Insomnia: Behavioral Treatment in the Elderly.

Sleep quality in elderly individuals is affected by increased mental and physical health issues associated with aging, but also a decrease in sleep drive and an advance of the circadian phase. These issues may, in part, be due to lifestyle changes in older adults, such as retirement and/or reduced social and physical activity, which can lead to spending more time in bed, resulting in chronic insomnia. Cognitive behavioral therapy for insomnia has been shown to be an effective treatment method for difficulty sleeping in elderly individuals and should be the first-line treatment due to its efficacy and safety profile.

The effects of white noise on sleep and duration in individuals living in a high noise environment in New York City.

INTRODUCTION: Undisturbed sleep has been shown to be important for both health and quality of life (Medic et al. [7]). The World Health Organization estimates that nearly 25% of the population suffers from disturbed sleep due to environmental noise (Health TWECfEa, [2]). Sleep disturbance associated with elevated noise levels is particularly prevalent in metropolitan areas. Our study tested the hypothesis that white noise would improve sleep in New Yorkers complaining of sleep difficulty due to elevated sound levels. METHODS: Ten adult participants were included in this study. All participants were recruited from a New York City based sleep clinic. Inclusion criteria was based on the presence of sleep disturbance and the reporting of high levels of environmental noise in participants' sleep location. The study was conducted using a within-subject, ABA design, with baseline, treatment phase, followed by another baseline (washout) period. Each phase lasted one-week, during which noise level and sleep were assessed. The treatment consisted of the application of a white noise device (Dohm Classic by Marpac, LLC) in the participants' bedroom. Sleep parameters were measured subjectively using the Consensus Sleep Diary (Carney et al. [15]), and objectively using a Motionlogger Actigraph. RESULTS: Paired sample t-tests were conducted to evaluate the hypothesis that white noise improves sleep in a high noise environment. Significance was found on the variables WASO, as measured by actigraphy, t(9) = 3.438, p = 0.007 and sleep latency as measured by sleep diary, t(9) = 2.947, p = 0.016. There was a trend toward significance on the number of awakenings during the night, as measured by sleep diary, t(9) = 2.622, p = 0.028 (Holm's sequential correction of p-value required a value of <0.01 to find significance on this comparison) and sleep efficiency (actigraph), t(9) = -2.121, p = 0.063. CONCLUSION: Our data show that white noise significantly improved sleep based on subjective and objective measurements in subjects complaining of difficulty sleeping due to high levels of environmental noise. This suggests that the application of white noise may be an effective tool in helping to improve sleep in those settings.

The Importance of Mask Selection on Continuous Positive Airway Pressure Outcomes for Obstructive Sleep Apnea. An Official American Thoracic Society Workshop Report.

Continuous positive airway pressure (CPAP) remains the major treatment option for obstructive sleep apnea (OSA). The American Thoracic Society organized a workshop to discuss the importance of mask selection for OSA treatment with CPAP. In this workshop report, we summarize available evidence about the breathing route during nasal and oronasal CPAP and the importance of nasal symptoms for CPAP outcomes. We explore the mechanisms of air leaks during CPAP treatment and possible alternatives for leak control. The impact of nasal and oronasal CPAP on adherence, residual apnea-hypopnea index, unintentional leaks, and pressure requirements are also compared. Finally, recommendations for patient and partner involvement in mask selection are presented, and future directions to promote personalized mask selection are discussed.

Nonpharmacologic Management of Excessive Daytime Sleepiness.

Unlike other reviews written on this topic, the focus of this article is primarily on nonpharmacologic treatments for daytime sleepiness that is not secondary to other medical or psychological conditions. To provide an appropriate background on primary excessive daytime sleepiness, what is considered optimal sleep in terms of sleep duration, sleep insufficiency, and sleep need is discussed in detail. This discussion is followed by an examination of the behavioral strategy of banking sleep. After briefly discussing behavioral interventions for sleepiness associated with narcolepsy, a new behavioral method of treating daytime somnolence is proposed and described.

Heart rate variability in restless legs syndrome and periodic limb movements of Sleep.

