Sleep disorder risk, perceived control over sleep, and mental health symptoms in paramedicine students.

Paramedics commonly experience both poor sleep and mental health symptoms. Clarifying whether sleep or mental health symptoms are a challenge prior to commencement of employment is important, as early prevention and intervention initiatives during training could support these workers. Paramedicine students (n=53) were included, with sleep disorder screening (obstructive sleep apnea, insomnia and restless legs syndrome), and mental health outcomes (depressive symptoms: Patient Health Questionnaire-9, and anxiety symptoms: General Anxiety Disorder-7). Data were analysed using robust regression models, adjusted for age, sex, and shift work status. Meeting criteria for a sleep disorder (n=21) was associated with higher scores for anxiety (8.2 [95% CI: 5.9-10.5] v 4.6, [3.4-5.8]) and depressive symptoms (11.1 [8.6-13.6] v 4.4 [3.1-5.7)] compared to those who did not meet the criteria for a sleep disorder (n=32). Depressive symptoms were lower in those with perceived control over sleep (5.2 [3.2-7.2] v 9.8 [7.7-11.8]). There was no interaction between sleep disorder risk and perceived control over sleep on mental health symptoms. Investigation and management of factors contributing to low perceived control over sleep, together with early screening and management of sleep disorders, are likely to be important priorities to support paramedic student wellbeing prior to commencing shift work.

Comparative Effectiveness of Supine Avoidance versus Continuous Positive Airway Pressure for Treating Supine-isolated Sleep Apnea: A Clinical Trial.

Rationale: About 20-35% of patients with obstructive sleep apnea (OSA) have supine-isolated OSA, for which supine sleep avoidance could be an effective therapy. However, traditional supine discomfort-based methods show poor tolerance and compliance to treatment and so cannot be recommended. Supine alarm devices show promise, but evidence to support favorable adherence to treatment and effectiveness at reducing excessive daytime sleepiness compared with continuous positive airway pressure (CPAP) remains limited. Objectives: To establish if alarm-based supine-avoidance treatment in patients with supine-isolated OSA is noninferior to CPAP in reducing daytime sleepiness. Methods: After baseline questionnaire administration and in-home supine-time and polysomnography assessments, patients with supine-isolated OSA and Epworth Sleepiness Scale scores ⩾8 were randomized to ⩾6 weeks of supine-avoidance or CPAP treatment, followed by crossover to the remaining treatment with repeat assessments. Noninferiority was assessed from change in Epworth Sleepiness Scale with supine avoidance compared with CPAP using a prespecified noninferiority margin of 1.5. Average nightly treatment use over all nights and treatment efficacy and effectiveness at reducing respiratory disturbances were also compared between treatments. Results: The reduction in sleepiness score with supine avoidance (mean [95% confidence interval], -1.9 [-2.8 to -1.0]) was noninferior to that with CPAP (-2.4 [-3.3 to -1.4]) (supine avoidance-CPAP difference, -0.4 [-1.3 to 0.6]), and the lower confidence limit did not cross the noninferiority margin of 1.5 (P = 0.021). Average treatment use was higher with supine avoidance compared with CPAP (mean ± standard deviation, 5.7 ± 2.4 vs. 3.9 ± 2.7 h/night; P < 0.001). Conclusions: In patients with supine-isolated OSA, vibrotactile supine alarm device therapy is noninferior to CPAP for reducing sleepiness and shows superior treatment adherence. Clinical trial registered with www.anzctr.org.au (ACTRN 12613001242718).

Associations of baseline obstructive sleep apnea and sleep macroarchitecture with cognitive function after 8 years in middle-aged and older men from a community-based cohort study.

