Predictors of sleepiness in obstructive sleep apnoea at baseline and after 6†months of continuous positive airway pressure therapy.

We evaluated factors associated with subjective and objective sleepiness at baseline and after 6 months of continuous positive airway pressure (CPAP) therapy in patients with obstructive sleep apnoea (OSA).We analysed data from the Apnoea Positive Pressure Long-term Efficacy Study (APPLES), a prospective 6-month multicentre randomised controlled trial with 1105 subjects with OSA, 558 of who were randomised to active CPAP. Epworth sleepiness scale (ESS) scores and the mean sleep latency (MSL) on the maintenance of wakefulness test at baseline and after 6 months of CPAP therapy were recorded.Excessive sleepiness (ESS score >10) was present in 543 (49.1%) participants. Younger age, presence of depression and higher apnoea-hypopnoea index were all associated with higher ESS scores and lower MSL. Randomisation to the CPAP group was associated with lower odds of sleepiness at 6 months. The prevalence of sleepiness was significantly lower in those using CPAP >4 h·night-1versus using CPAP ≤4 h·night-1 Among those with good CPAP adherence, those with ESS >10 at baseline had significantly higher odds (OR 8.2, p<0.001) of persistent subjective sleepiness.Lower average nightly CPAP use and presence of sleepiness at baseline were independently associated with excessive subjective and objective sleepiness after 6 months of CPAP therapy.

Impact of continuous positive airway pressure (CPAP) on quality of life in patients with obstructive sleep apnea (OSA).

Obstructive sleep apnea is a chronic illness with increasing prevalence. In addition to associated cardiovascular comorbidities, obstructive sleep apnea syndrome has been linked to poor quality of life, occupational accidents, and motor vehicle crashes secondary to excessive daytime sleepiness. Although continuous positive airway pressure is the gold standard for sleep apnea treatment, its effects on quality of life are not well defined. In the current study we investigated the effects of treatment on quality of life using the data from the Apnea Positive Pressure Long-term Efficacy Study (APPLES), a randomized controlled trial of continuous positive airway pressure (CPAP) versus sham CPAP. The Calgary Sleep Apnea Quality of Life Index (SAQLI) was used to assess quality of life. Overall we found no significant improvement in quality of life among sleep apnea patients after CPAP treatment. However, after stratifying by OSA severity, it was found that long-term improvement in quality of life might occur with the use of CPAP in people with severe and possibly moderate sleep apnea, and no demonstrable improvement in quality of life was noted among participants with mild obstructive sleep apnea.

Impact of Randomization, Clinic Visits, and Medical and Psychiatric Cormorbidities on Continuous Positive Airway Pressure Adherence in Obstructive Sleep Apnea.

STUDY OBJECTIVES: To evaluate factors associated with continuous positive airway pressure (CPAP) adherence in patients with obstructive sleep apnea (OSA) in the Apnea Positive Pressure Long-term Efficacy Study (APPLES) cohort. METHODS: The data from a prospective 6-mo multicenter randomized controlled trial with 558 subjects randomized to active CPAP and 547 to sham CPAP were analyzed to assess adherence to CPAP during first 2 mo (early period) and during months 5-6 (late period). RESULTS: Participants randomized to active CPAP had higher hours of nightly adherence compared to the sham CPAP group at both 2 (4.9 ± 2.0 h versus 4.07 ± 2.14 h, p < 0.001) and 6 mo (4.70 ± 2.08 h versus 3.41 ± 2.19 h, p < 0.001). Those assigned to sham CPAP were more likely to correctly identify their treatment group (70.0% versus 55.2%, p < 0.001). Irrespective of treatment group assignment, those who believed they were receiving active CPAP had higher hours of adherence than those who thought they were in the sham CPAP group at both 2 mo (4.91 ± 2.01 versus 4.17 ± 2.17, p < 0.001) and 6 mo (4.65 ± 2.10 versus 3.65 ± 2.22, p < 0.001). Among those randomized to active CPAP, older age was significantly related to CPAP use > 4 h per night. Presence of cardiovascular disorders was associated with higher hours of CPAP use, whereas presence of anxiety was associated with a trend toward lower hours of CPAP use. Presence of nasal congestion was associated with a decrease in mean daily CPAP use between the early and the late adherence period. The adherence during the week prior to a clinic visit was higher than the average adherence during the 2-mo period prior to the visit. CONCLUSIONS: Randomization to active therapy, belief that one is in the active treatment group, older age, and possibly presence of cardiovascular disorders are positively linked to CPAP adherence. Nasal congestion and anxiety are negatively associated with CPAP adherence. CPAP nightly usage increases as clinic visits approach.

