Effects of Weight Loss on Obstructive Sleep Apnea Severity. Ten-Year Results of the Sleep AHEAD Study.

Rationale: Weight loss is recommended to treat obstructive sleep apnea (OSA).Objectives: To determine whether the initial benefit of intensive lifestyle intervention (ILI) for weight loss on OSA severity is maintained at 10 years.Methods: Ten-year follow-up polysomnograms of 134 of 264 adults in Sleep AHEAD (Action for Health in Diabetes) with overweight/obesity, type 2 diabetes mellitus, and OSA were randomized to ILI for weight loss or diabetes support and education (DSE).Measurements and Main Results: Change in apnea-hypopnea index (AHI) was measured. Mean ± SE weight losses of ILI participants of 10.7 ± 0.7, 7.4 ± 0.7, 5.1 ± 0.7, and 7.1 ± 0.8 kg at 1, 2, 4, and 10 years, respectively, were significantly greater than the 1-kg weight loss at 1, 2, and 4 years and 3.5 ± 0.8 kg weight loss at 10 years for the DSE group (P values ≤ 0.0001). AHI was lower with ILI than DSE by 9.7, 8.0, and 7.9 events/h at 1, 2, and 4 years, respectively (P values ≤ 0.0004), and 4.0 events/h at 10 years (P = 0.109). Change in AHI over time was related to amount of weight loss, baseline AHI, visit year (P values < 0.0001), and intervention independent of weight change (P = 0.01). OSA remission at 10 years was more common with ILI (34.4%) than DSE (22.2%).Conclusions: Participants with OSA and type 2 diabetes mellitus receiving ILI for weight loss had reduced OSA severity at 10 years. No difference in OSA severity was present between ILI and DSE groups at 10 years. Improvement in OSA severity over the 10-year period with ILI was related to change in body weight, baseline AHI, and intervention independent of weight change.

Treatment of severe morning sleep inertia with bedtime long-acting bupropion and/or long-acting methylphenidate in a series of 4 patients.

STUDY OBJECTIVES: To assess the benefit of bedtime long-acting bupropion and/or long-acting methylphenidate in the therapy of severe morning sleep inertia (SI), a chronic condition that has major adverse consequences on level of functioning and quality of life, and for which there is no recognized therapy. METHODS: Patients underwent clinical interviews and examinations and completed comprehensive questionnaires. They underwent overnight video-polysomnography and next-day multiple sleep latency testing (apart from 1 case with obstructive sleep apnea). Treatments are described in the case reports. RESULTS: Case 1, a 16-year-old girl who was very late to school every day from severe morning SI despite obstructive sleep apnea being fully controlled with continuous positive airway pressure therapy, responded to bedtime bupropion-extended release (xl) 150 mg, together with methylphenidate-sr (sustained release), 36 mg (along with 20 mg methylphenidate taken 1 hour before the alarm would go off). She woke up in a timely fashion and has started her classes on time, with benefit maintained at 6-month follow-up. Case 2, a 29-year-old female with idiopathic hypersomnia and major depression and associated severe morning SI while maintained on 20 mg twice-daily generic Adderall, responded immediately (first night) to bedtime bupropion-xl, 150 mg, with benefit maintained at the 4-month follow-up. Case 3, a 74-year-old man with idiopathic hypersomnia and major depression maintained on daily methylphenidate-sr and direct-release methylphenidate, along with 300 mg bupropion-xl, developed progressively severe morning SI that immediately responded to changing his bupropion-xl regimen to 150 mg nightly and 150 mg every morning, with benefit maintained at the 3-year follow-up. Case 4, a 60-year-old female with idiopathic hypersomnia and severe morning SI, was immediately intolerant to bedtime bupropion-xl, which was discontinued. CONCLUSIONS: Bedtime use of long-acting bupropion and/or long-acting methylphenidate can be effective in the therapy for severe morning SI and warrants further clinical use along with systematic research.

Pulse transit time in pregnancy: a new way to diagnose and classify sleep disordered breathing?