Previous prospective studies examining associations of obstructive sleep apnea and sleep macroarchitecture with future cognitive function recruited older participants, many demonstrating baseline cognitive impairment. This study examined obstructive sleep apnea and sleep macroarchitecture predictors of visual attention, processing speed, and executive function after 8 years among younger community-dwelling men. Florey Adelaide Male Ageing Study participants (n = 477) underwent home-based polysomnography, with 157 completing Trail-Making Tests A and B and the Mini-Mental State Examination. Associations of obstructive sleep apnea (apnea-hypopnea index, oxygen desaturation index, and hypoxic burden index) and sleep macroarchitecture (sleep stage percentages and total sleep time) parameters with future cognitive function were examined using regression models adjusted for baseline demographic, biomedical, and behavioural factors, and cognitive task performance. The mean (standard deviation) age of the men at baseline was 58.9 (8.9) years, with severe obstructive sleep apnea (apnea-hypopnea index ≥30 events/h) in 9.6%. The median (interquartile range) follow-up was 8.3 (7.9-8.6) years. A minority of men (14.6%) were cognitively impaired at baseline (Mini-Mental State Examination score <28/30). A higher percentage of light sleep was associated with better Trail-Making Test A performance (B = -0.04, 95% confidence interval [CI] -0.06, -0.01; p = 0.003), whereas higher mean oxygen saturation was associated with worse performance (B = 0.11, 95% CI 0.02, 0.19; p = 0.012). While obstructive sleep apnea and sleep macroarchitecture might predict cognitive decline, future studies should consider arousal events and non-routine hypoxaemia measures, which may show associations with cognitive decline.

"The Days Are Long But the Nights Are Even Longer": A Mixed-Method Study of Sleep Disturbances Among Patients in an Inpatient Rehabilitation Program.

Objective: To assess sleep quality of patients on a rehabilitation ward and to identify staff practices and beliefs about management of sleep disturbance. Design: Mixed-methods design including patient surveys and staff interviews. Setting: Inpatient rehabilitation ward in a tertiary teaching hospital in Adelaide, Australia. Participants: Of the 345 screened inpatients who had been in a mixed post-acute rehabilitation ward for at least 5 days, 120 (43% women) were included. The mean age was 67.7 years and the main admission reason was functional decline (40%). Patients with stroke or traumatic brain injury were excluded. Eleven (n = 11) staff (a mix of doctors, nurses, and allied health) were interviewed. Main Outcome Measures: The surveys comprised of the Pittsburgh Sleep Quality Index, the Epworth Sleepiness Scale, the Flinders Fatigue Scale, and the Sleep Inertia Questionnaire. The survey results were compared with functional outcomes using the functional independence measure (FIM). Staff interviews delved into barriers to good sleep, ward practices, and knowledge about sleep hygiene. Results: 43% of the surveyed patients reported having healthy amount of sleep. Sleep quality was not significantly correlated with rehabilitation outcomes (assessed using FIM). Staff reported having a good awareness of sleep hygiene; however, acknowledged limitations about the environment and routine which were not conducive to healthy sleep. They identified several actions which could be taken to improve patients' sleep hygiene. Conclusions: Sleep disturbance is common for patients in rehabilitation. Rehabilitation wards should address this often-neglected critical component of rehabilitation to improve patient experience and potential participation in therapy. Introducing a systematic approach for assessing sleep during admission, establishing clear roles regarding sleep assessment and intervention among staff, and ensuring that patients and staff are aware of good sleep hygiene practices may promote better sleep during inpatient rehabilitation.

Establishing the acute physiological and sleep disruption characteristics of wind farm versus road traffic noise disturbances in sleep: a randomized controlled trial protocol.

Study Objectives: Despite the global expansion of wind farms, effects of wind farm noise (WFN) on sleep remain poorly understood. This protocol details a randomized controlled trial designed to compare the sleep disruption characteristics of WFN versus road traffic noise (RTN). Methods: This study was a prospective, seven night within-subjects randomized controlled in-laboratory polysomnography-based trial. Four groups of adults were recruited from; <10 km away from a wind farm, including those with, and another group without, noise-related complaints; an urban RTN exposed group; and a group from a quiet rural area. Following an acclimation night, participants were exposed, in random order, to two separate nights with 20-s or 3-min duration WFN and RTN noise samples reproduced at multiple sound pressure levels during established sleep. Four other nights tested for continuous WFN exposure during wake and/or sleep on sleep outcomes. Results: The primary analyses will assess changes in electroencephalography (EEG) assessed as micro-arousals (EEG shifts to faster frequencies lasting 3-15 s) and awakenings (>15 s events) from sleep by each noise type with acute (20-s) and more sustained (3-min) noise exposures. Secondary analyses will compare dose-response effects of sound pressure level and noise type on EEG K-complex probabilities and quantitative EEG measures, and cardiovascular activation responses. Group effects, self-reported noise sensitivity, and wake versus sleep noise exposure effects will also be examined. Conclusions: This study will help to clarify if wind farm noise has different sleep disruption characteristics compared to road traffic noise.