Sleep extension improves serving accuracy: A study with college varsity tennis players.

OBJECTIVE: This study investigated the effects of sleep extension on tennis serving accuracy, as well as daytime sleepiness in college varsity tennis players. METHODS: Twelve (seven females and five males) healthy students on a college varsity tennis team maintained their habitual sleep-wake schedule for a one-week baseline period followed by a one-week sleep extension period. Participants were requested to sleep at least nine hours, including naps, during the sleep extension period. Serving accuracy was assessed when participants were sleep deprived (prior to the sleep extension period) and after the sleep extension period. Levels of daytime sleepiness were monitored via the Epworth Sleepiness Scale and the Stanford Sleepiness Scale, and caffeine consumption was recorded throughout the study. RESULTS: Participants slept significantly more in the second week--the sleep extension week--compared with the first week--the baseline week (8.85 vs. 7.14 h; p<0.05). Following the sleep extension period, accuracy of the tennis serves improved significantly (35.7% vs. 41.8%; p<0.05), and the Epworth Sleepiness Scale and Stanford Sleepiness Scale scores declined significantly (12.15 vs. 5.67; p<0.05 and 3.56 vs. 2.67; p<0.05, respectively). CONCLUSIONS: This study demonstrates that an increase in sleep of approximately 2h per night significantly increased athletic performance in college varsity tennis players.

Impact of CPAP on activity patterns and diet in patients with obstructive sleep apnea (OSA).

STUDY OBJECTIVES: Patients with severe OSA consume greater amounts of cholesterol, protein, and fat as well as have greater caloric expenditure. However, it is not known whether their activity levels or diet change after treatment with CPAP. To investigate this issue, serial assessments of activity and dietary intake were performed in the Apnea Positive Pressure Long-term Efficacy Study (APPLES); a 6-month randomized controlled study of CPAP vs. sham CPAP on neurocognitive outcomes. METHODS: Subjects were recruited into APPLES at 5 sites through clinic encounters or public advertisement. After undergoing a diagnostic polysomnogram, subjects were randomized to CPAP or sham if their AHI was ≥ 10. Adherence was assessed using data cards from the devices. At the Tucson and Walla Walla sites, subjects were asked to complete validated activity and food frequency questionnaires at baseline and their 4-month visit. RESULTS: Activity and diet data were available at baseline and after 4 months treatment with CPAP or sham in up to 231 subjects (117 CPAP, 114 Sham). Mean age, AHI, BMI, and Epworth Sleepiness Score (ESS) for this cohort were 55 ± 13 [SD] years, 44 ± 27 /h, 33 ± 7.8 kg/m(2), and 10 ± 4, respectively. The participants lacking activity and diet data were younger, had lower AHI and arousal index, and had better sleep efficiency (p < 0.05). The BMI was higher among women in both CPAP and Sham groups. However, compared to women, men had higher AHI only in the CPAP group (50 vs. 34). Similarly, the arousal index was higher among men in CPAP group. Level of adherence defined as hours of device usage per night at 4 months was significantly higher among men in CPAP group (4.0 ± 2.9 vs. 2.6 ± 2.6). No changes in consumption of total calories, protein, carbohydrate or fat were noted after 4 months. Except for a modest increase in recreational activity in women (268 ± 85 vs. 170 ± 47 calories, p < 0.05), there also were no changes in activity patterns. CONCLUSION: Except for a modest increase in recreational activity in women, OSA patients treated with CPAP do not substantially change their diet or physical activity habits after treatment. .

Impact of treatment with continuous positive airway pressure (CPAP) on weight in obstructive sleep apnea.