STUDY OBJECTIVES: There are significant discrepancies between the prevalence of snoring and that of objectively defined sleep disordered breathing among pregnant women, suggesting subtle airflow limitations that may not be captured by conventional scoring. This study examined the performance of pulse transit time, an indirect measure of arterial stiffness and sympathetic activation, in pregnancy. METHODS: Pregnant women with obesity and snoring and a group of controls without symptoms of sleep disordered breathing were recruited in the first trimester. Women underwent a level III in-laboratory sleep monitoring study including an electrocardiogram and pulse oximetry, and pulse transit time was measured. Sleep disordered breathing was defined as an apnea-hypopnea index at least five events per hour of sleep. Statistical analysis was performed using Spearman correlation, Fisher's exact t-test, and univariate analysis. RESULTS: Of the 222 women, 38 met criteria for sleep disordered breathing. Pulse transit time drops were very prevalent (95% of participants with snoring had > 5 drops per hour). Median apnea-hypopnea index was 0.7 (interquartile range [IQR]: 2.6) events per hour whereas median pulse transit time drop index was 20.70 (IQR: 35.90) events per hour. Pulse transit time index was significantly higher in snorers with apnea-hypopnea index less than five events per hours and participants with apnea-hypopnea index greater than five events per hour compared to controls. Examination of random epochs with pulse transit time drops showed that 95% of pulse transit time drops were associated with airflow limitation. CONCLUSIONS: Pulse transit time ascertains frequent events of sympathetic activation in at-risk women with and without sleep disordered breathing beyond conventional apneas and hypopneas. Pulse transit time may be an important addition to the identification of clinically significant sleep disordered breathing in pregnant women, and may identify more sleep disordered breathing than apnea-hypopnea index.

Effects of a lifestyle intervention on REM sleep-related OSA severity in obese individuals with type 2 diabetes.

The aim of this study was to determine if an intensive lifestyle intervention (ILI) reduces the severity of obstructive sleep apnea (OSA) in rapid-eye movement (REM) sleep, and to determine if longitudinal changes in glycaemic control are related to changes in OSA severity during REM sleep over a 4-year follow-up. This was a randomized controlled trial including 264 overweight/obese adults with type 2 diabetes (T2D) and OSA. Participants were randomized to an ILI targeted to weight loss or a diabetes support and education (DSE) control group. Measures included anthropometry, apnea-hypopnea index (AHI) during REM sleep (REM-AHI) and non-REM sleep (NREM-AHI) and glycated haemoglobin (HbA1c) at baseline and year 1, year 2 and year 4 follow-ups. Mean baseline values of REM-AHI were significantly higher than NREM-AHI in both groups. Both REM-AHI and NREM-AHI were reduced significantly more in ILI versus DSE, but these differences were attenuated slightly after adjustment for weight changes. Repeated-measure mixed-model analyses including data to year 4 demonstrated that changes in HbA1c were related significantly to changes in weight, but not to changes in REM-AHI and NREM-AHI. Compared to control, the ILI reduced REM-AHI and NREM-AHI during the 4-year follow-up. Weight, as opposed to REM-AHI and NREM-AHI, was related to changes in HbA1c. The findings imply that weight loss from a lifestyle intervention is more important than reductions in AHI for improving glycaemic control in T2D patients with OSA.

The Effect of Changes in Cardiorespiratory Fitness and Weight on Obstructive Sleep Apnea Severity in Overweight Adults with Type 2 Diabetes.

STUDY OBJECTIVES: To examine the effect of changes in cardiorespiratory fitness on obstructive sleep apnea (OSA) severity prior to and following adjustment for changes in weight over the course of a 4-y weight loss intervention. METHODS: As secondary analyses of a randomized controlled trial, 263 overweight/obese adults with type 2 diabetes and OSA participated in an intensive lifestyle intervention or education control condition. Measures of OSA severity, cardiorespiratory fitness, and body weight were obtained at baseline, year 1, and year 4. Change in the apnea-hypopnea index (AHI) served as the primary outcome. The percentage change in fitness (submaximal metabolic equivalents [METs]) and change in weight (kg) were the primary independent variables. Primary analyses collapsed intervention conditions with statistical adjustment for treatment group and baseline METs, weight, and AHI among other relevant covariates. RESULTS: At baseline, greater METs were associated with lower AHI (B [SE] = -1.48 [0.71], P = 0.038), but this relationship no longer existed (B [SE] = -0.24 [0.73], P = 0.75) after adjustment for weight (B [SE] = 0.31 [0.07], P < 0.0001). Fitness significantly increased at year 1 (+16.53 ± 28.71% relative to baseline), but returned to near-baseline levels by year 4 (+1.81 ± 24.48%). In mixed-model analyses of AHI change over time without consideration of weight change, increased fitness at year 1 (B [SE] = -0.15 [0.04], P < 0.0001), but not at year 4 (B [SE] = 0.04 [0.05], P = 0.48), was associated with AHI reduction. However, with weight change in the model, greater weight loss was associated with AHI reduction at years 1 and 4 (B [SE] = 0.81 [0.16] and 0.60 [0.16], both P < 0.0001), rendering the association between fitness and AHI change at year 1 nonsignificant (B [SE] = -0.04 [0.04], P = 0.31). CONCLUSIONS: Among overweight/obese adults with type 2 diabetes, fitness change did not influence OSA severity change when weight change was taken into account. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov identification number NCT00194259.