Multi-night measurement for diagnosis and simplified monitoring of obstructive sleep apnoea.

Substantial night-to-night variability in obstructive sleep apnoea (OSA) severity has raised misdiagnosis and misdirected treatment concerns with the current prevailing single-night diagnostic approach. In-home, multi-night sleep monitoring technology may provide a feasible complimentary diagnostic pathway to improve both the speed and accuracy of OSA diagnosis and monitor treatment efficacy. This review describes the latest evidence on night-to-night variability in OSA severity, and its impact on OSA diagnostic misclassification. Emerging evidence for the potential impact of night-to-night variability in OSA severity to influence important health risk outcomes associated with OSA is considered. This review also characterises emerging diagnostic applications of wearable and non-wearable technologies that may provide an alternative, or complimentary, approach to traditional OSA diagnostic pathways. The required evidence to translate these devices into clinical care is also discussed. Appropriately sized randomised controlled trials are needed to determine the most appropriate and effective technologies for OSA diagnosis, as well as the optimal number of nights needed for accurate diagnosis and management. Potential risks versus benefits, patient perspectives, and cost-effectiveness of these novel approaches should be carefully considered in future trials.

The association between sleep spindles and cognitive function in middle-aged and older men from a community-based cohort study.

OBJECTIVES: Previous studies examining associations between sleep spindles and cognitive function attempted to account for obstructive sleep apnea without consideration for potential moderating effects. To elucidate associations between sleep spindles, cognitive function, and obstructive sleep apnea, this study of community-dwelling men examined cross-sectional associations between sleep spindle metrics and daytime cognitive function outcomes following adjustment for obstructive sleep apnea and potential obstructive sleep apnea moderating effects. METHODS: Florey Adelaide Male Ageing Study participants (n = 477, 41-87 years) reporting no previous obstructive sleep apnea diagnosis underwent home-based polysomnography (2010-2011). Cognitive testing (2007-2010) included the inspection time task (processing speed), trail-making tests A (TMT-A) (visual attention) and B (trail-making test-B) (executive function), and Fuld object memory evaluation (episodic memory). Frontal spindle metrics (F4-M1) included occurrence (count), average frequency (Hz), amplitude (µV), and overall (11-16 Hz), slow (11-13 Hz), and fast (13-16 Hz) spindle density (number/minute during N2 and N3 sleep). RESULTS: In fully adjusted linear regression models, lower N2 sleep spindle occurrence was associated with longer inspection times (milliseconds) (B = -0.43, 95% confidence interval [-0.74, -0.12], p = .006), whereas higher N3 sleep fast spindle density was associated with worse TMT-B performance (seconds) (B = 18.4, 95% confidence interval [1.62, 35.2], p = .032). Effect moderator analysis revealed that in men with severe obstructive sleep apnea (apnea-hypopnea index ≥30/hour), slower N2 sleep spindle frequency was associated with worse TMT-A performance (χ2 = 12.5, p = .006). CONCLUSIONS: Specific sleep spindle metrics were associated with cognitive function, and obstructive sleep apnea severity moderated these associations. These observations support the utility of sleep spindles as useful cognitive function markers in obstructive sleep apnea, which warrants further longitudinal investigation.

A micro-randomized pilot study to examine the impact of just-in-time nudging on after-dinner snacking in adults with type 2 diabetes: A study protocol.

