compared two studies in children with autism spectrum disorders, one of which provided a basic level of training in a single-site trial and the other of which provided more detailed training to parents and coordinators in a multisite trial. There was an increase in scorable nights in the multisite trial containing a one-hour structured parent training session. Our results support the use of educational tools in clinical trials that use actigraphy.

An official American Thoracic Society research statement: comparative effectiveness research in pulmonary, critical care, and sleep medicine.

BACKGROUND: Comparative effectiveness research (CER) is intended to inform decision making in clinical practice, and is central to patient-centered outcomes research (PCOR). PURPOSE: To summarize key aspects of CER definitions and provide examples highlighting the complementary nature of efficacy and CER studies in pulmonary, critical care, and sleep medicine. METHODS: An ad hoc working group of the American Thoracic Society with experience in clinical trials, health services research, quality improvement, and behavioral sciences in pulmonary, critical care, and sleep medicine was convened. The group used an iterative consensus process, including a review by American Thoracic Society committees and assemblies. RESULTS: The traditional efficacy paradigm relies on clinical trials with high internal validity to evaluate interventions in narrowly defined populations and in research settings. Efficacy studies address the question, "Can it work in optimal conditions?" The CER paradigm employs a wide range of study designs to understand the effects of interventions in clinical settings. CER studies address the question, "Does it work in practice?" The results of efficacy and CER studies may or may not agree. CER incorporates many attributes of outcomes research and health services research, while placing greater emphasis on meeting the expressed needs of nonresearcher stakeholders (e.g., patients, clinicians, and others). CONCLUSIONS: CER complements traditional efficacy research by placing greater emphasis on the effects of interventions in practice, and developing evidence to address the needs of the many stakeholders involved in health care decisions. Stakeholder engagement is an important component of CER.

[Sleep medicine differential diagnostics in psychiatry and psychotherapy]. / Schlafmedizinische Differenzialdiagnostik in Psychiatrie und Psychotherapie.

Complaints about disturbed sleep or increased daytime sleepiness are among the most frequent symptoms reported to psychiatrists by patients. Such complaints can be symptoms of an underlying psychiatric disorder or indicative of a separate or comorbid sleep disorder. Hence, basic knowledge in the differential diagnosis of sleep medicine pathologies is pivotal for psychiatrists and psychotherapists. In the present overview following a description of the diagnostic methods, the diagnostic work-up according to the major symptomatic clusters, namely disturbances in initiating and maintaining sleep, abnormal nocturnal movements and excessive daytime sleepiness will be presented.

Strengths, weaknesses, opportunities, and threats of using AI-enabled technology in sleep medicine: a commentary.

Over the past few years, artificial intelligence (AI) has emerged as a powerful tool used to efficiently automate several tasks across multiple domains. Sleep medicine is perfectly positioned to leverage this tool due to the wealth of physiological signals obtained through sleep studies or sleep tracking devices and abundance of accessible clinical data through electronic medical records. However, caution must be applied when utilizing AI, due to intrinsic challenges associated with novel technology. The Artificial Intelligence in Sleep Medicine Committee of the American Academy of Sleep Medicine reviews advancements in AI within the sleep medicine field. In this article, the Artificial Intelligence in Sleep Medicine committee members provide a commentary on the scope of AI technology in sleep medicine. The commentary identifies 3 pivotal areas in sleep medicine that can benefit from AI technologies: clinical care, lifestyle management, and population health management. This article provides a detailed analysis of the strengths, weaknesses, opportunities, and threats associated with using AI-enabled technologies in each pivotal area. Finally, the article broadly reviews barriers and challenges associated with using AI-enabled technologies and offers possible solutions. CITATION: Bandyopadhyay A, Oks M, Sun H, et al. Strengths, weaknesses, opportunities, and threats of using AI-enabled technology in sleep medicine: a commentary. J Clin Sleep Med. 2024;20(7):1183-1191.

From trenches to technology: a narrative review of sleep medicine in the military.