Sleep architecture following a weight loss intervention in overweight and obese patients with obstructive sleep apnea and type 2 diabetes: relationship to apnea-hypopnea index.

STUDY OBJECTIVES: To determine if weight loss and/ or changes in apnea-hypopnea index (AHI) improve sleep architecture in overweight/ obese adults with type 2 diabetes (T2D) and obstructive sleep apnea (OSA). METHODS: This was a randomized controlled trial including 264 overweight/ obese adults with T2D and OSA. Participants were randomized to an intensive lifestyle intervention (ILI) or a diabetes and support education (DSE) control group. Measures included anthropometry, AHI, and sleep at baseline and year-1, year-2, and year-4 follow-ups. RESULTS: Changes in sleep duration (total sleep time [TST]), continuity [wake after sleep onset (WASO)], and architecture stage 1, stage 2, slow wave sleep, and REM sleep) from baseline to year 1, 2, and 4 did not differ between ILI and DSE. Repeated-measure mixed-model analyses including data from baseline through year-4 for all participants demonstrated a significant positive association between AHI and stage 1 sleep (p < 0.001), and a significant negative association between AHI and stage 2 (p = 0.01) and REM sleep (p < 0.001), whereas changes in body weight had no relation to any sleep stages or TST. WASO had a significant positive association with change in body weight (p = 0.009). CONCLUSIONS: Compared to control, the ILI did not induce significant changes in sleep across the 4-year follow-up. In participants overall, reduced AHI in overweight/ obese adults with T2D and OSA was associated with decreased stage 1, and increased stage 2 and REM sleep. These sleep architecture changes are more strongly related to reductions in AHI than body weight, whereas WASO may be more influenced by weight than AHI. CLINICAL TRIAL REGISTRATION NUMBER: NCT00194259.

Validation of the Apnea Risk Evaluation System (ARES) device against laboratory polysomnography in pregnant women at risk for obstructive sleep apnea syndrome.

STUDY OBJECTIVE: To assess the validity of using the Apnea Risk Evaluation System (ARES) Unicorder for detecting obstructive sleep apnea (OSA) in pregnant women. METHODS: Sixteen pregnant women, mean age (SD) = 29.8 (5.4) years, average gestational age (SD) = 28.6 (6.3) weeks, mean body mass index (SD) = 44.7 (6.9) kg/m(2) with signs and symptoms of OSA wore the ARES Unicorder during one night of laboratory polysomnography (PSG). PSG was scored according to AASM 2007 criteria, and PSG AHI and RDI were compared to the ARES 1%, 3%, and 4% AHIs calculated with the ARES propriety software. RESULTS: Median PSG AHI and PSG RDI were 3.1 and 10.3 events/h of sleep, respectively. Six women had a PSG AHI ≥ 5 events/h of sleep and 11 had a PSG RDI ≥ 5 events/h of sleep. PSG AHI and RDI were strongly correlated with the ARES AHI measures. When compared with polysomnographic diagnosis of OSA, the ARES 3% algorithm provided the best balance between sensitivity (1.0 for PSG AHI, 0.91 for PSG RDI) and specificity (0.5 for PSG AHI, 0.8 for PSG RDI) for detecting sleep disordered breathing in our sample. CONCLUSIONS: The ARES Unicorder demonstrated reasonable consistency with PSG for diagnosing OSA in this small, heterogeneous sample of obese pregnant women.