AIM: To determine whether a digital nudge soon after dinner reduces after-dinner snacking events as measured objectively by continuous glucose monitoring (CGM) in patients with type 2 diabetes (T2D). METHODS: This is a single-site micro-randomized trial (MRT). People with T2D, aged 18-75 years, managed with diet or a stable dose of oral antidiabetic medications for at least 3 months, and who habitual snack after dinner at least 3 nights per week, will be recruited. Picto-graphic nudges were designed by mixed research methods. After a 2-week lead-in phase to determine eligibility and snacking behaviours by a CGM detection algorithm developed by the investigators, participants will be micro-randomized daily (1:1) to a second 2-week period to either a picto-graphic nudge delivered-in-time (Intui Research) or no nudge. During lead-in and MRT phases, 24-hour glucose will be measured by CGM, sleep will be tracked by an under-mattress sleep sensor, and dinner timing will be captured daily by photographing the evening meal. RESULTS: The primary outcome is the difference in the incremental area under the CGM curve between nudging and non-nudging days during the period from 90 minutes after dinner until 04:00 AM. Secondary outcomes include the effect of baseline characteristics on treatment, and comparisons of glucose peaks and time-in-range between nudging and non-nudging days. The feasibility of 'just-in-time' messaging and nudge acceptability will be evaluated, along with the analysis of sleep quality measures and their night-to-night variability. CONCLUSIONS: This study will provide preliminary evidence of the impact of appropriately timed digital nudges on 24 -hour intertitial glucose levels resulting from altered after-dinner snacking in people with T2D. An exploratory sleep substudy will provide evidence of a bidirectional relationship between after-dinner snacking behaviour, glycaemia and sleep. Ultimately, this study will allow for the design of a future confirmatory study of the potential for digital nudging to improve health related behaviours and health outcomes.

Associations of Baseline Sleep Microarchitecture with Cognitive Function After 8 Years in Middle-Aged and Older Men from a Community-Based Cohort Study.

Purpose: Prospective studies examining associations between baseline sleep microarchitecture and future cognitive function recruited from small samples with predominantly short follow-up. This study examined sleep microarchitecture predictors of cognitive function (visual attention, processing speed, and executive function) after 8 years in community-dwelling men. Patients and Methods: Florey Adelaide Male Ageing Study participants (n=477) underwent home-based polysomnography (2010-2011), with 157 completing baseline (2007-2010) and follow-up (2018-2019) cognitive assessments (trail-making tests A [TMT-A] and B [TMT-B] and the standardized mini-mental state examination [SMMSE]). Whole-night F4-M1 sleep EEG recordings were processed following artifact exclusion, and quantitative EEG characteristics were obtained using validated algorithms. Associations between baseline sleep microarchitecture and future cognitive function (visual attention, processing speed, and executive function) were examined using linear regression models adjusted for baseline obstructive sleep apnoea, other risk factors, and cognition. Results: The final sample included men aged (mean [SD]) 58.9 (8.9) years at baseline, overweight (BMI 28.5 [4.2] kg/m2), and well educated (75.2% ≥Bachelor, Certificate, or Trade), with majorly normal baseline cognition. Median (IQR) follow-up was 8.3 (7.9, 8.6) years. In adjusted analyses, NREM and REM sleep EEG spectral power was not associated with TMT-A, TMT-B, or SMMSE performance (all p>0.05). A significant association of higher N3 sleep fast spindle density with worse TMT-B performance (B=1.06, 95% CI [0.13, 2.00], p=0.026) did not persist following adjustment for baseline TMT-B performance. Conclusion: In this sample of community-dwelling men, sleep microarchitecture was not independently associated with visual attention, processing speed, or executive function after 8 years.

High night-to-night variability in sleep apnea severity is associated with uncontrolled hypertension.

Obstructive sleep apnea (OSA) severity can vary markedly from night-to-night. However, the impact of night-to-night variability in OSA severity on key cardiovascular outcomes such as hypertension is unknown. Thus, the primary aim of this study is to determine the effects of night-to-night variability in OSA severity on hypertension likelihood. This study uses in-home monitoring of 15,526 adults with ~180 nights per participant with an under-mattress sleep sensor device, plus ~30 repeat blood pressure measures. OSA severity is defined from the mean estimated apnea-hypopnoea index (AHI) over the ~6-month recording period for each participant. Night-to-night variability in severity is determined from the standard deviation of the estimated AHI across recording nights. Uncontrolled hypertension is defined as mean systolic blood pressure ≥140 mmHg and/or mean diastolic blood pressure ≥90 mmHg. Regression analyses are performed adjusted for age, sex, and body mass index. A total of 12,287 participants (12% female) are included in the analyses. Participants in the highest night-to-night variability quartile within each OSA severity category, have a 50-70% increase in uncontrolled hypertension likelihood versus the lowest variability quartile, independent of OSA severity. This study demonstrates that high night-to-night variability in OSA severity is a predictor of uncontrolled hypertension, independent of OSA severity. These findings have important implications for the identification of which OSA patients are most at risk of cardiovascular harm.