INTRODUCTION: The relationship between the autonomic nervous system and restless legs syndrome (RLS) and periodic limb movements of sleep (PLMS) consists of varied and somewhat conflicting reports. In order to further elucidate these complexities, a retrospective analysis of polysomnography (PSG) records and clinical data was performed. METHODS: Records from 233 adult subjects were randomly selected and organized into one of four groups ("non-RLS/PLMS" [n=61], "RLS" [n=60], "PLMS" [n=58], and "RLS/PLMS" [n=54]). Heart rate variability (HRV) analysis was based on 5-minute samples of 2-lead electrocardiogram data isolated from PSG recordings during wakefulness and NREM sleep, and included mean RR interval (labeled "NN") and standard deviation of the RR intervals (labeled "SDNN"), and HRV power, very low frequency (VLF), low frequency (LF), and high frequency (HF) spectral bands. RESULTS: A significant reduction in the VLF band in the PLMS group as compared to the non-RLS/PLMS group (542±674 vs. 969±1025 ms2, p=0.038) was found in wakefulness. Statistically significant differences were seen in the PLMS group as compared to the non-RLS/PLMS group with a reduction in SDNN (p=0.001) and the HF (p=0.001) band, and an increase in HRV power (p=0.001), and the VLF (p=0.005) and LF (p=0.001) bands in NREM sleep. CONCLUSIONS: The PLMS group exhibited reduced basal sympathetic activity in wakefulness, but basal sympathetic predominance during NREM sleep, distinguishing this group from the RLS and RLS/PLMS groups.

Nonpharmacologic Management of Excessive Daytime Sleepiness.

Unlike other reviews written on this topic, the focus of this article is primarily on nonpharmacologic treatments for daytime sleepiness that is not secondary to other medical or psychological conditions. To provide an appropriate background on primary excessive daytime sleepiness, what is considered optimal sleep in terms of sleep duration, sleep insufficiency, and sleep need is discussed in detail. This discussion is followed by an examination of the behavioral strategy of banking sleep. After briefly discussing behavioral interventions for sleepiness associated with narcolepsy, a new behavioral method of treating daytime somnolence is proposed and described.

The Cost of Insomnia and the Benefit of Increased Access to Evidence-Based Treatment: Cognitive Behavioral Therapy for Insomnia.

Insomnia is a highly prevalent, often chronic condition, which is left untreated or not treated according to recommended guidelines in most cases. This results in high health and financial burdens to society. The cost of untreated insomnia and the prevailing reliance on sedative-hypnotic use as a first-line treatment are evaluated in this article. The cost-benefit potential of cognitive behavioral therapy for insomnia is also assessed.

A new predictive model for continuous positive airway pressure in the treatment of obstructive sleep apnea.

BACKGROUND: Numerous mathematical formulas have been developed to determine continuous positive airway pressure (CPAP) without an in-laboratory titration study. Recent studies have shown that style of CPAP mask can affect the optimal pressure requirement. However, none of the current models take mask style into account. Therefore, the goal of this study was to develop new predictive models of CPAP that take into account the style of mask interface. METHODS: Data from 200 subjects with attended CPAP titrations during overnight polysomnograms using nasal masks and 132 subjects using oronasal masks were randomized and split into either a model development or validation group. Predictive models were then created in each model development group and the accuracy of the models was then tested in the model validation groups. RESULTS: The correlation between our new oronasal model and laboratory determined optimal CPAP was significant, r = 0.61, p < 0.001. Our nasal formula was also significantly related to laboratory determined optimal CPAP, r = 0.35, p < 0.001. The oronasal model created in our study significantly outperformed the original CPAP predictive model developed by Miljeteig and Hoffstein, z = 1.99, p < 0.05. The predictive performance of our new nasal model did not differ significantly from Miljeteig and Hoffstein's original model, z = -0.16, p < 0.90. The best predictors for the nasal mask group were AHI, lowest SaO2, and neck size, whereas the top predictors in the oronasal group were AHI and lowest SaO2. CONCLUSION: Our data show that predictive models of CPAP that take into account mask style can significantly improve the formula's accuracy. Most of the past models likely focused on model development with nasal masks (mask style used for model development was not typically reported in previous investigations) and are not well suited for patients using an oronasal interface. Our new oronasal CPAP prediction equation produced significantly improved performance compared to the well-known Miljeteig and Hoffstein formula in patients titrated on CPAP with an oronasal mask and was also significantly related to laboratory determined optimal CPAP.

Diagnostic accuracy of a mathematical model to predict apnea-hypopnea index using nighttime pulse oximetry.

The intent of this study is to develop a predictive model to convert an oxygen desaturation index (ODI) to an apnea-hypopnea index (AHI). This model will then be compared to actual AHI to determine its precision. One thousand four hundred and sixty-seven subjects given polysomnograms with concurrent pulse oximetry between April 14, 2010, and February 7, 2012, were divided into model development (n = 733) and verification groups (n = 734) in order to develop a predictive model of AHI using ODI. Quadratic regression was used for model development. The coefficient of determination (r(2)) between the actual AHI and the predicted AHI (PredAHI) was 0.80 (r = 0.90), which was significant at a p < 0.001. The areas under the receiver operating characteristic curve ranged from 0.96 for AHI thresholds of ≥ 10 and ≥ 15/h to 0.97 for thresholds of ≥ 5 and ≥ 30/h. The algorithm described in this paper provides a convenient and accurate way to convert ODI to a predicted AHI. This tool makes it easier for clinicians to understand oximetry data in the context of traditional measures of sleep apnea.