Airflow limitations in pregnant women suspected of sleep-disordered breathing.

BACKGROUND AND AIM: Pregnancy physiology may predispose women to the development of airflow limitations during sleep. The goal of this study was to evaluate whether pregnant women suspected of sleep-disordered breathing (SDB) are more likely to have airflow limitations compared to non-pregnant controls. METHODS: We recruited pregnant women referred for polysomnography for a diagnosis of SDB. Non-pregnant female controls matched for age, body mass index (BMI), and apnoea-hypopnoea index (AHI) were identified from a database. We examined airflow tracings for changes in amplitude and shape. We classified airflow limitation by (a) amplitude criteria defined as decreased airflow of > or =10 s without desaturation or arousal (FL 10), or decreased airflow of any duration combined with either 1-2% desaturation or arousal, (FL 1-2%); and (b) shape criteria defined as the presence of flattening or oscillations of the inspiratory flow curve. RESULTS: We identified 25 case-control pairs. Mean BMI was 44.0±6.9 in cases and 44.1±7.3 in controls. Using shape criteria, pregnant women had significantly more flow-limited breaths throughout total sleep time (32.4±35.8 vs. 9.4±17.9, p<0.0001) and in each stage of sleep (p<0.0001) than non-pregnant controls. In a subgroup analysis, pregnant women without a diagnosis of obstructive sleep apnoea (OSA) who had an AHI <5 had similar findings (p<0.0001). There was no difference in airflow limitation by amplitude criteria between pregnant women and controls (p=0.22). CONCLUSIONS: Pregnant women suspected of OSA have more frequent shape-defined airflow limitations than non-pregnant controls, even when they do not meet polysomnographic OSA criteria.

Motivational enhancement to improve adherence to positive airway pressure in patients with obstructive sleep apnea: a randomized controlled trial.

BACKGROUND: Obstructive sleep apnea (OSA) is associated with a variety of medical conditions. Positive airway pressure (PAP) is an effective treatment for improving sleep, yet adherence rates are low. The aim of the current study is to test two treatments versus standard care in improving adherence to PAP. METHOD: Two hundred twenty-seven patients with OSA were randomized to standard care (SC), education (ED) and motivational enhancement therapy (MET). Adherence was measured objectively and the first week of adherence (prior to the intervention) was used as an a priori moderator of the effect of the various interventions. Mediators of treatment response were also examined using theory-based measures of decisional balance and self-efficacy. RESULTS: Adherence declined over time for all three groups. There was a significant interaction between level of adherence during the first week of treatment and treatment group. Those who had moderate levels of adherence during their first week of PAP were more likely to adhere to treatment at follow-up if they had MET; those who had high levels of adherence during their first week of PAP were more likely to adhere to treatment at follow-up if they had ED. MET treatment increased the perception of the positive aspects of PAP, but ED did not. CONCLUSIONS: Initial adherence to positive airway pressure could help guide subsequent treatment plans. The results also support social cognitive theory in that educational approaches might be best suited for those who are ready for change whereas more motivational approaches might be best for those who are ambivalent about change.

Long-term effect of weight loss on obstructive sleep apnea severity in obese patients with type 2 diabetes.

STUDY OBJECTIVES: To examine whether the initial benefit of weight loss on obstructive sleep apnea (OSA) severity at 1 year is maintained at 4 years. DESIGN: Randomized controlled trial with follow-up at 1, 2, and 4 years. SETTING: 4 Look AHEAD clinical centers. PARTICIPANTS: Two hundred sixty-four obese adults with type 2 diabetes and OSA. INTERVENTIONS: Intensive lifestyle intervention with a behavioral weight loss program or diabetes support and education. MEASUREMENTS: Change in apnea-hypopnea index on polysomnogram. RESULTS: The intensive lifestyle intervention group's mean weight loss was 10.7 ± 0.7 (standard error), 7.4 ± 0.7, and 5.2 ± 0.7 kg at 1, 2, and 4 years respectively, compared to a less than 1-kg weight loss for the control group at each time (P < 0.001). Apnea-hypopnea index difference between groups was 9.7 ± 2.0, 8.0 ± 2.0, and 7.7 ± 2.3 events/h at 1, 2 and 4 years respectively (P < 0.001). Change in apnea-hypopnea index over time was related to the amount of weight loss (P < 0.0001) and intervention, independent of weight loss (P = 0.001). Remission of OSA at 4 years was 5 times more common with intensive lifestyle intervention (20.7%) than diabetes support and education (3.6%). CONCLUSIONS: Among obese adults with type 2 diabetes and OSA, intensive lifestyle intervention produced greater reductions in weight and apnea-hypopnea index over a 4 year period than did diabetes support and education. Beneficial effects of intensive lifestyle intervention on apneahypopnea index at 1 year persisted at 4 years, despite an almost 50% weight regain. Effect of intensive lifestyle intervention on apnea-hypopnea index was largely, but not entirely, due to weight loss.