Emerging applications of objective sleep assessments towards the improved management of insomnia.

Self-reported sleep difficulties are the primary concern associated with diagnosis and treatment of chronic insomnia. This said, in-home sleep monitoring technology in combination with self-reported sleep outcomes may usefully assist with the management of insomnia. The rapid acceleration in consumer sleep technology capabilities together with their growing use by consumers means that the implementation of clinically useful techniques to more precisely diagnose and better treat insomnia are now possible. This review describes emerging techniques which may facilitate better identification and management of insomnia through objective sleep monitoring. Diagnostic techniques covered include insomnia phenotyping, better detection of comorbid sleep disorders, and identification of patients potentially at greatest risk of adverse outcomes. Treatment techniques reviewed include the administration of therapies (e.g., Intensive Sleep Retraining, digital treatment programs), methods to assess and improve treatment adherence, and sleep feedback to address concerns about sleep and sleep loss. Gaps in sleep device capabilities are also discussed, such as the practical assessment of circadian rhythms. Proof-of-concept studies remain needed to test these sleep monitoring-supported techniques in insomnia patient populations, with the goal to progress towards more precise diagnoses and efficacious treatments for individuals with insomnia.

All-Cause Mortality in People with Co-Occurring Insomnia Symptoms and Sleep Apnea: Analysis of the Wisconsin Sleep Cohort.

Purpose: Insomnia symptoms and sleep apnea frequently co-occur and are associated with worse sleep, daytime function, mental health and quality of life, compared to either insomnia or obstructive sleep apnea (OSA) alone. This study aimed to investigate the association of symptoms of co-morbid insomnia and sleep apnea (COMISA) with all-cause mortality. Patients and Methods: Wisconsin Sleep Cohort data were analysed to assess potential associations between COMISA symptoms and all-cause mortality. Nocturnal insomnia symptoms were defined as difficulties initiating sleep, maintaining sleep, and/or early morning awakenings "often" or "almost always", and/or regular sedative-hypnotic medicine use. OSA was defined as an apnea-hypopnea index ≥5/hr sleep. Participants were classified as having neither insomnia symptoms nor OSA, insomnia symptoms alone, OSA alone, or COMISA symptoms. Associations between the four groups and all-cause mortality over 20 years of follow-up were examined via multivariable adjusted Cox regression models. Results: Among 1115 adult participants (mean ± SD age 55 ± 8 years, 53% males), 19.1% had COMISA symptoms. After controlling for sociodemographic and behavioral factors, COMISA symptoms were associated with an increased risk of all-cause mortality compared to no insomnia symptoms or OSA (HR [95% CI]; 1.71 [1.00-2.93]). OSA alone (0.91 [0.53, 1.57]) and insomnia symptoms alone (1.04 [0.55, 1.97]) were not associated with increased mortality risk. Conclusion: Co-morbid insomnia symptoms and sleep apnea is associated with increased all-cause mortality risk. Future research should investigate mechanisms underpinning COMISA and the effectiveness of different treatment approaches to reduce mortality risk for this common condition.

Reduction in fall risk markers following CPAP treatment of obstructive sleep apnoea in people over 65 years.