Comparison of the upper airway dynamics of oronasal and nasal masks with positive airway pressure treatment using cine magnetic resonance imaging.

PURPOSE: It is known that oronasal masks are not as effective at opening the upper airway compared to nasal only continuous positive airway pressure (CPAP) masks in patients with sleep-disordered breathing. However, the physiological mechanism for this difference in efficacy is not known; although, it has been hypothesized to involve the retroglossal and/or retropalatal region of the upper airway. The objective of this study was to investigate differences in retroglossal and retropalatal anterior-posterior space with the use of oronasal vs. nasal CPAP masks using real-time cine magnetic resonance imaging (cMRI). METHODS: Ten subjects (eight men, two women) with obstructive sleep apnea (OSA) were given cMRI with both nasal and oronasal CPAP masks. Each subject was imaged with each interface at pressures of 5, 10, and 15 cm of H2O, while in the supine position along the sagittal plane. RESULTS: The oronasal mask produced significantly less airway opening in the retropalatal region of the upper airway compared to the nasal mask interface. During exhalation, mask style had a significant effect on anterior-posterior distance p = 0.016. No differences were found in the retroglossal region between mask styles. CONCLUSIONS: Our study confirmed previous findings showing differences in treatment efficacy between oronasal and nasal mask styles. We have shown anatomic evidence that the nasal mask is more effective in opening the upper airway compared to the oronasal mask in the retropalatal region.

Referral Practices for Cognitive Behavioral Therapy for Insomnia: A Survey Study.

This study examined referring practices for cognitive behavioral therapy for insomnia (CBTI) by physicians at University of Michigan Hospitals and Weill Cornell Medical College of Cornell University. A five-item questionnaire was sent via email that inquired about the physician's patient load, number of patients complaining of insomnia, percent referred for CBTI, and impressions of what is the most effective method for improving sleep quality in their patients with insomnia. The questionnaire was completed by 239 physicians. More physicians believed a treatment other than CBTI and/or medication was most effective (N = 83). "Sleep hygiene" was recommended by a third of the sample. The smallest number of physicians felt that CBTI alone was the most effective treatment (N = 22). Additional physician education is needed.

Autonomic dysfunction in isolated rapid eye movement sleep without atonia.

OBJECTIVES: Autonomic dysfunction has been demonstrated in patients with rapid eye movement sleep behavior disorder utilizing heart rate variability parameters. We hypothesized that isolated rapid eye movement sleep without atonia is similarly associated with autonomic dysfunction as demonstrated by a reduction in heart rate variability. METHODS: An evaluation of 120 records demonstrating rapid eye movement sleep without atonia during polysomnography was performed. Many (n=99) were discarded owing to factors potentially affecting heart rate variability. The remaining 21 records were matched with 21 records of patients demonstrating normal REM atonia, and subjected to electrocardiogram analysis. The parameters measured included R to R interval (RR) length, RR standard deviation, heart rate variability power, and very low frequency, low frequency, and high frequency bands. RESULTS: Autonomic dysfunction was seen in patients with isolated rapid eye movement sleep without atonia as denoted by a reduction in heart rate variability compared to those with normal REM atonia. Significant differences between the groups were demonstrated in RR standard deviation (mean difference=0.1502 ± 0.317, 95% confidence interval [95% CI]=0.006, 0.295, p=0.042), heart rate variability power (mean difference=0.3005 ± 0.635, 95% CI=0.011, 0.589, p=0.042), and the low frequency band (mean difference=0.3166 ± 0.616 ms(2), 95% CI=0.036, 0.597, p=0.029), and a borderline significant reduction in the high frequency band (mean difference=0.3121 ± 0.686 ms(2), 95% CI=0.000, 0.624, p=0.050). CONCLUSIONS: Our data confirms the hypothesis that heart rate variability is reduced in patients with isolated rapid eye movement sleep without atonia. The values obtained are consistent with previous findings in rapid eye movement behavior sleep disorder patients. SIGNIFICANCE: This is the first report of autonomic dysfunction in isolated rapid eye movement sleep without atonia, revealing the need for further evaluation of the clinical significance and potential implications of this finding.