Subjective sleepiness and daytime functioning in bariatric patients with obstructive sleep apnea.

PURPOSE: The purpose of this study was to evaluate associations between obstructive sleep apnea (OSA) severity and self-reported sleepiness and daytime functioning in patients considering bariatric surgery for treatment of obesity. METHODS: Using a retrospective cohort design, we identified 342 patients who had sleep evaluations prior to bariatric surgery. Our final sample included 269 patients (78.6 % of the original cohort, 239 females; mean age = 42.0 ± 9.5 years; body mass index = 50.2 ± 7.7 kg/m(2)) who had overnight polysomnography and completed the Epworth Sleepiness Scale (ESS) and the Functional Outcomes of Sleep Questionnaire (FOSQ). Patients' OSA was classified as none/mild (apnea-hypopnea index (AHI) < 15, n = 112), moderate (15 ≤ AHI < 30, n = 77), or severe (AHI ≥ 30, n = 80). We calculated the proportion of unique variance (PUV) for the five FOSQ subscales. ANOVA was used to determine if ESS and FOSQ were associated with OSA severity. Unpaired t tests compared ESS and FOSQ scores in our sample with published data. RESULTS: The average AHI was 29.5 ± 31.5 events per hour (range = 0-175.8). The mean ESS score was 6.3 ± 4.8, and the mean global FOSQ score was 100.3 ± 18.2. PUVs for FOSQ subscales showed moderate-to-high unique contributions to FOSQ variance. ESS and global FOSQ score did not differ by AHI group. Only the FOSQ vigilance subscale differed by OSA severity with the severe group reporting more impairment than the moderate and none/mild groups. Our sample reported less sleepiness and daytime impairment than previously reported means in patients and controls. CONCLUSIONS: Subjective sleepiness and functional impairment were not associated significantly with OSA severity in our sample of patients considering surgery for obesity. Further research is needed to understand individual differences in sleepiness in patients with OSA. If bariatric patients underreport symptoms, self-report measures are not an adequate substitute for objective assessment and clinical judgment when evaluating bariatric patients for OSA. Patients with severe obesity need evaluation for OSA even in the absence of subjective complaints.

Trazodone for sleep disturbance during methadone maintenance: a double-blind, placebo-controlled trial.

BACKGROUND: To test whether trazodone, one of the most commonly prescribed medications for treatment of insomnia, improves subjective and/or objective sleep among methadone-maintained persons with sleep complaints, we performed a randomized, double-blind, placebo-controlled trial with 6-month follow-up. METHODS: From eight methadone maintenance programs in the northeastern United States, we recruited 137 persons receiving methadone for at least 1 month who reported a Pittsburgh Sleep Quality Index (PSQI) score of six or higher. Two-night home polysomnography (PSG) was completed at baseline and 1 month later, with morning surveys and urine drug toxicologies. Interviews assessed sleep over the past 30 days at baseline and 1-, 3-, and 6-month follow-ups. RESULTS: Participants averaged 38 years of age, were 47% male, and had a mean PSQI total score of 12.9 (±3.1). At baseline, intervention groups did not significantly differ on 10 PSG-derived objective sleep measures and 11 self-reported measures. Over 88% (n=121) of participants completed the PSG at 1-month. Without adjusting p-values for multiple comparisons, only 1 of 21 sleep measure comparisons was statistically significant (p<.05). The effect of trazodone on mean PSQI scores during the 6-month follow-up was not statistically significant (p=.10). Trazodone neither significantly increased nor decreased illicit drug use relative to placebo. CONCLUSIONS: Trazodone did not improve subjective or objective sleep in methadone-maintained persons with sleep disturbance. Other pharmacologic and non-pharmacologic treatments should be investigated for this population with high rates of insomnia.