OBJECTIVES: Falls in older people can lead to serious injury and significant societal health and financial burden. Obstructive sleep apnoea (OSA) is associated with impaired gait/balance and may increase fall risk, yet few studies examined whether treating OSA reduces fall risk. This study examined the effect of continuous positive airway pressure (CPAP) on fall risk markers in people over 65yrs diagnosed with OSA. DESIGN: Single arm intervention study. SETTING: University and tertiary care CPAP clinic. PARTICIPANTS: Individuals over 65 years diagnosed with OSA and recommended CPAP. INTERVENTION: 3-6 months CPAP therapy. MEASUREMENTS: 28 participants had a physiological profile assessment (PPA) at baseline and following 3-6 months of CPAP. The PPA examines visual contrast sensitivity, lower limb proprioception, knee extension strength, reaction time and postural sway to generate a fall risk score (FRS). t-tests were used to determine difference between pre- and post-treatment FRS. Regression was used to examine the associations between CPAP use and daytime sleepiness with FRS. RESULTS: CPAP significantly reduced the FRS ([Mean ± SD] 0.59 ± 1.0 vs 0.04 ± 1.1, p = 0.016), contrast sensitivity and lower limb proprioception (P < 0.05). Increased CPAP use was associated with improvement in FRS in unadjusted analysis (ß = -0.213, 95%CI -0.371 to -0.056, p = 0.01). Reduction in Epworth sleepiness score was associated with a reduction in FRS in unadjusted (p = 0.023) and adjusted analysis (adjusted for AHI p = 0.027 or O2Nadir p = 0.015). CONCLUSIONS: CPAP may reduce fall risk in people over 65yrs, possibly related to better CPAP adherence and reduced daytime sleepiness. Future controlled trials and mechanistic studies are needed to elucidate how CPAP may reduce fall risk.

Association Between Sleep Microstructure and Incident Hypertension in a Population-Based Sample: The HypnoLaus Study.

Background Poor sleep quality is associated with increased incident hypertension. However, few studies have investigated the impact of objective sleep structure parameters on hypertension. This study investigated the association between sleep macrostructural and microstructural parameters and incident hypertension in a middle- to older-aged sample. Methods and Results Participants from the HypnoLaus population-based cohort without hypertension at baseline were included. Participants had at-home polysomnography at baseline, allowing assessment of sleep macrostructure (nonrapid eye movement sleep stages 1, 2, and 3; rapid eye movement sleep stages; and total sleep time) and microstructure including power spectral density of electroencephalogram in nonrapid eye movement sleep and spindles characteristics (density, duration, frequency, amplitude) in nonrapid eye movement sleep stage 2. Associations between sleep macrostructure and microstructure parameters at baseline and incident clinical hypertension over a mean follow-up of 5.2 years were assessed with multiple-adjusted logistic regression. A total of 1172 participants (42% men; age 55±10 years) were included. Of these, 198 (17%) developed hypertension. After adjustment for confounders, no sleep macrostructure features were associated with incident hypertension. However, low absolute delta and sigma power were significantly associated with incident hypertension where participants in the lowest quartile of delta and sigma had a 1.69-fold (95% CI, 1.00-2.89) and 1.72-fold (95% CI, 1.05-2.82) increased risk of incident hypertension, respectively, versus those in the highest quartile. Lower spindle density (odds ratio, 0.87; 95% CI, 0.76-0.99) and amplitude (odds ratio, 0.98; 95% CI, 0.95-1.00) were also associated with higher incident hypertension. Conclusions Sleep microstructure is associated with incident hypertension. Slow-wave activity and sleep spindles, 2 hallmarks of objective sleep continuity and quality, were inversely and consistently associated with incident hypertension. This supports the protective role of sleep continuity in the development of hypertension.

A novel EEG marker predicts perceived sleepiness and poor sleep quality.