STUDY OBJECTIVE: To determine the impact of continuous positive airway pressure (CPAP) on weight change in persons with obstructive sleep apnea (OSA). DESIGN SETTING AND PARTICIPANTS: The Apnea Positive Pressure Long-term Efficacy Study (APPLES) was a 6-month, randomized, double-blinded sham-controlled multicenter clinical trial conducted at 5 sites in the United States. Of 1,105 participants with an apnea hypopnea index ≥ 10 events/ hour initially randomized, 812 had body weight measured at baseline and after 6 months of study. INTERVENTION: CPAP or Sham CPAP. MEASUREMENTS: Body weight, height, hours of CPAP or Sham CPAP use, Epworth Sleepiness Scale score. RESULTS: Participants randomized to CPAP gained 0.35 ± 5.01 kg, whereas those on Sham CPAP lost 0.70 ± 4.03 kg (mean ± SD, p = 0.001). Amount of weight gain with CPAP was related to hours of device adherence, with each hour per night of use predicting a 0.42 kg increase in weight. This association was not noted in the Sham CPAP group. CPAP participants who used their device ≥ 4 h per night on ≥ 70% of nights gained the most weight over 6 months in comparison to non-adherent CPAP participants (1.0 ± 5.3 vs. -0.3 ± 5.0 kg, p = 0.014). CONCLUSIONS: OSA patients using CPAP may gain a modest amount of weight with the greatest weight gain found in those most compliant with CPAP. COMMENTARY: A commentary on this article appears in this issue on page 995. CITATION: Quan SF; Budhiraja R; Clarke DP; Goodwin JL; Gottlieb DJ; Nichols DA; Simon RD; Smith TW; Walsh JK; Kushida CA. Impact of treatment with continuous positive airway pressure (CPAP) on weight in obstructive sleep apnea.

Effects of continuous positive airway pressure on neurocognitive function in obstructive sleep apnea patients: The Apnea Positive Pressure Long-term Efficacy Study (APPLES).

STUDY OBJECTIVE: To determine the neurocognitive effects of continuous positive airway pressure (CPAP) therapy on patients with obstructive sleep apnea (OSA). DESIGN, SETTING, AND PARTICIPANTS: The Apnea Positive Pressure Long-term Efficacy Study (APPLES) was a 6-month, randomized, double-blind, 2-arm, sham-controlled, multicenter trial conducted at 5 U.S. university, hospital, or private practices. Of 1,516 participants enrolled, 1,105 were randomized, and 1,098 participants diagnosed with OSA contributed to the analysis of the primary outcome measures. INTERVENTION: Active or sham CPAP MEASUREMENTS: THREE NEUROCOGNITIVE VARIABLES, EACH REPRESENTING A NEUROCOGNITIVE DOMAIN: Pathfinder Number Test-Total Time (attention and psychomotor function [A/P]), Buschke Selective Reminding Test-Sum Recall (learning and memory [L/M]), and Sustained Working Memory Test-Overall Mid-Day Score (executive and frontal-lobe function [E/F]) RESULTS: The primary neurocognitive analyses showed a difference between groups for only the E/F variable at the 2 month CPAP visit, but no difference at the 6 month CPAP visit or for the A/P or L/M variables at either the 2 or 6 month visits. When stratified by measures of OSA severity (AHI or oxygen saturation parameters), the primary E/F variable and one secondary E/F neurocognitive variable revealed transient differences between study arms for those with the most severe OSA. Participants in the active CPAP group had a significantly greater ability to remain awake whether measured subjectively by the Epworth Sleepiness Scale or objectively by the maintenance of wakefulness test. CONCLUSIONS: CPAP treatment improved both subjectively and objectively measured sleepiness, especially in individuals with severe OSA (AHI > 30). CPAP use resulted in mild, transient improvement in the most sensitive measures of executive and frontal-lobe function for those with severe disease, which suggests the existence of a complex OSA-neurocognitive relationship. CLINICAL TRIAL INFORMATION: Registered at clinicaltrials.gov. Identifier: NCT00051363. CITATION: Kushida CA; Nichols DA; Holmes TH; Quan SF; Walsh JK; Gottlieb DJ; Simon RD; Guilleminault C; White DP; Goodwin JL; Schweitzer PK; Leary EB; Hyde PR; Hirshkowitz M; Green S; McEvoy LK; Chan C; Gevins A; Kay GG; Bloch DA; Crabtree T; Demen WC. Effects of continuous positive airway pressure on neurocognitive function in obstructive sleep apnea patients: the Apnea Positive Pressure Long-term Efficacy Study (APPLES). SLEEP 2012;35(12):1593-1602.

Shift work disorder case studies: applying management principles in clinical practice.

Shift work disorder (SWD) is a circadian rhythm sleep disorder characterized by insomnia and excessive sleepiness. SWD, which is estimated to affect 10% of people who work night or rotating shifts, can have serious consequences such as accidents, loss of productivity, and depression. By enlisting the support of family, identifying and treating comorbid sleep disorders, and appropriately timing light and dark exposure (supplemented by melatonin), clinicians can help many shift workers improve their ability to sleep, maintain wakefulness, and possibly decrease other adverse effects of shift work. More aggressive treatment strategies and referral to a sleep specialist should be considered for patients who do not respond to these simple measures.