Assessing sleep in opioid dependence: a comparison of subjective ratings, sleep diaries, and home polysomnography in methadone maintenance patients.

OBJECTIVES: Comparisons of subjective and objective sleep measures have shown discrepancies between reported sleep and polysomnography (PSG) in non-drug dependent individuals with and without insomnia. Sleep may affect behavioral and physiologic aspects of drug abuse and dependence; patients in methadone maintenance therapy (MMT) for opioid dependence frequently report sleep problems. Whether subjective sleep reflects objective sleep in MMT patients is unknown. We undertook these analyses to establish the correlations among subjective and objective sleep measures in MMT patients. METHODS: We compared one week of daily sleep diaries, one night of home PSG, a questionnaire completed the morning after PSG, and the Pittsburgh Sleep Quality Inventory (PSQI) as well as demographics and drug use measures in 62 MMT patients with disturbed sleep (PSQI score > 5). RESULTS: Subjective and objective sleep durations were similar in this sample; average sleep times for the diary, morning questionnaire, and PSG were 340, 323, and 332 min, respectively. Average diary sleep time, subjective ratings of feeling rested, and PSG sleep efficiency were correlated significantly with PSQI score. Age was inversely correlated with PSG sleep time. Participants whose urine toxicology showed benzodiazapine use reported significantly longer sleep times on the morning questionnaire. CONCLUSIONS: Objective sleep measures confirm subjective measures in MMT patients with disturbed sleep. The high prevalence of sleep complaints in this population likely reflects pathology rather than sleep misperception. Both objective and subjective measures are useful in research and clinical settings for assessing sleep in opioid-dependent patients.

Predicting obstructive sleep apnea among women candidates for bariatric surgery.

BACKGROUND: More women than men pursue bariatric surgery for treatment of obesity. Untreated obstructive sleep apnea (OSA) in bariatric patients increases perioperative morbidity and mortality, and, therefore, most bariatric surgeons screen for OSA with polysomnography (PSG). We sought to develop a model for predicting OSA in women seeking bariatric surgery in order to use this diagnostic resource most efficiently. METHODS: We identified 296 women who had PSG in preparation for bariatric surgery. Regression and logistic regression analyses were used to assess the relationship between history and physical examination findings and OSA severity. After developing best statistical models, we constructed a summary index to identify patients exceeding clinical thresholds for mild (apnea-hypopnea index [AHI] ≥ 5) and moderate to severe disease (AHI ≥ 15). RESULTS: In our sample, most women (86%) had OSA, and more than half (53%) had moderate to severe disease. Multiple logistic regression showed that age, body mass index (BMI), neck circumference, hypertension, witnessed apneas, and snoring predicted AHI. Diabetes mellitus and daytime sleepiness measured with the Epworth Sleepiness Scale (ESS) were not significant predictors of OSA. Prediction models were statistically significant but had poor specificity for predicting OSA severity. CONCLUSIONS: OSA is highly prevalent in symptomatic and asymptomatic women planning bariatric surgery for obesity. Best prediction models based on clinical characteristics did not predict disease severity under conditions superior to those in which they might be applied. In light of the perioperative risks associated with OSA in bariatric patients, all women considering bariatric surgery for obesity should be evaluated for OSA with PSG.

Obstructive sleep apnea is more common than central sleep apnea in methadone maintenance patients with subjective sleep complaints.