STUDY OBJECTIVES: To determine if a novel EEG-derived continuous index of sleep depth/alertness, the odds ratio product (ORP), predicts self-reported daytime sleepiness and poor sleep quality in two large population-based cohorts. METHODS: ORP values which range from 0 (deep sleep) to 2.5 (fully alert) were calculated in 3s intervals during awake periods (ORPwake) and NREM sleep (ORPNREM) determined from home sleep studies in the HypnoLaus (N = 2162: 1106 females, 1056 males) and men androgen inflammation lifestyle environment and stress (MAILES) cohorts (N = 754 males). Logistic regression was used to examine associations between ORPwake, ORPNREM, and traditional polysomnography measures (as comparators) with excessive sleepiness (Epworth sleepiness scale >10) and poor sleep quality (Pittsburgh sleep quality index >5) and insomnia symptoms. RESULTS: High ORPwake was associated with a ~30% increase in poor sleep quality in both HypnoLaus (odds ratio, OR, and 95% CI) 1.28 (1.09, 1.51), and MAILES 1.36 (1.10, 1.68). High ORPwake was also associated with a ~28% decrease in excessive daytime sleepiness in the MAILES dataset. ORPNREM was associated with a ~30% increase in poor sleep quality in HypnoLaus but not in MAILES. No consistent associations across cohorts were detected using traditional polysomnography markers. CONCLUSIONS: ORP, a novel EEG-derived metric, measured during wake periods predicts poor sleep quality in two independent cohorts. Consistent with insomnia symptomatology of poor perceived sleep in the absence of excessive daytime sleepiness, ORPwake may provide valuable objective mechanistic insight into physiological hyperarousal.

Comorbidities and quality of life in Australian men and women with diagnosed and undiagnosed high-risk obstructive sleep apnea.

STUDY OBJECTIVES: In a population-based survey, we determined sex differences in health profiles and quality of life between individuals who have a confirmed diagnosis of obstructive sleep apnea (OSA) and those who are at high risk of OSA yet remain undiagnosed. METHODS: An online survey of Australian adults ≥ 18 years (n = 3,818) identified participants with self-reported diagnosed OSA (n = 460) or high-risk, undiagnosed OSA (OSA50 score ≥ 5, n = 1,015). Ever-diagnosed comorbidities, sociodemographics, and quality of life (EQ-5D-5L, Functional Outcomes of Sleep Questionnaire-10) were assessed. RESULTS: Women were more frequently represented in the high-OSA-risk group compared with those with diagnosed OSA (55.5%, n = 563, versus 43%, n = 198; P < .001). In sex-specific logistic regression analyses, diagnosed OSA was associated with increased likelihoods of ≥ 1 cardiovascular condition (odds ratio: 3.0; 95% confidence interval: 2.0-4.5), hypertension (1.9; 1.3-2.8), gout (1.8; 1.1-2.9), and chronic obstructive pulmonary disease (3.8; 2.1-6.9) in men. In women, an association with asthma (2.0; 1.3-3.0) was seen. Diabetes, arthritis, mental health conditions (ever-diagnosed), and all EQ-5D-5L dimensions were associated with an OSA diagnosis regardless of sex, except for EQ-5D-5L anxiety/depression, which was only associated with an OSA diagnosis in women. A diagnosis of OSA was associated with sleepiness-related impairment (lowest quartile of Functional Outcomes of Sleep Questionnaire-10) in men (1.6; 1.01-2.5) and women (2.2; 1.4-3.6). CONCLUSIONS: Sex-specific health conditions may drive diagnosis of OSA; however, clinical suspicion of OSA needs to be increased in men and women. The impaired quality of life and persistent sleepiness in participants with diagnosed OSA observed at a population level requires greater clinical attention. CITATION: Krishnan S, Chai-Coetzer CL, Grivell N, et al. Comorbidities and quality of life in Australian men and women with diagnosed and undiagnosed high-risk obstructive sleep apnea. J Clin Sleep Med. 2022;18(7):1757-1767.

Economic evaluation of diagnostic sleep studies for obstructive sleep apnoea in the adult population: a systematic review.

Evidence regarding the cost-effectiveness of limited channel tests compared to laboratory and home polysomnography (PSG) in diagnosing obstructive sleep apnoea (OSA) is unclear. Eligible studies were systematically sought across the following databases: MEDLINE, PsychINFO, SCOPUS, CINAHL, Cochrane, Emcare, Web of Science and ProQuest. Title and abstracts were screened before full-text review. Only full and partial economic evaluations reporting at least one economic outcome were included. A standardised template was used for critical appraisal and data extraction. Relevant findings were summarised using a qualitative approach adhering to economic reporting standards. Literature searches identified 999 non-duplicate abstracts, where 85 studies were retrieved for full-text review. The number of studies that met eligibility criteria and were included in the final analyses was 35, of which 31 investigated Level 3 and four assessed Level 4 tests. Based on the dominance ranking framework, both Level 3 and Level 4 tests were cost-effective compared to PSG. Although study designs and methodologies differ broadly, the findings indicated that using limited channel diagnostic sleep tests for OSA is associated with lower costs and non-inferior health outcomes relative to PSG. Limited channel tests also resulted in shorter waiting times and improved access to diagnostic services for patients with OSA. PROSPERO REGISTRATION NUMBER: CRD42020150130.