Shift work disorder: clinical assessment and treatment strategies.

Shift work disorder (SWD) occurs when individuals are unable to successfully synchronize their internal clocks with a work schedule that requires them to stay awake when it is dark and sleep when it is light. When assessing for SWD, clinicians should take a thorough sleep history and have the patient maintain a sleep diary. Clinicians should also be aware of conditions that commonly occur in conjunction with this illness, including sleep apnea, restless legs syndrome, depressive and anxiety disorders, and chronic fatigue. The primary goal of treatment for SWD is to reduce the rate of circadian misalignment by fostering better sleep when it is desired and improved alertness and functioning when appropriate. Nonpharmacologic strategies (eg, melatonin and light therapy) should be tried before considering medications to promote sleep and/or alertness.

The association between obstructive sleep apnea and neurocognitive performance--the Apnea Positive Pressure Long-term Efficacy Study (APPLES).

STUDY OBJECTIVES: To determine associations between obstructive sleep apnea (OSA) and neurocognitive performance in a large cohort of adults. STUDY DESIGN: Cross-sectional analyses of polysomnographic and neurocognitive data from 1204 adult participants with a clinical diagnosis of obstructive sleep apnea (OSA) in the Apnea Positive Pressure Long-term Efficacy Study (APPLES), assessed at baseline before randomization to either continuous positive airway pressure (CPAP) or sham CPAP. MEASUREMENTS: Sleep and respiratory indices obtained by laboratory polysomnography and several measures of neurocognitive performance. RESULTS: Weak correlations were found for both the apnea hypopnea index (AHI) and several indices of oxygen desaturation and neurocognitive performance in unadjusted analyses. After adjustment for level of education, ethnicity, and gender, there was no association between the AHI and neurocognitive performance. However, severity of oxygen desaturation was weakly associated with worse neurocognitive performance on some measures of intelligence, attention, and processing speed. CONCLUSIONS: The impact of OSA on neurocognitive performance is small for many individuals with this condition and is most related to the severity of hypoxemia.

The Apnea Positive Pressure Long-term Efficacy Study (APPLES): rationale, design, methods, and procedures.

STUDY OBJECTIVE: To assess the size, time course, and durability of the effects of long-term continuous positive airway pressure (CPAP) therapy on neurocognitive function, mood, sleepiness, and quality of life in patients with obstructive sleep apnea. DESIGN: Randomized, double-blinded, 2-arm, sham-controlled, multicenter, long-term, intention-to-treat trial of CPAP therapy. SETTING: Sleep clinics and laboratories at 5 university medical centers and community-based hospitals. PATIENTS OR PARTICIPANTS: Target enrollment is 1100 randomly assigned subjects across 5 clinical centers. INTERVENTIONS: Active versus sham (subtherapeutic) CPAP. MEASUREMENTS AND RESULTS: A battery of conventional and novel tests designed to evaluate neurocognitive function, mood, sleepiness, and quality of life. CONCLUSIONS: The Apnea Positive Pressure Long-term Efficacy Study (APPLES) is designed to study obstructive sleep apnea and test the effects of CPAP through a comprehensive, controlled, and long-term trial in a large sample of subjects with obstructive sleep apnea.

Symptom-Based Prevalence of Sleep Disorders in an Adult Primary Care Population.

The prevalence of sleep disorders in a primary care physician practice in Moscow, Idaho, was studied between February 7, 1997, and February 6, 1998. This primary care clinic visit population was surveyed for this 1-year period. Every patient above the age of 18 years who visited the Moscow Clinic in this time period was either approached by our on-site researcher during the patient's clinic visit or contacted via mail. Out of a total of 1249 adult patients who met with our on-site researcher during their clinic visit, 962 (77.0%) completed questionnaires and were interviewed for symptoms of sleep disorders. An additional 292 patients completed mailed questionnaires, resulting in a total of 1254 participants in the study. The percentages of patients in our sample reporting symptoms of the following sleep disorders were insomnia (32.3%), obstructive sleep apnea syndrome (23.6%), and restless legs syndrome (29.3%). This study demonstrates the need for heightened awareness and subsequent diagnosis and treatment of sleep disorders in the primary care population.