Diagnoses of military-relevant sleep disorders have increased substantially since the terrorist attacks of September 11, 2001. The cause of this increase appears to be complicated and multifactorial, with military and civilian populations clearly differing with respect to both the nature and distribution of sleep disorders diagnoses. In part, these differences may be attributable to the fact that a majority of service members are chronically sleep-restricted-an unavoidable consequence of continuous and sustained military operations that "set the stage" for development of specific sleep disorders. The purpose of this narrative review is to describe the military relevance of several common sleep disorders, assess the extent to which these disorders currently constitute a burden on the military health care system, and suggest strategies to alleviate that burden. The military health care system does not have enough sleep medicine providers to address the immediate and long-term consequences of sleep disorders in military personnel. Digital technologies and education packages can be leveraged to improve access to care. CITATION: Thomas CL, Carr K, Yang F, et al. From trenches to technology: a narrative review of sleep medicine in the military. J Clin Sleep Med. 2024;20(6):973-981.

The more the merrier? Working towards multidisciplinary management of obstructive sleep apnea and comorbid insomnia.

OBJECTIVES: The goal of this article was to provide an overview of the diagnostic considerations, clinical features, pathophysiology, and treatment approaches for patients with obstructive sleep apnea (OSA) and comorbid insomnia. METHOD: We begin with a review of the literature on OSA and comorbid insomnia. We then present a multidisciplinary approach using pulmonary and behavioral sleep medicine treatments. RESULTS: OSA and insomnia co-occur at a high rate and such patients have distinct clinical features. Empirically supported treatments are available for OSA and insomnia independently but there are no standards or guidelines for how to implement these treatments for patients who suffer from both disorders. CONCLUSIONS: Multidisciplinary treatment holds promise for patients with comorbid sleep disorders. Further research should be aimed at optimizing treatments and developing standards of practice for this population.

[Neurology and sleep medicine]. / Neurologie Und Schlafmedizin.

Neurology is frequently confronted with sleep disturbances and/or their effects. Sleep disturbances may be early, main- or escort symptom, in addition as well a factor of risk for a neurological illness. Goal of this contribution is to mediate a small overview of usual organic sleep disturbances and to give an insight into sleep medicine ways of thinking.

Recent advances in sleep research.

The past two decades have witnessed substantial progress in methodology and knowledge in sleep research all over the world. The paper at hand will present some recent local contributions to this field. The first is a European project (SIESTA) focusing on the creation of an automatic sleep classification system and a normative database, including polysomnographic (PSG) and psychometric measures, in order to make it possible to diagnose sleep-disordered patients as compared with and age- and sex-matched healthy controls between 20 and 95 years of age. Subsequently, two trials on nonorganic sleep disorders in generalized anxiety disorder (GAD) and bruxism, as well as two trials on organic sleep disorders, i.e. snoring/sleep-disordered breathing treated with a mandibular advancement device (I.S.T.) and restless legs syndrome treated with ropinirole and gabapentin, will be discussed.

Disruption in Health Care (and Sleep Medicine): "It's the End of the World as We Know it and I Feel Fine."

CITATION: Kirsch DB. Disruption in health care (and sleepmedicine): "it's the end of the world as we know it…and I feel fine.". J Clin Sleep Med. 2019;15(9):1185-1188.

Diversity in pediatric behavioral sleep intervention studies.

Studies designed to assess the efficacy of behavioral sleep interventions for infants and young children often report sleep improvements, but the generalization to children and families of diverse backgrounds is rarely assessed. The present study describes a systematic review of the racial, ethnic, and socioeconomic diversity of behavioral sleep intervention studies for young children. Thirty-two behavioral sleep intervention studies (5474 children) were identified using PRISMA guidelines. Each study was coded for racial and ethnic composition, parental educational attainment (an index of socioeconomic resources), and country of origin. Racial or ethnic information was obtained for 19 studies (60%). Study participants were primarily White and from predominantly White countries. Overall, 21 (66%) of the included studies provided information on parental education. Most of these studies had samples with moderate to high educational attainment. Behavioral sleep intervention studies to date include samples with insufficient diversity. Overall, this study highlights a critical gap in pediatric sleep intervention research and supports a call to further include families from diverse backgrounds when assessing behavioral sleep interventions.