OBJECTIVES: Opioid-dependent patients treated with methadone have subjective sleep complaints and disrupted sleep on polysomnography (PSG). Previous studies of sleep-disordered breathing (SDB) in this population have focused on central sleep apnea (CSA). Our objectives were to: (1) characterize obstructive sleep apnea (OSA) and CSA in patients in methadone maintenance treatment (MMT) for opioid dependence; (2) examine factors associated with SDB in this population; and (3) investigate whether SDB was related to severity of subjective sleep complaints in MMT patients with subjective sleep disturbances. METHODS: We analyzed OSA and CSA from one night of home PSG in 71 patients who were in MMT for at least 3 months and had a Pittsburgh Sleep Quality Inventory (PSQI) score >5. RESULTS: OSA (defined as obstructive apnea-hypopnea index (OAHI) > or = 5) was observed in 35.2% of our sample. OSA was associated with higher body mass index, longer duration in MMT, and non-Caucasian race. CSA (defined as central apnea index (CAI) > or = 5) was observed in 14.1% of the sample. CSA was not associated with methadone dose or concomitant drug use. Subjective sleep disturbance measured with the PSQI was not related to OSA or CSA. CONCLUSIONS: SDB was common in this sample of MMT patients and OSA was more common than CSA. Given the lack of association between presence of SDB and severity of subjective sleep difficulties, factors other than sleep apnea must account for complaints of disturbed sleep in this population.

Treatment effects on brain activity during a working memory task in obstructive sleep apnea.

Positive airway pressure (PAP) is the most common form of treatment for obstructive sleep apnea (OSA). Treatment adherence is notoriously low, and holidays from treatment are common. To date, there is no literature on the effects of acute withdrawal from PAP treatment on the brain activity of individuals with OSA. Nine participants with OSA performed a 2-Back verbal working memory paradigm during repeated functional magnetic resonance imaging (FMRI). Counterbalanced FMRI sessions were under conditions of PAP treatment (at least one consecutive week) or non-treatment (for two consecutive nights). Treatment effects on 2-Back-related brain activity were significant, with greater deactivation in the right posterior insula and overactivation in the right inferior parietal lobule. The observed responses to PAP treatment withdrawal were more extreme in all regions of interest, such that 2-Back-related activity increased and 2-Back-related deactivation decreased further relative to the 0-Back control task. The withdrawal of PAP treatment in effectively treated individuals with OSA might result in the need to reallocate resources in order to perform at the same cognitive level.

Home polysomnography in methadone maintenance patients with subjective sleep complaints.

OBJECTIVE: Most patients in methadone maintenance treatment (MMT) complain of poor sleep. Few studies have examined MMT patients' sleep using polysomnography (PSG), and none to our knowledge have employed home PSG. Standard sleep laboratory research protocols often require two consecutive PSG nights because of inter-night variability in sleep attributed to first-night adaptation to a novel sleep environment and recording procedures. The purpose of this study was to assess the stability of sleep measures across two consecutive nights of home PSG in opioid-dependent MMT patients. METHODS: Home PSG was performed in 50 MMT patients with subjective sleep complaints. Participants were 54% female and 82% white with mean age = 36.8 years, median methadone dose = 100 mg/day, and median MMT duration = 286 days. RESULTS: Thirty-six participants completed two consecutive nights of at-home PSG and 14 completed one. For the former group, no differences in sleep measures were found across recordings. The one-night group had significantly less total sleep time, Stage 2 sleep, REM sleep, and shorter REM latency than the two-night group. CONCLUSIONS: Home PSG is a viable method for recording sleep in opioid-dependent MMT patients, and was stable across consecutive nights of study. Two nights of home PSG for MMT patients, therefore, are not necessarily required and confidence in the reliability of data from one night of recording can be assumed. Excluding MMT research participants with one PSG may exclude patients with the worst sleep--precisely the group that most warrants investigation.

Insomnia among methadone-maintained individuals: the feasibility of collecting home polysomnographic recordings.

Sleep disturbance among methadone-maintained patients is highly prevalent. A full understanding of sleep disturbance requires polysomnographic measures along with subjective sleep quality measures. The goal of this study was to describe the authors' experiences in performing at-home unattended polysomnography in this population. Participants had a Pittsburgh Sleep Quality Index score of six or higher, which indicates clinically significant insomnia, and 65% of eligible individuals agreed to enroll. Among 88 participants (53% female, 82% white, and a mean methadone dose of 105 mg/day), each undergoing two nights of home polysomnography, we initiated 165 of a maximum of 176 recordings. Overall, 81.7% of participants provided at least one night of "acceptable" polysomnographic data of at least 4 hours duration. Urine toxicology on polysomnographic nights demonstrated that benzodiazepine use was common. The authors conclude that unattended polysomnography is feasible in a population of individuals receiving methadone maintenance treatment. Polysomnography signal quality and overall study success rates were similar to those in non-substance using populations.