High-quality and anti-inflammatory diets and a healthy lifestyle are associated with lower sleep apnea risk.

STUDY OBJECTIVES: Most studies on diet and sleep apnea focus on calorie restriction. Here we investigate potential associations between dietary quality (Healthy Eating Index [HEI], Dietary Inflammatory Index [DII]) and overall healthy lifestyle with sleep apnea risk. METHODS: National Health and Nutrition Examination Survey data (waves 2005-2008 and 2015-2018; n = 14,210) were used to determine HEI, DII, and their quintiles, with the fifth quintile indicating highest adherence to each dietary construct. A healthy lifestyle score was determined using diet, smoking, alcohol intake, and physical activity level. The STOP-BANG questionnaire was used to define sleep apnea risk. Generalized linear regression models with binomial family and logit link were used to investigate potential associations. The models were adjusted for socioeconomic status, lifestyle factors, and chronic conditions. RESULTS: The prevalence of high sleep apnea risk was 25.1%. Higher DII was positively associated with sleep apnea (odds ratioQuintile 5 vs Quintile 1 = 1.55; 95% confidence interval, 1.24-1.94; P for trend < .001), whereas higher HEI was associated with reduced sleep apnea risk (odds ratioQuintile 5 vs Quintile 1 = 0.72; 95% confidence interval, 0.59-0.88; P for trend = .007). Higher healthy lifestyle score was also associated with decreased odds of sleep apnea (P for trend < .001). There was a significant interaction between healthy lifestyle and sex with sleep apnea risk (P for interaction = .049) whereby females with higher healthy lifestyle scores had a lower risk of sleep apnea compared to males. CONCLUSIONS: Higher-quality and anti-inflammatory diets and a healthier overall lifestyle are associated with lower sleep apnea risk. These findings underline the importance of strategies to improve overall diet quality and promote healthy behavior, not just calorie restriction, to reduce sleep apnea risk. CITATION: Melaku YA, Reynolds AC, Appleton S, et al. High-quality and anti-inflammatory diets and a healthy lifestyle are associated with lower sleep apnea risk. J Clin Sleep Med. 2022;18(6):1667-1679.

Preferred Attributes of Care Pathways for Obstructive Sleep Apnoea from the Perspective of Diagnosed Patients and High-Risk Individuals: A Discrete Choice Experiment.

BACKGROUND: The current healthcare system is challenged with a large and rising demand for obstructive sleep apnoea (OSA) services. A paradigm shift in OSA management is required to incorporate the preferences of diagnosed patients and individuals at high risk of OSA. OBJECTIVES: This study aimed to provide empirical evidence of the values and preferences of individuals diagnosed with OSA and high-risk populations regarding distinct OSA care pathway features. METHODS: A discrete choice experiment was undertaken in two groups: those with a formal diagnosis of OSA (n = 421) and those undiagnosed but at high risk of having OSA (n = 1033). Participants were recruited from a large cross-sectional survey in Australia. The discrete choice experiment approach used mixed-logit regression models to determine preferences relating to eight salient features of the OSA management pathway, i.e. initial assessment provider, sleep study setting, diagnosis costs, waiting times, results interpretation, treatment options, provider of ongoing care and frequency of follow-up visits. RESULTS: The findings indicate that all eight attributes investigated were statistically significant factors for respondents. Generally, both groups preferred low diagnostic costs, fewer follow-up visits, minimum waiting time for sleep study results and sleep specialists to recommend treatment. Management of OSA in primary care was acceptable to both groups and was the most preferred option by the high-risk group for the initial assessment, sleep study testing and ongoing care provision. CONCLUSIONS: The discrete choice experiment results offer a promising approach for systematic incorporation of patient and high-risk group preferences into the future design and delivery of care pathways for OSA management.