A randomised controlled trial on the effect of mask choice on residual respiratory events with continuous positive airway pressure treatment.

INTRODUCTION: It has been found that mask style can affect the amount of continuous positive airway pressure (CPAP) required to reduce an apnoea/hyponoea index (AHI) to < 5/h on a titration study. However, it was not previously known whether switching from one CPAP mask style to another post titration could affect the residual AHI with CPAP. The purpose of this study was to investigate the differences in residual AHI with CPAP treatment between oronasal and nasal masks. METHODS: Twenty-one subjects (age mean (M)=62.9, body mass index (BMI) M=29.6 kg/m2) were randomised (14 subjects completed the protocol) to undergo an in-laboratory CPAP titration with either a nasal mask or an oronasal mask. Subjects were then assigned this mask for 3weeks of at-home CPAP use with the optimal treatment pressure determined on the laboratory study (CPAP M=8.4 cm of H2O). At the end of this 3-week period, data were collected from the CPAP machine and the subject was given the other mask to use with the same CPAP settings for the next 3weeks at home (if the nasal mask was given initially, the oronasal one was given later and vice versa). On completion of the second 3-week period, data on residual AHI were again collected and compared with the first 3-week period on CPAP. RESULTS: A Wilcoxon Signed-Rank Test (two-tailed) revealed that residual AHI with CPAP treatment was significantly higher with the oronasal compared with the nasal mask (z = -3.296, p<0.001). All 14 subjects had a higher residual AHI with the oronasal versus nasal mask, and 50% of the subjects had a residual AHI >10/h in the oronasal mask condition, even though all of these subjects were titrated to an AHI of < 5/h in the laboratory. CONCLUSION: A higher residual AHI was seen in all patients with the use of an oronasal mask compared with a nasal mask. Switching to an oronasal mask post titration results in an increase in residual AHI with CPAP treatment, and pressure adjustment may be warranted.

Cognitive and behavioral treatment options for insomnia.

Insomnia is a costly disorder that affects a significant number of people. In many cases, insomnia is comorbid with other illnesses, which complicates its diagnosis and treatment. Most often it is treated with medication; however, patients are not always safe using hypnotics, and medication does not attack the source of the disorder. Cognitive behavioral therapies are better for long-term treatment because they address factors causing or perpetuating insomnia, as opposed to treatments that focus on symptoms. This article examines various nonpharmacological treatments for insomnia. In addition, because circadian rhythm disorders may exhibit symptoms similar to insomnia, there is also a brief overview of 2 common circadian rhythm disorders, delayed sleep phase syndrome and advanced sleep phase syndrome.

REM behavior disorder associated with familial amyotrophic lateral sclerosis.

The association between RBD and synucleinopathies is well known. However, the association between RBD and other neuromuscular diseases has not been as well described. Our case study describes two siblings with familial ALS, confirmed by the identification of the L84F mutation in the SOD1 gene, and RDB. We hope this case study will promote future studies on the prevalence of this association and will stimulate research in identifying the underlying pathogenic mechanism.

Narcolepsy with cataplexy masked by the use of nicotine.

This report describes a case of narcolepsy with cataplexy masked by the chronic use of cigarettes and nicotine patches. It has been described that narcoleptic smokers report relief of symptoms by smoking tobacco cigarettes. In addition, a case describing partial treatment of sleepiness using a nicotine patch in an adolescent with narcolepsy was recently reported in this journal. Our case adds to the growing literature that nicotine may be used to manage symptoms associated with narcolepsy.

The efficacy of three different mask styles on a PAP titration night.

BACKGROUND: This study compared the efficacy of three different masks, nasal pillows, nasal masks and full face (oronasal) masks, during a single night of titration with continuous positive airway pressure (CPAP). METHODS: Fifty five subjects that included men (n=33) and women (n=22) were randomly assigned to one of three masks and underwent a routine titration with incremental CPAP applied through the different masks. RESULTS: CPAP applied through the nasal pillows and nasal mask was equally effective in treating mild, moderate, and severe sleep apnea. However, CPAP applied through the oronasal mask required a significantly higher pressure compared to nasal masks to treat moderately severe (2.8 cm of H(2)O ± 2.1 SD) and severe (6.0 cm of H(2)O ± 3.2 SD) obstructive sleep apnea. CONCLUSION: CPAP applied with either nasal mask was effective in treating mild, moderate, and severe sleep apnea. The oronasal mask required significantly higher pressures in subjects with moderate to severe disease. Therefore, when changing from a nasal to an oronasal mask, a repeat titration is required to ensure effective treatment of sleep apnea, especially in patients with moderate to severe disease.